PEDIATRIC DISORDERS HEAD INJURY Definition: Any trauma to the scalp, skull, meninges, or brain caused by mechanical force. Implementation A. Monitor for complications: determine neurological status. 1. Check for signs of increased intracranial pressure. a. Level of consciousness: alert and easily aroused or lethargic; in a stupor or coma. b. Restless, irritable, crying behavior. c. Vital signs: changes in respiratory rate, increased blood pressure, pulse pressure, decreased pulse. 2. Avoid actions that might increase intracranial pressure. a. Sudden changes in position. b. Bowel straining. c. Confused, noisy environment. B. Monitor vital signs. Report changes immediately. C. Maintain adequate respiratory exchange. Increased carbon dioxide levels increase cerebral edema. D. Protect from injury by using safety measures. 1. Maintain bedrest 2. Keep padded siderails up. E. Position head to promote fluid drainage, promoting venous return from brain: elevate head of bed 15 to 30 degrees with head straight. F. Monitor and protect child if seizure activity. 1. Observe and record type of seizure. 2. Note behavior that preceded seizure. G. Prevent infection if there is drainage from auditory canal or nose. 1. Place dry, sterile cotton loosely at orifice. 2. If drainage from nose is positive for glucose, do not suction nares (risk of secondary infection). 3. Maintain strict asepsis. H. Provide adequate nutrition and hydration. 1. Provide clear liquids as ordered. 2. Measure intake and output accurately. 3. Monitor IV if in place. HYDROCEPHALUS Definition: A condition in which the normal circulation of the spinal fluid is interrupted, resulting in pressure on the brain, deformity, and the progressive enlargement of the head. Implementation A. Actions depend on the cause of increased pressure. 1. Removal of part of choroid plexus to decrease production of cerebral spinal fluid. 2. Shunting of the fluid out of the brain to the heart or to the peritoneal cavity. B. Preoperative care. 1. Prevent pressure sores on head by changing child’s position, placing child’s head on sheepskin, or by holding the infant. 2. Provide good head support when the child is sitting in Fowler’s position. 3. Promote optimal nutritional status. 4. Keep eyes free of irritation. C. Postoperative care. 1. Observe for shunt malfunction and valve patency: watch for progressive increase in head circumference and signs of increased intracranial pressure. 2. Observe for infection: increased temperature, rapid pulse, irritability. 3. Position child flat on unoperated side. 4. Prevent postoperative complications: turn every 4 hours, evaluate lung sounds, and assess for signs of infection. 5. Protect the operative site: avoid pressure on the site; ensure sterile dressing changes. SPINA BIFIDA Definition: The failure of the posterior portion of the lamina of the bony spine to form, which causes an opening in the spinal column. Implementation A. Actions dependent on severity of condition. B. Neurological interventions. 1. observe for signs of hydrocephalus as it is a frequent complication. 2. Measure head circumference daily. 3. observe for signs of increased intracranial pressure. C. Urological interventions. 1. If child is catheterized, use sterile technique. 2. Keep a careful record of intake and output. 3. Teach parents Credé method if treatment is ordered. 4. Observe for signs of urinary tract infection. a. Increased temperature. b. Foul-smelling urine. c. Cloudy urine with possible mucus. D. Orthopedic interventions. 1. Provide opportunities for the child to exercise and develop unaffected areas. 2. Prevent contractures through proper positioning. a. Provide foot brace to prevent footdrop. b. Provide support for legs to prevent external rotation of the hips. 3. Implement range-of-motion exercises. EPILEPSY Definition: A series of seizures that result from focal or diffuse discharges in cortical neurons—symptoms of abnormal brain function. Implementation A. Prevent injury during seizure. 1. Remove any objects that may cause harm. 2. Remain with child during seizure and provide privacy if possible. 3. Do not force jaws open during seizure. 4. Do not restrict limbs or restrain. 5. Loosen restrictive clothing. 6. Check that airway is open. Do not initiate artificial ventilation during a tonic- clonic seizure without administering appropriate medications. 7. Apply oxygen by blow-by if available or appropriate. 8. Following seizure, turn head to side, to prevent aspiration and allow secretions to drain; suction as needed. B. Observe and document seizure pattern. 1. Note time, level of consciousness, and presence of aura before seizure. 2. Record type, character, progression of movements. 3. Note duration of seizure and child’s condition throughout. 4. observe and record postictal state. C. Administer and monitor medications—complete control achieved in 50 to 70 percent of epileptic children. 1. Drugs prescribed for partial or generalized seizures: carbamazepine (Tegretol), phenytoin (Dilantin), and mephenytoin. 2. Drug of choice for absence is ethosuximide. D. Administer postseizure procedures—speed of recovery. 1. Reduce stimuli—noise, lights, conversation. a. Place sources of light behind client. b. Keep away from fluorescent lights. 2. Remain with child after consciousness returns. a. Speak and move slowly. b. Use simple phrases—give child time to respond. CEREBRAL PALSY Definition: A nonspecific term used to describe a group of disorders characterized by motor and postural impairments due to abnormal muscle tone: cerebral palsy may also involve language, perceptual and intellectual deficits. The most common permanent physical disability of childhood, occurring in approximately 2 in 1000 live births. Implementation A. Each child requires an individualized program according to the particular manifestations of the disease and the child’s capacities. B. Major focus of interventions is to: 1. Develop motor control. 2. Develop communication skills. 3. Provide adequate nutrition. 4. Prevent orthopedic complications. CONGENITAL HEART DISEASE GENERAL PRINCIPLES OF IMPLEMENTATION A. Organize care and feedings to provide sufficient periods of rest. B. Feed the child by nipple or nasogastric tube. Formula should contain appropriate caloric concentration and fluid volume. C. Monitor regular analysis of oxygen concentration in isolette to ensure appropriate levels. D. Position infant in the knee-chest position during hypercyanotic episodes. The toddler assumes the squatting position by himself. E. Note laboratory values for oxygen saturation and signs of polycythemia. Oxygen saturation of arterial blood that is less than 92 percent is considered a sign of cyanotic heart disease. Hematocrit higher than 52 percent may be a sign of polycythemia. F. Obtain vital signs every 4 hours or more frequently if warranted. G. Check for signs of impending heart failure. 1. Increase in weight, edema. 2. Increased pulse. 3. presence of adventitious breath sounds. 4. Increase in cyanosis. 5. Liver margin palpable more than 1 to 2 cm below costal margin. H. Monitor daily weights for changes that may indicate alterations in the infant’s fluid status. I. Encourage family to participate in infant’s care—provide nurturing environment. RESPIRATORY SYSTEM The respiratory system accomplishes pulmonary ventilation through the process of inspiration and expiration. The act of breathing involves a complex chemical and osmotic process in which oxygen is taken into the lungs and carbon dioxide, the end product, is given off. System Implementation A. Administer oxygen as ordered. (No smoking allowed in room in which oxygen is running.) B. Maintain IV and/or oral fluid levels. C. Administer antibiotic therapy if bacterial infection is present. D. Provide postural drainage, coughing, deep breathing, and chest physiotherapy, and suctioning to aid in the removal of secretions. E. Administer antipyretic medication, such as Tylenol or aspirin, tepid sponge baths, or cooling mattress. F. Provide cool mist for humidifying air. G. Ensure adequate rest and provide a less stressful environment. H. Organize nursing care to give adequate rest periods. BRONCHIOLITIS Definition: Thick production of mucus that causes spasm and occlusion of the bronchioles and small bronchi. It occurs most frequently in infants and young children and is usually preceded by a viral upper respiratory infection (RSV). Implementation A. Place upright, “sniffing position” to facilitate breathing. B. Administer cool, moist oxygen. C. Maintain adequate hydration. D. Conserve child’s energy. E. Observe for signs of dehydration. 1. Sunken fontanel. 2. Poor skin turgor. 3. Dry mucous membranes. 4. Decreased and concentrated urinary output. TYPES OF PNEUMONIA Definition: Inflammation of the alveoli caused by bacteria, virus, Mycoplasma organisms, aspiration, or inhalation. Implementation A. Administer oxygen as ordered or required. B. Supervise antibiotic therapy. C. Monitor fluid balance D. Measure intake and output. E. Reduce body temperature with antipyretic medication, cool water mattress, or sponge baths. F. Maintain isolation for protection, if necessary. G. Conserve child’s energy. ASTHMA Definition: A pulmonary disorder which has physical, chemical or psychological influences causing the release of histamine and other substances resulting in edema of the bronchial walls, excess secretion of mucus by the bronchial glands, and constriction of the bronchioles. Implementation A. Suspected allergen is identified and removed. B. Supervise medication administration. 1. Beta-2 agonists: Albuterol, metaproterenol and terbutaline, sympathomimetics causing bronchodilation. 2. Corticosteroids: reduce inflammation. 3. Methylxanthines: aminophylline, usually best used in exercise-induced or noctural asthma. 4. Cromolyn: preventive only. C. Ensure removal and control of secretions. 1. Encourage large fluid intake: liquefies secretions and maintains electrolyte balance. 2. Provide humidified air or oxygen as needed. 3. Perform chest physiotherapy and postural drainage with lower airway congestion. D. Provide emotional support for parents and child to reduce anxiety. E. Educate child to live optimally with chronic problem. EPIGLOTTITIS Definition: An acute bacterial infection of the epiglottis, may occasionally be of viral origin. Usually caused by Hemophilus influenza type B or Pneumococci streptococci. Implementation A. Prepare for lateral neck films STAT to confirm diagnosis. Keep child in upright and “sniffing” position. Supine position may cause occlusion of the airway and respiratory arrest. B. Never use restraints; never use a tongue blade or stick anything into pharynx. C. Do not elicit a gag reflex—may cause further spasm of epiglottis. D. Prepare child for OR if elective intubation is to be done. E. Maintain tracheostomy set/intubation tray at bedside. F. Provide cool oxygen mist at all times. G. Monitor vital signs with respiratory status every hour with continuous close observation. 1. Monitor respiratory rate, grunting, retracting, stridor, color, restlessness. 2. Auscultate breath sounds; evaluate use of accessory muscles. H. Monitor hydration status. Keep child NPO. 1. Start IV. Check urinary output, specific gravity, skin turgor, tears. 2. Maintain patency of IV, administer IV antibiotics (Ampicillin, cephalosporin until culture and sensitivity back). I. Monitor temperature every 2 hours—give Tylenol for temperature > 100°F as ordered. J. Place on continuous cardiorespiratory monitor and pulse oximetry. K. Isolate for 24 hours after start of antibiotic therapy. L. Prepare if intubation procedure done. 1. Maintain child in upright position. 2. Administer humidified oxygen—assist with CPAP or mechanical ventilation if necessary. Usually child only needs airway and then can breathe spontaneously. 3. Check every hour to maintain tube patency. 4. Restrain child in the same manner as you would for cleft palate repair (prevents bending elbows) to prevent accidental extubation (remains intubated at least 12 to 48 hours). M. Monitor signs prior to extubation. 1. Ability to swallow. 2. Resolution of sepsis. 3. Temperature within normal limits for 12 hours. 4. Resolution of swelling. 5. NPO 4 hours prior to extubation. CYSTIC FIBROSIS Definition: Cystic fibrosis is a genetic disorder in which the mucus-producing exocrine glands, particularly those of the lungs and pancreas, are abnormal. They produce thick and viscous mucus. Abnormal mucus production I the pancreas leads to pancreatic insufficiency and, in the lungs, to emphysematous changes. Implementation A. Provide adequate nutritional maintenance. Clients with CF require 130 percent more than normal daily requirements. 1. Pancreatic enzymes, Viokase and Cotazym, prior to meals. 2. Water-soluble vitamins. 3. Fat-soluble vitamins A, D and E in watermiscible form. 4. Diet high in calories and protein and low in fat. 5. Sodium balance. B. Provide adequate respiratory maintenance. Major objective is to keep lungs clear of mucus. 1. A new drug, dornase alfa, improves lung function by draining plugged airways. a. Breaks down extra-cellular DNA in purulent sputum. b. Drug is inhaled through a special nebulizer device. 2. IPPB Mucomyst. 3. Mist tent at night to liquefy secretions. 4. Postural drainage, TID, following IPPB. 5. Breathing exercises. (Children tend to breathe shallowly.) C. Administer antibiotics and corticosteroids as ordered to treat infection. D. Provide parental education. 1. Information about the disease and its long-term effects. 2. Genetic counseling. 3. Resource centers such as National Foundation for Cystic Fibrosis and local organizations. 4. Care of the child at home. a. Normal family routine. b. Children are irritable, frightened and insecure. c. Children need attention, discipline and reassurance. RENAL SYSTEM The genitourinary system—the kidneys and their drainage channels—is essential for the maintenance of life. This system is responsible for excreting the end products of metabolism as well as regulating water and electrolyte concentrations of body fluids. System Implementation A. Monitor laboratory results of serum electrolytes. (Refer to Medical-Surgical chapter for major electrolyte disorders.) B. Provide excellent skin care. C. Monitor IV solutions for appropriate electrolytes depending on the disorder. D. Monitor urine. 1. Utilize Hemastix and Clinitest for each voiding. Check presence of blood, protein and ketones. 2. Describe the appearance of urine: dark, light, cloudy, pink, mucus present. 3. Evaluate the specific gravity of the urine. 4. Monitor for possible urinary tract infection. E. Monitor edema through daily weights. F. Measure intake and output. G. Monitor vital signs every 4 hours or more frequently if warranted. H. Administer medications—antihypertensives. I. Evaluate for rapid respirations associated with acidosis. J. Isolate children who have an increased susceptibility to infection. K. Control infection, if present, with appropriate medications. L. Collect urine specimens from children suspected of having urinary tract infections. M. Provide diet for degree of renal dysfunction. URINARY DISORDERS HYPOSPADIAS Definition: Malposition of the urethral opening behind the glans penis, along the ventral surface. Epispadias is a condition in which the urethra is located on the upper surface of the penis. CRYPTORCHIDISM (UNDESCENDED TESTES) Definition: The absence of one or both testes from the scrotum. URINARY TRACT INFECTIONS Definition: Urinary tract infection is a term that refers to a wide variety of conditions affecting the urinary tract in which the common denominator is the presence of microorganisms. Implementation A. Force fluids (after cultures are obtained) to amount appropriate for age. B. Administer antibiotics as indicated by culture and sensitivity results. 1. Specific for causative bacteria (given 1 to 2 weeks) 2. Common drugs—penicillins, sulfonamide, aminoglycosides, trimethoprim- sulfamethoxazole, or Cefixine 3. Monitor side effects: nausea, vomiting, vertigo, diarrhea, rash, pruritus, urticaria. C. Teach mother and child to wipe child front to back.. D. If stool in diaper, clean immediately, wiping front to back.