Immunity
7 General Rules: (1) immune response better to
similar vaccine ex:live virus- Varicella (2)
inactivated- no affect to immune response/ live-
affected by antibody, ↓ immune response “vaccine
failure” (3) no contraindication to simultaneous
vaccine admin (4) live- long lasting, single dose/
inactivated- multiple dose, periodic boost (5) ↑
interval b/t dose no interference; ↓ interval interfere & antitoxin Vacc: DTaP
w/ antibody response (6) live- similar to natural dz/
inactivated- local, with or w/o fever (7)
contraindication- severe rx or encephalopathy w/i 7
day pertussis / precaution- chance
4 Temp. Contra/ Precautions (maybe later):
immunosuppressive, pregnancy, recent receipt of
antibody = NO live, T>100.5
Birth → Hep B
2,4,6 mos → DTaP, IPV, PCV, HIB, Rota Teq
15&18 mos → DTaP, IPV, PCV, HIB
12 mos & 4 yrs → MMR, Varicella
>2 yrs → Hep A, Meningitis (MPSV 4) (if
indicated)
Documentation: date, name, manufact., dose, lot #,
exp. date, site, signature/title / on pt chart / in
immunization network system/ for parent record
Teach: side/ adverse effects, Tylenol q4-6h for 24 hrs, w/swallow/ Tx: resp.support, rest, orchitis w/ warmth
cold compress for 1st 24hrs, then warm, call clinic,
ER / when to return, next appt
Passive Immunity→ other person/animal, immune
globulin (LIVE - Varicella), mother to baby, ↓ with
time
Prenatal Complications
Hep B: affect liver, Risk→school age, blood-sex, Tx →
birth Vacc: HB
Hep A: liver, risk→5-14, fecal-oral-sex, Vacc: >2 Hep
A
Diphtheria: resemble cold, wht on tonsil, risk→septic,
death 7-10 days, Tx: peni, antitoxin Vacc: DTaP
Tetanus:(Lockjaw), affect CNS, stiff neck/jaw, Tx: TIG
Pertussis:(Whoop), URI, night cough, risk→pneum,
hemorr., death, contact/ droplet Tx: O2, fluid, intubate,
rest Vacc: DTaP
Rotavirus: gastroenteritis Tx: rehydrate, Vacc:Rotateq
Haemophilus Influenza (HIB): OM, epiglottitis,
meningitis Tx: antibio. Vacc: HIB
Strep: Pneu, OM, Bacterial Mening., bacteremia,
sinusitis, risk → <2yrs Tx: Peni & support Vacc:
Scarlet Fever: naso secrete, airborne/direct, ↑T, wht
tonsil-slough=stwberry tongue, rash, blanches (Pastia
sign) Tx: antibiotic NO VACCINE
Poliomyelitis: present throat & feces, mild-pain/stiff Tx:
assisted resp. vent. Vacc: VAPP
Influenza: pneum. Tx: treat/support Vacc: @risk, EGG
allergies/ nasal=live
Rubeola (Measles): resp., blood, urine/ direct, body
fluids/ fever, 3C’s→coryza, cough, conjunctivitis Vacc:
MMR (live)
Meningitis: invasive, risk→<5&college, droplets, fatal,
neuro deficit, hearing, limb loss, Tx: Antimicrob
Vacc:MPSV
Rubella(German): transplacental: birth
defects/abortions
Mumps: saliva, urine/ direct, droplet/ earache
Vacc: MMR, LIVE
Roseola Infantum: irritable, pink macules, <2, NO
Vacc
Erythema Infectiosum(5th): slapped check, reappear
w/ sun, avoid pregos, NO VACCINE
Varicella Zoster(Chkpox, Shingle): direct, airborne,
objects/ rash→trunk, scalp, extreme/ vesicle then crust
Tx: isolate Vacc:Varicella (still transmit w/ no spots)
LIVE
Active Immunity→ own body, natural infection,
vaccine, long-lasting
Abortion (miscarriage) → <20wks → spontaneous/induced
Etiology: 50-60% genetic, low progesterone, DM or endocrine d/o, infection (syphilis, rubella), uterine
abnormal (fibroids, incomplete cervix)
1. Threatened - vag. bleed, cervix closed, part/complete expulsion
Tx: u/s, HCG, peripad count, foul odor?, no limits
2. Inevitable- cannot be stopped, cervix dilates, may ROM
Tx: natural expulsion, retained D&C
3. Complete- all products expelled
Tx: BED rest, no sex
4. Incomplete- not all expel (in vagina), active bleed w/ cramp, cervix is open
Tx: CV stabilize, stop bleed → T&CM, IV, D&C
5. Missed- fetus die in utero not expel, brownish d/c, cervix closed, >6wks retain = DIC
Tx: u/s, D&C, PGE → induce ctx/ Comps: Infection, DIC
6. Recurrent/Habitual- >3 abortions Tx: cerclage
Dx: U/S, HCG ↓, bleeding (excessive)
Tx: assess bleed, VS, approp activity level, support→ rest, iron supple, no sex, RhoGam

DIC→ bleeding (seem w/missed) Tx: delivery, admin blood

Ectopic Pregnancy- 12wks evident, non-wht >35

Hx: PID, scar, IUD, tubal ligation, induce abort
S&S: ↓ HCG, PAIN, refer shoulder pain, tender abd.
Tx: stop bleed, blood prod., antibiotic, RhoGam, Methotrexate, laparoscopy; W/ Ectopic Rupture→ severe pain,
Hypovolemic shock
Labs: ↓ HCG, ↓RBC, ↑ WBC, ↓ HGB
Care: NPO until BS, ambulate, VS, still fertile w/ one tube, ↑ risk recurrence

Hydatidiform Mole- abn. growth, placenta NOT fetus develop, convert to cluster of cysts, Higher incidence
Asia & tropical
(1) Complete-“empty egg” (no genetic material), embryo die early, 20% progress to Malignant GTD
(2) Partial- triploid, fetal sac or w/ heartbeat, little change survive, 5% malignant.
S&S: excessive N/V = ↑ HCG, enlarge uterus, vag. bleed, early Preeclampsia, ↑ thyroid, no fetal move/HR,
snowy pattern on u/s, 1-2 million HCG titer (400,000)
Tx: most abort spont, suction curettage, occas hysterectomy, RhoGam, *frequent HCG q1-2wks for 1 yr= risk
for CA, CXR=metastasis, no prego 1 yr, cure >5 yr absence of malignant

Placenta Previa- placenta in lower uterus

(1) Marginal- “low lying” >3cm from os (2) Partial- <3 cm (3) total- completely covers
Dx: U/S, NO Vaginal exam
S&S: painless, bright red bleed
Tx: Bedrest, Deliver→ C-Section
Care: assess bleed, no vag exam, FHR, IV LRS, blood→ T&CM

Abruptio Placentae- separation of placenta from uterus (1) Marginal- at edges (2) Partial- at center, blood is
trapped (concealed) (3) Complete- total w/ massive bleed
RF: short umb. cord, hx, abd trauma, htn, cocaine
S&S: vag. bleed, low-intensity ctx, no reassure FHT
Comp: shock, fetal hypoxia, DIC, couvelaire uterus= blue in color
Tx: CV status, IV, blood, Fetal monitor, abd. girth and fundal ht= concealed blood, delivery depend on
separation, NO VAG exam until previa r/o
Anemia- common in preg., ↑ iron d/t ↑ BV (esp. 2nd half), mom usually NOT fetus
Dx: Hg<10 / Hct <35
Class: Hereditary- sickle cell, thalassemia / Acquired- nutritional, blood loss
1. Iron Deficiency- 80% RF: ↓ iron, mal-absorption, blood loss
S&S: fatigue, ↑ HR, pallor, anorexia, irritable Tx: PO iron, Imferon inj. if no PO
Care: food= lean meat, drk. veg., egg, whole grain, legume, shellfish, MAX absorption if taken with
Vitamin C b/t meals
2. Megaloblastic (Folic Acid)- prevalent w/ twins, immature dysfunctional RBCs fail to divide and enlarge
(mega) and become fewer
Tx: PO folic acid Care: food= drk. veg., red meats, fish, poultry, legumes
**water and microwave destroy
Effect on Preg: PP infection, hemorrhage, tire easily, minimal blood loss not tolerated, delay wound heal, ↑CO
Fetus: ↓ Hg abort, stillbirth, SGA, preterm; hypoxic labor d/t impair uteroplacental O2, Neural tube
defects= cleft lip and palate

Hyperemesis Gravidarum- uncontrollable vomiting, ↑ blood/ ketones in urine, ↓ K, recovery slow and
frequent relapse
RF: Mole, ↑HcG & estrogen, Vit. B def., PUD d/t H. Pylori
S&S: vomiting, ↓ electrolytes (K, Na, Cl, H) / severe→ wt. loss, ↑ Hct&BUN, ↓ BP & ↑ HR, jaundice,
Wernicke’s encephalopathy / extreme→ death
Tx: NPO, IV- hydrate, Phenergan, Vit. B6, ginger, TPN, FHR, I&O, jaundice, AVOID narcotics
Effect Fetus: low birth wt., CNS & skeletal effects

UTI- bacteria (glucosuria growth)

RF: E. Coli, ↑ risk preterm, IUGR, sepsis
Tx: Antibiotic→ Nitrofurantoin (Macrodantin) & Ampicillen, Cephalosporin SAFE, early only→ Sulfonamide
Care: 8-12 glass H2O, cranberry, VOID frequent, vit. c, cotton panties; NO→ carb, sugar, alcohol, caffeine

Contraception & Fertility

Contraception- prevent pregnancy, BOTH partners accept

1. Sterilize- (1) Vasectomy- 1mth before all sperm gone (2) Tubal ligation- consider perm., no STD protect
2. Hormonal- (1) Norplant- rod, suppress ovulation, thicken mucus, easy reverse, long-last, WT <131#,
remove q5yr, removal difficult & costly (2) Depo-Provera- reversible, long-last, IM q3mth (3) Pill- suppress
ovulation (LH&FSH), NO→ >35 & smoke, BF mom; same time qd (4) Morning After- take w/i 12-24hr
unprotect sex, N&V, follow-up care (%) IUD- prevent implantation, safe > 35, easy, reversible, ectopic
pregnancy, **check placement of string
3. Barrier Method- (1) Spermicide- kill sperm, irritation, wait 8hr before douche (2) Condom- barrier,
inexpensive, accessible, latex allergy, heat detroy, better w/ spermicide (3) Diaphragm- cover cervix
entrance, use w/ cream or jelly, resize w/ 10-15# wt. gain/loss or after birth, leave in place 6-8 hr after
4. Withdrawal- 80% effective, fluid can escape, no protection

Infertility- not conceive >1 year (1) Primary- never (2) Secondary- formerly prego no more
→ Male- avoid hot baths, sauna Care: Listen, support, referrals

CV/Hem Pt. II
Infective Endocarditis- inflamed cardiac valves and Endocardium, common in child w. CHD, bacteria (strep&
staph) most caustic
S&S: begin flu-like, chest pain, “Janeway lesions”, neuro impaired, new or changing murmur, petechiae
Tests: + blood culture, ↑ sed. rate, c-r protein / Echo- vegetation
Tx: prevent: oral hygiene, Amoxicillin or Clindamycin / PROMPTLY→ IV antibiotic. 4-8wks, excise veg. or
replace valve
Care: Neuro/Cardio assess., ↓T, murmur change to MD, stay out of school

Rheumatic Fever- inflamed joint, SQ, connective tissue, blood vessels, heart (Comp→ RHD- mitral and aortic
valve damage) d/t B-Hemolytic Strep, 5-15 yrs susceptible
Tests: ↑ASO titer & + Strep
S&S: Arthritis, Carditis (most serious), Chorea (thrashing), Erythema marginatum (under nipple), SQ nodule w/
severe carditis on hand
Tx: YEARS→ PO or IM Penicillin/ Erythromycin, Aspirin/corticos. PROPHLAXIS→ recurrence, w/out
cardiac = 5 yrs, RHD = 10 yrs
Care: drug compliance, CPR teach

Kawasaki Dz- cause HD in children usually <5 yrs, Dec.-March, lymph node syndrome, systemic vasculitis
Comp: CAD→ coronary aneurism, MI= abd. pain, inconsolable cry, shock, restless
S&S: 3 Stages: Acute(10-14 days), Subacute (day 15-25), Convalescent (day 26 - normal sed. rate) / T>103
→Fever of 5 days with 4 of 5: (1) non-purulent conjunctivitis (red sclera) (2) stwbry tongue (3) red/peel palms
and soles (4) polymorphous rash (5) enlarge lymph nodes
** Prolonged T unresponsive to antibiotics work up Dz **
Tx: High dose IV immune globulin, salicylates= prevent stroke, Coumadin= heart, cortico= inflame
Care: defer LIVE vacc., teach CPR

Sickle-Cell Dz- inherited autosomal recessive dz, lifelong, produce sickle Hg/ chronic anemia/ ischemic tissue
= ↓O2 from RBC shape
RBCs→ deoxygen & dehydration stretch to sickle shape, cause vascular occlusion, pain, and organ infarction,
hemolize in spleen and cause pooling and infarction → enlarge, remove, Bactrim
S&S: result from obstruction→ anemia & pallor=↓ Sats., jaundice, fatigue= ↓O2, cholelithiasis= gallstones,
delay G&D, avascular necrosis hips and shoulders= no O2 to bone, retinopathy= blindness, PAIN
3 Forms: (1) Vaso occlusive- occlude blood vessels= lungs, heart, urine, joint (2) acute sequestrian- pooling of
blood in spleen= abd. pain (3) Aplastic- severely depressed RBCs= anemia
Tx: test at birth, HYDRATION, splenectomy w/ Penicillin until 5 yrs, Morphine/NSAIDS= pain, Vaccines=stay
healthy as possible

Hemophilia- deficiency of clotting factor, excessive bleeding (1) Factor VIII- cause A (2) Factor IX- cause B
(3) Factor XI- cause C→ less severe than A&B = Treat what they are missing**
→lifelong, no cure, x-link autosomal recessive= mom to son
S&S: prolonged bleeding, hemorrhage, bruising, epistaxis, hematuria= kidney damage, hemarthrosis
Tx: prevent excess bleed= give missing Factor, self administer thru CV access port, NO ASA
Prophylaxis→ Mild Hem A- Desmopressin (DDAVP) = stop bleed (vasoconstrict) / A&B- Aminocaproic
(Amicar) or Tranexamic Acid (Cyclokapron) = stabilize clots and nosebleeds
Care: avoid excessive activities, protect joints, NO ASA, treat bleed: RICE
PP Complications

Hemorrhage- Early= 1st 24 hr / Late= >24 hr, saturate > 1peripad per hr., steady trickle or slow seep
1. Early→ Dx: Uterine atony (lack muscle tone to contract when placenta separates)
S&S: difficult to find fundus, boggy uterus, excessive lochia or lrg. clots
Tx: massage fundus, assist to urinate/ catheter, rapid IV Pitocin, IV Methergine, IM Hemabate to control
atony, Cytotec- control bleed, LRS and blood
2. Late→ Dx: subinvolution, placenta fragments, infection
Tx: Control bleed w/ Oxytocin, Methergine, PGE, dilation and curettage, antibiotics

Laceration- firm fundus w/ bleed

Hematoma- visible mass, firm fundus, ok lochia, ↓BP/ ↑P, unrelieved pain and pressure

Puerperal Infection- bacteria after childbirth, potentiate by endometrial lining & lochia→ granulocytes usually
protect but acidity is ↓ by amniotic fluid, blood, and lochia
S&S: T>100.4 for 2 days of 10

Endometritis- normal inhabitants→ spread to fallopian tubes. & ovaries could sterilize/ abscess
S&S: fever, chills, malaise, anorexia, abd. pain & cramp, foul-smell lochia
Tx: PO antibiotics after IV, Fowler’s= promote drainage, VS q2h w/ fever → q4h after

Wound Infection- break in skin/mucous

S&S: edema, warmth, redness, tender & pain, drain, fever
Tx: I&D, antibiotics, warm compress, debride

UTI- bladder traumatized after delivery, catheter, E. Coli

S&S: dysuria, urgency, frequency, low-grade fever, N&V
Tx: antibiotic, ↑ fluids, perineal care

Mastitis- usually d/t Staph aureus

S&S: flu-like, fatigue, achy, chills, wedge shape area that is red, hot, edematous, painful
Tx: antibiotics, continue BF and emptying, heat/ ice packs, breast support

Common Peds Problems

 skin surface area to body volume > in infants and sml. children = greater absorption
 Endocrine sweat glands mature 2-3 yrs olds
 IgA mature 2-5 yrs = NB less resistant to organisms

Bacteria Infection - highly contagious, react to gram stain, able to grow in O2

1. Strep (Impetigo)- circular, oozy w/ crusting
2. Staph (Impetigo)- no defined edge, can mix w/ Strep
3. Richettsial- parasitic anthropod - tick Rocky Mtn Spotted Fever
4. Borrelia- arthropod - tick Lyme Disease
5. Cellulitis- infect SQ tissue, usually d/t Impetigo
Tx: culture, topical & PO antibiotic, elevate, warm compress

Parasitic Infection (Skin & Scalp)

1. Lice- capitis (hair), pubis, & coporis (body), transparent after death
Tx: prevent reinfestation, Medicated shampoo→ Lindane (neurotoxic) & Nix, smother lice, R&C→environ
2. Scabies- mite, need human skin to live, burrow in epidermis, lay egg, then die 4-5 wks, egg hatch 3-5 days,
locate in wrist, webbing, elbows, groin, buttocks
S&S: track marks, itching, inflammation, papule, vesicle, nodule Comp: Impetigo
Tx: Elimite (permethrine cream)

Fungal Infection (Skin & Mouth)- moist environment, yellowish

1. Candidiasis- cutaneous (diaper dermatitis), oral (thrush)
Tx: PO or topical Mycostatin, keep clean & dry, prevent Impetigo
2. Tinea (Ringworm) - capitis (alopecia), corporis (body), cruris (jock itch), pedis (athlete’s foot)
S&S: round lesion, rough center ** head & skin contagious / cruris & pedis NOT
RF: obese, poor hygiene, friction Dx: woodlamp
Tx: capitis→ Selenium shampoo, PO Griseofulvin x 6wks= compliance issue, bad taste, liver problem, take
w/ fatty meal / corporis, pedis & cruris→ antifungal “Lotrimin”

Viral Infections
1. HSV 1- common cause viral encephalitis children d/t suck on pacifier w/ infection, clear body fluid transmit,
Herpes Labialis (lip)- fever blister / Oral- severe <5 / Ocular (eyelids and mucous membrane) / Whitlow
(hands)- severe pain on fingers, last for wks, thumb suck w/ Labialis can result
2. HSV 2- rare <14 yrs, suspect abuse
3. Molluscum Contagiosum- infect skin and mucus, upper chest, and abd., self-limiting (6-12mth)
S&S: clusters, thicker & tougher lesion “wart-like”

Inflammatory Dz
1. Atopic (eczema)- crusty, dry lesion, flaky; behind knee, elbow **precursor to asthma
2. Seorrheic (cradle cap)- must moisturize
3. Psoriasis- proliferate keratinocyte
4. Contact- irritant/ allergy Ex: belt buckle, dye, soap
5. Acne Vulgaris- block sebaceous and hair gland
Tx: clean, moisturize, corticosteroid

6. Erythema Multiform- acute/ recurring autoimmune, lesions erupt 2-3 wks by healing in 6 wks, severe form
trigger by meds (Tetra) and infection = Steven Johnson Syndrome
S&S: red forms (hive), burns/blisters, corneal ulcer or severe mucous membrane

Helminthes- worms that live as parasite in GI tract Tx: oral meds

Pinworms- hand to mouth, nocturnal anal itch
Roundworm- contaminate soil/ food, can cause abd. pain
Tapeworm- handle/ eat infect beef or pork, cause wt. loss
Hookworm- skin penetration from soil, lead to blood loss, malnutrition, anemia, dermatitis, pneumonitis (lung)
Insects- protein in saliva in skin cause itching, Erythema, allergic rx, lead to Impetigo
Tx: antihistamine, antipruritic, remove stinger by horizontal scrape
Brown Recluse & Black Widow- 2-8 hrs get pain, edema, Erythema followed by blister; venom necrotoxic,
take months to heal→ leave scar, no antivenin
Ticks- transmit Lyme dz., Rocky Mtn Fever, blood feed, remove in entirety
Scorpion- hide in gravel & sand box, fatal rx <3 yrs
Tx: ice pack, tourniquet proximal, do NOT excise wound or give Narcotics, antivenin
Chiggers- harvest mite, burrow hair follicle and skin pore, like warm areas

Child Abuse

1. Physical- skin, abd, chest, bone (50% mortality rate), unusual burn, delay in care, skeletal→ rib fx<5 rare,
transverse or oblique of long bone, bucket handle→ violent shake holding trunk, skull/head→ ↑morbid/mortal
a) Shaken Baby- <4-5 mths, fatal from hypoxia & cerebral edema, retinal hemorr (brain inj.), metaphysical fx
b) Munchasen by Proxy- difficult to dx, mom make sick to gain attention
2. Sexual- 5-15 yrs highest S&S: discomfort walking, torn/bloody clothes, discharge, urine pain, poor
sphincter control, STDs, unwilling to participate, depressed, destructive, eating d/o, nightmares
3. Passive/Neglect- 50% common, poison, overdose on med, ingest adult meds
a) FTT- (Organic→ no wt. gain d/t illness, CHD) (Non-organic→ PP blues, poverty, poor bonding) (Mixed→
physical cond. interfere with care; ex: cleft lip/palate, cardiac prob)
S&S: <5th percentile, delay G&D, ↓ muscle mass, abd. distention, weakness, cachexia (pot belly), avoidance
Tx: ↑ caloric intake to grow 2-3x average rate, multivitamin & minerals, tx illness
4. Emotional- follow other forms and result from ↓ self-esteem
→Reporting abuse- ALL suspect, document correct & specific
MUST report= stranger rape, physical assault

Pediatric AIDS - HIV

HIV- acquired, cell-mediated AIDS- advances manifestation of illness

Transmission: NB→ perinatally from mom; ZDV (Zidovudine) ↓ chance during pregnancy
Children→ < 5; abuse
Adolescent→ risky behavior, unprotect sex, hemophilia
Review: CD4 primary receptor for HIV, depletes and reduces # in immune response
S&S: NB→ untx develop aids by 1
Children→ FTT G&D, early infections (immunocompromised)
Dx: oral candidiasis, pneumocystitis carini pneumonia (PCP)
Labs: ELSIA, Western Blot→ measure antibodies to the virus, CD4 counts <200 mm^2 → indicate immune
response well-being
Tx AIDS: give ALL vaccines but LIVE, Antiretroviral therapy (ZVD)→preserve immune function, delay
disease process, PCP prophylaxis→ Bactrim 6mth-1 yr old; antibiotics
Neurological Dysfunction

Neuro Assessment
1. Head- size & shape; NB→ fontanels, scalp veins, sutures Child→ headache
2. LOC- earliest indicator of improve or deterioration in neuro status; GCS used
Eyes- most imp. indicator in older child
Motor- younger able to obey commands
3. Eyes- fixed & dilated pupil is an EMERGENCY; CNIII dysfunction (Doll’s eye maneuver- rotate head to
one side then other and eye movement should be opposite.
4. Motor- response to pain, reflexes

Increase Intracranial Pressure- a ↑ or ↓ in ICP should be accompanied by ↑ or ↓ in CSF= Monroe-Kellie

Hypothesis; children→ skull expansion & widen sutures, once max is reached ↑ in ICP results
S&S: LOC→ irritable, restless; Vitals→ ↑T, variable P, ↓ deep R, ↑ BP >> Cushing Triad- ↓P, ↓R, ↑BP late
sign; Eyes→ setting sun, dilated vessels; Motor→ poor feed, high cry; nausea/vomit esp AM, slur speech;
Posturing→ decorticate= cortex prob., arms flexed on chest, LE extended / decerebrate= midbrain prob.,
extended UE & LE can be evident w/ painful stimuli
Dx: Lumbar puncture→ chk fluid, protein, glucose; CT, MRI→ lesions; EEG→ damage to nervous trans; X-
ray→ bone fxs; CBC, ABG
Tx: VS q2min - q2h, ↑ HOB, Diuretics, O2, Antibiotics

Spinal Bifida- failure of fusion in vertebral column w/ varying amt tissue protruding; 1st 28 days gestation,
closing margins create neural tube, ↑ Folic acid help prevent
Dx: prenatal, feel “bony” prominence, hair tuft, X-ray, MRI
1. Spina Bifida Occulta- incomplete fusion of arch L5- S1
2. Meningocele- sac like protrusion which cover bony defect and contain meninges and CSF (no roots)
3. Meningomyelocele- nerve roots in the sac
S&S: minimal weakness to complete paralysis of legs, ↓ sensory in bowel and bladder; may develop
Hydrocephalus (80%) - Arnold Chiari
Tx: Surgery→ does not correct neuro damage; Pre-op→ prone, head down, feet clear/ DO not touch dressing
Care: ↑ Risk for Infection, alter skin integrity,

Hydrocephalus- imbalance of CSF formation & absorption, CSF absorbed back in venous circulation by
arachnoid villi; excessive CSF production, obstructed pathway, defective absorption, enlarged ventricles in the
brain
Cause: tumor, congenital malformation, inflammatory lesion, post-op spina bifida
Types: (1) Communicating- normal ventricular but absorp prevent for SAS
(2) Noncommunicating- obstruction prevent any or all CSF from leaving; a) Aqueductal Stenosis- Sylvius
reduced in size; b) Dandy-Walker - atresia; c) Arnold Chiari- downward displace of cerebellar tonsils thru
Foramen Magnum cause 4th ventricle displacement (90% meningomyelocele)
S&S Infant: rapid growth, ↑FOC, bulging anterior fontanel, distended scalp, irritable, poor feed, setting sun,
sluggish/ unequal pupil response, high cry, alter resp. pattern
S&S Child: frontal headache, strabismus, diplopia, papilledema, confusion, ataxia, seizure, blindness,
decerebrate rigidity, ↑ BP, ↓ HR, alter R
Dx: ↑ FOC, translusence, setting sun, CT, MRI, lumbar puncture
Tx: Surgery, puncture to remove fluid, Diuretics, Shunting→ VP- ventricle to peritoneal cavity & VA- ventricle
to RA of heart
Care: watch for ICP, leave bandage alone, position opposite side bandage, alter tissue perfusion, skin integrity,
nutrition, family process, G&D

Lead Poisoning- ingest, inhale or placental transfer of lead, cause metabolic effects lead to anemia &
encephalopathy, store in bone & teeth, decrease ↓ in any dose
S&S: Mild (10-15 ug/dL)- GI disturbance; Moderate (15-69)- fatigue, anemia, myalgia, abd. pain, muscle
weakness; Severe (>70)- paralysis, seizure, death **>25 usually hospitalized
Dx: blood test (BLL)- venous blood or finger prick, X-ray- lead line on long bone, abd. flakes in gut
Tx: chelating agents (remove lead)- excrete in urine and deposit in bone (1) EDTA- monitor CBC (2) BAL-
adjunct to EDTA, never alone, monitor VS, burning on lips (3) Succimer- GI upset
Care: alter tissue perfusion: cerebral d/t toxicity & drug therapy

Juvenile Diabetes (Type 1)- younger than 20, pancreas unable to produce & secrete insulin leading to inability
to burn, convert, and store sugar causing accumulation in blood, usually during puberty
Cause: genetics, autoimmune→ islet cell antibodies (HLA), virus→ beta cells attacked
Patho: little to no insulin, need sugar, fats & protein oxidized (toxic-DKA), hyperglycemia d/t unable to use
glucose, K leaves d/t dehydration can go to heart BAD= dysrhymias
S&S: ketonuria= acidosis and coma, fruity breath, Polyuria, polyphagia, polydipsia, enuresis
Tests: FBG→ 100-125; GTT→ 140-199, should return to fast value after 2 hrs

Two Comps:
1. Hyperglycemia- ↑ BG; Cause: infection, ↓exercise, ↑ food, not taking insulin
S&S: N&V, fever, dehydration, abd. pain, Kussmaul, coma, acidosis
Tx: insulin bolus, bicarb if pH >7.0, EKG, hourly checks, IV fluids w/ K when renal establish, I&O

2. Hypoglycemia- <60; Cause: increased insulin, ↑ exercise w/ no food, gastroenteritis

S&S: Mild→ irritable, yawning, lethargy; Moderate→ sweating, nervous, tremor, faint, blur vision; Severe→
↑HR, ↓ LOC, profuse sweat, seizure, coma, death
Tx: drink orange/ apple juice, simple sugar, hard candy, glucose tab / RECHECK BG 20-30 min after, repeat if
less than 80, give complex card (PB on toast)

Care: diet, insulin therapy w/ 2x day NPH & Regular, Somogyi→ ↑BG in AM, check at 3am, give snack before
bed; 8-9 yr old can give self at least one own shot, own blood test

Special Consider: (1) Honeymoon- may not need insulin for period of time, not cured (2) Sick Day Rule-
change in diet when ill ex: whole instead of skim milk
- adult ht usually normal if dx before growth spurt, impotence may occur
Errors of Metabolism- absent or deficient enzyme essential to cellular metabolism, result in conditions of
abnormal protein, carb or fat metabolism; autosomal recessive (both parents); mandatory NB screen for PKU &
hypothyroid

Phenylketonuria (PKU)- defect in metabolism of amino acids, unable to metabolize phenylalanine (needed for
protein synthesis), abn. phenyl acids excreted in urine, result in impaired development of brain & CNS
Dx: screen done at birth, 48-72 hr after ingest formula, Guthrie blood test > 4mg/d, dx if 2 tests 24hrs apart are
>20 mg/dl
S&S: jaundice, vomiting, musty or horsy odor, FTT, eczematous lesions, seizures, abnormal EEG, mental
Tx: dietary ASAP→ restrict PKU intake, milk substitute, amino acid supplement, frequent levels
Prognosis- good if dx made before brain damage and pt adhere to diet

Congenital Hypothyroidism CH (Cretinism)- inadequate TH produced from NB to 2 yrs, crucial for G&D of
skeletal and nervous system, ↑ incidence of other abnorm if infant has CH
S&S: depend on amt of thyroid tissue present, dry, cold, mottled skin, hypothermia, resp. distress, abd.
distention, delayed meconium passage, anemia, delay development of CNC leading to mental retardation, bone
age retarded
UnTX: depressed nasal bridge, large tongue, short forehead, puffy eyelids
Dx: Guthrie Blood Test, thyroid scan, x-ray to determine bone age
Tx: life-long Levothyroxine (Synthroid), start ASAP to prevent retardation, cannot handle milk & sugar
Prognosis: same as PKU

Galactosemia- defect is metabolism of carbs, genetic d/o, failure to convert galactose to glucose, cannot digest
milk & sugar, lead to hepatic dysfunction (cirrhosis) and CNS damage
S&S: galactosuria, jaundice, diarrhea, vomit, baby fail to gain wt., ascites, bleeding, sepsis, portal htn, cataracts,
cerebral damage, mental retardation
Dx: Beutler Test, sepsis work up
Tx: Life long, eliminate milk (even breast) and lactose from diet, receive lactose free formula or soy based,
antibiotics if septic or infection
Care: similar to PKU but easier to maintain, AVOID penicillin (contain lactose)
Prognosis: favorable if diet maintain & dx early

Cystic Fibrosis- dysfunction of exocrine glands (mucous producing), thick & sticky secretions interfere w/
proper function of body organ, esp. lungs & pancreas, unable to digest fat, protein, and some sugars
S&S: steatorrhea (undigested fat), protuberant abd., rectal prolapse, slow growth, FTT, huge appetite, absence
of Trypsin in stool, chronic/ recurrent infection, chronic cough, noisy R, wheezing, barrel chest, SOB, cyanosis,
digital clubbing
Dx: family hx, Sweat Test, measure of duodenal fluid, stool collect, Pulmonary Function Test, chest x-ray
Care: Diet= ↑calories, ↑ protein, ↑ in salt, ↓fat (or mod), vitamin therapy, MCT, pancreatic enzymes, aerosols 3-
4x/day, postural drainage, breathing exercise, Mist tent/O2 when ill, ↑ meds d/t ↑ BMR, rest before meals,
vaccines, protect from URI
Prognosis: 50% live until 18, candidates for heart-lung transplant

Tay-Sachs Dz- defect in metabolism of lipids, fatal, Jewish descent common, neuronal degeneration d/t
accumulation of lipids in neurons
S&S: cherry-red spot of the macula of eye with grayish rim, poor muscle tone, rapid mental retardation,
progressive, seizures, decelerate posturing (contracture), “doll-like”
Dx: genetic screen, amniocentesis
Tx: palliative only
Care: comfort, reduce stimuli, skin care, feed with G-tube
Prognosis: progressive until death 13-30 months after onset of S&S
Gastrointestinal Dysfunction

Vomiting- spitting up, regurgitation, vomiting, projectile, improper feeding, infection, dietary problems,
motion, obstruction; center located in medulla
(1) Higher cortical center- d/t unpleasant sight, odor, fright (2) Chemosensitive trigger- chemical & drug toxin,
infection, radiation, ICP, inner ear infection (3) Reflex excitement- vagal & sympathetic nerves from GI
disturbance or viscera
S&S: Regurgitation→ feeding, wet burp, barely sour, non-pain, 1x per feed, minimal amt; Vomit→ forceful,
very sour, colored (bleed), cry before, abd. pain, continued emptying until retch
Dx: CBC, urine, x-ray, blood, ABGs
Tx: Hydration, position to prevent aspirate, oral care, begin small amt ORT (oral rehydration therapy) q1-5min,
AVOID fatty, spicy, fried foods

GERD- incompetent lower esophageal sphincter, permit reflux into esophagus, common in premie, child w/
neuro impair and esophageal surgery
S&S: vomit, wt. loss, FTT, ↑ appetite, resp. problem= asthma, recurrent OM, bleeding, recurrent pneumonia
Dx: Barium swallow, radionuclide, pH probe monitor
Tx: thicken feedings, small, slow feeding, burp often b/t, upright, prone when awake, supine when asleep,
Tucker sling, Meds: Reglan, Zantac, pepcid
Surgery: Nissen-Hill Fundoplication to tighten LES
Care: nutrition, hydration, CPR train

Diarrhea- ↑ # of stools, ↓ consistency, greenish in color; cause usually bacteria(E.Coli, Shigella, Salmonella),
viral (Rotavirus & Norwalk), parasite, fungus; prostaglandin release cause cramp & ↑ peristalsis, lead to
dehydration, loose Na and K; renal failure can result w/ irreversible acidosis and death
S&S: effortless expulsion, unlimited frequency, foul odor, + occult blood, Metabolic acidosis→ impair renal
function; Shock→ d/t attempt to maintain fluid volume, BP↓
Dx: CBC, CMP, x-ray = bowel abn, stool culture, Guaiac Test, stool pH
Tx: ORT, complex CHO, lactobaccilus supplement, no OTC antidiarrheal, skin care, Rotavirus vacc, wash hand

Dehydration- imp. in children since comprise greater fraction of wt (60-90%), must replace ½ ECF/day, ↑
metabolic rate, <2 does not concentrate urine d/t immature kidneys, ↑ R rate, ↑ surface area to wt. ratio, total
output exceeds intake
Normal Fluid Requirement: 0-10 = 100mL / 11-20 = 50mL / >20 = 20mL → Ex: 25 kg = 1600 mL/day
Urine Output: infant toddler = 2-3 mL/kg/hr / preschool= 1-2 mL/kg/hr
Types of Dehydration:
(1) Isonatremic- Na WNL (138-145), water & electrolytes lost in equal; continuous loss lead to CV collapse
Tx: quick treat <24 hr (esp. 1st 8hr → ↑ rate)
(2) Hypernatremic- Na > 150, water lost greater proportion than electrolytes
Tx: slow rate H20 & Na over 48 hrs, monitor Na closely= want to reduce slow
(3) Hyponatremic- Na < 135; high loss electrolytes
Tx: rapid over 24 hrs., (esp. 1st 8hr.)
Care: do rapid ORT unless severe - IV, make sure kidney function proper

Cleft Lip & Palate- during 7-8th wk fatal life, risk for OM and infection
Tx: Lip→ 2-3 days; surgery- Cheiloplasty Palate: 6-24 mths
Care: no oral temp, pacifier, hands in mouth, rinse w/ water after feed
Pre-Op→ airway clearance, nutrition Post-Op→ supine, ↑ HOB, pain, restraints, airway
Tracheo-Esophageal Fistula (TEF)- failure in separation of esophagus & tracheal tubes before 8wk; hx
polyhydraminios
(1) Fistula- incomplete fusion lead to closure of laryngotracheal tube (abn. opening b/t trachea & esophagus)
(2) Atresia- deficient growth; underdeveloped esophagus (not connected to stomach)

Types:
Type A-Esophageal atresia→ blind pouch at end with no comm. to trachea; drooling, choke on feed w/
cyanosis, NPO/ G-Tube
Type C- Esophageal atresia/ distal TE fistula→ esophagus to blind pouch and distal connected to tachea or
bronchus (87-90%)
Type E- Trachea-Esophageal fistula→ normal trachea & esophagus connected by fistula; just snip apart, NPO,
TPN feed, can swallow w/ choking

S&S: cough, choke, drool, NG tube will coil back, abdominal distention (girth)
Tx: NG tube can’t advance, abd. radiography, suction at bedside, NPO, TPN/ enteral feed

REMEMBER:
- Abruption placenta: painful vag. Bleeding, abd pain, back pain
- an anemic patient may be at risk for pp infection
- if vaginal bleeding in 3rd trimester, no pelvic exams until placenta previa is ruled out
- abruptio placenta: deliver baby ASAP and control hemorrhage
- if getting postpartum rubella vaccine, don’t get pregnant for 2-3 months.
- perineal pads should be weighed before and after use to gauge the amount of lochia
- primary causes of subinvolution are infections and retained placental fragments
- methergine may be given pp to help prevent hemorrhage by causing the uterus to contract
- baby born to Hep B mom will need Hep B immune globulin and vaccine within 12 HOURS of birth
- HIV mom: no breastfeeding
- if UTI, don’t drink carbonated drinks, they’ll alkalinize the urine. Instead drink cranberry, prune, and
apricot juices to acidify the urine.
- a mom with Hep. B virus should not breastfeed, should wear gloves when bottlefeeding, and should
practice good handwashing.
- in the immediate pp period, mom vitals should be checked q 15 min during the 1st hour and q 30 min. for
the next 2 hours.
- notify the physician if clots in the lochia are bigger than 1 cm
- average lochia flow requires 6 peripads/day. More than 8 is considered danger.
- how to know if a pp woman with an epidural developed a vulvar hematoma: changes in vital signs r/t
hypovolemia, main one is increase in pulse. (ice pack to tx hematoma). Serious hematomas require surgery
to stop the bleeding if pt is becoming hypovolemic. These surgery pts will need to be on antibiotics postop
to prevent infection in the wound
- mastitis pt: DO need to continue to breastfeed; empyting affected breast is important to prevent abcess.
Will need abx tx, can use analgesics, ice packs, supportive bra.
- saturation of more than 1 pad/hour even in immediate pp is danger.
- asepsis most important focus for HIV mom
- if HTN, have risk of abruption placenta

Rheumatic Fever
- cause by beta hemolytic strep infection
ss: tachycardia, rash, fever, chest pain migratory large joint pain, chorea & skin nodules.
*administer penicillin until age 21
Kawasaki Disease
- vasculitis infection of the small vessels
ss: dry red cracked lips, rashes arms & legs conjunctivitis, strawberry tongue, peeling skin on the palms & soles of feet
high fever, unresponsive to antibiotic, impaired swallowing, coronary aneurysm
Gamma Globulin IV 400mg/kg/day x weight in kg
Live attenuated vaccine must delayed-polio, MMR
Cystic Fibrosis
- is hereditary disorder, lung congestion & infection
Ss: positive sweat test, bulky greasy stools, meconium ileus, early chronic dry cough deficient in vits. A, D &K fat soluble
vits.
GERD
Ss: frequent or persistent cough, heart burn, abdominal pain, recurrent aspiration, anemia
Main concern: airway obstruction, fluid and electrolyte imbalance & apnea
Spina Bifida
- a congenital malformation of spinal column
- many areas of the central nervous system may not develop or function adequately.
Ss: club feet, hip dysplexia, latex allergy or sensitivity
Cleft Lip and Palate
- cleft lip repair at 2 months
- cleft palate repair at 2 years
Sickle Cell Disease
- cell half-moon shape, blood O2 decrease
- common to African-Americans
- cause of anemia- an imbalance bet. Red cell destruction & production
- 12 to 20 days RBC life span
- avoid overheating during physical activities
Ss: hypoxia, organ dysfunction due to ischemia and infarction, painful episodes
Esophageal Atresia & Tracheoesophageal Fistula
- infants do not have meconium because saliva cannot enter the stomach
ss: 3 C’s – coughing, choking & cyanosis
Ectopic Pregnancy
- zygote implants outside the cavity
- Intra abdominal bleeding is common cause of ectopic pregnancy.
Ss: sharp localized pain when the cervix is touched during vaginal exam, sudden acute abdominal pain , Keh’r sign – pts.
lie down there is a pain in the tip of shoulder due to accumulation of fluid in the peritoneal cavity, due to rupture of zygote
Methotrexate (Trexall) – treatment a folic acid antagonist, inhibits cell growth, allowing the tube to be saved
Laparoscopy – small incision into the tube & removal of embryo
Hyperemesis Gravidarum
- increased BUN & decrease urinary output
- ketoacidosis -breakdown of fat stored to make metabolic needs.
- high level of hCG & estrogen
Hydatidiform Mole
- absence of FHTs, grape-like clusters of vesicles, vaginal discharge that may contain vesicles, uterus enlarge to fast.
- Asian women at risk 45 yrs and above.
- hCG should be measured weekly until normal then rechecked every 2-4 weeks then every 1 to 2 months for 6 months to
1 year
Interventions: surgical removal of neoplasm,monitor ring for pre-eclampsia & choriocar-cinoma , hysterectomy
Incompetent Cervix
- cervix dilates prematurely usually occur during 4 months of pregnancy
- repeated spontaneous & painless second trimester pregnancy.
Placenta Previa
- painless vaginal bleeding, low implantation of placenta
Placenta Abruption
- sharp sudden abdominal pain
- premature placental separation\
- causes, cocaine use, PIH, manual vacuu aspiration, abortion procedure, rapid decompression of the uterus, multipara,
domestic violence