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Pediatric Nursing PEDIATRIC NURSING By Daryl

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Pediatric Nursing PEDIATRIC NURSING By Daryl Powered By Docstoc
					PEDIATRIC NURSING

  By: Daryl Joel C. Dumdum, RN
  Growth and Development
• Growth
  – Increase in size of a structure.
• Development
  – Maturation of structures
• Cephalocaudal
  – Head to Toe
• Proximo-Distal
  – Trunk to Peripheries
• Phylogeny
  – Development or evolution of a species or group
• Ontogeny
  – Development of an individual within a species
     Rates of Development
• Fast Growth Periods
  – INFANCY and ADOLESCENTS
• Slow Growth Periods
  – TODDLER THROUGH SCHOOL AGE
• FETAL and INFANCY
  – The Head and neurologic tissue grow faster than other
    tissues
• TODDLER and PreSCHOOL
  – The trunk grows more rapidly than other tissues
• The limbs Grow most during School age periods
• The trunk grows faster than other tissue during
  adolescence
            Theorists
Sigmund Freud ( Psychosexual Theory)
  0-1 - ORAL STAGE
  1-3 - ANAL STAGE
  3-6 - PHALLIC STAGE
  6-12- LATENCY STAGE
  12 and Above - GENITAL SAGE
             ERIK ERIKSON
            (PSYCHOSOCIAL)
•   0-1 INFANCY          • Trust vs mistrust
•   1-3 TODDLER          • Autonomy vs shame
•   3-6 PRESCHOOL        • Initiative vs guilt
•   6-12 SCHOOL AGE      • Industry vs inferiority
•   12-18 ADOLESCENT     • Identity vs role
•   18-35 Early Adult      confusion
•   35-60 Middle Adult   • Intimacy vs Isolation
•   60 and above Late    • Generativity vs
    Adult                  stagnation
                         • Ego Integrity vs
                           Despair
               Jean Piaget
              (COGNITIVE)
• 0-2 Sensorimotor
  – Reflexes, repetition of acts
• 2-4 Preconceptual
  – Egocentrism, use of symbols, magical thinking
• 4-7 intuitive/ preoperational
  – Cause and effect
• 7-11 Concrete operations
• 11-15 Formal Operations
  – Reality & Abstract thought
    MEASUREMENT TOOLS
• Chronological Age -Assessment of
  developmental tasks related to birth date
• Mental age-assessment of cognitive
  development
  – IQ
• Denver Developmental age
  – Generalized assessment tool. Measures gross
    motor, fine motor, language, and personal-
    social development from newborn to 6 yrs
  – Does not measure intelligence
• Growth Parameters
  – Bone Age: x-ray of tarsals and carpals
  – Growth charts
              Neonate
          Birth to 1 month
• Weight increases weekly by 5-7oz (142-
  198g)for first 6 months
• Length; grows 1 inch monthly for the first
  6months
• Head Growth: equal to or slightly larger
  than the chest. Increases by ½ inch
  monthly for the first 6moths
• Brain Growth: Increase in size about 2/3
  adult size at 1year and 90% adult size at
  2 years
                  Neonate
              Birth to 1 month
•   Behavior is reflex controlled
•   Flexed extremities
•   Can lift head slightly off bed when in prone
•   Hearing and touch are well developed at birth
•   Sight not fully developed until 6 years
     – Differentiate darkness from light at birth
     – Rapidly develops clarity of vision within 1 foot
     – Fixates on moving objects
             Neonate
         Birth to 1 month
• Cries to express displeasure
• Smiles indiscriminately
• Receives gratification through
  sucking
• Makes throaty sounds
             1-4 months
• Posterior fontanel closes
• Moro Reflex and Tonic neck reflex begins
  to fade
• Gains Head control: Balances head in
  sitting position
• Rolls from back to side
• Begins voluntary hand-mouth activity
• Begins to be able to coordinate stimuli
  from various sense organs
• Hearing: locates sound by turning and
  visually searching
                1-4 months
•   Vision: beginning hand eye coordination
•   Prefers human face
•   Follows objects at 180°
•   Accommodation is equal to adult
•   Crying becomes differentiated at 1 month
    – Decreased during awake periods
    – Ceases when parent is in view
• Vocalization distinct from crying at 1
  month
    – Squeals to show pleasure at 3 moths
    – Coos, babbles, laughs, vocalizes when smiling
         SOLITARY PLAY
• BIRTH to 4 months
  – Provide variety of brightly colored
    objects, different sizes and textures
  – Hang mobiles within 8-10 inches of
    infant‟s face
  – Expose to various environmental
    sounds; use rattles, musical toys.
                  5-6 months
• Birth weight doubles at 6 months
• Eruption of teeth begins
    – Lower incisor first
    – Causes increased saliva and drooling
    – Enzyme released during teething causes diarrhea, facial
      skin irritation
    – Slight fever
•   Intentional rolling over
•   Supports weight on arms
•   Creeping
•   Can grasp and let go voluntarily
•   Transfers toys from one hand to another
             5-6 months
• Sits with support
• Hearing: can localize sounds above and
  below the ear
• Vision: smiles at own mirror image and
  responds to facial expressions of others
• Taste: sucking needs have decreased and
  cup weaning can begin; chewing, biting
  and taste preference begin to develop
• Vocalization: begins to imitate sounds
• Socialization: recognizes parents, stranger
  anxiety begins to develop
            5-6 months
• SOLITARY PLAY
  – Provide brightly colored toys to hold and
    squeeze
  – Allow infant to splash in bath
  – Provide crib mirror
• Begins to imitate
• Can find partially hidden objects
              7-9 months
• Teething continues
  – 7 months: upper central incisor
  – 9 months: upper lateral incisor
• Sits unsupported; goes from prone to
  sitting position
• Crawls
• Pulls self to standing position
• Develops finger-thumb opposition (pincer
  grasp)
• Preference for dominant hand evident
• Can fixate on small objects
• Beginning to develop depth perception
             7-9 months
• Begins to understand object permanence,
  searches for dropped objects
• Reacts to adult anger; cries when scolded
• Imitates simple acts and noises
• Responds to simple commands
• Vocalization: verbalizes all vowels and
  most consonants
• Socialization: increased stranger anxiety
  and anxiety over separation from parent
• Exhibits aggressiveness by biting at times
• Understands the word “NO”
               10-12 months
•   Birth weight triples
•   Length: 50% increase over birth length
•   Head and chest circumference equal
•   Teething
    – Lower lateral incisors erupt
    – Average of 8 deciduous teeth
•   Creeps with abdomen off floor
•   Walks with help or cruises
•   May attempt stand alone
•   Can sit down from upright position
•   Weans from bottle to cup
            10-12 months
• Able to discriminate simple geometric forms
• Able to follow rapidly moving objects
• Vocalization: imitates animal sounds, can say 4-5
  words but understands many more (ma, da)
• Socialization: begins to explore surroundings
• Play games such as pat-a-cake, peek-a-boo
• Shows emotions such as jealousy, affection,
  anger, fear
• Recognizes objects by name
• Looks and follows pictures in book
• Shows more goal-directed actions
                1-3 years
• Slow growth
• Primary dentition (20 teeth) completed by 2 ½
  years
• Develops sphincter control necessary for bowel
  and bladder control
• Walks alone by 18 months
• Climbs stairs and furniture by 18 months
• Runs fairly well by 2 years
• Jumps from chair or step by 2 ½ years
• Balances on one foot
• Rides tricycle
              3-5 years
• Permanent teeth may appear late in
  preschool
  – Molars behind last temporary teeth
• Walks upstairs with alternating feet
  by 3 yrs
• Walks downstairs using alternate feet
  by 4 years
• Stands on 1 foot by 3 years
• Hops on 1 foot by 4 yrs
                 3-5 years
• Skips and hops on alternate feet by 5 years
• Balances on 1 foot with eyes closed by 5 years
• Throws and catches ball by 5 years
• Jumps off 1 step by 3 years
• Jumps rope by 5 years
• Hands dominance is established by 5 years
• Builds a tower of blocks by 3 years
• Ties shoes at 5
• Copies a circle by 3 yrs
• Copies squares, traces a diamond by 4 yrs
• Copies a diamond and triangle , print letters and
  numbers at 5
• Handles scissors well at 5 years old.
              6-12 years
• Slow growth continues
• Dentition
  – Loses first primary teeth at about 6 years
  – By 12 years has all permanent teeth except
    final molars
• Vision completely mature
• Gross motor skills: children are very
  energetic, develops greater strength
• Develops smoothness and speed in fine
  motor control
             12 yrs old
– Girls
  • Increase in size of breast & genitalia
  • Appearance of axillary & pubic hair
  • Menarche
– Boys
  • Deepening of voice
  • Development of muscle
  • Increase in size of penis & testes
  • Production of viable sperm
                  12-18
• Adolescence
  – Play - continuation of competitive play
  – Fear - of obesity
           - of replacement from friends
           - of death
           - of acne
  – Significant Development
    • They have distinctive odor
  • Nocturnal emission/ wet dreams are present
  • Sperm is viable by the age of 17
  • Testes & scrotum increases at age 17
  • Breast & female genitalia increases until the
    age of 18
– Characteristics
  • Idealistic
  • Rebellions
  • Performance
  • Conscious of body image
• Adventure some
• Smoking
• Alcoholism
• Drug addiction
• Premarital sex
      Interventions for the ill or
          hospitalized Child
•   Speak in quiet, pleasant tones
•   Use words appropriate to age
•   Do not explain more than necessary
•   Always explain what you are going to do and its
    purpose
•   Be honest; do not lie about whether something
    will hurt
•   Do not make a promise you know you cant make
•   Do not threaten, if necessary, punish the act not
    the child
•   Never shame the child by using terms like baby
    or sissy
   Interventions for the ill or
       hospitalized Child
• Involve parents in child care
• Promote independence
• Allow choices where possible, but do not
  use yes/no questions unless you can
  accept a “no “ answer
• Teach parents to anticipate next stage of
  development
• If parents cannot stay with the child,
  encourage them to bring in a favorite toy,
  pictures of family members, or to make a
  tape to be played for the child
   Interventions for the ill or
       hospitalized Child
• PLAY
  – Is a way to solve problems, becomes
    enculturated, express creativity,
    decreases stress in the environment,
    prepare for different situations,
    sublimate sensations, enhance fine and
    gross motor development as well as
    social development
  – Make play appropriate for mental age
    and physical disease
  – Use multisensory stimulation
   Interventions for the ill or
       hospitalized Child
• Provide toys safe for mental age
• Offer play specific to age groups
  – Infants and Toddler: enjoys repetition,
    solitary play, parallel play
  – Preschooler: likes to role play and make
    believe play. Associative play
  – School age: likes groups, organized
    activities (to enhance sharing)
    cooperative play, group goals with
    interaction
 Preparation for procedures
• Allow the child to play with the equipments to be
  used but provide safety
• Demonstrate procedure first on a doll
• Teach the child skills that will be needed after the
  procedure and provide time for practice
• Desensitize the child
• Describe sensations to be felt by the child post-
  procedure
• Parents can often be helpful in preparing the child
  for the procedure, but needs to be prepared as
  well
• Inadequate preparation results in heightened
  anxiety that may result in regressive behavior,
  uncooperativeness, or acting out
    Failure to Thrive (FTT)
• A condition in which a child fails to gain
  weight and is persistently less than the 5th
  percentile on growth charts
• When related to inorganic cause it is
  usually due to disrupted maternal - child
  relationship
• Other pathology especially absorption and
  hormonal dysfunctions must be ruled out
  first before a diagnosis of FTT can be
  obtained
    Failure to Thrive (FTT)
• Growth and development delay
  usually improve with appropriate
  stimulation
• S/S
  – Sleep disturbances: voluntary
    regurgitation and reswallowing
  – History of parental isolation and social
    crisis with inadequate support systems
  – Delayed growth and development
  – Disturbed maternal and- infant
    interaction
     Failure to Thrive (FTT)
• Nursing Interventions:
   – Provide consistent care
   – Teach parents positive feeding techniques.
   – Maintain face to face posture with the child
   – Talk to child encouragingly during feeding
   – Involve parents in care
      • Provide supportive environment
      • Give positive feedback
      • Demonstrate and reinforce responding to
        child‟s cues
             Child Abuse
• Physical, emotional, or sexual abuse of
  children; may result from intentional and
  nonaccidental actions or may be from
  intentional and nonaccidental acts of
  omission (neglect)
• In sexual abuse 80% of children know
  their abuser
• Adults who abuse are more likely victims
  of abuse also
• Only 10 % of abusers have serious
  psychologic disturbance, but most have
  low self-esteem, little confidence and low
  tolerance to frustrations
            Child Abuse
• Abuse is most common among
  toddlers as they exercise autonomy
  and parents may sense loss of power
• Assessment findings:
  – No history to explain injury
  – Delay in seeking medical attention
  – History changes with repetition
  – Injury not consistent with injury
  – Skin injuries (bruises, burns,
    lacerations)
          Child Abuse
– Injury may show outline of instruments
  use and may be in varying stages of
  healing
– Musculoskeletal injuries, fractures,
  sprains, dislocations,
– CNS injuries like subdural hematoma,
  retinal hemorrhage
– Abdominal Injuries may include
  lacerated liver, ruptured spleen
– Observation of parents and child may
  reveal interactional problem
             Child Abuse
• NURSING INTERVENTIONS:
  – Attend to physical needs of the child
    first
  – Report suspected child abuse to
    appropriate agency
  – Encourage parents to express feelings
    concerning abuse, hospitalization, and
    home situation
  – Provide education
  – Initiate referrals for long term follow-up
    (community agencies, pediatric and
    mental heath clinics)
SIDS
(Sudden Infant Death Syndrome)
• Sudden death of any young child that is
  unexpected by history and in which
  thorough postmortem examination fails to
  demonstrate adequate cause of death
• Cannot be predicted, cannot be prevented
• Peak age: 3 months ; 90% by 6 months
• Usually occurs during sleep; there is no
  struggle and death is silent
• Diagnosis made at autopsy
SIDS
(Sudden Infant Death Syndrome)
• Although cause is unknown, chronic
  hypoxemia and apnea are suggested
  factors
• ASSESSMENT:
  – Incidence higher in preterm infants,
    twins or triplets, low birth weight infants
  – Infants with abnormalities in respiration,
    feeding, or other neurologic symptoms
    at higher risk
            SIDS
     (Sudden Infant Death
         Syndrome)
• NURSING INTERVENTIONS:
 – Nursing care is directed at supporting
   parents/family
 – Provide a room for the family to be
   alone if possible. Stay with them;
   prepare them for how infant will look
   and feel ( baby will be bruised and
   blanched due to pooling of blood until
   death was discovered; also cold)
 – Let parents say goodbye to the baby
   (hold, rock)
SIDS
(Sudden Infant Death Syndrome)
 – Reinforce that death was not their fault
 – Provide appropriate support referrals;
   clergy, significant others
 – Explain how parents can receive
   autopsy results
 – Notify Family physician or pediatrician.
         Death and Dying
• Parental Response
  – Major life stress event
  – Initially parents experience grief in
    response to potential loss of child
  – Responses might include shock and
    disbelief, denial, guilt, and depression
  – May have long term disruptive effects
    on family system
    • Stress may result to divorce
    • Behavioral problems
        Death and Dying
• Child‟s Response
  – Child concepts to death depends on
    mental age
  – Infants and toddler
    • Live only in present
    • Are concerned only with separation from
      mother and being alone and abandoned
  – Preschooler
    • See death as temporary, a type of sleep or
      separation
       Death and Dying
– School age
  • Have a concept of time, causality, and
    irreversibility (but still questions it)
– Adolescents
  • Are thinking about the future and knowing
    that they can not participate
  • May express anger at impending death
  • May find it difficult to talk about death
  • May wish to plan own funeral
  • May wish to write something for friends and
    family
  NURSING IMPLICATIONS
• Communicating with dying child
  –   Use the child's own language
  –   Do not use euphemisms
  –   Do not expect an immediate response
  –   Never give up hope
  –   Do not leave the child
  –   Do not whisper in the room
  –   Touch is therapeutic
  –   Continue reading favorite stories of the child
  –   Lat parents participate
               Who ha!
• The nurse has assessed four
  children of varying ages; which one
  requires further evaluation?
  1. a 7-month old who is afraid of
     strangers
  2. A 4 year old who talks to an imaginary
     playmate
  3. A 9 yr old with enuresis
  4. A 16 yr old who had nocturnal
     emissions
                       All right!
•    The nurse is caring for a 5 year old child who
     has leukemia and is now out of remission and
     not expected to survive. The child says to his
     mother, “will you take care of me when I am
     dead the way you do now?” The childs mother
     asks the nurse how to respond. The nurse „s
     response should be based on which of the
     following understanding of the child‟s behavior?
    1.   The child is denying that he has a terminal problem
    2.   The child may be hallucinating
    3.   Children of this stage do not understand the finality of
         death
    4.   Most 5 yr old children have a great fear of mutilation
            Grabeh na to!
• When Child abuse is suspected, the
  nurse knows that abusive burns will
  1.   Have a number of scars
  2.   Have identifiable shapes
  3.   Display an erratic pattern
  4.   Be on one side of the body
             Todo na talaga!
•    The Nurse is talking with a mother of a
     one year-old child in a well baby clinic.
     Which statement the mother makes
     indicates a need for more instruction in
     keeping the child safe?
    1. I have some syrup of ipecac at home in case
       my child ever needs it
    2. I put all medicines on the highest shelf in the
       kitchen
    3. We have moved all the valuable vases and
       figurines out of the family room
    4. My husbund put the gates up at the top and
       bottom of the stairs
            YEYE! BONEL!
• The presence of what condition
  would necessitate a change in the
  standard immunization schedule for
  a child?
  1.   Allergy to eggs
  2.   Immunosuppression
  3.   Congenital defects
  4.   Mental Retardation
Common Pediatric Disorders
• Autosomal Dominant
 – Allele responsible for the disease is
   dominant
 – Only one parent needs to pass on the
   gene.
 – Examples:
   • Huntington‟s chorea
   • Myotonic muscular dystrophy
   • Night blindness
 – Genetic Counselling: 50% chance with
   each pregnancy that the child will have
   the disease or disorder
Common Pediatric Disorders
• Autosomal Recessive
  – Allele responsible for disease will not result ihn
    expression if the other allele in the pair is
    dominant
  – Both parents must pass on the genes
  – Examples:
     •   Cystic fibrosis
     •   PKU
     •   Sicke cell anemia
     •   Albinism
     •   Tay- Sachs
Common Pediatric Disorders
 – Genetic Counselling:
   • 25% chance with each pregnancy of haing a
     child with the disorder
   • 50% chance with each pregnancy of having
     a child who is a carrier of the disease but
     will not manifest the symptoms.
   • 25% chance with each pregnancy of having
     a child will neither have the disease nor be a
     carrier.
• Sex - linked ( X-linked)
  Inheritance
  –Inheritance of characteristics
   located on X and Y chromosomes
  –Examples:
    •Color blindness
    •Baldness
    •Hemophillia A and B
  –Genetic Counselling
    •If a woman is a carrier and her
     partner does not have the disorder
      – 50% chance that her son will have the
        disorder
–50% chance her daugther will
 become a carrier
–If a man has a sex-linked disorder,
 all his daughters will be carriers
 but none will manifest the disease.
   Chormosome Disorders
• Down Syndrome
  – Caused by an extra chromosome 21 (
    total of 47)
• Assessment Findings
  – Head and Face
    • Small head, flat facial profile, broad flat
      nose
    • Small mouth, normal- size protruding
      tongue
    • Low Set ears
  – Extremities
    • Short Thick Fingers and hands
   Chormosome Disorders
  – Simian creases ( Single crease along
    palms)
  – Muscle weakness, lax joints
• Associated anomalies and disorders
  – Congenital heart defects
  – GI structural defects
  – Increase incidence of leukemia
  – Increased Incidence of Respiratory
    infection
  – Visual defects
• Mental Retardation
   Chormosome Disorders
• Nursing Interventions
  – Provide parent education concerning
    • Increased susceptibility to respiratory
      infection
    • Nutritional Needs
    • Medication Administration if necessary
  – Promote developmental progress
  – Provide genetic counselling
   Fluid And Electrolyte, Acid
          Base Balance
• Dehydration
  – Isotonic Dehydration
    • Water and electrolytes loss are
      proportionate
  – Hypotonic dehydration
    • Electrolytes deficit exceeds water loss
  – Hypertonic Dehydration
    • Water loss exceeds electrolyte loss
             Diarrhea
• A change in consistency and
  frequency of stools
• Caused by bacteria and viruses,
  parasites, poisons, inflammation,
  malabsorption, allergies, etc
• Leads to metabolic acidosis
• Also causes loss of bicarbonate and
  potassium
             Diarrhea
• Signs/ Symptoms
 – Frequent stools with abdominal
   cramping
 – Decreased urine output, decreased tears
   and saliva, dry mucous membranes, dry
   skin with poor turgor
 – In children less than 18 mos. Depressed
   anterior fontanel
 – Increased Pulse Rate and decreased BP
 – Sunken Eyes
 – High pitched cry
               Diarrhea
• Nursing Interventions
  – NPO to rest bowel if ordered
  – Administer IV Fluids as ordered
  – Resume Oral feeding slowly
  – Provide skin care
  – Monitor lab results
  – Isolation if infectious
  – Anti - diarrheal drugs
              Vomiting
• Differs from spitting up (dribbling of
  undigested formula, often with
  burping)
• If prolonged may result in metabolic
  alkalosis or aspiration
• Nursing Interventions:
  – Treat the underlying cause
  – Hydration
  – Assess amount of vomitus, frequency,
    and nature
             Vomiting
– Prevent complications
– Administer anti-emetic Medications
  • Trimethobenzamine HCl ( Tigan)
  • Promethazine HCl (Phenargan)
Nuerologic
 Disorder
                 HYDROCEPHALUS
• Increased amount of CSF within the
  ventricles of the brain
• May be caused by obstruction of CSF flow
  or by overproduction or inadequate
  reabsorption of CSF
• Classification
  – NONCOMMUNICATING/OBSTRUCTIVE
    • obstruction within the ventricles such as congenital
      malformation, neoplasm, or hematoma
  – COMMUNICATING/CONGENITAL
    • inadequate absorption of cerebrospinal fluid (CSF)
      resulting from infection, trauma, or obstruction by
      thick arachnoid membrane or meninges
Clinical findings
• 1. Increasing head size in the infant because of
    open sutures and bulging fontanels
• 2. Prominent scalp veins and taut, shiny skin
• 3. "Sunset" eyes (sclera visible above iris),
    bulging eyes, and papilledema of retina
• 4. Head lag, especially important after 4 to 6
    months
• 5. Increased intracranial pressure: projectile
    vomiting not associated with feeding,
    irritability, anorexia, high shrill cry, seizures
• 6. Damage to the brain because increased
    pressure decreases blood flow to the cells,
    causing necrosis
Therapeutic interventions
• 1. Relief of hydrocephalus
  – a. Removal of the obstruction if that is
    the cause
  – b. Mechanical shunting of fluid to
    another area of the body-ventricular
    peritoneal shunt: catheter passed
    subcutaneously to the peritoneal cavity;
    revised as necessary
• 2. Treatment of complications
• 3. Management of problems related
  to effect on psychomotor problems
    Nursing Care of Infants and
    Children with Hydrocephalus
A. Assessment
• 1. Head circumference/fontanels
• 2. Signs of increased intracranial pressure

B. Analysis/Nursing Diagnoses
• 1. Altered family process related to having
  a seriously ill child
• 2. Risk for infection related to shunt
• 3. Risk for injury related to increased
  intracranial pressure
• 4. Risk for skin breakdown related to
  immobility
Planning/Implementation
• 1. Prevent breakdown of scalp, infection,
  and damage to spinal cord
  – a. Place the infant in a Fowler's position to
    facilitate draining of fluid; infant should be
    positioned flat postoperatively with no
    pressure on shunted side
  – b. When holding the infant, support the neck
    and head
  – c. Observe shunt site (abdominal site in
    peritoneal procedure) for infection
• 2. Monitor for increasing intracranial
  pressure
  – a. Carefully observe neurologic signs
  – b. Measure head circumference
  – c. Use minimal sedatives or analgesics, which
    can mask symptoms
  – d. Check the valve frequently for patency
Promote adequate nutrition
  – a. Monitor for vomiting, irritability,
    lethargy, and anorexia, because these
    will decrease the intake of nutrients
  – b. Perform all care before feeding to
    prevent vomiting; hold infant if possible
  – c. Observe for signs of dehydration


4. Keep eyes moist and free of
  irritation if eyelids incompletely cover
  corneas
5. Postoperative nursing care: similar to that for cardiac
   surgery with the addition of:
• a. Place the infant or child on bed rest after surgery, with
   minimal handling to prevent damage to shunt
• b. Support parents
    – (1) Continued shunt revisions are usually necessary as
       growth occurs
    – (2) Usually very concerned about developmental delay
• c. Observe for brain damage by recording milestones during
   infancy
• d. Teach parents
    – (1) Pumping of the shunt, if indicated, to maintain
       patency
    – (2) Signs of increasing intracranial pressure and
       infection
    – (3) Evidence of dehydration
                SPINA BIFIDA
1. Failure of posterior vertebral arches to
   fuse during embryonic development
2. Causes: idiopathic, sibling with neural
   tube defect, radiation, viral,
   environmental factors
   3. 85%= lower thoracic lumber or sacral
   area, 15% = upper thoracic & cervical
   regions
TYPES
   1. SPINA BIFIDA OCCULTA
   2. SPINA BIFIDA CYSTICA
     2.1. MENINGOCELE
     2.2. MYELOMENINGOCELE
                 SPINA BIFIDA
•   MEDICAL MANAGEMENT
•     1. SURGERY: CLOSURE OF SAC,
    SHUNT, ORTHOPEDIC PROCEDURES
•     2. DRUG THERAPY: Antibiotics
•     3. Immobilization
•   ASSESSMENT FINDINGS
•     1. Examine the defect for size, level,
    tissue covering & CSF leakage
•     2. Motor/sensory involvement
•     3. Bowel & bladder function:
    NEUROGENIC BLADDER
              SPINA BIFIDA

DIAGNOSTIC TEST
   1. PRENATAL:
   ALPHAFETOPROTEIN
NURSING INTERVENTIONS
1. Prevent trauma to the sac:
   covering, positioning, keeping
   dryness, antibiotics )
2. Prevent complications (
   hydrocephalus, neurogenic bladder,
   immobilization )
               CEREBRAL PALSY
1.Neuromuscular disorders resulting from
   damage to or altered structure of the
   part of the brain responsible for motor
   function
2. Causes
3.   2.1. PRENATAL: genetic, trauma or
   anoxia to mother
     2.2. PERINATAL: drugs at delivery,
   precipitate delivery, fetal distress,
   breech deliveries with delay
     2.3. POST NATAL: kernicterus or
   head trauma
                   CEREBRAL PALSY
MEDICAL MANAGEMENT
   1. DRUG therapy: anti-anxiety, skeletal muscle
   relaxants, local nerve blocks
   2. PT/OT
   3. Speech/audiology therapy
   4. Surgery
ASSESSMENT FINDINGS
  –   Spasticity
  –   Athetosis
  –   Ataxia
  –   Tremors
  –   Rigidity
                     CEREBRAL PALSY
ASSOCIATED PROBLEMS
   a. Mental retardation   e. Orthopedic problems
   b. Hearing loss         f. Visual disabilities
   c. Defective speech     g. Disturbances of body image,
   touch, perception
   d. Dental anomalies     h. Feelings of worthlessness

NURSING INTERVENTIONS
   1. Obtain a careful pregnancy, birth, and childhood
   history
   2. Limit stimulation
   3. Assist in ADL, demonstration of procedure is essential
   4. Provide a safe environment ( safety helmet, padded
   crib )
   5. PT
          Meningitis
• A. Most common CNS infection of
  infants and children
• B. Inflammation of the meninges
  by viral or bacteria that travel
  via the cerebrospinal fluid
Classification: culture of cerebrospinal fluid
  used to help identify organism

• 1. Bacterial: caused by pus-forming
  bacteria, especially meningococcus,
  pneumococcus, and influenza bacillus

• 2. Tuberculous: caused by tubercle
  bacillus

• 3. Viral or aseptic: caused by a wide
  variety of viral agents
Clinical findings
• 1. Opisthotonos: rigidity and
  hyperextension of         the neck
• 2. Headache
• 3. Irritability and high-pitched cry
• 4. Signs of increased intracranial pressure
• 5. Fever, nausea, and vomiting
• 6. Meningococcal meningitis: petechiae
  and purpuric skin rash

Therapeutic intervention - massive doses of
  intravenous antibiotics
      Children with Meningitis

A. Assessment
• 1. Fever
• 2. Headache, irritability
• 3. Vomiting
• 4. Seizures
• 5. Nuchal rigidity
B. Analysis/Nursing Diagnoses
• 1. Altered family processes related to
  having a child with a serious illness

• 2. Risk for infection related to
  presence of infective organisms

• 3. Risk for injury related to presence
  of infection
C. Planning/Implementation
• 1. Provide for rest
• 2. Decrease stimuli from the environment
  (control light and noise)
• 3. Position on the side with head gently
  supported in extension
• 4. Institute respiratory isolation
• 5. Maintain fluid balance because of meningeal
  edema
      a. Record intake and output carefully
      b. Correct any deficits
      c. Monitor IV fluid
      d. Daily weights
• 6. Provide emotional support for parents, since
  child usually    becomes ill suddenly
• 7. Administer antibiotic therapy as prescribed
• 8. Observe for complications such as septic shock
  and circulatory collapse
D. Evaluation/Outcomes
• 1. Child shows decreasing severity of
  illness
• 2. Family verbalizes fears regarding
  child's prognosis
CardioVascular
   Disorder
         CONGENITAL HEART DEFECTS

• Acyanotic Heart Defects
  – Oxygenated blood is shunted from the
    systemic to pulmonary circulation ( left
    to right shunt) and blood leaving the
    aorta is completely oxygenated
• Cyanotic Heart Defects
  – Unoxygenated blood is shunted from
    the right to the left side of the heart
    where it mixes with oxygenated blood
   Acyanotic Heart Defects
• Atrial Septal Defect ( ASD )
  – Abnormal opening in the septum
    between left and right atria, causing a
    left to right shunt
• Ventricular Septal Defect (VSD)
  – Opening in the septum between
    ventricles, causing a left - to - right
    shunt
• Patent Ductus Arteriosus (PDA):
  Failure to close at birth
   Acyanotic Heart Defects
• Coarctation of the Aorta
  – Narrowing of the Aorta usually just
    beyond the left subclavian artery
• Pulmonary Stenosis
• Aortic Stenosis
• Endocardial Cushion defects
   ATRIAL SEPTAL DEFECT
• Four types
  – Ostium secundum
    defect
  – Ostium primum
    defect
  – Sinus venosus
    defect
  – Coronary sinus
    septal defect
          Manifestations
• prominent right ventricular cardiac
  impulse
• palpable pulmonary artery pulsations
• Mitral valve prolapse
  – In patients with mitral valve prolapse,
    an apical holosystolic or late systolic
    murmur often is heard radiating to the
    axilla.
          Management
• Cardiac catheterization
• surgical closure

NURSING:
 Oxygenation
 Emotional Support
 Education
  Ventricular Septal Defect
• A ventricular septal defect (VSD),
  which is a hole between the 2 lower
  chambers of the heart, may occur as
  a primary anomaly with or without
  additional major associated cardiac
  defects
• VSD is a developmental defect of the
  interventricular septum whereby a
  communication exists between the
  cavities of the two ventricles.
          Manifestations
• Infants with small defects
  – Normal vital signs
  – Clear lungs
  – Absence of jugular venous distension
    (JVD), hepatomegaly, or edema
  – Mildly hyperactive precordial impulse
  – Second heart sound (S2): S2 may be
    obscured entirely by the holosystolic
    murmur, which is well localized at the
    left sternal border.
                Manifestations
• Infants with large VSDs
   –   Cyanosis
   –   Clubbing
   –   Erythrocytosis
   –   Prominent RV lift, maximal in xiphoid region, revealed
       on palpation
   –   Very short or no systolic murmur
   –   S2 - Loud, palpable, single, or closely split
   –   S3 of right ventricular origin - May be present
   –   Squatting in 15% of patients
• Hemoptysis: Hemoptysis occurs in 33% of
  patients (never in patients <24 y); it occurs in
  100% of patients by age 40 years and
  contributes to cause of death.
           Management
– Furosemide in a dosage of 1-3 mg/kg/d in 2 or
  3 divided doses is used. Long-term furosemide
  treatment results in hypercalcemia and renal
  damage and electrolyte disturbances. Increase
  the caloric density of the feedings.
– Captopril in a dosage of 0.1-0.3 mg/kg 3 times
  daily can be useful to reduce systemic
  afterload.
– Digoxin in a dosage of 5-10 mcg/kg/d may be
  indicated if diuresis and afterload reduction do
  not relieve symptoms adequately
   Patent Ductus Arteriosus
• The ductus arteriosus is normally patent during
  fetal life. This patency is promoted by continual
  production of prostaglandin E2 (PGE2) by the
  ductus. Prostaglandin antagonism, such as
  maternal use of nonsteroidal anti-inflammatory
  medications, can cause fetal closure of the ductus
  arteriosus. This can be associated with severe
  fetal cardiovascular compromise.
• Normally, functional closure of the ductus
  arteriosus occurs by about 15 hours of life in
  healthy infants born at term. This occurs by
  abrupt contraction of the muscular wall of the
  ductus arteriosus, which is associated with
  increases in the partial pressure of oxygen (PO2)
  coincident with the first breath.
          Manifestations
 – The apical impulse is laterally displaced.
   A thrill may be present in the
   suprasternal notch or in the left
   infraclavicular region.
 – The first heart sound (S1) is typically
   normal. The second heart sound (S2)
   often is obscured by the murmur
• MANAGEMENT
 – Surgical ligation
    Cyanotic Heart Defects
• Tetralogy of fallot
  – Pulmonary stenosis
  – Coarctation of the Aorta
  – Ventricular Septal Defect
  – Right Ventricular Hypertrophy
• Symptoms Depends on the degree of
  pulmonary stenosis
    Cyanotic Heart Defects
ASSESSMENT
  S/SX= CYANOSIS, Polycythemia, clubbing of
  digits, poor growth, squatting, risk for blood
  clots, CHF( LEFT SIDE )
A.3. NURSING INTERVENTIONS
a.3.1. Don‟t interfere when squatting
a.3.2. Organize care
a.3.3. Administer oxygen
a.3.4. Meet needs quickly
a.3.5. Use soft nipple for feeding
a.3.6. Provide careful skin care
a.3. 7. Antibiotic prophylaxis
                   RHD
• Caused by GABHS
• Signs and symptoms
  – Fever
  – Migratory poly arthritis
  – Malnourished
• Treatment:
  – Aspirin
  – Sumapen
  – Supportive
Disorder of the
 Hematologic
    System
          SICKLE CELL ANEMIA
•   A. Autosomal disorder affecting
    hemoglobin
•   B. Defective hemoglobin causes red
    blood cells to become sickle shaped and
    clump together under reduced oxygen
    tension; initially fetal hemoglobin
    prevents sickling
MEDICAL MANAGEMENT
  b.1. Drug therapy: UREA,
  ANALGESIC/NARCOTICS( avoid aspirin ),
  ANTIBIOTICS
  b.2. Exchange/blood transfusion
  b.3. Hydration
  b.4. Bed rest
  b.5. Surgery
         SICKLE CELL ANEMIA
ASSESSMENT FINDINGS
1. Abdomen ( first sign: colic )
2. Lower extremities ( hand-foot syndrome,
    ulcers)
3. Spleen ( splenomegaly )
4. Bones ( osteoporosis )
5. Nervous system ( CVA )
6. Kidneys ( infarts, enuresis )
7. Heart ( Heart failure = hemosiderosis )
8. Genitals (impotence)
         SICKLE CELL ANEMIA
Vasoocclusive crisis (pain episode):
  most common and non–life-
  threatening
  – a. Results from sickled cells
    obstructing blood vessels, causing
    occlusion, ischemia, and potential
    necrosis
  – b. Symptoms include fever, acute
    abdominal pain (visceral hypoxia),
    hand-foot syndrome, priapism, and
    arthralgia without an exacerbation of
         SICKLE CELL ANEMIA
2. Splenic sequestration crisis
• a. Results from the spleen pooling large
    quantities of blood, which causes a
    precipitous drop in blood pressure and
    ultimately shock
• b. Acute episode occurs most commonly
    in children between 8 months and 5
    years of age; can result in death from
    anemia and cardiovascular collapse
• c. Chronic manifestation is termed
    functional asplenia
           SICKLE CELL ANEMIA
3. Aplastic crisis: diminished red blood cell
    production
• a. May be triggered by a viral or other infection
• b. Profound anemia results due to rapid
    destruction of red blood cells combined with a
    decreased production

4. Hyperhemolytic crisis: increased rate of red
    blood cell destruction
• a. Characterized by anemia, jaundice, and
    reticulcytosis
• b. Rare complication that frequently suggests a
    coexisting abnormality such as glucose-6-
    phosphate dehydrogenase deficiency
          SICKLE CELL ANEMIA
5. Stroke: sudden and severe complication
    with no related illnesses
• a. Sickled cells block the major blood
    vessels in the brain
• b. Repeat strokes in 60% of children who
    have experienced previous one

6. Chest syndrome: clinically similiar to
    pneumonia
7. Overwhelming infection
• a. Streptococcus pneumonia
• b. Haemophilus influenzae type B
           SICKLE CELL ANEMIA
DIAGNOSTIC TEST
d.1. Sickle cell test
d.2. Sickledex
d.3. Hgb electrophoresis

NURSING INTERVENTIONS
1. Hydration & oxygenation
2. Avoid tight clothing
3. Bed rest
4. Correct metabolic acidosis
5. Decrease emotional stress
             SICKLE CELL ANEMIA
Therapeutic interventions
• 1. Prevention of sickling phenomenon
    –   a. Adequate oxygenation
    –   b. Adequate hydration
    –   c. Administration of hydroxyurea to limit
        sickling
•   2. Treatment of crisis
    –   a. Rest
    –   b. Hydration/electrolyte replacement
    –   c. Pain management
    –   d. Antibiotic therapy
    –   e. Blood products
        SICKLE CELL ANEMIA
Assessment
• 1. Vital signs
• 2. Neurologic signs
• 3. Vision/hearing
• 4. Location and intensity of pain
                   CELL ANEMIA
         SICKLE Diagnoses
. Analysis/Nursing
• 1.   Body image disturbance related to:
   –   a. Retarded growth and maturation
   –   b. Limited activity tolerance
   –   c. Chronic illness

• 2. Fear related to:
   – a. Unfamiliar environment
   – b. Separation from support system

• 3. Pain related to tissue ischemia

• 4. Altered tissue perfusion (cardiovascular)
  related to decreased oxygen tension
         SICKLE CELL ANEMIA
Planning/Implementation
• 1. Prevent crisis
  – a. Avoid infection, dehydration, and other
    conditions causing strain on body, which
    precipitates a crisis; prophylactic use of
    pneumococcal, meningococcal, and
    Haemophilus flu vaccines
  – b. Avoid hypoxia: treat respiratory tract
    infections immediately
  – c. Avoid dehydration
     • (1) May cause a rapid thrombus formation
     • (2) Daily fluid intake should be calculated according
       to body weight (130 to 200 ml per kilogram [2 to 3
       oz per pound])
     • (3) During crisis, fluid needs to be increased,
       especially if the child is febrile
       SICKLE CELL ANEMIA
• 2. During crisis provide for:
  – a. Adequate hydration (may need IV
    therapy)
  – b. Proper positioning, careful handling
  – c. Exercise as tolerated (immobility
    promotes thrombus formation and
    respiratory problems)
  – d. Adequate ventilation
  – e. Control of pain; use narcotics;
    schedule to prevent pain
  – f. Blood transfusions for severe anemia
       SICKLE CELL ANEMIA
• 3. Provide for genetic counseling
  – a. Disorder mostly of blacks; can be
    found in Mediterranean people
  – b. Parents need to know the risk of
    having other children with trait or
    disease
  – c. If both parents are carriers, each
    pregnancy has 25% chance of
    producing a child with the disease
  – d. Screen young children for the
    disorder, since clinical manifestations
    usually do not appear before 6 months
    of age
       SICKLE CELL ANEMIA
. Evaluation/Outcomes
• 1. Child reports minimal pain
• 2. Child verbalizes feelings about
  disease process
• 3. Child demonstrates positive body
  image
• 4. Child does not exhibit signs of
  sickling
                   HEMOPHILIA
•   TYPES
    –         b.1. Hemophilia A: Factor VIII
    –         b.2. Hemophilia B: Christmas
        disease/factor IX deficiency
    –         b.3. Hemophilia C: Factor XI deficiency
    –   ASSESSMENT FINDINGS
    –         1. Prolonged bleeding after minor
        injury
    –         2. Bruising, hematomas, no petechiae
    –         3. Hemarthrosis
    –         4. Peripheral neuropathies
    –         5. Prolonged PTT, anemia
    –
            HEMOPHILIA
NURSING INTERVENTIONS
1. Control acute bleeding episode ( I-C-E
   )
2. Provide care for hemarthrosis
3. Administer cryoprecipitate
4. Provide client teaching: prevention of
   trauma & genetic counselling
Dengue Hemorrhagic Fever
/Dengue Shock Syndrome
• Caused by Dengue Virus (I,II,III,IV)
• Vector: Aedes Aegyptii
• MOT: Mosquito bite
• Signs/ Symptoms:
  – Petichial rash
  – Epistaxis
  – Hematemesis
  – Melena
  – DHN
Disorder of the
 Respiratory
    System
                  CYSTIC FIBROSIS
GENERAL INFORMATION
1. Dysfunction of the exocrine glands ( respiratory, GIT,
    sweat, salivary, pancreas )
2. Autosomal recessive inheritance
3. Affected organs: ( 1 ) PANCREAS, ( 2 ) RESPIRATORY,
    ( 3 ) REPRODUCTIVE, ( 4 ) LIVER
4. Fatal disease: average age at death is 20 years
MEDICAL MANAGEMENT
1. Pancreatic involvement: promote absorption of nutrients
    1.a. Diet modification: predigested formula, high
    calorie/low fat, high protein
    1.b. Pancreatic enzyme supplementation
2. Respiratory involvement: chest physiotherapy, antibiotic
             CYSTIC FIBROSIS
ASSESSMENT FINDINGS
1. PANCREATIC INVOLVEMENT
( 1 ) FTT, steatorrhea, meconium ileus,
    rectal prolapse, voracious appetite,
    protruding abdomen, vit ADEK
    deficiencies, anemia
( 2 ) Diagnostic test: DECREASE TRYPSIN,
    FECAL FAT increase
2. RESPIRATORY INVOLVEMENT
( 1 ) S/SX of respiratory distress, barrel
    chest, productive cough, pseudomonas
    infection,                    clubbing of
    digits
           CYSTIC FIBROSIS
3. ELECTROLYTE INVOLVEMENT
• ( 1 ) HYPONATREMIA, Salty taste of
   sweat
• ( 2 ) PILOCARPINE IONTOPHORESIS
   SWEAT TEST = 2-5 x normal amount
NURSING INTERVENTIONS
1. PANCREATIC INVOLVEMENT
   1.1. Pancreatic enzymes with meals
   1.2. Provide highcalorie, high
   carbohydrate & protein, low fat
             CYSTIC FIBROSIS
2. RESPIRATORY INVOLVEMENT
2.1. Administer antibiotics
2.2. Administer expectorants, mucolytic
2.3. Avoid cough suppressants
2.4. Breathing exercises, postural drainage
   4 times/day
2.5. Provide aerosol treatments, mist tent
3. ELECTROLYTE IMBALANCE
3.1. High sodium intake
Disorder of the
     GIT
              CLEFT LIP AND PALATE
•   GENERAL INFORMATION
    –   Failure of merging between the medial
        nasal and maxillary processes at the
        fifth week of embryonic development, on
        one or both sides
•    MEDICAL MANAGEMENT
•     1. Speech therapist,
    dentist/orthodontist,
    audiologist,otolaryngologist, pediatrician
•     2. Surgical correction
•          2.1. CHEILOPLASTY( 2 months
    )
•          2.2. PALATOPLASTY ( 18
           CLEFT LIP AND PALATE
•   NURSING INTERVENTIONS
•    D.1 Pre-operative CHEILOPLASTY
•    1. Proper positioning in feeding
•    2. Burp frequently
•    3. Use a large-holed nipple
•    4. Use a rubber-tipped syringe
•    5. Gavage feeding
•    6. Finish feeding with water
•    7. Provide SFF
• D.2 Post-operative CHEILOPLASTY
•    1. Maintain patent aiway
•    2. Assess color, monitor amount of
  swallowing
•    3. DO NOT PLACE IN PRONE
  POSITION
•    4. Anticipating child‟s needs
•    5. Use elbow restraints
•    6. Keep suture line clean
•    7. Provide pain control relief
• D.3. Pre-operative
  PALATOPLASTY
•   1. Infant should be weaned to
  cup before surgery
• D.4. Post-operative
  PALATOPLASTY
•   1. POSITION ON SIDE
•   2. Have suction available
•   3. Prevent injury or trauma to
                     PYLORIC STENOSIS
•       GENERAL INFORMATION
    –     also known as infantile hypertrophic pyloric stenosis
          (IHPS), is the most common cause of intestinal
          obstruction in infancy. It occurs secondary to
          hypertrophy and hyperplasia of the muscular layers of
          the pylorus.
•       MEDICAL MANAGEMENT
•        b.1. Noninvasive: thickened feedings
•        b.2. Surgery: Pyloroplasty

•       ASSESSMENT FINDINGS
        1. Olive-size bulge under right rib cage
        2. FTT
        3. Projectile vomiting
        4. Dehydration
•       5. DIAGNOSTIC TEST: UGIS, Serum electrolytes,
        Hematocrit
                PYLORIC STENOSIS
•   NURSING INTERVENTIONS
•     D.1. PRE-OPERATIVE
•     1. Administer replacement fluids
•     2. Prevent vomiting ( give thickened feeding,
    high fowler‟s position, place on right side after
    feeding )
•     3. Prevent aspiration
•     D.2. POST-OPERATIVE
•     1. Advance DAT
•     2. Place on right side after feeding
•     3. Monitor I & O, signs of infection
              INTUSSUSCEPTION
GENERAL INFORMATION
  – a segment of intestine invaginates into
    the adjoining intestinal lumen, causing a
    bowel obstruction.
• A. Telescoping of one portion of the
  intestine into another; occurs most
  frequently at the ileocecal valve
• B. Males affected two times more
  frequently than females
• C. Usually occurs between 3 to 12 months
  of age
            INTUSSUSCEPTION

Classification
• 1. Ileocecal: invagination at the
  ileocecal valve; most common type
• 2. Ileoileal: one part of ileum
  invaginates on another section of the
  ileum
• 3. Colocolic: one part of the colon
  invaginates on another section of the
  colon
Clinical findings
• 1. Healthy, well-nourished infant or
  child who wakes up with severe
  paroxysmal abdominal pain,
  evidenced by kicking and drawing
  legs up to the abdomen
• 2. One or two normal stools, then
  bloody mucus stool ("currant jelly-
  like“ stool)
• 3. Palpation of sausage-shaped mass
• 4. Other signs of intestinal
  obstruction usually present
   MEDICAL MANAGEMENT


• 1. Barium enema to reduce
  telescoping
• 2. Surgery ( if with Peritonitis )
  – Medical reduction by hydrostatic
    pressure (barium enema)
  – Surgical reduction; sometimes with
    intestinal resection
   Children with Intussusception



Assessment
• 1. Sudden, acute, intermittent
  abdominal pain
• 2. Vomiting
• 3. Red "currant jelly-like" stools
• 4. Tender, distended abdomen
           INTUSSUSCEPTION
Planning/Implementation
• 1. Same as for any abdominal
  surgery
• 2. Make provisions for frequent
  parental visits because the problem
  usually occurs when the child is 6 to
  8 months of age and separation
  anxiety is acute
Evaluation/Outcomes
• 1. Child does not show physiologic
  manifestation of pain
• 2. Family can verbalize feelings
  about the illness
• 3. Child consumes sufficient
  nutrients for growth
• 4. Child does not exhibit signs of
  dehydration
Analysis/Nursing Diagnoses
• 1. Pain related to invaginating bowel
• 2. Altered family processes related to
  having a child with life-threatening illness
• 3. Altered nutrition: less than body
  requirements related to:
  – a. Decreased intake
  – b. Increased peristalsis
• 4. Risk for fluid volume deficit related to:
  – a. Vomiting
  – b. Diarrhea
                CELIAC DISEASE
    –   Absorptive disorder of the GI tract
•   MEDICAL MANAGEMENT
•     1. Diet therapy: BROW free/gluten-
    free
•     2. TPN
•   ASSESSMENT FINDINGS
•     1 Steatorrhea
•     2. Chronic diarrhea
•     3. FTT
•
             CELIAC DISEASE
•   4. Distended abdomen, muscle wasting
•     5. Abdominal pain, listlessness
•     6. Vit A,D,E,K deficiency
•     7. Diagnostic test: ( 1 ) PANCREATIC
    ENZYMES & SWEAT CHLORIDE
•                     TEST ( 2 ) Jejunal &
    duodenal biopsy: ATROPHY OF MUCOSA
•   NURSING INTERVENTIONS
•     1. Monitor gluten-free diet
•     2. Provide fat-soluble vitamins
     Hirschsprung Disease
• Absence of aganglionic nerve in the
  portion of the colon
• Characteristic sign:
  – Ribbon-like stool
  – Symptoms, same as pyloric stenosis
• Management:
  – Resection of the colon
  – Colostomy
Disorder of the
Renal System
     NEPHROSIS/NEPHROTIC SYNDROME
•   PATHOPHYSIOLOGY
•    1. PROTEINURIA
•    2. HYPOALBUMINEMIA
•    3. EDEMA
•    4. HYPERLIPIDEMIA
•   MEDICAL MANAGEMENT
•    1. DRUG THERAPY: Steroids,
    antibiotics, diuretics, Antimetabolites (
    Cytoxan )
•    2. Bed rest
•    3. Diet: HIGH PROTEIN, LOW
    SODIUM
     NEPHROSIS/NEPHROTIC SYNDROME
•   ASSESSMENT FINDINGS
•     1. Anorexia, vomiting, diarrhea, malnutrition
•     2. Pallor, lethargy
•     3. Hepatomegaly
•   NURSING INTERVENTIONS
•     1. Bed rest             4. I & O and weight
    monitoring
•     2. Diet                 5. Protect from
    known sources of infection
•     3. Maintain skin integrity          6.
    Provide scrotal support
•
Pediatric
Oncology
                    LEUKEMIA
•   GENERAL INFORMATION
•   TYPES
•     b.1. ACUTE LYMPHOCYTIC LEUKEMIA (
    ALL )
•     b.2. ACUTE NONLYMPHOCYTIC
    LEUKEMIA ( ANLL )
•   MEDICAL MANAGEMENT
•     1. Diagnosis: blood studies, bone marrow
    biopsy
•     2. Treatment stages
•           a. Induction: intense & potentially life
    threatening
•           b. CNS prophylaxis
•           c. Maintenance: 2 to 3 years
                   LEUKEMIA
•   ASSESSMENT FINDINGS
•     1. BLOOD: ANEMIA, BLEEDING,
    INFECTION
•     2. Enlarged lymph nodes
•     3. Enlarged spleen & liver
•     4. Abdominal pain with weight loss &
    anorexia
•     5. Bone pain
•   NURSING INTERVENTIONS
•     1. Provide care for client receiving
    chemotherapy, radiation therapy
•     2. Support for family & child
          WILM’S TUMOR/NEPHROBLASTOMA
•       GENERAL INFORMATION
    –     is the most common type of kidney cancer in children.
          About 90% of kidney cancers in children are Wilms
          tumors.

•       MEDICAL MANAGEMENT
•         1. Nephrectomy( 24-48 hours of diagnosis )
•         2. Radiation therapy
•         3. Chemotherapy: Vincristine, Daunorubicin,
        Doxorubicin
•       ASSESSMENT FINDINGS
•         1. Mother notices MASS while bathing or dressing
        child; nontender, midline near
•                 liver
•         2. Hypertension, hematuria, anemia
•         3. Diagnostic test: IVP
    WILM’S TUMOR/NEPHROBLASTOMA
• NURSING INTERVENTIONS
•   1. DO NOT PALPATE ABDOMEN
•   2. Handle carefully when bathing
•   3. Provide care for a client post
  nephrectomy
•   4. Provide care for a client
  receiving chemotherapy, radiation
  therapy
                   HODGKIN’S LYMPHOMA
•       GENERAL INFORMATION
    – is a cancer that starts in lymphatic tissue. Lymphatic
      tissue includes the lymph nodes and related organs
      that are part of the body's immune and blood-forming
      systems.
    MEDICAL MANAGEMENT
•         1. DIAGNOSIS: Lymphangiogram, biopsy( REED-
        STERNBERG CELLS ),
•                                splenectomy
•         2. RADIATION THERAPY, CHEMOTHERAPY
•       ASSESSMENT FINDINGS
•         1. Enlarged nodes in lower cervical region; nodes are
        NONTENDER, PAINLESS,
•                FIRM & MOVABLE
•         2. Recurrent, intermittent fever
•
         HODGKIN’S LYMPHOMA
•   3. Night sweats
•     4. Weight loss, malaise, lethargy
•     5. Pruritus
•   NURSING INTERVENTIONS
•     1. Provide care for child on
    chemotherapy, radiation therapy
•     2. Protect from infection if
    splenectomy is performed
•     3. Provide support for child/adolescent
    parents
POISONING
             Poisoning
• A. Ingestion of a toxic substance or
  an excessive amount of a substance
• B. More than 90% of poisonings
  occur in the home
• C. Highest incidence occurs in
  children under 4
• D. Improper storage is the major
  contributing factor to poisonings
             Poisoning
A. Assessment
• 1. Vital signs
• 2. Need for respiratory or cardiac
  support
• 3. Treat other symptoms such as
  seizures
• 4. See Clinical Findings under type of
  poisoning
                     Poisoning
Analysis/Nursing Diagnoses
• 1. Altered family processes related to sudden
  hospitalization and
       emergency aspects of illness

• 2. Fear related to sudden hospitalization and treatment
  (multiple
       injections for lead poisoning)

• 3. Risk for injury related to sources of toxic substances in
  the
       environment

• 4. Risk for injury related to presence of toxic substance in
  the body

• 5. Risk for poisoning related to immature judgment of child
                Poisoning
C. Planning/Implementation
• 1. Terminate the exposure
  – a. Empty the mouth of pills, plant parts, or
    other material
  – b. Thoroughly flush eyes with tap water if they
    were involved
  – c. Flush skin and wash with soap and soft cloth
  – d. Remove clothing, especially if pesticide,
    acid, alkali, or hydrocarbon involved
  – e. Bring the victim into fresh air if an
    inhalation poisoning
  – f. Give water to dilute ingested
              Poisoning
• 2. Identify that a poisoning has
  occurred
  – a. Call the local poison control center,
    emergency facility, or physician for
    immediate advice regarding treatment
  – b. Save all evidence of poison
    (container, vomitus, urine, etc.)
  – c. Be alert to signs and symptoms of
    potential poisoning in absence of other
    evidence
              Poisoning
• 3. Do not induce vomiting
  – a. If the person is comatose, in severe
    shock, or convulsing or has lost the gag
    reflex; these conditions can increase the
    risk of aspiration
  – b. If the poison is a low-viscosity
    hydrocarbon; once aspirated,it can
    cause a severe chemical pneumonitis
  – c. If the poison is a strong corrosive
    (acid or alkali), emesis of the corrosive
    redamages the mucosa of the
    esophagus and pharynx
                Poisoning
• 4. Remove the poison
  – a. Dilute with water
  – b. Induce vomiting except as contraindicated
    by administering ipecac syrup (for 6- to 12-
    month-olds give 10 ml of ipecac syrup with 8
    to 12 oz of water, for 1- to 2-year-olds give 15
    ml of ipecac syrup with 8 to 16 ounces of
    water; over 12 years of age give 30 ml of
    ipecac syrup with 16 ounces of water); if
    vomiting does not occur repeat once in 20
    minutes for those over 12 months of age; for
    those under 12 months of age ipecac is not
    repeated
            Poisoning
– c. Administer activated charcoal 1 g per
  kg 30 to 60 minutes after inducing
  vomiting
– d. Prepare appropriate equipment for
  potential medical use, such as gastric
  lavage
5. Whether vomiting is spontaneous or
  induced, prevent aspiration
– a. Keep the child's head lower than the
  chest
– b. When alert, place the head between
  the legs
                 Poisoning
• 6. Observe for latent symptoms and
  complications of poisoning
  – a. Monitor vital signs
  – b. Treat as appropriate (e.g., institute seizure
    precautions, keep warm and position correctly
    in case of shock, reduce temperature if
    hyperpyretic)


• 7. Support the child and parent
  – a. Keep calm and quiet
  – b. Do not admonish or accuse the child or
    parent of wrongdoing
                   Poisoning
• 8. Teach prevention of poisoning
  – a. Assess possible contributing factors in the occurrence
    of an accident, such as discipline, parent-child
    relationship, developmental ability, environmental
    factors, and behavior problems

  – b. Institute anticipatory guidance for possible future
    accidents based on the child's age and maturational
    level

  – c. Refer to a visiting nurse agency for evaluation of the
    home environment and the need for safety measures

  – d. Provide assistance with environmental manipulation
    when necessary
                 Poisoning
– e. Educate the parents regarding safe storage of all
  substances

– f. Teach children the hazards of ingesting nonfood items
  without supervision

– g. Caution against keeping large amounts of drugs on
  hand, especially children's varieties

– h. Discourage transferring drugs to containers without
  safety caps

– i. Discuss problems of discipline and children's
  noncompliance
                  Poisoning
. Evaluation/Outcomes
• 1. Child recognizes and does not ingest harmful substances

• 2. Child is treated without complications

• 3. Child receives medication with minimal distress

• 4. Toxin is eliminated from body

• 5. Child expresses feelings and concerns

• 6. Parents express confidence in care

• 7. Parents and child have knowledge concerning prevention
  of future poisoning
     Acetaminophen
       Poisoning
• A. One of the most common
  drugs taken by children
  –1. Toxic dose 150 mg/kg
   body weight
  –2. Therapeutic use of 150
   mg/kg/day for several days
   has resulted in toxicity
           Acetaminophen
             Poisoning
• Clinical findings - symptoms of overdose
  –   1. Profuse diaphoresis
  –   2. Nausea and vomiting
  –   3. Pallor
  –   4. Weakness
  –   5. Pain in right upper quadrant
  –   6. Slow, weak pulse
  –   7. Confusion
  –   8. Decreased urine output
  –   9. Jaundice
  –   10. Coagulation abnormality
  –   11. Coma
  –   12. Liver failure
      Acetaminophen
        Poisoning
• Therapeutic interventions
  –1. Induce vomiting with
   ipecac syrup, lavage
  –2. Administer IV fluid
  –3. Administer an antidote
   (acetylcysteine)
        Acetaminophen
          Poisoning
Specific Nursing Care of Children with
  Acetaminophen Poisoning
• A. Identify ingested substance and
  amount
• B. Monitor the electrocardiograph
• C. Measure intake and output
• D. Measure and record the vital signs
  frequently
• E. Obtain blood for hepatic and renal
  function tests
• F. Support the child and family
    Salicylate Toxicity and
            Poisoning
• Toxic dose: 300 to 500 mg
  per kilogram of body weight
  or 7 adult aspirins (28 baby
  aspirin) for a 9-kg (20-lb)
  child
    Salicylate Toxicity and
           Poisoning
• Clinical findings
  – 1. Mild salicylate toxicity (items i to k are of
    little value in small children)
     •   a. Diaphoresis
     •   b. Nausea
     •   c. Vomiting
     •   d. Dehydration
     •   e. Delirium
     •   f. Oliguria
     •   g. Hyperpnea
     •   h. Hyperpyrexia
     •   i. Ringing in the ears
     •   j. Dizziness
     •   k. Disturbances of hearing and vision
  Salicylate Toxicity and
         Poisoning
– 2. Salicylate poisoning
  • a. Hyperventilation: confusion, coma
  • b. Metabolic acidosis: anorexia, sweating,
    increased temperature
  • c. Bleeding, especially if chronic ingestion
• C. Therapeutic interventions
  –1. Induce vomiting, gastric
   lavage, activated charcoal,
   saline cathartics
  –2. IV fluids
  –3. Vitamin K if bleeding
  –4. Peritoneal dialysis in
   severe cases
           Lead Poisoning
            (Plumbism)
Data Base
• A. A prevalent, significant, preventable health
  problem that causes neurologic and intellectual
  damage from even low levels of lead

• B. Blood lead concentration should be less than
  10 mg per 100 ml of blood

• C. Associated with increased levels of lead in the
  environment and pica
   – 1. Most common source is lead-based paint
   – 2. Soil, dust, or drinking water with lead
   – 3. Parental occupations, hobbies
          Lead Poisoning
           (Plumbism)
• D. Clinical findings (chronic ingestion)
  – 1. Loss of weight, anorexia
  – 2. Abdominal pain, vomiting
  – 3. Constipation
  – 4. Anemia, pallor, listlessness, fatigue
  – 5. Lead line on teeth and long bones
  – 6. Protein in urine as a result of proximal
    tubular damage
  – 7. Behavioral changes (impulsiveness,
    irritability, hyperactivity, or lethargy)
  – 8. Headache, insomnia, joint pains
  – 9. Brain damage, convulsions, death
• E. Therapeutic interventions
   – 1. Objective: reduce concentration of lead in the blood
     and soft tissue by promoting its excretion and deposition
     in bones
       • a. Calcium disodium edetate (Calcium Disodium
         Versenate, calcium EDTA)
           – (1) Urine lead content monitored; peak excretion
             in 24 to 48 hours
           – (2) Adverse effects: acute tubular necrosis,
             malaise, fatigue, numbness of extremities, GI
             disturbances, fever, pain in muscles and joints
       • b. Dimercaprol (BAL)
           – (1) Generally used in conjunction with calcium
             disodium edetate
           – (2) Adverse effects: local pain at the site of
             injection; may cause persistent fever in children
             receiving therapy; rise in blood pressure
             accompanied by tachycardia after injection
  • c. d-penicillamine
     – (1) Oral chelating agent
     – (2) Increases urinary excretion, but less effective
       than calcium EDTA
     – (3) Adverse effects: transient decrease in white
       blood cells and platelets; rash; enuresis;
       abdominal pain
– 2. Prevention of further ingestion
Specific Nursing Care of Children with Lead Poisoning
• A. Determine environmental exposure

• B. Screen children at risk by recognizing clinical findings,
  especially behavior changes

• C. Plan preparation of the child and rotation of injection
  sites if therapeutic intervention includes IM chelating
  agents; warm moist applications may relieve discomfort of
  injections

• D. Observe child carefully and closely

• E. Plan discharge and follow-up care of the child

• F. Prevent future lead poisoning by parental and child
  education, appropriate environment, and supervision of
  child and siblings

				
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