PEDIATRIC NURSING

Division

Newborn to Adolescent (up to 18 years) – focus on Pediatric diseases Neonate (Newborn) – 0-28 days of life that can survive extra-uterine life Infant – 29 days-1 year old Toddler – 1-3 years old

Conditions in Pediatric Nursing

1. Cardiovascular System Most Dangerous – 1st trimester

o Period of organogenesiso Beginning of the development of the baby

Hereditary Steroids-cleft lip Rubella Virus

o caused by German measleso it can penetrate the placentao serves as the nutrients, supply

Low Birth WeightHeart- first to be developedBrain- folic acid (dizziness) is the first sign the fetus is developing the brain

Glucose/SugarGlucose- hypoglycemia

Confirmatory Test for Pregnancy- ultrasoundH-mole – pregnancy test (+) not confirmatory test

Grape sized Positive Signs of Pregnancy

o Fetal skeletono FHT to know breech presentationo Ultrasoundo Fetal movement

Congenital Heart Defects (intrauterine life)o AVA – normalo 1 vein and 1 arteryo Blue baby syndrome – baby turns blue when starts cryingo RDS – o Tetralogy of Fallot – bluish baby

ACCYANOTIC

PDA- Patent DuctusArteriosus ASD- Artrial Septic Defect VSD- Ventricular Septic Defect COA- Coarctation of the Aorta

Poor sucking and swallowingo Early indication of heart defect

CYANOTIC TOGA (Transposition of great artery) TOF (Tetralogy of Fallot)

For black person, first thing to asses for signs of cyanosis:

Buccal mucosa (palate) – to first test to determine if the black baby is cyanotic Palms Nail beds(Capillary Refill Test) Other name is Blanch Test

Normal: < 3 seconds

Nursing Diagnosis: Ineffective Tissue Perfusion

RISK FACTORS:

1. Familial Tendency (history of disease) - 30% chance of inheriting the disease

2. Mother was exposed to rubella virus

German Measles 3 C’s

CNS damage – Mental Retardation Congenital Cataract (Blindness) Congenital heart defects

3. Mother > 40 years old Primigravida

Hormonal Imbalances

Estrogen and Progesterone maintains pregnancy

4. Failure of the heart structure to progress

Septal Defect- when shunts does not close

2 TYPES OF CONGENITAL HEART DEFECT

1. Accyanotic From Left to Right2. Cyanotic From Right to Left

Newest Disease by World Health Organization – Broken Heart Syndrome

tachypnea tachycardia insomnia

ACYANOTIC HEART DEFECTS

1. Ventricular Septal Defect (VSD)

Opening between 2 ventricles

Signs and Symptoms

Pathognomonic Sign: Systolic murmur at the lower boarder of sternumby auscultation

O2 saturation at the right side of the heart

o Cardiac catheterization (Invasive Procedure) in order to determine the location of the defect

*before injecting dyes, test for allergy then flush after using toilet

Hypertrophy at the right side of the heart

Nursing Responsibilities:

NPO (Nothing per Orem) 6-8o before the procedure Dye- check for the allergies (Anaphylactic Shock)

CBR (Complete Bed Rest) s BRP’s (Bathroom privileges)

Protect the site by applying pressure

Assess for the complication Fever – sign of infection Absent/Weak palpatory pulse – thrombi

o Poor circulation

2. Atrial Septral Defect (ASD)

Failure of the foramen ovale to close

An ASD is a hole in the wall between the two upper chambers of the heart. This defect usually

does not cause any symptoms or problems in a young child. However, over a lifetime there can

be harmful effects on the heart and lungs. Many holes can be closed through a one-day

procedure in the cardiac catheterization laboratory. If surgery is needed, surgeons usually

perform an ASD repair before a child begins school.

Right Side Lying Position

Increase pressure at the left side of the heart

The Foramen Ovale should close w/in 24 hrs after birth up to 3 months up to 1 year

Signs and Symptoms

Pathognomonic Sign: Systolic murmur at the upper boarder of sternum O2 saturation at the right side of the heart Hypertrophy at the right side of the heart

Management for ASD and VSD

1. Long-term antibioticso To prevent sub-acute bacterial endocarditis/Infection

Inflammation of the endocardium

2. Open heart surgery

3. Patent Ductus Arteriosus (PDA)

Failure of the Ductus Arteriosus to close PDA is a heart problem that is usually noted in the first few weeks or months after birth. It is

characterized by a connection between the aorta and the pulmonary artery which allows oxygen-

rich (red) blood that should go to the body to recirculate through the lungs

Ductus Arteriosus should close within 24 hours after birth up to 1 month

Signs and Symptoms

Pathognomonic Sign: 1. Continuous machinery like murmur Prominent radial pulse

Normal – (-) radial pulse PDA - (+) radial pulse Normal – (+) Femoral pulse COA - (-) Femoral pulse

Hypertrophy at the Right Ventricle

Drug of choice = Indomethacin

Prostaglandin inhibitor that facilitate the closure of the DA

Management

Surgery – Ligation of PDA

4. Coarctation of Aorta (COA)

Narrowing/Stenosis of the aorta

Coarctation of the aorta is a malformation of the aorta where the largest blood vessel in the body

is narrow or small. Pediatric cardiac surgeons are able to surgically enlarge the narrowed aorta.

Signs and Symptoms

Pathognomonic Sign: Absence of Femoral pulse

Nursing Intervention

Monitor the Blood Pressure in the four extremities

PULSE REVEALBounding Pulse Increase BP –upper extremitiesWeak /Thready/Palpatory Decrease BP – lower extremities

Drug Of Choice : Digoxin

Digoxin is derived from the leaves of a digitalis plant. Digoxin helps make the heart beat stronger and with a more regular rhythm.

Management

Surgery: Angioplasty

CYANOTIC HEART DEFECTS

Nursing Diagnosis:

Ineffective tissue perfusion Decrease Cardiac Output

1. Transposition of the Great Arteries (TOGA)

Aorta arises from Right Ventricle PA arises from Left Ventricle

Direction of the blood is from Right Atrium – Tricuspid valve – Right ventricle – Aorta s O2

Signs and Symptoms

Cyanosis-1st cryPinkish –normalBlue -Dangerous

-Cyanotic Congenital Defect- Respiratory Distress Syndrome

Normal cry Abnormal cry-strong -cat-like cry-vigorous (“meow”-lusty“O-ha” cri-du-chat syndrome

Deficiency of chromosome # 5Through DNA testingLegal identification- anklet tag

-high pitch shrill cry (Increase Intracranial pressure)CSF – has blood brain barrierHydrocephalus –abnormal enlargement the head

Polycythemia vera

Increase no. of RBC’s/Red Blood Cells

Due to consistent a decrease of O2

Plethora

Ruddy skin (redness discoloration due to Polycythemia Vera PV)

Cardiomegaly

Enlargement of the heart due to decrease O2 of the body (viscous blood) that will cause Overfatigue of the Myocardium – muscle of the heart

2. Tetralogy of Fallot (TOF)

Boot shape

4 Main Conditions:

1. Pulmonary artery stenosis2. Ventricular Septal Defect/VSD3. Overriding of Aorta4. Right Ventricular Hypertrophy

Signs and Symptoms

High level of Cyanosis Polycythemia vera Severe Dyspnea

Squatting/Knee-chest positiono Promotes lung expansion

o Inhibits venous return

o Relieves from difficulty of breathing

Tet-spells or Blue-spellso bluish discoloration due to short episodes of hypoxia

MR/Mental Retardation(Mild)o Decrease O2 – brain

Syncope (Fainting)o Decrease O2 –brain

o 6 minutes without oxygen – Irreversible brain damage

GR/Growth Retardationo Decrease O2- vital organs(systemically)

Clubbing of fingerso Decrease tissue perfusion

X-ray filmo Boot-shape of the heart

Management:

Positioning knee chest/squatting

Administer O2 as ordered. 1-3 canula

Retrolental fibroplasia / Retinopathy of Prematurity

Too much oxygen or Increase O2 (toxicity/overdosage)

Blindness

No valsalva maneuver Vasoconstriction Increase beat of the heart

*Increase in the stimulation of the Vagus nerve

Bradycardia

* Increase workload of the heart

DOB Cyanosis

Increase the fiber in the diet

Propanolol

Antihypertensive drug Decrease Heart Spasm

Surgery BLT ( BlalockTaussig procedure)

anastomosis (to put together) of pulmonary artery and subclaian artery thus increase peripheral blood flow

Check the skin color, no cyanosis (postoperative)sign if the operation is successful

ACQUIRED HEART DISEASE

RHF (Rheumatic Heart Fever)

Systemic inflammatory disease that affects the brain, heart, joints and Subcutaneous tissues It is caused by microorganisms (M.O)

o GABHS(Grouo A Beta Hemolytic Streptococcus)

3-5x history of sorethroat/year

Tonsillectomy- removal of tonsil

Sign if there is blood after tonsillectomy – Frequent swallowing

Thyroidectomy – removal of thyroid

Sign if there is blood after thyroidectomy – blood in the nape area

Complications

RHD (Rheumatic Heart Disease)- destruction of the bicuspid valve

Tool

Jones Criteria – in order to diagnosed the patient with RHF/RHD

Major (S/SX)

Poly arthritis Subcutaneous Nodules

Carditis Erythema Marginatum Chorea (St. Vitous Dance)

purposeless movement of the body and the hands

Minor (S/SX)

Arthalgia (joint pain)

Lower grade fever Increase ASO titer – anti- streptolysin =first laboratory test that will confirms the patient

manifest tonsillitis or RHF -increase ESR (Erythrocyte sedimentation rate) – inflammation -increase creactive protein – (CRP)

* Presence of 2 major – diagnosis

*Presence of 1 major + 2 minor history of sorethroath patient + of RHF

Management:

1.Increase oral Fluid Intake (OFI) 2.CBR- because of joint pain 3.Throat swab exam – Doctor/ Physician

to determine the culture& sensitivity to determine the bacteria

Laryngospasm – RA ( Respiratory Arrest)

Antibiotic

Ampicillin Erythromycin every 6 hrs.

ASA (Acetyl Salicylic Acid) Aspirin – given after meals (gastric irritation)

Overdose of aspirin –“tinnitus” = tingling sensation of the ears

Five actions of Aspirin

Analgesics Antipyretics Anti inflammatory Anti platelet Anti thrombotic

MULTI-ORGAN SYSTEM DISORDERS

Kawasaki Disease

a.k.a mucutaneous lymphnode syndrome is an autoimmune disease in which the medium-sized blood vessels throughout the body become

inflamed. It is largely seen in children under five years of age. It affects many organ systems, mainly those including the blood vessels, skin,mucous membranes and lymph nodes; however, its rare but most serious effect is on the heartwhere it can cause fatal coronary artery aneurysms in untreated children. 

Signs and Symptoms

Bilateral conjunctivitis Strawberry tongue Lymphadenopathy

Polymorphous Rash Desquamation of the Skin Vasculitis

Management:

Reverse isolation Aspirin Therapy Immune Globulin IV(DOC)

anti- inflammation decrease risk of CAD/Coronary Artery Disease

o Angina Pectoris chest pain Problem in digestion

II. RESPIRATORY SYSTEM DISORDERS

LOBECTOMY – removal of one lobe of the lung PNEUMONECTOMY –removal of lung

Normal RR:

30-60 bpm (newborn) shallow irregular respirations periods of apnea <15 seconds

>15 seconds – RDS/Respiratory Distress Syndrome

1. Asthma Bronchoconstriction - Narrowing of the bronchus

Nursing Diagnosis:

Ineffective Airway Clearance Ineffective Breathing Pattern

INTRINSIC (Internal Stressors)

Stress Type A personality – workaholic perfect Emotions

EXTRINSIC (External stressors or environmental factors)

Allergens (dust), pollens, perfumes Drugs(antibiotics) Foods(seafood), chocolates Change of the weather from hot to cold

No skin testing - the immune system of the infant is not yet fully develop

2 to 3 months – allergic reactions

Signs and Symptoms

Hacky, non-productive cough SOB/DOB Prolonged expiratory period Expiratory wheezes(Pathognomonic sign)

-musical breath sound

-bronchoconstriction Itchiness at the base of the neck

DRUGS:

1. Albuterol –First line of drug

2. Salbutamol

3. Aminophylline

IndicationsUsed as a bronchodilator in reversible airway obstruction due to asthma. May be used in cases of Pulmonary edema and pulmonary congestion secondary to heart failure

STATUS ASTHMATICUS -recurrent episodes of asthmatic attack

Epinephrine – Drug of Choice

Indications

Adrenalin is used in cases of anaphylactic shock, cardiac arrest, and resistant ventricular fibrillation.

Signs and Symptoms

Absence of wheezes/wheezing sound – report immediately to the physician it indicates

airway obstructions

Management:

Positioningo head elevated, high fowlers, semi fowlers, sitting position

Administer O2 as ordered Monitor the V/S –especially the RR Monitor Skin color – presence of cyanosis

2. RESPIRATORY DISTRESS SYNDROME/RDS

Deficiency of surfactant

Preterm Babies

Type II alveolar cells that produce the surfactant

3 Best Explanation why surfactant is important surface tension Promotes lung expansion Prevents lung collapse(atelectasis)

Diagnostic Procedures

Amniocentesis - aspiration of amniotic fluid

Lecthin/Sphingomyelin (L/S) ratio = 2:1

Indicates lung maturity

Shake’s test

If bubbles last for sometime ( + )lung maturityIf bubbles disappear quickly ( – )lung maturity

Signs and Symptoms

Pathognomonic sign: Inspiratory grunting Tachypnea Restlessness Nasal Flaring Sternal Retraction

Management: Positioning

head elevated Proper suctioning

5-10 seconds 5-15 seconds

To prevent HYPOXIA

Corticosteroid

Betamethasone

o Prevents RDS

o Promotes surfactant maturation

Bronchodilators

3. Laryngotracheobronchitis (LTB)

inflammation of the Larynx, Trachea, Bronchus

Croup presents itself as a severe form of cough. It commonly occurs among children between six months and five or six years of age.

VIRAL INFECTION1. Parainfluenza virus 1, 2, 32. Respiratory Sincytial Virus(RSV)

Signs and Symptoms

Pathognomonic Sign: Inspiratory Stridor

Rooster-like sound due to laryngoconstriction

Barking/Croupy Cough

“seal-barking”

Labored respirations Respiratory acidosis

Diagnostic Procedure:

Throat swab test

Management:

Positioning high fowlers

Administer O2 as doctors ordered Bronchodilator

Corticosteroid Prednisone – anti –inflammation

It is used to treat certain inflammatory diseases (such as moderate allergic reactions) and (at higher doses) some types of cancer, but has many significant adverse effects. It is usually taken orally but can be delivered by intramuscular injection or intravenous injection.

HEMATOLOGICAL SYSTEM DISORDER

Omphlagia – bleeding of the umbilical cord Omphalitis – infection of the umbilical cord

Hemophilia

Genetically acquired Disease Deficiency of clotting factors X-linked recessive genes

Usual carrier: Mother Rare 1% - Father: carrier

Usually affected: son Daughter: affected

3 TYPES OF HEMOPHILIA

1. Hemophilia A (80%) most common also known as “classic” deficiency of the clotting factor # 8

2. Hemophilia B (18%) also known as “Christmas Disease” deficiency of the clotting factor # 9

3. Hemophilia C (2%) rarest absence of clotting factor # 11

Signs and Symptoms

Hemarthosis Hematuria

Bleeding of the joints Blood in the Urine

Melena Epistaxis Hemorrhages

Black tarry stool Bleeding of the Nose

Diagnostic procedures

1. Platelet CountNormal value = 150,000 – 400,000 m3

2. Phrothrombin Time (PT) – Normal

3. Partial Thromboplastin Time (PTT) – AbnormalN/V PTT of infants < 90 secs

Management:

Provide safety precautionary measures Control the bleeding

Closed supervision Avoid direct/contact sports like: Games for them are board games like:

Ball games Chess Monopoly

Fencing Domino

Tug of war Scrabble

Track n’ field Snakes and adders

Avoid invasive procedure (NGT, Foley catheter, etc.) PD 996 under EPI

injection is promoted through immunization for children by using a small gauge needle in inserting and then you apply firm pressure for 5-10 minutes after you inject the syringe not exceeding to avoid obstruction of blood flow

Falls

Past Interventions Current Interventions

Splint the affected area R - est Immobilized I - ce Elevate C -ompress

E -levate

Blood Transfusion Cryoprecipitate - 20-30 minutes Fresh Frozen Plasma (FFP) - 1 hour

Note: Be at the bedside of the client for the first 15 mins. Because this is the time you watch out for any allergic reactions and hypertension.

If hypertension, itching, fever or plank pain occurs: Stop the transfusion Flush with PNSS(Plain Normal Saline Solution) Notify the physician

No aspirin therapy

Sickle Cell Anemia

autosomal recessive gene both the parents are the carrier of the trail also known as painful crisis

Normal RBC Sickle Cell Anemia

Biconcave disk Crescent shaped RBC

lifespan of normal RBC – 120 days

Normal RBC Hgb A

10-12 days only

Normal RBC is replaced by an abnormal RBC

Abnormal RBC Hgb S

Pathophysiology

Sickle Cell Anemia

O2(dehydration, Infxn, Stress, Vigorous exercise, altitude environment)

Sickling process

Short lifespan of the RBC Viscosity of the blood Obstruction of the circulation

10-12 days Slow circulation PS: vaso-occlusive crisis

Max. 20 days

O2 Sickling process Ischemia Necrosis

RBC Anemia

Organ damage

Pain

Complication

Arthritis – most common complications

OTHER COMPLICATIONS (LEGHEK)

Liver damage - Destruction of hepatocytes Eyes - Retinal detachment Genital - Priapism (painful and continuous erection) that can lead to sterility Heart - Myocardial Infarction Extremities - leg ulceration Kidneys Renal Failure

Management:

Hydration highest possible answer Oxygenation Pain Management

Narcotic Analgesia Morphine

Blood Transfusion Packed Red Blood Cells - 4 hours

Encourage the patient to increase the iron and Folic Acid intake FOLIC ACID – promote maturation of RBC

Leukemia Cancer of WBC (White Blood Cells) Group of malignant disease characterized a rapid proliferation of immature WBC’s

2 TYPES:1. Lympho – it affects the Lymphatic System (Immune system)

2. Myelo – it affects the bone marrowBone Marrow

Red – Erythropoiesis (production of RBC) Yellow – Fats

ACUTE LYMPHOCYTIC LEUKEMIA

Target children 2-10 years old most common good prognosis ( Undergoes Chemotherapy)

Diagnostic Procedure1. Peripheral Blood

Smear -for Immature WBC’s

2. Complete Blood Count - RBC = anemia - WBC = leukocytosis - WBC = leukopenia - platelet = thrombocytopenia

S/Sx: Bruises ecchymosis (bluish

discoloration Melena Hematuria Gum bleeding

3. Bone Marrow AspirationAdult - post. Iliac cresChild - Sternum,Infant -Anterior Tibia

POST BONE MARROW ASPIRATION

BLEEDING

Position the pt. on the affected area to increase pressure

Management:

Provide Neutropenic Precautions Reverse isolation Avoid fresh fruits and fresh flowers(harbor M.O)

Administer Chemotherapy as orderedSide Effects: Nausea and Vomiting Anorexia Mouth sores Alopecia – Low self esteem --- offer a wig or cap

GASTROINTESTINAL SYSTEM DISORDER

MOUTH

ESOPHAGUS

STOMACH

SMALL INTESTINES

LARGE INTESTINES

RECTUM

ANUS

Functions: To maintain Fluid and Electrolyte balance Process and absorbs nutrients from the metabolism To excrete waste products from the digestive process

Disorders

Cleft lip

Failure of the median maxillary of the nasal process to fuse by 5-8 weeks of pregnancy

Most common for Boys Surgery (Cheiloplasty) - repair of the lips

Note: It is done 1-3 months, to save the sucking reflex

“Rule of 10”

o 10 weeks old

o 10 grams of hemoglobin

o 10 lbs of weight

Cleft palate

Failure of the palate to fuse by 9-12 weeks of pregnancy

Most common for Girls

Surgery (Palatoplasty) – repair of palate

Note: It is done 6-8 months, to save the speech

Signs and Symptoms

Evident at birth During feeding, the milk escapes to the nostrils

o Risk for aspiration

Frequent colic, otitis media, Upper Respiratory Tract Infection

Nursing Management

Provide a soft, large nipple

Burp the patient as possibleo to prevent colic

Pre-operative careo Provide an emotional support to the mothero Positioning - upright positiono Burp the patient as frequent as possible

Post-operative careo Positioning

Side lying (post cheiloplasty) to facilitate the drainage of the secretions Prone (post palatoplasty)

o Feeding methods

Rubber-tipped syringe (post cheiloplasty) Soup spoon, paper cup (post palatoplasty)

Note: Avoid straw and fork

o Apply elbow restraints

Decrease the movement of the childo Apply Logan Bar

To maintain the suture lineWash with ½ strength hydrogen peroxide

Hirschsprung’s Disease

Congenital Aganglionic Megacolono Aganglionic – is the absence of ganglion cells w/c are responsible for peristaltic

movement No rhythmic contractions

Signs and Symptoms

Palpable fecal matter Abdominal distention Vomiting

o bilous

o it contains fecal matter

Halitosis (bad breath) Anorexia Loss of weight Chronic constipation

PS: ribbon-like stools

Diagnostic Procedure:

Barium Enema

Ultrasound

Rectal Biopsy

o Conclusive test

o Reveal: Absence of ganglion cells

Management:

Monitor Intake and Output Administer enema as ordered

Intussusception

Invagination or telescoping of one bowel to another portion

Signs and Symptoms

Palpable sausage – shaped mass in the abdomen Vomiting

o bilous

o mucoid

Presence of currant jelly stoolso Bloody and mucoid

Persistent paroxysmal abdominal paino Peritonitis

Surgery

Exploratory Laparotomy

Management

Monitor the Vital Signs Monitor the passage of stools

Hypertropic Pyloric Stenosis

Progressive thickening of the muscle layer of the pylorus that causes narrowing and obstruction

Signs and Symptoms

Palpable olive-shaped mass Upper abdominal distention Projectile vomiting non-bilous mucoid Visible peristaltic waves

o From Left to right

Diagnostic Procedure:

Ultrasound

Abdominal x-ray (upper area) c Barium swallow

Surgery

Pyloromyotomy (Fredet Ramstedt) – to loosen the tight muscle

Pre-operative care:o Thickened formula (not easily vomitted)

Post-operative care:

o Maintain clear liquid diet for the patient 24 hours

Nursing Management

Monitor the hydration status of the patient. Monitor the dehydration and metabolic alkalosis Monitor the weight Diet

Bronchiolitis

Inflammation of the fine bronchioles and small bronchi

Signs and Symptoms

Nasal Flaring Intercoastal and Subcostal Retractions on Inspiration Increased Respiratory Rate Mild Fever Wheezing Tachycardia Cyanosis

Diagnosis

Chest Radiograph

Chest radiograph of an infant w/ bronchiolitis

Pulse Oximetry

Nursing Management

Antipyretics Hydration Anti RSV Immunoglobulin Humidified Oxygen Nebulized Bronchodilators Epinepherine and anti-inflammatory medications Provide Adequate Ventilation

Celiac Disease

Is the sensitivity of abnormal immunologic response to protein particularly the gluten factor of protein found in found in grains – wheat, rye, oats and barley.

Signs and Symptoms

Steatorrhea – Bulky, foul-smelling stools Anorectic Irritable Skinny Spindly extremities Wasted Buttocks

child w/ Celiac Disease

Diagnosis

Serum Analysis of antibodies against gluten (IgA)

Endoscopy

Oral Glucose Tolerance Test

Nursing Management

Gluten - free Diet

Maintain Hydration

Systems Plus College FoundationAngeles City

College of Nursing

In Partial Fulfillment

Of the Requirements in NCM 102

“Pediatric Nursing”

Submitted to:

Mr. Arnel Jay Sali, RM, RN, MSN

Submitted by:

Buenafe, Ma. Cresencia S.

BSN Level II