Child Health Final

Child Development: Chapters 1,5,6,21 &22 (7 questions)

General Trends in Height & Weight Gain During childhood
Birth weight doubles by the first 4-7 months
Birth weight triples by end of the first year
Birth weight quadruples by the age of 2.5 years
Birth height increases by 50% by end of 1st year
Height at age 2 years is about 50% of eventual adult height
How to help them with the milestone
Ericksons Stages:
Trust vs. mistrust (0-1 years)
Autonomy vs. shame and doubt (1-3 years)
Initiative vs. guilt (3-6 years)
Industry vs. inferiority (6-12 years)
Identity vs role confusion (12-18 years)
Role of Play In Development
Content of Play
o Social-affective Play
Infant takes pleasure in relationships with people
o Sense Pleasure Play
Nonsocial stimulating experience that originates from
objects in the environment. Anything that can
stimulate their senses
o Skill play
Repeating an action over and over again
o Unoccupied behavior
Focusing attention momentarily on anything that
strikes their interest
o Dramatic/Pretend Play
Begins in late infancy (11-13 months). Is the
predominate form of play in preschool children
o Games
Imitative games: pat-a-cake
Formal games: ring-around-a-rosy
Competitive games: board games
Social Character of Play
o Onlooker Play

o
o

Children watch what other children are doing, but do

not enter into play
Solitary Play
Interest is centered on their own activity. Play with
toys alone, different from those used by others in
their same area
Parallel Play
Children play independently but among other
children
Associative Play
Children play together and are engaged in a similar
or even identical activity, but there is no
organization, division of labor, leadership assignment
or mutual goal
Cooperative Play
Play is organized, and children play in a group with
other childrenthere is a goal for this type of play

Chapter 6 focuses on assessing a Child and How to

communicate with them
How to administer medication?
Nutrition: breast milk (no feeding until food they start siting
up); if breastfeed they need iron and vitamin D.
DO WE NEED TO KNOW PIAGET COGNITIVE THEORY? PAGE 71
(Maybe? She does not remember if there are Piaget questions
on the final)

Infectious disorders/Communicable Diseases: Chapters 14 (4

questions)
Communicable Disease:

Identification of the infectious agent is of primary importance to prevent

exposure of susceptible individuals

Prodromal symptoms = symptoms that occur between early manifestations of

the disease and its overt clinical syndrome

Can be prevented through immunizations and hand-washing, as will as

standard precautions
Nursing Alert:

If a child is admitted to the hospital with an undiagnosed exanthema (skin

eruption) strict Transmission-Based Precautions (Contact, Airborne, and
Droplet) and Standard Precautions are instituted until diagnosis is confirmed.
Childhood communicable disease requiring these precautions include:
diphtheria, chickenpox, measles, TB, adenovirus, Haemophilus influenza type

b, influenza, mumps, Mycoplasma pneumonia infection, pertussis, plague,

strep pharyngitis, pneumonia, and scarlet fever.
When lotions with active ingredients such as diphenhydramine in Caladryl are
used, they are applied sparingly, especially over open lesions, where
excessive absorption can lead to drug toxixity, Use these lotions with caution
in children who are simultaneously receiving an oral antihistamine. Cooling
the lotion in the refrigerator beforehand often makes it more soothing on the
skin than at room temperature.

Chicken Pox:

Transmission:

Direct Contact, droplet airborne spread

Clinical Manifestations

Prodromal Stage
o
Slight fever
o
Malaise
o
Anorexia
o
Rash highly pruritic (begins as macule papule vesicle)

Distribution
o
Centripetal spreads to face and proximal extremities (sparse on
distal limbs and areas exposed to less heat)

Constitutional s/s
o
Fever
o
Irritability from pruritus
Nursing Consideration/Treatment

Airborne and contact precautions (negative air pressure room)

Keep child at home until vesicles have dried and crusty (usually 1 week
after onset)

Incubation 2-3 weeks

Give bath and change clothes and linens daily

Administer topical calamine lotion (intact or dried lesions)

Keep childs finger nails short and clean-apply mittens if child scratches

Teach child to apply pressure to itchy area instead

DO NOT use Aspirin

Childhood Immunization for prevention

Make give acyclovir to someone to prevent it from them getting it really bad
Measles (Rubeola): **
Transmission:

Direct contact, with droplets of infected person

Airborne
Clinical Manifestations:

Prodromal (catarrhal) stage

o
Fever
o
Malaise in 24 hours followed by
Coryza
Conjunctivitis
Koplik Spots (small irregular red spots with minute, bluish
white center first seen on the mucosa)
Symptoms gradually increase until second day after rash
appears

Rash
o
Appears 3-4 days after onset of prodromal stage
o Starts on face then spreads downward

After 3-4 days assumes brownish appearance and fine desquamation

occurs
o
Isolation until 5th day of first appears
o
4 days prior to rash

Constitutional s/s
o
Anorexia
o
Abdominal pain
o
Malaise
o
Generalized lymphadenopathy
Nursing Considerations/Treatment

Airborne precautions

Isolation until 5th day

Rest

Antipyretics for fever

Eye care
o
Dim lights if photophobia is present
o
Clean eyelids with warm saline to remove secretions or crust
o
Do not rub eyes

Coryza, cough
o
Cool mist vaporizer
o
Petrolatum layer around nares to protect skin
o
Fluids and soft bland foods

Skin care
o Clean, use tepid baths prn
Prevention:

Childhood immunization and Vitamin A supplementation

Erythema Infectiosium - Fifths Disease
Transmission

Respiratory secretions and blood

Clinical Manifestations

Rash appears in 3 stages

o
Stage 1
Slapped face on the cheeks
Leaves within 1-4 days
o
Stage 2
Maculopapular red spots appear, symmetrically distributed in
upper and lower extremities
Proximal distal
o
Stage 3
Subsides, but reappears with sun, heat or cold
Nursing Considerations/Treatment

Isolation only needed if child is hospitalized or with aplastic crisis

Respiratory isolations if in hospital

NO pregnant females

Antipyretics, analgesics and anti-inflammatory drugs

After they break out of rash, they are not contagious

Rosella Infantum

Transmission

Possibly acquired from saliva of health adultno reported contact with

infected
o
Incubation 5-15 days
o
Limited to children <3 years of age
Clinical Manifestations
o
Persistent high fever, while child appears well
o
Rash
Discrete rose-pink macules or maculopapules 1st on TRUNK
spread to NECK, FACE and EXTREMETIES
Nonpruritic
Fades on pressure (blanchable)
Last 1-2 days
o
Associated S/S
Cervical and post auricular lymphadenopathy
Inflamed pharynx
Cough
coryza
Nursing Considerations/Treatment
o
Teach parents measures to reduce fever, and dosage on antipyretics
to prevent overdose
o
If child is prone to seizures, discuss appropriate precautions and
possibility of recurrent febrile seizures.

Mumps
Transmission:

Direct contact with or droplet spread from an infected person

Agent: paramysovirus
Saliva from infected person
Incubation 2-3 weeks
Clinical Manifestations:

Fever

Headache

Malaise

Followed by parotitis
Nursing Considerations/Treatment:

Droplet and Contact Precautions; maintain isolation during period

May cause orchitis and meningoencephalitis

Encourage rest and decreased activity until swelling subsides

Encourage fluids and soft bland diet foods, avoid chewing

Apply hot or cold compresses to neck

To relieve orchitis provide warmth and local support with tight fitting
underpants (can lead to sterility for males)

Painful for them to chew

German Measles (Rubella)

Agent: Rubella virus

3 day measles (kids recover during 3 days)

Droplet precautions

Avoid contact with pregnant women

Vaccine given at 15 months

Clinical Manifestations

Prodromal Stage

o
o
o
o

low grade fever

headache
malaise
anorexia

o
o
o
o

mild conjunctivitis
coryza
sore throat
coughRash

o
o

1st appears on face rapidly appears downward to neck, arms, trunk, legs
By the end of first day, body disappears in the same order it began
Nursing Consideration/Treatment

Droplet precautions

Antipyretics and analgesics

Child should be completely recovered in 3-4 days

Avoid contact with during pregnancy (teratogenic effect on fetus)

The child receives the immunization NOT the mother
Scarlet Fever

Group A strep

Droplet Precautions until 24 hours after initiation

Incubation period: 3-5 days (with symptoms beginning on the 2nd day)

Complications: Peri-tonsillar and retropharyngeal abscess & carditis

Rash appears within 12 hrs everywhere, except face

Clinical Manifestations

Abrupt high fever

Increased pulse
Vomiting
Headache
Chills
Malaise

Abdominal pain
Halitosis
First day: white strawberry
tongue
Third day: Red Strawberry
tongue

Nursing Considerations/Treatment

Antibiotics

Encourage rest during febrile time

Relive discomfort of sore throat with analgesics, gargles, lozenges antiseptic throat sprays and cool mists

Encourage fluid intake

Begin with soft diet when child can eat

Discard toothbrush, avoid sharing drinks and eating utensils

The child receives the

Conjunctivitis (Pink Eye)
Pink eye is caused by many things
In NBs chlamydia, gonorrhea, or Herpes
Infants can by sign of tear duct obstruction
Infections and is HIGHLY CONTAGIOUS
Clinical Manifestations
Itching
Purulent drainage
Inflamed Conjunctivitis
Crusting eyelids
Nursing Considerations

Keep eye clean

Remove accumulated secretions wiping the inner canthus downward and outward away from the
opposite eye
Warm, moist compresses, such as clean washcloth wrung out with hot tap H2O
Instill medication after cleansing eye
Instruct the child to refrain from rubbing the eye and to use good hand-washing technique
NURSING ALERT
Signs of serious conjunctivitis include reduction or loss of vision, ocular pain, photophobia, exophthalmos (bulging
eyeball), decreased ocular mobility, corneal ulceration, and unusual patters of inflammation. Refer patient to
HCP if they have any of these signs
Stomatitis
Caused by Herpes virus
Inflammation of the oral mucosa
May be infectious or non-infectious
May be caused by local or systemic factors.
Canker Sore

Cold Sores or Fever Blisters

Treatment Management:
Relief & prevention of the spread
of Herpes Virus
Good hand washing is a must!
Wear gloves when examining lesions.

Health Promotion: Chapter

10,12,16 & 17 (4 questions)
Health promotion and problems of
different age groups
Milestones: Look at TABLE 10-1
page 310-314

SeparationAnxiety

Betweenages4and8months,infantsprogressthroughthefirststageofseparationindividuationandbegintohavesome
awarenessofthemselvesandtheirmothersasseparatebeings.Atthesametime,objectpermanenceisdeveloping,andinfants
areawarethattheirparentscanbeabsentandismanifestedthroughapredictablesequenceofbehaviors.

Duringtheearlysecondhalfofthefirstyear,infants
protestwhenplacedintheircribs,andashorttime
later,theyobjectwhentheirmothersleavetheroom.
Infantsmaynotnoticethemothersabsenceifthey
areabsorbedinanactivity.However,whenthey
realizeherabsence,theyprotest.Fromthispointon,
theybecomealerttoheractivitiesandwhereabouts.
By11to12months,theyareabletoanticipateher
imminentdeparturebywatchingherbehaviors,and
theybegintoprotestbeforesheleaves.Atthispoint,
manyparentslearntopostponealertingthechildto
theirdepartureuntiljustbeforeleaving.

StrangerFear
Asinfantsdemonstrateattachmenttooneperson,they
correspondinglyexhibitlessfriendlinesstoothers.
Betweenages6and8months,fearofstrangersand
strangeranxietybecomeprominentandarerelatedto
infantsabilitytodiscriminatebetweenfamiliarand
unfamiliarpeople.Behaviorssuchasclingingtothe
parent,crying,andturningawayfromthestrangerare
common.

Thebestapproachforthestranger(includingnurses)is
totalksoftly;meetthechildateyelevel(toappear
smaller);maintainasafedistancefromtheinfant;and
avoidsudden,intrusivegestures,suchasholdingout
thearmsandsmilingbroadly.

Teething
Oneofthemoredifficultperiodsininfants(and
parents)livesistheeruptionofthedeciduous
(primary)teeth,oftenreferredtoasteething.Theage
oftootheruptionshowsconsiderablevariationamong
children,buttheorderoftheirappearanceisfairly
regularandpredictable(Fig.1010).Thefirstprimary
teethtoeruptarethelowercentralincisors,which
appearatapproximately6to10monthsofage
(average,8months).Thesearefollowedcloselybytheuppercentralincisors.Aquickguidetoassessmentofdeciduousteeth
duringthefirst2yearsis:Ageofthechildinmonths6=Numberofteeth.Forexample:8monthsofage6=2teethatthis
time.
Teethingisaphysiologicprocess;somediscomfortiscommonasthecrownofthetoothbreaksthroughtheperiodontal
membrane.Somechildrenshowminimumevidenceofteething,suchasdrooling,gumrubbing,increasedfingersucking,or
bitingonhardobjects.Othersareveryirritable,havedifficultysleeping,andrefusetoeatsolidfoods.Generally,signsof
illnesssuchasfever(<38.9C),vomiting,ordiarrheaarenotsymptomsofteethingbutofillnessandmaywarrantfurther
investigation.Becauseteethingpainisaresultofinflammation,coldissoothing.Givingthechildacoldteethingringhelps
relievetheinflammation(donotfreezeliquidfilledteethingrings).Severalnonprescriptiontopicalanestheticointmentsare
available,suchasBabyOraJel,althoughparentsandhealthcareworkersshouldbeawareoftherisksofusingtopical
anestheticproducts(absorptionratesvaryininfants)(Markman,2009).Theactiveingredientinmostofthemisbenzocaine,
whichmayrarelycausemethemoglobinemia.Ifsuchproductsareused,parentsareadvisedtoapplythemcorrectly

Discipline (box
pg33)
Immunizations
(know which ones
to give at what
age)
Injury prevention

Disorder

Pathophysiology

Clinical Manifestation

Treatment/Teaching

ADHD

Developmentally
inappropriate degree of
inattention,
impulsiveness and
hyperactivity

Hyperactive
BOX 17-2 on page
502 has the diagnostic
criteria

Drug therapy;
Methyphenidate
hydrochloride (Ritalin)
Dextoamphentamine
sulfate (Dexedrine)
Began on a small
dosage that is gradually
increased
Must be assessed
every 6 months for
appropriate growth
and development
milestones
Require a more
structured
environment than
most children
The nurse should help
families identify new
appropriate
contingencies and
reward systems to meet
the childs developing
needs
Encourage consumption
of nutritious snacks in
the evening when the
effects of the
medication are
decreasing, and serving
frequent small meals
with healthy on the go
snacks are helpful

Chronic Illness in Children: Chapter 18 (4 questions)

Impact of Childs Chronic Illness or disability
Page 540
Amajorgoalinworkingwiththefamilyofachildwithchronicorcomplexillnessistosupportthefamilyscopingand
promotetheiroptimalfunctioningthroughoutthechildslife.Longterm,comprehensive,familycenteredapproachesextend
beyondsupportingthechildandfamily
duringthecriticalperiodsof
diagnosisandhospitalization.Rather,
comprehensivecare
involvesformingparentprofessional
partnershipsthatcan
supportafamilysadaptationacrossthe
trajectoryoftheillnessto
themanychangesthatmaybenecessaryin
daytodaylife,determine
expectationsofandforthechild,and
providealongterm
perspective(Box182)

BOX 18-4 page 542 Supporting siblings of children with special

needs
The child with special
Needs
BOX 18-6 (Coping
Patterns Used By
Children with Special
Needs (page 545)

Cognitive Disorders:
Chapter 19 (2
questions)
Cognitive Impairment
(page 572)
Nursesplayamajorrolein
identifyingchildrenwithCI.In
thenewbornandearlyinfancy
periods,fewsignsarepresent,withtheexceptionofDownsyndrome(p.576).After
thisage,however,delayeddevelopmentalmilestonesarethemajorcluestoCI.In
addition,nursesmusthaveahighindexofsuspicionforearlybehaviorpatternsthat
maysuggestCI(seeBox192).Parentalconcerns,suchasdelayeddevelopment
comparedwithsiblings,needtobetakenseriously.Allchildrenshouldreceive
regulardevelopmentalassessment,andthenurseisoftenthepersonresponsiblefor
performingsuchassessments(seeChapter5).Whendelaysarefound,thenursemust
usesensitivityanddiscretioninrevealingthisfindingtoparents.
EducateChildandFamily
TeachChildSelfCareSkills

 PromoteChildsOptimalDevelopment
EncouragePlayandExercise
ProvideMeansofCommunication
EstablishDiscipline
Disciplinemustbeginearly.Limitsettingmeasuresneedtobesimple,consistentlyapplied,andappropriateforthechilds
mentalage.Controlmeasuresarebasedprimarilyonteachingaspecificbehaviorratherthanonunderstandingthereasons
behindit.Stressingmorallessonsisoflittlevaluetoachildwholacksthecognitiveskillstolearnfromselfcriticismorfroma
lessonbasedonpreviouswrongdoing.Behaviormodification,especiallyreinforcementofdesiredactions,andtimeoutare
appropriateformsofbehaviorcontrol.

EncourageSocialization
ProvideInformationofSexuality
HelpFamilyAdjusttoFutureCare
CareforChildDuringHospitalization

Down Syndrome (Page 577)

- Support Family at Time of Diagnosis
Parentsusuallypreferthatbothofthembepresentduringtheinforminginterviewsotheycansupportoneanotheremotionally.
Theyappreciatereceivingreadingmaterialaboutthesyndromeandbeingreferredtoothersforhelporadvice,suchasparent
groupsorprofessionalcounseling.

- Assist Family in Preventing Physical Problems

- Assist in Prenatal Diagnosis and Genetic Counseling

Respiratory Disorders: Chapter 23 (4 questions)
Disease

Pathophysiology

Clinical Manifestations

Treatment/ Teaching

Nasopharyngitis

Younger children
Aka the common cold
Rhinovirus (winter & spring) Fever
Irritability
Restlessness
Poor feeding and decrease
fluid intake
Nasal mucus
V/D
Older children
Dryness & irritation of
nose & throat
Nasal d/c
Sneezing
Muscle aches
Cough
Physical Assessment:
Edema
Vasodilation of the
mucosa

Managed at home
Antipyretics
Rest
Decongestants &
cough suppressants DO
NOT GIVE if <6 years
(For decongestants the
book actually says you
can give, but be
cautions for children
over 12 months, so she
said she wont ask a
question about it)
Elevate the HOB
Suctioning and
vaporization (saline
nose drops & gentle
suction with a bulb
syringe before feeding
and sleep time maybe
useful
Increase fluids
Infection of control
(proper PPE)
Prevention: avoid contact
with infected person, and
hygiene
Parents are instructed to
notify HCP if any of the
following s/s
Refusal to take oral fluids
and decreased urination
Evidence of earache
Respirations faster than
50-60 bpm in a toddler or

Laryngotrachesobronc
hitis

Part of the croup

syndrome
Affects children <5 years
Cause by Para-influenza,
RSV and influenza A&B
Inflammation of mucosa
lining of the larynx and
trachea causing narrowing
of the airway
Will go to bed and wake
up with a bad cough

Slowly progressive
Stridor
Suprasternal retractions
Barking or seal-like
cough
Increasing respiratory
distress and hypoxia
Can progress to
respiratory acidosis,
respiratory failure, and
death
NURSING ALERT:
Early signs of
impending airway
obstruction include
increased pulse and
respiratory rate;
substernal and
intercostal retractions;
flaring nares and
increased restlessness
Cold humidify air

Airway maintenance is
priority
Providing adequate
respiratory exchange
Maintain hydration (PO or
IV)
Watch for dehydration:
Weigh diaper over a 24
hour period
Should be 1mL/kg/hr.
> 6 months, >30kg
should be 30 mL/hr.
High humidity with cool
mist
Oxygenation status thru
pulse oximetry
Nebulizer treatments:
Epinephrine
Steroids (IM prefer) slow
release from muscle
tissue vs. oral they with
clear a lot fater

Pharyngitis

Strep throat
GABHS
At risk for rheumatic fever
& acute
glomerulonephritis

Younger children
Fever
General malaise
Dysphagia
Abdominal pain
Physical assessment:
Mild-to-moderatehyperemia

Throat culture to rule out

GABHS
If streptococcal infection is
present oral penicillin is
prescribed, erythromycin
for children allergic to PCN
Obtain a throat swab
culture
Instruct parents on
administering antibiotics,
Older children

Cold or warm compresses

Fever (may reach 40C 104
to the neck,
F)
Warm saline gargles
Headache
Manage pain with
Anorexia
acetaminophen or
Dysphagia
ibuprofen
Abdominal pain
Offer cool liquids or ice
Vomiting
chips
Physical Assessment;
Children consider
Mild to bright red,
infectious to others at
edematous pharynx
the onset of symptoms
Hyperemia of tonsils and
and up to 24 hours
pharynx, may extended to
after the initiation of
soft palate and uvula
antibiotic therapy,
Often abundant follicular
replace toothbrush after
exudate that spreads and
have been taking
coalesces to form
antibiotics for 24 hours
pseudomembrane on
DRUG ALERT
tonsils
Never administer
Cervical glands enlarged
Penicillin via IV, it may
and tender
cause an embolism, or
toxic reaction
w/insuring deaths in
minutes instead
administer IM to

Epiglottitis

Serious obstructive
inflammatory process that
occurs predominantly in
children 2-5 yrs.
Caused by H influenza
Abrupt onset
Emergency NEEDS for
ASAP

3 predictive
observations:
Cough
Drooling
Agitation

Croup Syndrome

Affect larynx, trachea

bronchi
Ie. Are epiglottis,
laryngitis,
larngotracheobronchitis
(LTB) and tracheitis

NURSING ALERT:
Throat inspection
should be attempted
only when immediate
endotracheal
intubation can be
performed
Child goes to be

When epiglottis is
asymptomatic to
suspected the nurse
awaken later
should not attempt to
complaining of sore
visualize epiglottis
throat and pain on
directly with tongue
swallowing
depressor or take a
Stridor (aggravated when
throat culture but refer
supine)
to the child for medical
High fever
evaluation
Rapid pulse and
Start IV infusion
respiration
Continuous monitoring of
Tripod position
respiratory status and
pulse oximetry
ABGs if child is intubated
Prevention HIb vaccine

Hoarseness
Barking cough
Inspiratory stridor

RSV (AND
BRONCHOLITIS)

Respiratory syncytial
Initial:
virus. Most common cause
Rhinorrhea (1st)
of bronchiolitis
Pharyngitis
RSV affects the epithelial
Cough, sneezing
cells of the respiratory
Wheezing
tract. The ciliated cells
Possible ear or eye
swell, protrude into the
drainage
lumen, and lose their cilia
Intermittent fever (1st)
Bronchiolar mucosa swells
With progression of
and lumina are
illness:
subsequently filled with
Increased coughing and
mucus and excaudate
wheezing
walls of the bronchi and

Tachypnea and
bronchioles are infiltrated
retractions
Intraluminal obstruction

cyanosis
leads to :
Severe illness:
Hyperinflation
Tachypnea >70 bpm
Emphysema
Listlessness
Atelectasis
Apneic spells
Poor air exchange
Poor breath sounds

Treat the symptoms

Contact precautions

Asthma

Chronic inflammation
disorder of the airways
Characterized by:
Recurring symptoms
Airway obstruction
Bronchial hyperresponsiveness

Dyspnea
Wheezing
Coughing

TX
Short acting medication:
B2 agonist
Anticholinergic
Systemic corticosteroids
Long acting medication:
Inhaled corticosteroids
Cromolyn sodium &
nedocromil
Long acting b2 agonist
Methylxanthines
Leukotrines modifiers

Cystic Fibrosis

Inherited autosomal
recessive trait
Mechanical obstruction
caused by the
increased viscosity of
mucous gland
secretions
Affects other organs

Meconium ileus
Abdomen distention
Vomiting
Failure to pass stool
Rapid development of
dehydration
GI
Large, bulky, loose, foul
stool
Eat a lot (early in
disease)
Lose appetite (later in
disease)
Weight loss
Marked tissue wasting
Failure to grow
Distended abdomen
Thin extremities
Yellow or pale brown
skin
Deficient in vitamins
A, D, E, K
anemia
Lungs
Wheezing
Dry non-productive
cough
Increased dyspnea
Paroxysmal cough
Obstructive emphysema
and patchy areas of

Diet: High caloriecdiet

with high fat
Treat and prevent
pulmonary infections
Flutter muscu clearance
device
High frequency chest
compression
Broncholdilator
medication
Replacement of
pancreatic enzymes
given with meals and
snacks (take extra
enzymes when high fat
foods are eaten)
NURSING ALERT
Signs of
pneumothorax are
usually nonspecific
and include
tachycardia, dyspnea,
pallor, and cyanosis.
A subtle drop in O2
saturation (increased
by pulseoximetry)
may be a early sign
of pneumothorax

Medications associated with respiratory dysfunction (action & adverse effects):

SIDS-pg 401:
GI Disorders: Chapter 24 (5 questions)
Disease

Pathophysiology

Clinical Manifestation Therapeutic Management

Hirschsprung
Disease

Congenital
abnormality
Results in obstruction
from inadequate
motility of part of the
intestine
Aka: aganglionic
megacolon
Mutations of RET
proto-oncogene have
been found
In the majority of
cases aganglionosis
is restricted to the
internal sphincter,
rectum and part of
the sigmoid colon
Absence of ganglion
cells in the intestines
that results in loss of
rectosphincteric
reflex and an
abnormal
microenvironment of
cells of the affected
intestine
Absence of these
cells results in a lack
of enteric nervous
system stimulation,
which decreases the
internal sphincters
ability to relax

Table 24-3
NB
Failure to pass
meconium within 2448 hours
Refusal to feed
Biolous vomiting
Abdominal distention
Infancy
Growth failure
Constipation
Abdominal distention
Episode of diarrhea
and vomiting
Signs of enterocolitis:
explosive, watery
diarrhea, fever,
appears significantly
ill
Childhood
Constipation
Ribbon-like, foul
smelling stools
Abdominal distention
Visible peristalsis
Easily palpable fecal
mass
Undernourished
anemic appearance

Surgery
Removal of the aganglion portion of
the bowel to remove obstruction,
restore normal motility and preserve
function of external sphincter
Soave endorectal pull-through: pulling
the end of the normal bowel through
the muscular sleeve of the rectum;
Complication: constipation
(enterocolitis) and fecal incontinence
Diet low in fiber, high calorie,
high protein
Anorectal myomectomy: for very
short segment diseases
Prior to surgery child is stabilized with
fluid and electrolyte replacement
Preop
Make sure that physical status is
good, if not treat with enemas; a low
fiber, high calorie and high protein
diet or TPN in severe cases
Decrease bacterial flora with
antibiotics and colonic
irrigations using antibiotic soln
In children: empty bowels with saline
enemas and decrease bacterial flora
with oral or systemic antibiotics and
colonic irrigations (bowel cleansing)
Emergency preop care includes:
monitor vital signs for signs of shock,
fluid, electrolyte replacement, plasma
or blood derivatives and observe for

Cleft lip or Cleft Facial malformation

Palate
that occurs during
embryonic
development
Most common
congenital
deformities
Clefts of the lip (CL)
and palate (CP) can
occur alone or
together
Most are caused by
genetics and
environmental
factors
Exposure to
teratogens such as
alcohol, cigarette
smoking,
anticonvulsants,
steroids and retinoids
are associated with
higher risk
The severity of CP
has an impact on
feeding; the infant is
unable to create
suction in the oral
cavity that is
necessary for feeding
(ability to swallow is
normal)

Apparent at birth
Sometimes seen
on ultra sounds

Surgical correction of Cleft Lip

Occurs 2-3 months
Rule of ten: 10 weeks old, 10lbs,
hgb of 10
Tennison-Randall triangular flap (Z
plasty)
Millard rotational advancement
technique
Nasoallveolar may be used to bring
cleft segments together prior to
surgery
Surgical Correction of Cleft
Palate
Occurs between 6-12 months
Veau Wardill-Kilner VY pushback
procedure
Furlow double opposing Z plasty
May need a 2nd surgery to improve
velopharyngeal for speech.
Nursing teaching highest priority
is learning how to feed their
infants and
CL may interfere with the infants
ability to achieve an adequate
anterior lip seal; no difficulty
breastfeeding, use wide based bottles
CP reduces the infants inability to
suck, which interferes with
breastfeeding and traditional bottle
feeding
Positioning in an upright position, with
head supported by caregivers hand

Esophageal
Rare malformations
Atresia with
that represent a
Tracheoesophag failure of the
eal Fistula
esophagus to
develop as a
continuous passage
and the trachea &
esophagus to
separate into distinct
structures
Can occur alone or
both
Cause is unknown
When a mother had
polyhydraminose
(excessive amnioc
fluid in sac), thats
when you would
suspect it

Box 24-9
Excessive frothy
mucus from nose
and mouth
3 Cs of
tracheoesophage
al fistula:
Coughing
Choking
Cyanosis
Apnea
Increased
respiratory
distress during
feeding
Abdominal
distention
Suspected in
cases of
polyhydramnios
(excessive fluid in
the amniotic sac)

As a nurse, if you suspect this you will

be there for the 1st feeding and
administer water in a medicine cup to
look for the 3Cs
If its there stop giving them the water
baby stays NPO and
As a nurse you want to maintain
patent airway, prevention of
pneumonia, gastric blind pouch
decompression, supportive therapy
and surgical repair of anomaly.
When EA with TEF is suspected, the
infant is immediately deprived of
oral intake, IV fluids are initiated
and the infant is positioned to
facilitate drainage of secretions
and decrease the likelihood of
aspiration
Mouth and pharynx suctioned
frequently because of accumulated
secretions
Double-lumen catheter placed into
the upper esophageal pouch and
attached intermittent or
continuous low suction
Infants head kept upright
(30degrees) to help with removal of
fluid collected in the pouch and
prevent aspiration of gastric content
Antibiotics if there is concern of
aspiration of gastric content
Surgery:
thoracotomy

Hypertrophic
Pyloric
Stenosis

Occurs when the

circumferential
muscle of the pyloric
sphincter becomes
thickened, resulting
in elongation and
narrowing of the
pyloric channel
It produces an outlet
obstruction and
compensatory
dilation, hypertrophy
and hyperperistalsis
of stomach
Develops first 2-5
weeks of birth
Causes projectile
vomiting,
dehydration,
metabolic alkalosis
and growth failure
Genetic
predisposition
Circular muscle of the
pylorus thickens as a
result of hypertrophy
and hyperplasia
(increased mass).
This produces sever
narrowing of the
pyloric canal between
stomach and
duodenum, causing

Box 24-11
Projectile vomiting
May be ejected 3-4 ft
from child when in a
side-lying position or 1
foot when in supine
position
Occurs shortly after
feeding, but may not
occur for several hours
Nonbilious vomitus
that may be blood
tinged
Infant hungry, avid
feeder, eagerly
accepts a second
feeding after vomiting
episode
No evidence of pain or
discomfort other than
hunger
Weight loss or
failure to gain
weight
Signs of dehydration
Distended upper
abdomen
Readily palpable
olive-shaped tumor
in epigastrium just to
the right of the
umbilicus

Preop
Restoring hydration and electrolyte
balance, metabolic alkalosis must be
corrected
NPO receive IV fluids with glucose and
electrolyte replacement
Assess: Vital signs, skin mucous
membranes, and daily weight
Stomach decompress with an NG tube,
the nurse must ensure the tube is
patent and functioning properly. Also
responsible for measuring and
recording the type and amount of
drainage
Postop
IV fluids administered until the infant is
taking and retaining adequate
amounts by mouth
Monitoring same things that were
assessed
Observed for responses to the stress of
surgery and for evidence of pain
Surgical incision is inspected for
drainage or erythema and any signs of
infection, report ASAP
Feedings usually being 4-6 hours postop
Teach parents how to care for incision
Observation and feeding recordings
are important

Intussusceptio Children ages

n
3months-3years
Common in children
with cystic fibrosis
Unknown cause
Occurs when one
segment of the bowel
telescopes into
another segment,
pulling the mesentery
with it
The mesentery is
compressed and
angled resulting in
lymphatic and venous
obstruction
As edema from
obstruction increases
pressure increases.
When pressure
equals arterial
pressure, arterial
blood flow stops
results in ischemia
and pouring of mucus
into the intestine +
leaking of blood
and mucus into
intestinal lumen
resulting in currant
jelly-like stools

Sudden acute
abdominal pain
Child screaming and
drawing knees into
chest
Child appearing normal
and comfortable
between episodes of
pain
Vomiting
Lethargy
Passage of red,
current jelly-like
stools (mixed with
blood and mucus)
Tender, distended
abdomen
Palpable sausageshaped mass in
upper right
quadrant
Empty lower right
quadrant (dance sign)
Eventual fever,
prostration and other
signs of peritonitis
Fetal position in pain

Assess children with severe colicky

abdominal pain combined with
vomiting, which is a significant sign
NURSING ALERT: The classical traid s/s:
abdominal mass, abdominal pain,
and bloody stools. Children might
initially be seen screaming, irritable,
lethargy, vomiting, diarrhea or
constipation, fever, dehydration and
shock. Can be life threatening, the
nurse should be aware of alternative
presentations, observe the child
closely, and refer them for further
evaluation.
Treatment consists of radiologistguided pneumonia (air enema) with
or without water-soluble contrast or
ultrasound guided hydrostatic
(saline) enema.
IV fluids, NG decompression and
antibiotic therapy may be used before
hydrostatic reduction
Laparoscopic surgery that involves
manually reducing the invagination
and when indicated, resecting any
nonviable intestine
Look at stool, if stool is normal then no
further procedure; however, if stool
remains jelly-bloody like then surgery
is required
NURSING ALERT: Passage of
normal brown stool usually
indicates that intussusception has

Celiac Disease

Characterized by
villous atrophyin the
small bowel in
response to the
protein gluten
It is a permanent
intestinal intolerance
to dietary wheat
gliadin and related
proteins that
produces mucosal
lesions in genetically
susceptible
individuals

Impaired Fat
absorption

Corn and rice become substitute grain

foods

Steatorrhea
(excessively large,
pale, oily, frothy stools

Advise child and patients to read labels

carefully

Exceeding foulsmelling stools

Impaired nutrient
absorption
Malnutrition
Muscle wasting
(especially prominent
in legs and buttocks)

Exact cause is
unknown, accepted
Anemia
that it is an
immunologically
Anorexia
mediated small
intestine enteropathy Abdominal distention
Gluten is found in
wheat, barley, rye
and oat grains
When individuals are
unable to digest the
gliadin component of

Behavioral changes
Irritability
Uncooperativeness
Apathy
Celiac crisis: Acute,

Diet requires a wheat-barley, and rye

free diet
A diet high in calories and proteins
with simple carbohydrates such as
fruits and vegetables, but low in fat
Avoid high fiber foods, such as: nuts,
raisins, raw vegetables and raw fruits
with skin until inflammation has
subsided

Congenital Disorders: Chapter 25 (7 questions)

Pathophysiology

Clinical Manifestations

Nursing
Consideration/Teachin
gs

Congestive Heart
Failure

Inability of the heart to

pump an adequate
amount of blood to the
systemic circulation at
normal filing pressures to
meet demands
In children, it occurs
secondary to structural
abnormalities that result
in increased blood volume
and pressure within the
heart
Right-sided failure = R
ventricle is unable to
pump blood effectively
into the pulmonary artery,
resulting in increases
pressure in the R atrium
and systemic venous
circulation
Left-sided-failure = L
ventricle is unable to
pump blood into the
systemic circulation,
resulting in increases
pressure in the L atrium
and pulmonary veins. The
lungs become congested
with blood, causing
elevated pulmonary
pressures and pulmonary
edema

Impaired Myocardial
Function
Tachycardia
Sweating
Decreased urinary
output
Fatigue
Weakness
Restlessness
Anorexia
Pale, cool extremities
Weak, peripheral pulses
Decreased BP
Gallop rhythm
Cardiomegaly
Pulmonary Congestion
Tachypnea
Dyspnea
Retractions (infants)
Flaring nares
Exercise intolerance
Orthopnea
Cough, hoarseness
Cyanosis
Wheezing
Grunting
Systemic Venous
Congestion
Weight gain (best way
to determine HF in
child/infant)
Hepatomegaly
Peripheral edema
(especially periorbital)

Administer digoxin.
But first check the
apical pulse. Do not
administer if to an
infant if the pulse is
<90-110 bpm; and
young children if the
pulse is <70 bpm
Monitor afterload
reduction by measure
BP before and after ACE
administration
Assess serum
electrolytes and renal
function
Clustering treatment to
minimize unnecessary
stress
Monitor temperature
because hyperthermia
or hypothermia because
it increases the need for
oxygen
Skin breakdown from
edema is prevented with
a change of position
every 2 hours
Reduce Respiratory
Distress, through careful
assessment, positioning
and oxygen
administration which
can reduce respiratory

Endocarditis

Is an infection of the
inner lining of the heart
(endocardium),
generally involving the
valves
Mainly caused by staph
or strep

Onset usually insidious

Unexplained fever (low
grade and intermittent)
Anorexia
Malaise
Weight loss
Characteristic findings
caused by extra cardiac
emboli formation
Splinter hemorrhages
(thin black nails) under
nails
Osler nodes (red,
painful intradermal
nodes found on pads of
phalanges)
Painless hemorrhagic
areas on palms and
soles
Petechiae on oral
mucous membranes
May be present
Hear failure
Cardiac dysrhythmias
New murmur or
change in previously
existing one

Administration of highdoses of antibiotics IV

2-8 weeks
Take blood cultures
periodically
Prophylactic antibiotics
therapy 1 hour before
certain procedure that
increase risk
Notify the dentist, if
the child gets any
dental procedure
Oral care needs to be
maintained to reduced
the chance of
bacteremia from oral
infection
The nurse teaches that
any unexplained fever,
weight loss, or change
in behavior (lethargy,
malaise, anorexia) must
be brought to the HCPs
attention

Hypoxia

A reduction in tissue
oxygenation that results
from low oxygen
saturation and PaO2 and
results in impaired
cellular processes

Cyanosis
Desaturated venous
blood
Clubbing
Hypercyanotic spells
Polycythemia
(increased blood cells)

Keep child hydrated

Place infant-chest
position when having
hypercyantoic spells
Pulmonary hygiene
Treat pulmonary
infections aggressively

Kawasaki Disease

Acute systemic vacuities Child must have fever

of unknown cause
for more than 5 days
along with 4-5 clinical
Occur in children in
criteria
younger than 5 years of
Changes in the
age
extremities: in the
Initial stage of the
acute phase edema,
illness, is extensive
erythema of the
inflammation of the
palms and soles; in
arterioles, venules and
the subacute phase,
capillaries occurs,
periungual
causing many of the s/s
desquamation
Can cause formation
(peeling) of the
of coronary artery
hands and feet
aneurysms in some
Bilateral conjunctival
children
injection
(inflammation)
without exudation
Changes in the oral
mucous membranes,
such as erythema of
the lips,
oropharyngeal
reddening; or
strawberry tongue
Polymorphous rash
Cervical
lymphadenopathy
(one lymph node > 1.5
cm)

High does of IV
gamma globulin
(IVGG) along with
aspirin and then
antiplatelets
Monitor heart function
I&O
Daily weights
Assess for signs of heart
failure
Symptoms relief:
Cool clothes
Unscented lotions
Soft loose clothing
Mouth care
Clear liquids
Soft foods
Quiet environment

Teach parents about

CPR

Congenital Heart Defects:

Defect w/
increased
pulmonary blood
flow

Atrial Septal
Defect (ASD)

Ventricle Septal
Defect (VSD)

Atrioventricular
Canal Defect

Patent Ductus
Arteriosus (PDA)

Pathophysiology

opening in the
Opening in the
septum between the
septum between the
atriums
ventricles
blood from L atrium L-to-R shunt is
(high pressure) flows caused by the flow
into the R atrium
of blood from L
(low pressure)
ventricle (high
causes flow of
pressure) to R
oxygenated blood
ventricle (low
into the R side of
pressure).
heart
Increased pressure
in the R ventricle
causes the muscle
to hypertrophy
Spontaneous
closure most
likely occurs
during the 1st year
of life in children
having small or
moderate defects
(usually by 4 years)
Might be noticed
2-8 weeks

Incomplete fusion of Failure of the fetal

the endocardial
ductus arteriosus
cushions
(artery connecting
the aorta &
Consists of low ASD
pulmonary artery)
with a high VSD
to close w/in the
A large AV valve
first week
that allows blood

Allows blood to flow

to flow between
from the Aorta to
all 4 chambers
Pulmonary Artery
Most common

This shunt usually

defect in children
closes at 12-72
with Down
hours; 2-3 weeks
Syndrome
seals shut
L R shunt
Causes an
increase workload
of the L side of
heart, increase in
pulmonary
vascular
congestion &
potentially
increase in in R.
ventricular
pressure and
hypertrophy
NSAIDS will can it
to premature
closure

Clinical
Manifestations

Asymptomatic
Acyonotic
Fatigue easily

Heart failure is
common
Acyonotic

Treatment/Teaching Pericardial patch or

Procedures
s
Darcon patch
Procedures
Patient receives lowdose of aspirin for 6
months

Moderate to
severe heart
failure
If asymptomatic
follow child and
watch for it to close
on its own
Mild cyanosis
increases with
crying
High risk for
pulmonary vascular
obstructive disease
Results going from
aorta pulmonary
artery
Widened pulse
pressure
Bounding pulse

Asymptomatic
Signs of heart
failure
Acyontoic
May hear a heart
murmur at birth
and when they
come for a follow
up you might not
hear anything

Procedures

Indomethacin
(ibeuprofen)
promotes closure
You dont want it to
close in utero only
when the baby is
born
NSAIDs promote
opening, and
indomethacin
promotes closure

Obstructive Defects
Pathophysiology

Coartatation of the
Aorta
Aorta is narrowed
Increased pressure
proximal (head and
upper extremities)
Decreases distal
pressure (body and
lower extremities)

Aortic Stenosis
Narrowing of aortic
valve closer to the
ventricles
Causes resistance of
blood flow in the L
ventricle, and
pulmonary vascular
congestion (pulmonary
edema)

Pulmonic Stenosis
Narrowing of the
entrance of the
pulmonary artery
Resistance to blood flow
causes R ventricular
hypertrophy
Can reopen foramen
ovale, shunting of
unoxygenated blood
into the L atrium

Clinical Manifestations Increase BP upper

extremities, low BP in
lower extremities
Bounding pulses in
arms
Weak or absent
femoral pulses
Cool lower extremities
Hear failure signs
Since L side is working
harder, it may cause L
ventricle hypertrophy
May go unnoticed if the
PDA does not close
OLDER KIDS:
Dizziness
Headaches
Fainting
nosebleeds

Treatment/ Teachings

prostaglandin E to
keep the PDA open
Balloon angioplasty

Leads to heart failure

NB
Decrease CO (hard for
blood to come out)
Faint pulses
Hypotension
Tachycardia
Poor feeding
syncapy (pass out)
Children
Exercise intolerance
Chest pain
Dizziness when standing
for a long time
Systolic ejection
murmur may be present

Asymptomatic
Cyanosis
Heart failure
Decrease of CO (severe
cases)
Cardiomegaly

If they have severemoderate they need to

avoid competitive or
intense sports because
it can lead to sudden
death
Balloon angioplasy

Balloon angioplasty

Decreased Pulmonary
Blood Flow

Pathophysiology

Tetraology of Fallot

4 defects in 1
VSD
PS
Overriding aorta
R Ventricular
hypertrophy
shunt direction depends
on the difference
between pulmonary and
systemic vascular
resistance
unoxygenated blood to
the body

Mixed Defects (Mixed

Blood)

Transposition of the
Great Arteries/Great
Vessels

Clinical manifestations

Cyanotic
bluespells or tet
spells (knee to chest
position)
clubbing
hypoxia

Truncus Arteriosus

Treatment/Teaching

Blalock Taussing Shunt

Different procedures

Hypoplastic L Heart
Syndrome

Pathophysiology

Oxygenated blood
Blood ejected from the L Underdevelopment of L
goes back and fourth
and R ventricles enters
side of heart results in
unless there is
the common trunk so
hypoplastic L ventricle
another defect that
that pulmonary and
aortic atresia
allows the blood to
systemic circulation are An ASD or patent
go to the other side,
mixed
foramen ovale allows
the child can be okay for Blood goes towards
blood to flow from L
a while
the lungs since the
atrium-to-R atrium and
Pulmonary artery
pressure in the lungs is
R ventricle-to-out to
leaves the R ventricle lower.
pulmonary artery
lungs aorta
Aorta leaves the R
systemically
ventricle
Gives lungs extra blood
Pulmonary congestion

Clinical Manifestations Cyanotic

Heart failure
cardiomegaly

heart failure
poor feeding
poor growth
lung congestion
fatigue
hypoxemia
cyanosis
poor growth
activity intolerance

Mild cyanosis
Signs of heart failure
until PDA closes
Once PDA closes
progressive
deterioration with
cyanosis and decreases
CO
Pulmonary congestion

Treatment/Teaching

prostaglanding E
(keeps it open)
procedure

procedures (preferably
within the first month of
life)

It is a step procedure,
more than 1 procedure
will occur

Medications:
Digitalis glycosides (digoxin) improve contractility (read page 839 Family-Centered Care for
Administering)
o NURSING ALERT: Infants rarely receive more than 1 ml (50 mcg or 0.05 mg) of digoxin
in one does; a higher dose is an immediate warning of a dosage error. To ensure safety,
compare the calculation with another staff members calculation before giving the drug
o Measure the elixir in the dropper and stresses the level mark as the meniscus of the fluid
that is observed at eye level.
Angiotensin-converting enzyme (ACE ) inhibitors reduce the afterload on the heart, which
makes it easier for the heart to pump
o Monitor BP before and after administration and observe symptoms of hypotension and
notify HCP if BP is low
o Careful assessment of serum electrolytes and renal function
Beta-Blockers decrease in heart rate, decreases BP and decreases vasodilation
o Monitor BP
o Side effects: dizziness, headaches and hypotension

Diuretics eliminate excess H2O and salt to prevent accumulation

o Furosemide (Lasix):
Drug of choice
Causes excretion of Cl- and K+
o Cholrothizide (Diuril):
can cause hypokalemia, acidosis with large doses
o Spironolactone (Aldactone):
weak diuretic
K+ sparing effect
Takes several days to take effect

Clinical Consequences of Congenital Heart Disease

Care of children after Cardiac Interventions
Monitor BP
Montior

Hematologic Disorders: Chapter 26 (3 questions

Disorder

Pathophysiology

Clinical Manifestation

Nursing Management

Leukemia (ALL
classifications)

Cancer of the lymphoid

progenitor, affecting B or
T cells
Most common in children
3-7
Overproduction of WBCs,
but count is low
These cells do not
deliberately attack,
instead cellular
destruction happens by
infiltration and
subsequent competition
for metabolic elements

Malaise and Fatigue

Fever
Bleeding gums
Lymphadenopathy
Splenomegaly
Petechiae
Weight Loss
Meningitis
Anorexia
Dyspnea

Use of chemotherapeutic agents:

induction therapy, CNS prophylactic
therapy, intensification therapy and
maintenance therapy
Prepare child and family for dx and
therapeutic procedure
Relieve pain, narcotics are adjusted
titrated and administered around th
for best control of pain
Prevent complication of
myelosuprression caused by
chemotherapeutic agents:
Infection: secondary to neutropeni
Nurse must use all measure to cont
transfer of infection, monitored for
infection and elevation in temperat
antibiotics given; adequate proteinintake provides child with better ho
defense against infection and increa
tolerance of chemo therapy. Use of
private room, restrictions of all visit
health personal with active infection
strict, hand-washing technique with
antiseptic solution.
NURSING TIP: The child is not
immunized against live viral vac
(measles, rubella, mumps) until
immune system is capable of
responding appropriately to the
vaccine. Most institutions have
individual guidelines regarding
vaccinations in children underg
immunosuppressive therapy.

Lymphomas
(Hodgkin and NonHodgkins Disease

Increased lymph nodes

Lymphomas are the 3rd
most common group of
malignancies in kids and
adolescents
A group of neoplastic
diseases that arise from
the lymphoid and
hematopoietic systems
Divide into two
HL originates in the
lymphocytes and mainly
involves the lymph
system
Metastasizes to nonnodal
or extralymphatic sites:
spleen, liver, bone
marrow and lungs.

Treatment is chemotherapy for childr

Non-Hodgkin
And for Hodgkins it is chemo and ra
Chemo is for children younger than 3
radiation can be used on children old
3.
Similar to treatment therapy above

Sickle Cell Disease

(SCD)

Includes all the those

Pallor, jaundice
hereditary disorders
Splenomegaly
whose clinical,
hematologic and
Leg ulcers
pathologic features are
related to the presence of
Priapism
HbS.
SCA is a type of SCD
Delayed puberty
Most common genetic
disease world wide
Infection

Record I&O including IV fluids

Childs weight should be taken on

admission to compare to baseline fo
evaluating hydration
Be aware of signs of ACS and CVA
ACS signs:
Wheezing

Acute pain crisis from

infractions of the lung,
kidney, spleen, or
femoral head will also
have fever

Hypoxia

Blindness

Cough

Stroke

Tachypnea

Malnutrition

Chest pain
Fever

CVS signs:
Neurological impairment

SCD (first 2 years):

Dactylitis

Severe anemia

leukocytosis

Paralysis
Vital signs & BP monitor closely for
impeding shock
Narcotics given around the clock

Gastriurinary Disorders: Chapter 27 (7 questions)

Disorder

Pathophysiology

Clinical
Manifestation

Nursing Management

Urinary Tract
Infection

Predisposing Factors:
Short female urethra close to
vagina and anus
Incomplete emptying
bladder, they have stasis:
allows any bacteria that
come from the urethra to
grow
Stasis of reflux, when the
child voids, urine backflows
up the ureters and then flows
back down into the empty
bladder. It sits in the bladder
and then bacteria from the
urethra grow and the next
time the child voids it
happens again, except that
now the urine that was in the
bladder goes into the ureters,
and can then go into the
kidneys.
Over distention of bladder
Concentrated urine
Constipation
E.coli 80%
The key to prevention UTI is
to maintain adequate blood
supply to the bladder wall by
avoidance of over distention
and higher bladder pressure
NURSING ALERT: a child
who exhibits the following
should be evaluated for

Box 27-1
Neonatal Period
(birth-1month):
Poor feeding
Vomiting
Failure to gain
weight
Rapid respiration
(acidosis)
Respiratory
distress
Spontaneous
pneumothorax or
pneumomomedias
tinum
Frequent urination
screaming on
urination
Poor urine stream
Jaundice
Seizures
Dehydration
Enlarged kidneys
or bladder
Infancy (1-24
months)
Poor feeding
Vomiting
Failure to gain
weight
Excessive thirst
Frequent urination

antibiotic therapy should be

administered once pathogen
is identified
Several antibiotics are
specifically used to treat
UTIs:
Penicillins
Sulfonamide
Cephalosporin
Nitrofurnatoion
Surgical correction for
primary reflux or bladder
neck obstruction
When a UTI is suspected
collect a specimen (cleanvoided specimen)
In infants and young
children suprapubic
aspiration of urine or sterile
catheterization should be
done in infants and young
children who are seen with
high fever
Increase fluid intake
Children who have recurrent
UTI might be given low dose
antibiotics, given at bedtime
to allow the drug to remain
in the bladder.
Prevention:
Wipe front to back

Nephrotic
Syndrome

Characterized by increased
glomerular permeability to
plasma protein, which results
in massive urinary protein
loss.
Rare in children younger than
6 months
Uncommon infants younger
than 1 year
Unusual after 8 years
Most common between 2-7
years of age
A loss of protein reduces the
serum albumin level
(hypoalbuminemia),
decreasing colloidal osmotic
pressure in the capillaries.
As a result the vascular
hydrostatic pressure exceeds
the pull of the colloidal
osmotic pressure, causing
fluid to accumulate in the
interstitial spaces (edema)
and body cavities, particularly
in the abdominal cavity
(ascites).
Shift of fluid from the plasma
to the interstitial spaces
reduces vascular fluid
(hypovolemia), which in turn
stimulates the reninangiotensis system and the
secretion of antidiuretic

Refer to chart
below
Edema
Proteinuria
Hypoalbuminemia
Hypercholestolemi
a in the absence
of hematuria and
HTN
Hallmark is
massive
proteinuria
(higher than 2+
on urine dipstick)
GFR is usually
normal or high
Serum protein
concentration is
low
Serum albumin
significantly
reduced
Plasma lipids
elevated
Complications:
Circulatory
insufficiency
secondary to
hypervolemia and
thermo-embolism
Infections that
may be seen in

Refer to chart below

Complications:
Rarely do children develop
renal failure with oliguria
that significantly alters fluid
and electrolyte imbalance
resulting in hyperkalemia,
acidosis, hypocalcaemia, or
hyperphosphatemia
Cerebral complications

Acute
May be a primary event or
Glomerulonephrit
manifested by a systemic
is
disorder
Most cases are post-infection
and have been associated
with pneumococcal,
streptococcal, and viral
infection.
Can occur at any age
Affects early school aged
children with peak age onset
of 6-7 years
Uncommon in children
younger than 2 years
Can occur after a strep
infection with certain strains
Immune complexes are
deposited in the glomerular
basement membrane.
The glomeruli become
edematous and infiltrated with
polymorphonuclear
leukocytes, which occlude
capillary lumen
The resulting decrease in
plasma filtration results in an
excessive plasma and
interstitial fluid volumes,
leading to circulatory
congestion and edema.
HTN due to fluid retention and
renin production

Refer back to
question 1 above
Oliguria
Edema
HTN
Circulatory
congestion
Hematuria
Proteinuria
Sometimes they
only have a
history of mild
cold
Onset appears
after an average
of 10 days
Urinalysis of acute
phase shows
Hematuria
Proteinuria
They usually both
parallel each other
3+ or 4 +
Gross
discoloration of
urine reflects RBC
and hemoglobin
content
Microscopic
reveals many RBC,
leukocytes,

Treated at home if:

Urine output is ok
BP is okay
Treated in a hospital if:
A lot of edema
HTN
Gross hematuria
oliguria

Wilms Tumor

nephroblastoma
most common malignant renal
and intra-abdominal tumor of
childhood
more commonly to occur in
African Americans
peak age of dx is 3 years
probably arises from
malignant , undifferentiated
cluster of primordial cells
capable of intitiating the
regeneration an abnormal
structure
FAVORS the LEFT kidney.
Test used for diagnosis: X-ray,
ultrasounds, CT, CAT scan,
bone marrow biopsy
STAGES OF WILMS TUMOR
Stage I: tumor is limited to
kidney and completely
resected
Stage II: tumor extends
beyond kidney but is
completely resected
Stage III: Residual nonhematogenous tumor is
confined to abdomen
Stage IV: heamatogenous
metastases; deposits are
beyond stage III, namely, to
lung, liver, bone and brain
Stage V: bilateral renal

Abdominal swelling:
Firm
Non-tender
Confined to one
side (L)
Hematuria (less
than one fourth of
cases)
Fatigue and malaise
HTN (occasionally)
Weight loss
Fever
Manifestations
resulting from
compression of
tumor mass
Secondary
metabolic alteration
from tumor or
metastasis
If metastasis
symptoms of lung
involvement:
Dyspnea
Cough
SOB
Chest pain

Nursing Alert: To reinforce

the need for cautions post a
sign on the bed that reads:
DO NOT PALPATE
ABDOMEN. Careful
bathing and handling are
also important in preventing
trauma to the tumor site
Once confirmed, surgery is
scheduled ASAP 24-48 hours
upon admission
As a nurse it is important to
prep parents and children
within this 24-28 hour
period: simple, repetitive
and focused (not much
time)
BP is monitored because
HTN from excess renin
production is possible
Prep parents about
chemotherapy side effects
before surgery and children
after; ie alopecia (hair loss)
Tumor affected kidney and
adjacent adrenal gland are
removed
A large trans-abdominal
incision is performed
Great care is needed to
keep the encapsulated
tumor intact, because if
ruptured it can spread to

Acute Renal
Failure

When kidneys are suddenly

unable to regulate the volume
and composition or urine
appropriately in response to
food and fluid intake
The featured principal is
oliguria, associated with
azotemia, metabolic acidosis,
and diverse electrolyte
disturbances

Specific:
Oliguria
Anuria uncommon
(except in
obstructive
disorders)
Nonspecific (may
develop):
Nausea
Vomiting

Not common in childhood

Drowsiness

Usually reversible

Edema

Severe reduction of GFR, an

elevated BUN level, and
significant reduction in renal
blood flow

HTN

Clinical course is variable and

depends on cause

Manifestations of
underlying disorder
or pathologic
condition

Monitor fluid balance

Monitor vital signs 4-6 hours
Observe for complications
continuously
Blood transfusion is only
recommended if hgb drops
below 6g/dL
May require dialysis
Usually admitted to ICU,
because they require
intensive care.
Limiting fluid intake requires
ingenuity on the caregiver
to cope with the child that is
really thirsty

Rationing the daily fluid

intake in small amounts of
fluid served in containers
In reversible ARF, there is a
Complications:
that give the impression of
period of severe oliguria, or a Hyperkalemia: No
larger volumes is one
low-output phase, followed by
extra K+
strategy.
an abrupt onset of diuresis, or HTN:
a high-output phase, and then
antihypertensive
Older children who
a gradual return (or toward)
drugs
understand the rationale of
normal urine volumes
Anemia:

Nephronic Syndrome

Acute
glomerulonephritis

Clinical
Manifestation

Box 27-2 pg 914

Box27-3 pg 915
Weight gain
Edema
Puffiness of face
Especially
(facial edema)
preorbital
Especially around
Facial edema
the eyes
more prominent
in the morning
Apparent on

Spreads during
arising in the
morning
the day to
involve
Subside during
extremities and
the day
abdomen
Abdominal

Anorexia
swelling (ascites)
Urine
Pleural effusion
Cloudy, smoky
Labial or scrotal
brown
swelling
(resembles tea or
Edema of
cola)
intestinal mucosa,
Severely reduced
possibly causing:
volume
Diarrhea
Pallor
Anorexia
Irritability
Poor intestinal
Lethargy
absorption
Child appearing
Ankle or leg
ill
swelling
Child seldom
Irritability
expresses
Easily fatigued
specific
Lethargic
complaints
BP normal or
Older children
slightly decreased
complaining of
Susceptibility to
Headaches

Nutritional Therapy:
Low-salt diet
Severe cases = fluid
restriction
Nursing
Management

Edema complications =
diuretic therapy initiated to
provide temporary relief
from edema
Due to severe protein loss =
infusion 25% of albumin is
used
Acute infections = tx with
antibiotics
1st line of therapy =
corticosteroids

Moderate sodium
restriction and
fluid if child has
HTN and edema
During periods of
oliguria K+ is
restricted

A record of
daily weight is
the most useful
in for assessing
fluid balance
Acute HTN is
anticipated and
identified early
BP is taken 4-6
hours; HTN and
diuretics are used

Starting dose for prednisone

is usually 2 mg/kg/day for 6 Antibiotics used
to treat children
weeks; followed by 1.5
with evidence of
mg/kg every other day for 6
strep infection, to
weeks
help with
Side effects: weight gain,
spreading it to
rounding of face, behavior
others
changes, and appetite
Note volume and
changes. Long term:

Increasedintercranial Pressure: Chapter 28

Chapter 28: Child with Cerebral Dysfunction 4 Questions
Clinical Manifestations of ICP (box 28-1)
Infants:


Tense, bulging fontanel

Separated cranial sutures-enlarged head *

Macewen (cracked-pot) sign

Irritability and restlessness *

Drowsiness

Increased sleeping
Children:

Headache *

Nausea (sometimes) *

Forceful vomiting *

Diplopia, blurred vision *

Seizures *

Indifference, drowsiness
Late S/S in infants and children

High pitched cry *

Increased frontoocipital circumference
Distended scalp veins *
Poor feeding *
Crying when disturbed
Eyes: setting-sun sign *

Decline in school performance

Diminished physical activity and motor
performance
Increased sleeping
Inability to follow simple commands
Lethargy

Glasgow Coma Scale:

Coma assessment that consists of 3-part assessment eye opening, verbal response and motor response

A score of 15 is the best unaltered level of consciousness (LOC)

A score of 3 is the worse score- extremely decrease LOC

Neuro Examination:
Vital Signs
Skin
Eyes:
Doll Head Maneuver:

Rotate the childs head quickly to one side and to the other.

Normal response: eyes move in the opposite direction

Caloric test (aka oculovestibular test):

Only do when child is unconscious

Irrigate the external auditory canal with 10ml of ice water for 20 seconds

Elicited with childs head up (HOB 30 degrees)

Normal response: movement of eyes toward the side of stimulation

NURSING ALERT(S)

The sudden appearance of a fixed and dilated pupil(s) is a neurologic emergency

Any tests that require head movement are not attempted until after cervical spine injury has been ruled out

The caloric test is painful and is never performed on a child who is awake or on an individual with a ruptured
tympanic membrane

Motor Function
Posturing:

Flexion

Extension
Reflexes:
NURSING ALERT

3 key reflexes that demonstrate neurologic health in young infants are the: Moro, tonic neck and withdrawal
reflexes
Procedures:

Lumbar puncture is contraindicated when there is a suspicion of ICP

Nursing Care of the Unconscious Child

Emergency measures are directed toward ensuring

o
Patent airway (breathing) and circulation
o
Treating shock (stabilizing the spine)
o
Reduce ICP

Continual observation of LOC

DRUG ALERT:

When opioids are used, bowel elimination must be closely monitored because of the potential constipating effect.
Stool softeners should be given with laxatives as needed to prevent constipation

NURSING ALERT
o
Respiratory obstruction and subsequent compromise leads to cardiac arrest. Maintaining an adequate,
patent airway is of the utmost importance
NURSING ALERT:
o
The HOB is elevated to 30 degrees, and the child is positioned, so that the head is maintained in
midline to facilitate venous drainage and avoid jugular compression. Turning side to side is
contraindicated because of the risk of jugular compression.

Hypoxia and the Valsalva maneuver can increase ICP

Suctioning in contraindicated, unless it is necessary; Make sure it is brief and preceded by hyperventilation with
100% O2. If suctioning, oxygenate prior to suctioning. Suctioning should be brief. Increase in intrathoracic
abdominal pressure will be transmitted to the cranium. Avoid neck vein compression

Make sure to watch for overhydration, it can cause cerebral edema

Antipyretic agents are usually not effective, therefore external cooling should be used, which consists of
evaporation (sponge baths), conduction (ice packs, cooling blankets), convection (fans), and radiation (skin
exposure)
Mouth care is performed at least 2X a day, because the mouth tends to get dry coated with mucus. Clean teeth
with soft toothbrush or clean with gauze-saturated saline. Chap stick for lip (make sure it is not an oil based
product.
NURSING ALERT:
o The eyes should be examined regularly and carefully for early signs of irritation or inflammation.
Artificial tears or a lubricating ointment is placed in the eyes every 1-2 hours. Eye dressings may
be necessary to protect the eyes from possible damage

HEAD INJURY:

3 major causes: Falls, Motor Vehicle Injuries and Bicycle or sports related injuries

Contrecoup = know that a child can have injury on the opposite side of injury
Clinical Manifestations (BOX 28-3)
Minor Injury:

May or may not lose consciousness

Transient period of confusion

Somnolence

Listlessness
Signs of progression:

Altered mental status (difficulty arousing

child)

Mounting agitation
Sever Injury:

Signs of increased intracranial pressure

(box 28-1)

Bulging fontanel (infant)

Retinal hemorrhages

Extraocular palsies (especially CNIII)

Associated Signs

Scalp trauma

Other injuries (to extremities)

Major complications of Heady Injury

Irritability
Pallor
Vomiting (one or more episodes

Development of focal lateral neurologic

signs
Marked changes in vital signs

Hemiparesis
Quadriplegia
Elevated temperature
Unsteady gait
papilledema

Hemorrhage
Infection
Cerebral Edema
Herniation
Bradycardia
Decreased motor response to command
Decreased sensory response to painful stimuli
Alterations in pupil size and reactivity
Extension or flexion posturing
Cheyne-Strokes respiration
Papilledema
Decreased consciousness
Comma

NURSING ALERT (S)

Posttraumatic meningitis should be suspected in children with increasing drowsiness and fever who also have
basilar skull fractures

Children with subdural hematoma and retina hemorrhages should be evaluated for the possibility of child
abuse, especially shaken baby syndrome

Stabilize a childs spine after head injury until spinal cord injury is ruled out

Deep, rapid, periodic or intermittent and gasping respirations; wide fluctuations or noticeable slowing of the
pulse: and widening pulse pressure or extreme fluctuations in BP are signs of brainstem involvement.. Note that
the marked hypotension may represent internal injuries

Observation of asymmetric pupils or one dilated, nonreactive pupil in a comatose child is a neurologic
emergency

Bleeding from the nose or ears needs further evaluation, and watery discharge from the nose
(rhinorrhea) that is positive for glucose (as tested with Dextrostix) suggest leaking of CSF from skull
fracture
Nursing Considerations/Treatment

NPO or restricted to clear liquids, until vomiting does not occur

IV fluids for comatose child, or continuously vomiting

Daily weight

I&Os

Serum osmolality to detect early s/s of: H2O retention, excessive dehydration, and states of hypertonicity or
hypotonicity

Neurological assessment, most important is LOC assessment; try to have by one single observer, so they
can notice any slow changes
Safety Measures: side rails up, seizure precautions
Provide a quiet environment
Provide sedation and analgesic for child
Report any seizure
Document drainage of any orifice
Suture for lacerations
Antiepileptic for seizures
Antibiotics if lacerations or CSF leakage

NURSING ALERT:

Suctioning through the nares is contraindicated because of the risk if the catheter entering the brain parenchyma
through a fracture in the skull
Teaching

Check child every 2 hours, if child is asleep wake them up

s/s of increased ICP

no narcotics or pain medication, report HCP

Vomiting could be a sign of ICP, contact HCP

Bacterial Meningitis
Prevention:

Immunization of Hib
Nursing Consideration:

Keep room quiet

Keep environmental stimuli to a minimum

HOB slightly elevated

Side lying positioning

Evaluate for pain (acetaminophen with codeine); Careful to evaluate patient for a fever before administration,
because this can the fever go away and a fever is an indicator of infection

Vital signs

Promote adequate fluid and nutritional status

Observation of VS, neurological signs, LOC, I&Os

Frequent assessment of open fontanels

Maintaining IV infusion for antibiotic therapy

Isolation Precautions
NURSING ALERT:

A major priority of care of a child suspected of having meningitis is to administer antibiotics ASAP. The
child is placed on respiratory isolation for at least 24 hours after initiation of antimicrobial medication

Endocrine System: Chapter 29 (5 questions)

o
o
o

o
o
o

Type 1: destruction of pancreatic beta cells, which produce insulin; this usually
leads to absolute insulin deficiency.
Abrupt onset
<20 years
3Ps: polyuria, polydipsia, polyphagia and underweight; others: blurred vision and
fatigue
Type 2: usually arises because of insulin resistance in which the body fails to use
insulin properly combined with relative (rather than absolute) insulin deficiency
Gradual onset
Adults, but increasing in children
Presenting symptoms may be r/t long term complications, overweight
Nursing Considerations/Treatment

Type 1 replacement of insulin that the child can not produce

Types of insulin:
Rapid acting: (Novolog, Lispiro)
Onset 15 minutes
Peak 30-90 min
Duration
Short aciting (Novolin R.)
Onset 30 min
Peak 2-4 hours
Duration
Administer 30 mintues before meals
Intermediate-acting (Novolin NPH)
Onset 2-6 hours
Peak 4-14 hours
Duration 14-20 hours
Long-acting (Lantus)
Onset 6-14 hours
Peak 10-16 hours (no peak)
Duration All day
Nursing Consideration/Treatment:
NURSING ALERT:
Hypoglycemic episodes most commonly occur before meals or when the insulin effect
is peaking
Hypoglycemic s/s: pallor, tremulosness, palpations, , sweating, hunger, weakness,
dizziness, headache.etc REMEMBER cold and clamy give some candy
Give a 10-15 g simple carb (1 TBS of sugar) , followed by a complex carb and a
protein (slice of bread or cracker and protein such as PB or milk
Glucagon functions by releasing stored glycogen from the liver and requires about
15-20 minutes to elevate the blood glucose levels
Teaching
Timing of food consumption must be regulated to correspond to the timing and action
of the insulin prescribed
Extra food is needed for increased activity
Concentrated sweets are discouraged
Fat is recommended to be reduced to 30% or less of total caloric requirement
Intake of dietary fiber

Exercise lowers blood glucose levels, if exercised is unplanned one can compensate
by providing extra snack. If person is exercising consistently then insulin can be
reduced

Integumentary System: Chapter 30 (3 questions)

Relief of pruiurits by cooling the affected area and increasing the skin pH with
cool baths or compresses and alkaline applications (baking soda baths)

Clothing and bed linen should be soft and lightweight to decrease the irritant
from friction and stimulation

Keeping fingernails short and trimmed reduce the risk for secondary
infections

Antipyretic medications can be prescribed for sever itching, especially if it

disrupts rest
NURSING ALERTS

Application of heat tends to aggravate most conditions and its use is usually
reserved for reducing inflammatory process, such as folliculitis and cellulitis

Signs of wound infections are

Increased erythema, especially
o
Pain
beyond the would margin
o
Increased temperature
Edema
Purulent exudate
Do not put anything in a wound that you would not put in an eye. The safest solution
is normal saline
Advise parents that the yellow gel forming under hydrocolloid dressings may look like
pus and has a distinct odor (somewhat fruity) but is normal leakage
Provide written instructions and demonstrate to parent the correct amount of topical
medication to apply. If more than one prescription is applied, mark the containers
with numbers so the parents remember the correct order of application. Stress that
more is not necessarily better with some medications such as steroids
IV drugs are more likely to cause a reaction than oral drugs, Stop the drug but
maintain the infusion with normal saline

o
o
o

Neuroskeletal System: Chapter 31 (2 questions)

Immobilization:
Inactivity leads to a decrease in the functional capabilities of the whole body
as dramatically as the lack of physical exercise leads to muscle weakness

Most of the pathological changes that occur during immobilization arise from
decreased muscle strength and mass, decreased metabolism, and bone
demineralizations

The daily stress on bone created by motion and weight bearing maintain the
balance between bone formation and reabsorption
Nursing Care/ treatment

Systems that can be affected secondarily circulatory, respiratory, renal,

muscular, GI systems

With long-term immobilization there may be neurological impairment, and

changes in electrolytes (especially calcium), nitrogen balance, and the
general metabolic rate

Prevent skin breakdown placed on a pressure-reduction mattress to prevent

skin breakdown,

Can use the Braden Q scale in the assessment for pressure ulcer
development for children at risk for kin breakdown

Antiembolism stockings or intermittent compression devices

Anticoagulant therapy

Diet: high protein, high caloric foods are encourage to prevent negative
nitrogen balance if there is anorexia due to decrease in GI mobility

Nasogastric or gastrostomy feedings or IV fluids may be needed to maintain

nutrition

When possible upright position

Have child associate with others by increasing environmental stimuli and

allowing social contact with others

Use dolls or stuffed animals to illustrate and explain immobilization methods

Have them participate in their own care

Growth Plate (Physeal) Injuries

It is the weakest point of the cartilage; therefore it is a frequent site of
damage during trauma. It is important because it may affect future bone
growth.
Clinical Manifestation (BOX 31-2)
Signs of injury:
Generalized swelling

Deformity
Pain or tenderness

Diminished functional use of affected

limb or digit
May also demonstrate:

Bruising

Crepitus (grating sensation at

a fracture site)

Severe muscular` rigidity

NURSING ALERT

A fracture should be strongly suspected in a small child who refuses to walk

or crawl
Nursing Consideration/Treatment

Goal:
o To regain alignment and length of the bony fractures (reduction)

o To retain alignment and length (immobilization)

o To restore function to the injured parts
o To prevent further injury and deformity

Fractures are splinted or casted to immobilize and protect the injured

extremity

EMERGENCY TREATMENT (pg. 1059):

o
Determine the mechanism of injury
o
Assess the 6Ps
o
Move the injured part as little as possible
o
Cover open wounds with sterile or clean dressing
o
Immobilize the limb, including joints above and below the fracture
site; do not attempt to reduce the fracture or push protruding bone
under the skin.
o
Use a soft splint (pillow or folded towel) or rigid splint (rolled
newspaper or magazine)
o
Uninjured leg can serve as a splint for leg fracture if no splint is
available
o
Reassess neurovascular status
o
Apply traction if circulatory compromise is present
o
Elevate the injured limb if possible
o
Apply cold to the injured area
o
Call emergency medical services or transport to medical facility
NURSING ALERT:

Compartment syndrome is a serious complication that results from

compression of nerves, blood vessels, and muscle inside a closed space. The
injury may be devastating, resulting in tissue death, and this requires
emergency treatment (fasciotomy). The 6Ps of ischemia from a vascular, soft
tissue, nerve, or bone injury should be included in an assessment of any
injury:
o
o
o
o
o
o

Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Pressure

The Child in a Cast

Cast Application:

Consider the childs developmental stage before

o
Preschool: use a plastic doll or stuffed animal to explain procedure
o
Let them know what to expect: like that it will get warm during
application
o
Use distracting methods: like blowing bubbles, asking them questions
that focus on them etc

Turn child every 2 hours to help dry body cast evenly

Support a plaster cast with a pillow, and handle with palms of hands

Hot spots felt or foul smelling odor can indicate infection

NURSING ALERTS:

Heated fans or dryers are not used because they cause the cast to dry on the
outside and remain wet beneath or cause burns from heat conduction by way
of the cast to the underlying tissue

Cast

Observations such as pain (unrelieved by pain medication 1 hour after

administration, especially with passive ROM), swelling, discoloration (pallor,
cyanosis) of the exposed portions, decreased temperature, paresthesia, or
the inability to move the distal exposed part(s) should be reported ASAP.
Pallor, paralysis, and pulselessness are late signs.
LOOK at Family Centered Care-Cast Care PG 1061
Feeding a child in a hip-spica cast supine with head elevated;
Children in spica cast usually find prone position easier for self feeding
Removal
Explain what the child should expect, tickling sensation and heat may be felt.
Reassurance that it will be okay, let them keep cast at the end (if they want
to)
Teach them that they can use mineral oil or lotion to remove particles left
behind.

evelopmental Dysplasia of the Hip:

A spectrum of disorders related to abnormal development of the hip that may

occur at any time during fetal life, infancy or childhood.
Diagnostic Testings (LOOK at pg 1069):

Ortonali
o
Involves abducting the thighs to test for hip subluxation or dislocation
o
With clunk elicited (infants < 4 weeks)
o
Positive test hip reduced by abduction

Barlow Test
o
Thighs are adducted
o
Positive test hip is dislocated by adduction

Clinical Manifestations:
Infants

Asymmetry of gluteal and

Shortening of the limb on the

thigh folds
affected side

Limited abduction (as seen in

Broadening of the perineum

flexion)
(in a bilateral dislocation)

Apparent shortening of the

Decreased hip abduction

femur (level of knee flexion)
Older Infants:
Affected leg appears shorter than the other
Telescoping or piston mobility of joint-head femur felt to move up and down in
buttock when extended thigh is pushed first toward childs head and then pulled
distally
Trendelenburg sign-When child stands first on one foot and then on the other
(holding onto a chair, rail) bearing weight on affected hip, pelvis tilts downward on
normal side instead of upward, as it would with normal stability
Greater trochanter prominent and appearing above a line from anterosuperior iliac
spine to tuberosity of ischium

o
o
o
o
o

Marked lordosis and waddling gait (bilateral hip dislocation)

Nursing Consideration/Treatment
Major problem is the maintenance of the device and adaptations with child
and/parent
NB-6months
Pavlik Harness,
Hip in an abducted, reduced position
Worn continuously until the hip is proved stable on clinical and ultrasound
examination, usually for 6-12 weeks
Since infants grow rapidly, the straps should be checked weekly for adjustments
(parents are not allowed to adjust it)
Removing depends on the providers recommendation, which will be based on the
deformity and family level of understanding
Skin care to prevent breakdown are very IMPORTANT
Always put on undershirts (or a shirt with extension that close at the crotch) under
the chest straps and put knee socks under the foot pieces to prevent the straps from
subbing the skin
Check frequently (at least 2-3X a day) for red areas under the straps and the clothing
Gentle massage healthy skin under the straps once a day to stimulate circulation, In
general avoid lotions and powders, because they can cake and irritate the skin
Always place the diaper under the straps
Other devices are used for adduction contracture is present
When there is difficulty maintain stable reduction, a hip spica cast is used and
changed periodical to accommodate the childs growth.
Duration of treatment on the development of the acetabulum, but is usually
accomplished within the 1st year
6-24 months
Surgical closed reduction is performed
Spica cast for almost 12 weeks OR a abduction orthosis may be used
Open reduction is performed if hip remains unstable
Older Children
More difficult to accomplish in this age group, the older the child gets the harder it is
to reconstruct
Requires several procedures, and complete reconstruct
NURSING ALERT:

The former practice of double or triple diapering for DDH is not recommended
because there is no evidence to support its efficacy.

Clubfoot
A complex deformity of the ankle and foot that includes forefoot adduction,
midfoot supination, hindfoot varus, and ankle equinus
Nursing Consideration/Treatment

Goal is to achieve: painless, plantigrade, & stable foot

Ponseti method; Serial casting is stared right after birth

Weekly gentle manipulation and serial long-leg cast allow for gradual
repositioning of the foot.

Extremities are casted until maximum correction is achieved can take 6-10
weeks

Then tenotomy is performed

Then long-leg cast is performed and left for 3 weeks

Ponseti sandals or straight-laced shoes placed in abduction are then

fitted to prevent recurrence

Inability to achieve normal foot alignment after casting and tenotomy

indicates the need for surgical intervention

Parent Teaching:

Understand the importance of regular cast changes, and the role they play in
the long-term effectiveness of the therapy

Teach parent care of the cast appliances

Osteogenesis Imperfecta
Osteoporosis syndrome in children
Heterogeneous inherited disorder of connective tissue
Defective periosteal bone formation and reduced cortical thickness of
bones
Nursing Consideration/Treatment

Primarly supportive

Bisphiosphonate therapy with IV pamidronate to promote increased bone

density and prevent fractures has become standard therapy for many
children (however, long bones are weekend by prolonged treatment

Lightweight braces and splints help support limbs, prevent fractures and help
to get around

Physical therapy

Surgery to treat manifestations

Parent Teaching

Require careful handling to prevent fractures: supported when being turned,

positioned, moved, held. Never hold by the ankles when diapered, instead lift
by the buttocks or support with pillow

Education regarding childs limitation, and suitable activities

Occupational planning

Genetic counseling
NURSING ALERT:

Children with multiple fractures should be screened for OI. The possibility
that non-accidental trauma is the cause of the fracture in children must be
carefully elevated by a multidisciplinary team

Slipped Capital Femoral Epiphysis

Spontaneous displacement of the proximal femoral epiphysis in a posterior
and inferior direction

Develops before or during accelerated growth (puberty)

Clinical Manifestation (BOX 31-8)

Very often obese (body mass index >95%)

Limp on affected side

Possible inability to bear weight because of sever pain

Pain in groin, thigh or knee

o
May be acute, chronic or acute-on-chronic
o
Continuous or intermittent

Affected leg is externally rotated

Loss of abduction and internal rotation as severity increases


Shortening of lower extremity
Nursing Consideration

Non-weight bearing to prevent further slippage

Surgery within 24 hours of dx (depends on the surgeon

Surgical pinning in situ involves the placement of a single pin or multiple pin
s and scres through the femoral neck osteotomy for deformity

Hip arthroscopy before situ pinning in shown to decrease pain and allow early
hip movement

Postsurgical care includes NON-WEIGHT bearing with CRUTCH AMBULATION

until painless ROM

Postop care involves hemodynamic stabilization and assessment for

complication
NURSING ALERT:

Children with hip issues such as Legg-Calve-Perthes or SCFE often present

with groin, thigh or knee pain. This is often because of referred pain and is
anatomically related to the obturator nerve. Any time a child presents with
groin, thigh, or knee pain a complete hip examination is paramount to rule
out underlying hip pathology

Osteomyelitis

o
o
o
o

o
o
o
o

Infectious process in the bone tissue

Can be caused by hematogenous sources and exogenous sources

Clinical Manifestations

General
Possible history of trauma to affected
bone
Child appears very ill
Irritability
Local
Tenderness
Increased warmth
Diffuse swelling over involved bone
Involved extremity painful, especially
on movement

o
o
o
o

Restlessness
Elevated Temperature
Rapid Pulse
Dehydration

o
o

Involved extremity held in semi flexion

Surrounding muscles tens and
resistant to passive movement

Nursing Consideration/Treatment

Collect culture

Start empiric antibiotics

When the infectious agent is identified, continue antibiotic treatment for 3-4
weeks (6 wks-4 months sometimes)

Monitor hematologic, renal, hepatic, ototoxic side effects

To prevent antibiotics-associated diarrhea in some children, administer a

probiotic

Position comfortably with affected limb supported

Temporary splint or cast may be applied

Avoid weight-bearing in the acute phase

Child may require long-term pain medication to deal with bone pain

Carful observation of IV equipment and site (PICC line can be inserted for long
term antibiotics)

Implement standard precautions: wound care to prevent infection

Provide child with activities for those confined to bed for some time during
the acute phase, but may be allowed to move on a stretcher or wheelchair if
isolation is not necessary. Mainly the child will have complete bed rest and
immobility of limb

Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis)

A chronic autoimmune inflammatory disease causing inflammation of joints

and other tissue with an unknown cause
Chronic inflammation of the synovium with joint effusion and eventual
erosion, destruction, and fibrosis of the articular cartilage
Chronic and acute uveitis can cause permanent vision loss if undiagnosed
and not aggressively treated; Uveitis is unique to JIA

Clinical Manifestations

Arthritis tends to wax and

wane (increase and then
decrease); s/s increase with
stressors

Joint deformity

Functional disability

Stiffness

Swelling
Loss of mobility in affected
joints
Warm to touch, usually
erythema
Tender to touch in some cases
Growth retardation

Nursing Consideration/Treatment

GOAL: control pain, preserve joint ROM, minimize effects of inflammation

such as joint deformity and promote normal growth and development

Drugs therapy (opioid analgesics are usually avoided):

o
NSAIDs
Teach parent not to give on an empty stomach
o
Methotrexate (in combination with NSAIDs)
Monitor CBC and liver function
Patient education on birth defects
Teach teens to avoid alcohol
o
Corticosteroids
PO, IV, eye drop for UVEITIS
Teach about long term effects: Cushing syndrome,
osteoporosis, increased infection risk, glucose intolerance,
cataracts and growth suppression
o
Biologic agents
Teach about Side effects: increased risk for infection, rare
reports about demyelinating disease and pancytopenia, and
allergic reaction
Because of the infection risk, evaluate child for TB exposure

Physical and Occupational Therapy

Caloric intake needs to match energy needs to avoid weight gain, if child is
inactive

Sleep and rest

Firm mattress, electric blanket, or sleeping bag helps provide warmth,

comfort and rest

Nighttime splints to help maintain ROM (splint should not be painful or

impede sleep)

Well-child care to assess growth, development, and immunization

requirements needs to be coordinated between the primary care provider and
rheumatologist

Seek medical attention ASAP for other illnesses (like URI) to prevent arthritis
flare ups

School nurse should be aware, and notified of childs condition (child needs to
take medication and, come in to rest if needed)

A formal school hearing may be necessary to obtain an Individualized

Education Program, ensured by public law, which includes intensive school
modifications

Moist heat is best for relieving pain and stiffness

Bathtub with warm water

Also daily whirlpool bath, paraffin bath or hotpacks prn for acute swelling and
pain

hotpacks applied using a bath towel wrung out after being immersed in hot
water or headed in a microwave oven-apply to area and cover with plastic for
20 minutes

painful hands or feet can be immersed in a pan of warm water for 10 minutes
2-3 X daily

pool therapy best and easiest for exercise

You want the child to perform ADLs on their own; therefore, advise to use
helpful devices, self-adhering fasteners, tongs for manipulating difficult
objects, grab bars installed in bathrooms for safety, and raised (higher) toilet
seat

Parent Teaching

Begin the day by waking up the child early, administering medication and
then letting them sleep for an hour

Take a hot bath (or shower)

Perform a simple ritual of limbering-up-exercise

Exercise, heat and rest are spaced throughout the day

Neuromuscular System: Chapter 32 (3 questions)

Cerebral Palsy:

Group of permanent disorders of the development of movement and posture,

causing activity limitation, that are attributed to non-progressive disturbances that
occurred in the developing fetal or infant brain

Other medical disorders associated: mental impairment, seizures or epilepsy, growth

problems, impaired vision or hearing and abnormal sensation or perception

Many develop the condion during prenatal development or childbirth, very few
afterwards
Nursing Considerations/Treatment

Supportive

Since jaw control in often compromised, more normal control can be

achieved if the feeder provides stability of the oral mechanism from the
side or front of face

Safety precautions are implemented, such as having child wear protective helmets if
they are subject to falls or capable of injuring their heads on hard objects

Home and environment should be adapted to their need to prevent bodily harm

Administer appropriate immunizations to prevent childhood illnesses and protect

against respiratory infection: influenza, pneumonia

Dental problems, dental care is very important

Federally approved safety restraint should be used at all times in cars, and
recommended for them to ride in the back of car in a rear facing position

Physical, speech and occupational therapy

Use devices that will help with ADLs, and make sure the patient does as much as
possible. Since they might get tired offer frequent rest periods.
Nursing Alert:

Mobile infant walkers are discouraged in children with CP. They pose a risk for
injury
Spina Bifida:

Midline defects involving failure to the osseous (bony) spine to close

Can be prevented if the mother takes folic acid (should be taken by all females of
who are capable of getting pregnant
Nursing Consideration/Treatment

Assess infant for level of neurological involvement

Movement of extremities or skin response, especially an anal reflex that might

provide clues to the degree of motor or sensory impairment

Observation of urinary output

Abdominal distention revealing bladder distention

The head circumference is measured daily and the fontanels are examined for sings
of tension or bilging

Infant is placed in an incubator or warmer so temperature can be maintained without

clothing or covers that might irritate the spinal lesion

When an overhead warmer is use, dressings over defect requires more moistening,
because of the dehydrating effects of radiation heat

Sterile normal saline, moist, nonadherent dressing over defect

Sac must be carefully cleansed if it becomes soiled or contaminated

Positioning the child is important; the child must be kept in the prone position to
minimize tension on the sac and the risk for trauma; prone with hips slightly flexed

and supported to reduce tension on the defect. Put a pad between the knees to
counteract hip subluxation
Turn infants head for feedings
Prone position is maintained after surgical closure, although many neurosurgeons
allow a side-lying or partial side lying position
Children with SB are at high risk for developing latex allergies, because of repeated
exposure to latex products during surgery and procedures-need a latex free
enviornment

NURSING ALERT:
Observe for early signs of infection, such as temperature instability (axillary), irritability,
and lethargy, and for signs of increased intracranial pressure, which might indicate
developing hydrocephalus.
Duchenne Muscular Dystrophy

Most severe and most common muscular dysfunction in childhood

Inherited as an X-linked recessive trait and the single-gene defect

High mutation rate with a positive family history in 65%

Genetic counseling

Early onset, usually between 3-7 years of age

Progressive muscular weakness, wasting and contractures

Calf muscle hypertrophy in most patients

Loss of independent ambulation by 6-12 years of age

Slowly progressive, generalized weakness during teenage years.

Clinical Manifestations:
Relentless progression of muscle weakness, possible death from respiratory or
cardiac failure
Waddling gait
Lordosis
Frequent falls
Gower sign: child turns onto side or abdomen; flexes knees to assume a kneeling
potions; and then with knees extended, gradually pushes torso to an upright position
by walking the hands up the legs
Enlarged muscles especially calves, thighs and upper arms; feel usually firm
or woody on palpation
Later stage: profound muscular atrophy
Mental deficiency
Complications:
o Contracture deformities of hips, knees, and ankles
o Disuse atrophy
o Cardiomyopathy
o Obesity and at times under nutrition
o Respiratory compromise and cardiac failure