SELECTED

PEDIATRIC
DISEASES
 Respiratory Anatomy &
Physiology
• The respiratory system consists of two main parts- the
upper and the lower tracts
 Respiratory Anatomy &
Physiology
The UPPER respiratory system consists of:
• 1. nose
• 2. sinuses
• 3. mouth
• 4. pharynx
• 5. larynx
• 6. epiglottis
UPPER RESPIRATORY
TRACT INFECTION
ACUTE NASOPHARYNGITIS
(CORYZA)
• Most frequent infectious
disease in children
• Average of 10-12 colds/
year
• Incubation period- 2-3
days
• The COMMON COLDS
 ETIOLOGIC AGENT
1. Rhinovirus-most common cause
2. Parainfluenza virus
3. Respiratory syncytial virus (RSV)
4. Adenovirus
5. Influenza virus
6. Coxsackie virus
 SIGNS AND SYMPTOMS
1. nasal congestion
2. watery rhinitis
3. low grade fever
4. mucus membrane is edematous
5. cervical lymph node may be swollen and
palpable
6. body malaise
 TREATMENT
• Common colds is self-limiting
• supportive care
• relief of nasal obstruction - use of
isotonic saline drops and aspiration
• antipyretic or analgesic agents
• antitussive is sometimes used for
persistent cough
 Streptococcal
Pharyngitis
• Strep throat
• Spread by infected nose or throat mucus
through coughing or sneezing

S/sx: pain on swallowing, fever, headache,

swollen lymph nodes, swollen hyperemic
tonsils w/ OR w/out pus

Dx: throat SWAB and culture & sensitivity

Group A beta-Hemolytic Streptococcal
Bacteria – Gram (+) bacteria
 TREATMENT & MANAGEMENT
PHARYNGITIS
1. antibiotics- 10 day-course of oral antibiotics
(Pen G or Clindamycin)
2. high fluid intake
3. relief of pain

• COMPLICATION: Rheumatic Fever, Rheumatic

Heart Disease, Acute Glomerulonephritis
 TONSILLITIS
term commonly used to refer to infection and
inflammation of palatine tonsils
palatine tonsils - located on both side of pharynx
Adenitis - refers to infection and inflammation of the
adenoids ( pharyngeal) tonsils
adenoids - located in the nasopharynx
Tubal tonsils - located at entrance to the Eustachian
tube
Lingual tonsils - located at base of tongue
 ETIOLOGY
• <3 years old - often viral
• school age children – often
bacterial
 Signs and Symptoms
1. difficulty of swallowing (dysphagia)
2. painful swallowing (odynophagia)
3. fever
4. lethargy
5. mouth breathing
6. difficulty hearing (Eustachian tube)
7. halitosis
8. sleep apnea
 TREATMENT
1. antipyretic
2. analgesics
3. Antibiotics ( 10 day course – usually Penicillin
but may be Erythromycin if allergic to penicillin)
is prescribed for bacterial infections to prevent
the complication of rheumatic fever.
4. Surgical – tonsillectomy with adenoidectomy
 INDICATIONS FOR
TONSILLECTOMY
1. chronic tonsillitis (not done if inflamed
because may spread infection)
2. Recurrent tonsillitis (4-6x/year)
3. Peritonsillar Abscess
4. Sleep apnea

Nursing diagnosis: Pain related to Surgical

Procedure
 TONSILLECTOMY
Post –op Care:
• 1. Observe for, & report unusual bleeding
( frequent swallowing)
• 2. Help prevent bleeding by discouraging the
child from coughing & clearing the throat.
• 3. Position the child on the side or the abdomen
(prone) to facilitate drainage from the throat
 TONSILLECTOMY
• 4. Provide appropriate teaching . Instruct the
child & parents to:
• a. Observe activity restrictions, especially
upon the child’s return to school.
• b. Avoid persons with known infections.
• c. Avoid acidic & other irritating foods.
• d. Monitor the child for bleeding, especially
immediately postoperatively & 5 to 10 days
post op when tissue sloughing occurs.
 EPISTAXIS
1. keep pt in upright position with head tilted
slightly forward to minimize the amount of
blood pressure in nasal vessels, keep blood
moving forward not back to nasopharynx

2. apply pressure to the side of the nose with

your fingers, may have ice compress
 EPISTAXIS
3. Ask the child to stop crying because crying
increases pressure in the blood vessels of
the head and prolonged bleeding
4. control of bleeding, can give epinephrine
(1:1000) to constrict blood vessels
5. can put nasal packing for continuous
pressure on the site of the ruptured blood
vessel
Epiglottitis
• Inflammation of epiglottis
("cherry-red“)

• Hemophilus influenza type

B

• 2-7 yo

Pathophx: upper respiratory

infection inflammation
of epiglottis
 EPIGLOTTITIS
S/sx: high fever, sore throat, cough hoarseness,
drooling, dysphagia

Dx: CBC, elevated c-reactive protein (CRP),

culture of epiglottis, neck xray

> it is considered an emergency because the

swollen epiglottis is not allowing the airway to
open.
- this emergency situation occurs most commonly in
children between 3 and 6 years of age.
 EPIGLOTTITIS

NURSE ALERT!!! “ Never illicit

gag reflex-may cause complete
obstruction”
Nsg Dx:

Ineffective breathing pattern r/t inflammation

Ineffective airway clearance r/t inflammation
Parental anxiety r/t respiratory distress in child

MANAGEMENT
• Emergency treatment (intubation)
• Moist air
• hydration
• O2
• Antibiotics – chloramphenicol, co-amoxiclav
• Assurance to avoid agitation
LOWER RESPIRATORY
TRACT INFECTION
Respiratory Anatomy & Physiology

The LOWER respiratory system consists

of:
• 1. Trachea
• 2. Bronchus
• 3. Bronchioles
• 4. Respiratory unit
 The BRONCHI
• RIGHT BRONCHUS • LEFT BRONCHUS

• Wider • Narrower
• Shorter • Longer
• More Vertical • More horizontal
 Retraction
• Supraclavicular/ Suprasternal retraction -
suggest upper airway obstruction

• intercostal retraction- suggest lower airway

obstruction
 Bronchitis

• Inflammation of bronchi
• Starts as URTI

S/sx:
• initially low grade fever, colds
• 3-4 days after, roughening breath sounds, rales, dry,
hacking unproductive cough
• Cough w/ sputum production - clear to purulent,
dyspnea, chest pain
 BRONCHITIS
Dx: clinical
Elevated C-reactive protein (CRP) –
bacterial

Mgmt:
rest
CPT
Fluids
antibiotics
 Bronchitis
Viral Bacterial
Etio Rhinovirus,Influenza, S. pneumoniae,
RSV, Parainfluenza S. aureus,
adenovirus, paramyxovirus H. Influenzae,
M. Catarrhalis

S/sx Rhinitis, cough, malaise, higher fever and a more prod

chills, mild fever, sore cough
throat
Dx Clinical Elev c-reactive CHON
Xray – normal

Course Mild & self-limiting Up to 2 weeks

Rx supportive empirical; amox-
tetracycline,
erythromycin
 Bronchiolitis
• inflammation & swelling of bronchioles w/
mucous in airways

• RSV,parainfluenza, Adenovirus, influenza

• 0-2 yo, peak 6 mos old

• transmitted via droplets

 BRONCHIOLITIS
Pathophx:
mild upper respiratory infection edema of airway and
accumulation of mucus airway narrowing
hypoxemia

S/sx: wheezing, tachypnea, wet hoarse cough, fever,

poor appetite, difficulty sucking, restless sleep,
retractions

Dx: cxr, pulse oximetry, throat culture

 BRONCHIAL ASTHMA
• chronic, reversible , obstructive airway disease,
characterized by wheezing. It is caused by smooth
muscle spasm w/ hypertrophy of the bronchial tubes, or
swelling of the bronchial mucosa, after exposure to
various stimuli.
 Hypersecretion of mucus
 Most common chronic disease in childhood. Most children
experience their first sx by 5yo
• exercise, nocturnal occurrence, seasonal, hx of allergy, stress
 Types of Bronchial Asthma

A. Extrinsic or Atopic Asthma: r/t external allergens such

as:
• -contactants: dust, chemicals, soaps, perfumes, lotions,
make-up
• -inhalants: dust, hay, scents, smoke, sprays
• -ingestants: food, milk, chicken, beef, pork, eggs, etc.
• -Sudden changes in temperature
 Types of Bronchial Asthma

B. Intrinsic or Non-Atopic Asthma= not r/t external

allergens
Stress
Fatigue
Lack of Sleep
Anxiety
C. MIXED type of Asthma= both types present
 Pathophysiology of Asthma
• Heredity + Allergens &/or Stress

• Release of IgE from B lymphocytes

• IgE + Mast cells of respiratory tract = damage to mast cells

• Release of: Histamine, Bradykinin, Serotonin,

Leukotriennes, Prostaglandins, ECF-A, SRS-A from
damaged mast cells to respiratory membranes
 Bronchial Asthma
• =S-ecretions: copious, viscous, sticky, stringy, whitish
• =S-pasms: laryngo-tracheo-bronchial spasm
• =S-welling: edema of the airway

• Airway Obstruction

•
Dyspnea
Signs & Symptoms of Bronchial
Asthma
• Successive episodes of coughing: dry, hacking,
non-productive cough
• Increased respiratory secretions: whitish, stringy
• Wheezing on expiration
• Prolonged expiration
• Dry lips and mucous membranes (mouth)
• Dyspnea, Tachypnea, Tachycardia
• Apprehension and restlessness
 Nursing Interventions

Long-term Goal: Patient will achieve an open airway

and adequate ventilation as manifested by
normal VS and relief of symptoms
Short-term Goal:
a. Liquify secretions
b. Easily expectorate and drain secretions
c. Relieve spasms
d. Decrease swelling of airways
Nsg Dx:
Impaired Gas Exchange r/t
bronchiolar obstruction,
atelectasis and
hyperinflation
Parental anxiety r/t respiratory
distress in child
Management
• nebulization
• hydration
• O2
• positioning
• TSB
• Monitor VS esp RR
• support
 Pneumonia
• Inflammation of lung parenchyma

Bacterial and atypical pathogens:

NB – GBS, Gr (-) bacilli, chlamydia
Children – S. pneumoniae, H. Influenzae, M. catarrhalis
Adolescents – S and M Pneumoniae, M. catarrhalis
Hospital acquired – Pseudomonas, Klebsiella, E. Coli,
Enterobacter sp

Viral Pneumonia - RSV, Parainfluenza, Adenovirus,

Influenza
Pathophx: aspiration/hematogenous/inhalation
alveoli inflammation hypoxemia

S/sx: fever, chills, cough, irritability, poor feeding,

restlessness, headache, GI sx, tachypnea, use of
accessory muscles, decreased BS, crackles,
dullness on percussion, chest retractions

Dx: cxr, blood and sputum c/s

PNEUMONIA
Parameter Bacterial Viral Atypical
Age Any Any 5-15 yo

Onset Abrupt Variable Insidious

Fever High Variable Low-grade

Toxicity Toxic Variable Non-toxic

Inc RR Common Common Uncommon

Perimeter Bacterial Viral Atypical

Cough Productive Non prod Non prod

Assoc sx Mild coryza Mild coryza Bullous

myringitis,
pharyngitis

PE (+) variable Fine

consolidation crackles,
few crackles wheezing

Inc WBC common variable Uncommon

Nsg Dx:
• Ineffective breathing pattern r/t physiologic effects
of Pneumonia
- O2, monitor VS, CPT, encourage coughing and
deep breathing

• Risk for deficient fluid volume r/t diminished oral

intake and increased insensible fluid losses sec to
diaphoresis, dyspnea and fever
- weigh and monitor daily, sips of fluid, temp control,
monitor I and O
 PNEUMONIA
• Activity Intolerance r/t effects of Pneumonia
and Tachypnea

- rest periods, O2, small frequent feedings,

gradual increase in activity, support and
contact with family
 Tuberculosis
• High incidence in infancy and adolescence

• Primary Complex – based on xray; first encounter

of a child w/ TB; Ghon’s tubercle w/ lymphangitis
and regional (hilar) lymphadenopathy

• Primary Pulmonary TB – clinical TB

• d/t Mycobacterium Tuberculosis

Dx: exposure, s/sx (2 or more), PPD, Chest Xray,
sputum AFB test
POSITIVE PPD TEST
 Classification of
TB
Class I TB exposure – (+) exposure
Class II TB infection – (+) exposure and PPD
Class III TB disease – active TB or 3 or more of
criteria
Exposure, s/sx, (+) tuberculin
test, xray, sputum
exam, culture
Class IV TB inactive – (+/-) hx of prev TB, (+/-) hx of
prev hx of chemotherapy,
(+)xray evidence of healed
lesion and (+) PPD
S/sx: fever, wt loss, cough, anorexia, night
sweats, painless lymphadenopathy

Tx: Intensive
INH, Rifampicin, PZA x 2 mos

Maintenance
INH, Rifampicin x 4 mos
 Respiratory Distress
Syndrome
• Preterm, infants of diabetic mothers, C/S, hx of
asphyxia

S/sx: inc RR, chest retractions, nasal

flaring,expiratory grunt, cyanosis, HPN,
hypothermia

Dx: ABG, Xray

Mgmt: surfactant replacement, O2, ventilation,
supportive care
Decreased surfactant

lungs collapse

Inc pulmonary resistance

blood shunts through F.O. and D.A.

poor lung perfusion and gas exchange

further decrease in surfactant hypoxia

acidosis
Cardiovascular
Disorders
 Fetal
Circulation
• placenta provides the
exchange of gas and
nutrient

• four shunts in fetal

circulation:
– Placenta
– Ductus venosus
– Foramen Ovale
– Ductus arteriosus
 CONGENITAL HEART
DEFECTS
• CHD are structural defects of the heart, great
vessels, or both that are present at birth.

• Children with CHD are more likely to have

associated defects such as tracheoesophageal
fistula (TEF)

• CHD is second only to prematurity as a cause of

death in the first year of life.
CONGENITAL HEART
DEFECTS
1.Acyanotic Heart Disease
L R shunt
high pressure to low pressure
oxygenated to unoxygenated blood

2. Cyanotic Heart Disease

R L shunt
low pressure to high pressure

3. Obstructive Defects
 ACYANOTIC HEART DISEASE
1. Atrial Septal Defect

• Opening between atria

• late childhood/early
adulthood
• S/sx: cyanosis(CHF),
dyspnea, fatigue, failure
to thrive, split S2
• Mx: Abx, surgery 1-3 yo
• Cx: endocarditis, heart
failure
• Postop: monitor arrhythmia,
administer antibiotics
 ACYANOTIC HEART
DISEASE
2. Ventricular Septal Defect

• Opening in ventricular
septum
• Most common
• S/sx: respi infections,
failure to thrive, dyspnea,
fatigue, pansystolic murmur
• Mx: close spontaneously
otherwise surgery <2 yo
• Cx: pulmonary HPN,
endocarditis, heart failure
• Postop: monitor arrhythmia,
administer antibiotics
ACYANOTIC HEART DISEASE
3. Patent Ductus Arteriosus

• Aorta to pulmonary artery

• Common in prematurity,
high altitude, maternal
rubella
• females
• S/sx:clubbing, dyspnea,
“machinery murmur”
(2nd-3rd ICS)
• Cx: heart failure,
endocarditis, pulmonary
artery stasis/HPN
• Mx: Indomethacin,
surgery
 CYANOTIC HEART DISEASE
1. Tetralogy of Fallot (TOF)

• S/sx: cyanosis, clubbing,

dyspnea, fatigue, squatting,
“Tet spells”, failure to thrive,
systolic murmur,
polycythemia
• Cx: thromboembolism, CVA
• Mx: O2, knee-chest position,
surgery 1-2 yo
• Postop: monitor for
arrhythmia
Blalock Taussig: anastomose
SC and pulmo art.
- avoid BP and venipuncture
in right arm
CLUBBING IN TETRALOGY
OF FALLOT
CLUBBING OF THE FINGERS
 CYANOTIC HEART DISEASE
2. Transposition of the Great
Vessels

• Aorta from R ventricle

• Pulmonary a. from L
ventricle
• Males
• S/sx:cyanosis, murmurs
• Mx: PGE for PDA, Balloon
catheter to create ASD,
definitive surgery 1 wk-3
mos
 CYANOTIC HEART DISEASE
3. Total Anomalous Pulmonary
Venous Return

• Pulmonary vein
drain to SVC or R
atrium
• PDA or foramen
ovale essential
• S/sx: cyanosis,
fatigue
• CX: R heart failure
• Mx: PGE, surgery
 OBSTRUCTIVE DEFECT
Coarctation of the Aorta

• Constriction of aorta
• S/sx: asymptomatic HPN,
irritability, headache,
epistaxis, dyspnea,
claudication, higher BP in
upper extremities, dec
femoral and distal
pulses,systolic murmur
• Cx:chronic HPN
• Mx:surgery 2 yo
• Postop: monitor
abdominal pain,
antihypertensives
COARCTATION OF THE
AORTA
Ndx:
Ineffective cardiopulmonary and peripheral
tissue perfusion related to impaired
cardiac function
• Proper positioning to maintain respiration
• Conserve energy to promote rest
• Quiet activities and stimulation
• Anticipate needs
• Administer prescribed drugs
COARCTATION OF THE
AORTA
Activity intolerance r/t effects of
congenital heart defect and
dyspnea

• Rest periods
• Adequate nutrition
small frequent feedings
iron supplementation
 Obstructive Defect
2. PULMONIC STENOSIS
Obstruction of blood flow from the right ventricle to the
pulmonary artery
PULMONIC VALVE
Backflow of blood towards the right ventricle

Right Ventricle has to PUMP HARDER to push the blood to the

pulmonary artery for Oxygenation

RIGHT VENTRICULAR ENLARGEMENT

RIGHT-SIDED CONGESTIVE HEART FAILURE

 Obstructive Defect
3. AORTIC STENOSIS
• Involves an obstruction of the ventricular outflow of the
blood
• S/SX: faint pulse, hypotension, tachycardia, poor feeding,
exercise intolerance, chest pains
• DX; ECG, Echocardiography reveals left ventricular
hypertrophy.
• MX:
• Surgical aortic valvulotomy or prosthetic valve
replacement.
• - Balloon Angioplasty to dilate the narrow valve.
 Obstructive Defect
3. AORTIC STENOSIS
Obstruction of flow to the AORTA
• AORTIC VALVE
Backflow of blood towards the LEFT VENTRICLE

Left Ventricle has to PUMP HARDER to push the blood to the

AORTA for distribution of oxygenated blood

LEFT VENTRICULAR HYPERTROPHY with Regurgitation of

oxygenated blood back to the LUNGS

LEFT-SIDED CONGESTIVE HEART FAILURE (Respiratory Signs)

 Kawasaki Disease/
Mucocutaneous Lymph Node
Syndrome

• Before puberty, peaks 4 yo

• S/sx:spiking fever x 5 days, bilateral conjunctivitis,

reddened pharynx, dry lips, strawberry tongue,
cervical lymphadenopathy, peripheral edema,
erythema and desquammation, truncal rash, arthritis

• Patho: Respi infection immune complex

systemic vasculitis aneurysm and MI

• Dx: clinical
Mx: Salicylates and Immunoglobulins
KAWASAKI DISEASE
 KAWASAKI
• Risk for ineffective peripheral tissue
perfusion related to inflammation of blood
vessels
- Observe for chest pain, color changes,
vomiting

• Pain r/t swelling of lymph nodes and

inflammation of joints
- Comfort measures, administer pain
medications
 KAWASAKI
Other Measures:
Protect edematous areas
Record intake and output
Offer soft food
Administer prescribed medication
 Rheumatic
Fever J. N. E. S.
• Autoimmune
• Grp A Beta hemolytic strep
• 6-15 yo, peaks 8 yo
• 1-3 wks after untreated infection
• Dx: 5 major criteria –
polyarthritis, carditis,
subcutaneous nodules,
erytHema marginatum,
sydenham’s chorea
minor – fever,
polyarthralgia, hx of RF, inc
ESR, antecedent strep
infection
• To diagnose, either 2 major or 1
major and 2 minor present
• Cx:mitral valve insufficiency and
myocarditis
 RHEUMATIC FEVER
Mgmt: salicylate, penicillin
Ndx:
Risk for noncompliance r/t knowledge deficit
about importance of long term therapy
- prevent initial and recurrent attacks
Decreased cardiac output r/t disease process
- bed rest, comfort and appropriate activities
 RHEUMATIC FEVER

Nursing Care
• Monitor vital signs
• Provide adequate nutrition
• Promote safety to prevent
chorea related injuries
Gastr ointestin
al Disor der s
 Cleft Lip and Palate
• failure of fusion of
maxillary and median
nasal process
• hereditary
• unilateral/bilateral
• Males

Mx: surgery - Cheiloplasty

• Rule of 10’s- AGE=10 wks,
WT=10 lbs, HgB=10 gm
 Cleft Palate
• midline opening of
palate
• usually w/ Cleft lip
• Female
• surgery 6-18 mos -
allow anatomic
changes <1 yo ie
formation of
palatine arch and
tooth buds
Ndx:
• Risk for imbalanced nutrition, less than
body requirements r/t feeding problems
• Risk for ineffective airway clearance r/t
oral surgery
• Risk for infection during post op period
 Nursing Care
Preop
• Adequate nutrition; sips of fluid btw feeding in
upright position; use rubber tipped syringe; Burp
• Prevent ear and upper respiratory tract infection
• Address body image and speech concerns
• Reassurance to parents

Postop
• monitor respiratory distress d/t edema,
hemorrhage
• Suction mucus and blood gently
• dropper feeding 1st 3 weeks; regular feeding after
• Anticipate needs and position to prevent tension
on sutures
• Position side lying in cleft lip; prone in cleft palate
 Tracheoesophageal
Fistula

• Communication of the esophagus and trachea

• maternal hydramnios and prematurity
• S/sx:coughing, choking, cyanosis, dyspnea,
excessive secretion, abdominal distention
• Dx: Ba swallow
 TEF
Ndx:
• Risk for imbalanced nutrition, less
than body requirements r/t inability
for oral intake
• Risk for infection r/t aspiration or
seepage of stomach contents into
lungs
• Risk for impaired skin integrity r/t
gastrostomy tube insertion site
 Nursing care
Preop
• Suction regularly
• Elevate the head
• Gastrostomy feeding
• hydration
• O2
Postop
1. Observe for respiratory distress
2. Proper positioning –avoid hyperextension of neck
3. Continue suction
4. Prevent wound infection
5. Provide pacifier
Hirschprung’s
Disease
• Aganglionic megacolon
• Absence of innervation to a
bowel segment usually
rectosigmoid colon
• No peristaltic activity in
affected area
• Familial
• males
• S/sx:constipation, ribbonlike
stools or no meconium,
abdominal distention,
vomiting
• Dx: Ba enema, biopsy
• Mx:colostomy, surgery
 HIRSHSPRUNG’S DISEASE

Ndx:
• Constipation r/t reduced bowel
function
• Imbalanced nutrition, less than
body requirements r/t reduced
bowel function
 Nursing Care
Preop
1. Daily enemas w/ 0.9% NaCl
*Tap/hypotonic water will cause cardiac
congestion or cerebral edema
2. Minimal residue diet w/ vitamin supplementation
3. Position semi fowlers to relieve dyspnea from
distended abdomen
4. pacifier

Postop
1. Observe for abdominal distention
2. Small frequent feedings after NGT removal
3. Colostomy care
4. Assist parents to cope with children’s feeding
problems
Intussusception
• 2-6 mos
• Invagination of intestine
< 1 yo – idiopathic
> 1 yo – “Lead point”
• S/sx:intense abdl pain,
vomiting, blood in stool
“currant jelly”, abdominal
distention (sausage shaped
mass)
• NECROSIS: fever,
tachycardia, rigid abdomen
• Dx:sonogram “coiled spring”
• Mx:Ba enema (reduction by
hydrostatic pressure),
surgery
Ndx:
• Pain r/t abnormal abdominal peristalsis
• Risk for deficient fluid volume r/t bowel
obstruction
• Nsg care:
1. NPO
2. Adequate hydration via IV therapy
3. Promote parent-infant bonding
4. Provide comfort measures - pacifier for infants
 Pyloric Stenosis

• Hypertophy/hyperplasia of
pyloric sphincter
• Males
• S/sx:nonbillous vomiting,
s/sx of of dehydration and wt
loss, abdominal distention,
“olive” sized mass RUQ,
visible peristalsis
• Dx:xray-”string sign”, USG,
endoscopy
• Mx: surgery
 PYLORIC STENOSIS
Ndx:
• Risk for deficient fluid volume
r/t inability to retain food
• Risk for infection at site of
surgical incision r/t danger of
contamination from feces d/t
proximity of incision to diaper
area
 PYLORIC STENOSIS

Postop
1. dropper feeding 4-6 hrs after surgery 45 min- 1 hr
duration; oral rehydration soln then half strength
breastmilk/formula at 24 hr interval
2. Side lying position
3. Monitor weight and return of peristalsis
4. Wound care
5. Pacifier for oral needs
Celiac Disease/Gluten sensitive
Enteropathy/Celiac Sprue
• Malabsorption syndrome that occurs when the
mucosa of the proximal small intestine is sensitive
to gluten. (wheat, rye, oats, barley)
• inability to absorb fat, thus steatorrhea, deficient fat
soluble vitamins, malnutrition and distended
abdomen
• S/Sx appears bet 1-5 yo after introduction of gluten
in the diet.
• S/sx:diarrhea, wt loss, anorexia, irritability, anemia
(Fe deficiency)
 Celiac Disease
Pathophysiology:
• Intolerance for or inability to digest gluten
>>>accumulation of the amino acid
glutamine>>>toxic to intestinal mucosal
cell>>> intestinal villi atrophy >>>reduction
of absorptive surface of the small intestine.
 Celiac Disease
• CELIAC CRISIS (due to ingestion of gluten, infections,
prolonged fasting) = acute vomiting and diarrhea & may
lead to F & E imbalance & rapid dehydration.
• Dx: Biopsy of the jejunum reveals the mucosal surface with hyperplastic
villus atrophy. ( Definitive diagnosis of celiac disease). This characteristic
lesion return to normal after dietary restriction of gluten which helps
confirm the dx.

• Mx: hydration, gluten free diet, vitamin & Fe supplementation , avoid

cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some
chocolates, some ice cream, donuts, pies, hotdogs,
 Celiac Disease

Foods allowed:
• 1. Meats: beef, pork, poultry & fish
• 2. Eggs
• 3. Milk & dairy products: milk, cheese, cream
• 4. Fruits & veg: all
• 5. Grains: rice, corn, gluten free wheat flour, corn
flakes, corn meal & gluten free pre-cooked
cereals
 Diaphragmatic
Hernia
• Herniation of intestinal
content into the thoracic
cavity
• Left side
• S/sx:respiratory difficulty,
cyanosis, retractions, (-)
breath sounds affected
side, scaphoid abdomen
• Cx: pulmonary HPN
• Mx: ’E’ surgery
 DIAPHRAGMATIC
HERNIA
Ndx:
Risk for ineffective airway
clearance r/t displaced bowel
Risk for imbalanced nutrition, less
than body requirements, r/t NPO
status
 Nursing Care
Preop
• Elevate head
• Low intermittent suction

Postop
1. Semi-fowlers
2. Maintain warm, humidified envt – lung fluid
drainage
3. Suction prn
4. Chest pptx
5. NPO – prev pressure on diaphragm
 Necrotizing
Enterocolitis
- Bowel develops necrotic patches, interfere w/
digestion, lead to paralytic ileus, peritonitis and
perforation
- D/t ischemia sec shock or hypoxia, infection,
immature GIT immune protection
S/sx: abdomen tense and distended, stool (+) for occult
blood, > 2 ml gastric residual, bradycardia, apnea
Dx: abdominal xray
Mgmt: d/c feeding, IV or TPN, Antibiotic, colostomy,
surgery for perforation
 Inguinal Hernia
• Protrusion of a bowel
through the inguinal ring
• males
• S/sx: painless lump in the
groin
• Cx: bowel strangulation
• Mx: surgery <1 yo
• Post op Nursing care:
wound care
assess circulation in
the leg
 Cystic Fibrosis
• Autosomal recessive
• Dysfunction of exocrine glands; inc viscosity
of mucous glands
• Affects lungs, pancreas, intestines and sweat
glands
• S/sx: GI - meconium ileus, rectal prolapse,
steatorrhea, malnutrition, failure to thrive
Respiratory – recurrent infection,cough,
dyspnea, clubbing, cyanosis
Sweat Gland – ”salty taste”
Other – males infertile, abnormal glucose
tolerance
Dx: history, sweat test (NaCl 2-5x the normal),
absence of pancreatic enzymes,
immunoreactive trypsinogen in blood and
pulmonary involvement
Mx: chest physiotherapy, antibiotics,
pancreatic enzymes, vitamins, lung or
pancreas transplant
 CYSTIC FIBROSIS
Ndx:
• Imbalanced nutrition, less than body
requirements r/t inability to digest fats
• Ineffective airway clearance r/t inability
to clear mucus from the respiratory
tract
 Nursing Care
1. Hi calorie, Hi CHON, moderate fat diet
2. Nebulization and physiotherapy
3. Frequent Position changes when in bed
4. Oral care
5. Adequate rest and comfort
Neurological
Disorders
 Brain Tumor
• Second most common form of cancer in children
• 1-10 yo, peak 5 yo
• Usual location - brainstem or cerebellum
• TYPES:
Astrocytoma- glial tissue; 5-8 yo
Medulloblastoma – cerebellum; 5-10 yo; cause
compression of 4th ventricle; most common
Brain stem tumor – support tissue of neural cells;
paralysis of 5th-7th, 9th-10th CN
 BRAIN TUMOR
S/sx: headache, vision changes, vomiting,
enlarging head circumference,
papilledema, lethargy, ataxia, nystagmus,
personality changes, seizures, lethargy,
coma

Dx: skull films, bone scan, CT scan, Lumbar

puncture, MRI, angiography

Mx: surgery, chemotx

 BRAIN TUMOR

Preop
1. Stool softeners
2. Dexamethasone
3. Dilantin
4. Shave head
5. Prepare patient and family
psychologically
 BRAIN TUMOR SURGERY
(CRANIOTOMY)

Postop
1. Proper position – low fowler’s
2. Anticipate needs
3. Saline eye drops as needed
4. Monitor VS and NVS
5. Regulate IV
6. Observe head dressings
7. Provide comfort and opportunity for self
expression
Benign Febrile Seizure
• 6 mos - 5 years
• fever >/= 38.5C
• generalized tonic-clonic
• rarely persist > 10 minutes
• Postictal stage
• 30-40 % recurrence
• (+) family history
CONVULSION/SEIZURE
 NURSING CARE
• Turn child to side & allow to drool
• Do not restrain
• Do not put anything in the mouth
• Dec temp
• Refer if:
sx persist
another sx occurs
delirious/difficult to rouse after sx
 Erb Duchenne’s
Paralysis
• Damage on C5-C6 due to birth trauma
• Unilateral
• S/sx: shoulder adducted, internally
rotated, elbow extended, forearm pronated
and the wrist flexed “waiter’s tip”, (-) moro
reflex
• Mx: PT, surgery
• Nsg care: advise exercise and frequent
follow up
ERB DUCHENE’S PALSY
C5 & C6
 Cerebral Palsy
• Damaged motor function d/t anoxic brain injury
secondary to infection, perinatal asphyxia,
metabolic disorder

• Nonprogressive

• TYPES:
Spastic– most common (65%); hypertonicity
Athetoid/dyskinetic – worm-like
Ataxic – wide based gait w/ repetitive movement
Mixed – spastic and athetoid
• S/sx: spasticity/rigidity, difficulty feeding, delayed
speech and motor devt, mood swings, impulsive,
short attention span, irritable

• Dx: Clinical

• Mx: antispastics, antibiotics, surgery, nutrition,

prevention of injury, PT

NDx: Risk for injury r/t neuromuscular impairment

Self care deficit r/t neuromuscular impairment
- ensure safety, assist in ADL, ensure adequate
nutrition, assist children achieve maximum potential
 Hydrocephalus
• Impaired circulation and absorption of CSF
2 TYPES:
1. Obstructive/Noncommunicating – w/n ventricular
system
2. Nonobstructive/Communicating – obliteration of
SA cisterns or malfunction of arachnoid villi
S/sx: head enlargement, ant fontanel wide and bulging,
scalp veins dilated, broad forehead, sclera bshows
above iris, brisk tendon reflexes, spasticity,
irritability, lethargy, poor appetite, cracked pot
sound on percussion
 HYDROCEPHALUS
Ndx:
Risk for ineffective cerebral tissue
perfusion related to increased
intracranial pressure
- monitor vs, head circumference, I and
O
- O2
- position flat or head 30 deg
- do not lie on operative site
 HYDROCEPHALUS
Risk for imbalanced nutrition, less than body
requirements, related to increased intracranial
pressure
- NPO until bowel sounds return
- position head w/o flexion
- observe for constipation
- note how child sucks
- IV fluids
- obtain daily weight
 Spina Bifida
• Collective term for all SC disorders

Spina Bifida Occulta – posterior laminae fail to fuse

- dimpling, abnormal tufts of hair

Meningocoele - meninges herniate through unformed

vertebrae; protrusion covered by a layer of skin
- usually occurs in the lumbar region
- protrusion is covered by a skin layer or only the
clear dura mater
 SPINA BIFIDA
Myelomeningocoele – SC and meninges
protrude through the vertebrae defect
- absent motor and sensory function
- flaccidity, lack of sensation in LE
- loss of bowel and bladder control
- may be accompanied by hydrocephalus

Dx: sonography
 SPINA BIFIDA
• Risk for infection r/t rupture or bacterial
invasion of the neural tube sac
- position side lying or prone
- keep sac moist
- place under radiant warmer
- post op – prone until site is healed
• Risk for ineffective cerebral tissue perfusion r/t
increased intracranial pressure
- measure head circumference
- assess for s/sx of inc ICP
 SPINA BIFIDA
• Risk for impaired skin integrity r/t required prone
positioning
- reposition head every 2 hrs if w/ hydrocephalus
- change diapers frequently
• Impaired physical mobility r/t neural tube d/o
- passive exercises
- may use leg braces, crutches
- inspect lower extremities and buttocks for irritation
or possible infection
• Risk for impaired elimination r/t neural tube d/o
- intermittent catheterization
- surgery
 Meningitis
• Inflammation of meninges
• Bacterial, Tuberculous, viral

S/sx: opisthotonus, neck rigidity, irritability, high pitched cry

Dx: Lumbar puncture, Bld C/S, Ct scan, MRI

NDx: Risk for infection r/t presence of infective organism

Tx: Abx
Hematologic
Disorders

HEMATOLOGIC DISORDER
 Iron Deficiency
Anemia
Infant’s iron supply 4-6 mos
Anemia – 9-24 mos

S/sx: pallor, tachycardia, irritability, Hg < 9

g/dl, susceptible to infection

Mgmt: iron fortified formula, iron rich diet

and vitamins
Nsg care: give iron w/ vit c, use w/ dropper
at the back of the mouth, expect black
stools, provide iron rich food
 Hemophilia A
• Inherited interference w/ blood coagulation

• Factor VIII

• Sex linked recessive

• S/sx: excessive bleeding

NB – apparent
Pre-school – accidents/falls
School age – bleeding between joints
Adolescent – ulcers, hematuria
• Mx: factor VIII transfusion
NDx: Acute pain r/t bleeding into joints

Nursing Care

• Promote safety
• Watch out for bleeding – rest area, ice
compress, elevate body part
• Monitor transfusion reaction
• Passive ROM
• Assist in gaining control of situation
 Hemophilia B

• Christmas Factor
• Clotting Factor IX
 ACUTE LYMPHOCYTIC
LEUKEMIA
• Uncontrolled proliferation of WBC

• Lymphoblast

• Most frequent CA in children

• 2-16 yo

• Males
 LEUKEMIA
S/sx: pallor, low grade fever, lethargy,
petechiae, bleeding, vomiting, anorexia,
bone pain, painless lymphadenopathy

Dx:WBC variable w/ blasts, low platelet

and hematocrit, anemia

BMA > 25% blast cells

BONE MARROW
ASPIRATION
 LEUKEMIA
Mx: chemotherapy

Cx: CNS s/sx, renal failure

NDx: Risk for infection r/t decreased immune

function
Activity intolerance r/t reduced oxygen
carrying capacity of blood
 Nursing Care
• Prevent infection
• monitor bleeding and transfusion
reactions
• Provide comfort and pain alleviation
• Health teaching
• Emotional and psychological support
Genitourinary
Disorders
 Urinary Tract
Infection
• Females
• E coli
• Ascending infection
• S/Sx:infants – mimic GI d/o; dysuria,
frequency, hematuria, low grade fever,
abdominal pain and bedwetting
• Dx: urine culture
suprapubic any amount
clean catch > 100,000/ml
• Mx: antibiotic
hydration
 Acute
Glomerulonephritis
• Inflammation of glomeruli or kidney
• Follows infection with strep10-14
days
• 5-10 yo
• Males
S/sx:sudden onset of edema and
hematuria, proteinuria,
hypertension

Dx: urinalysis and 24 hour urine

hypoalbuminemia
inc ESR, BUN, Crea,
antistreptolysin O
Mx: semi fowlers
diuretics, antibiotics
O2
antihypertensives

Nsg Care:
quiet play activities
diet – normal CHON, mod salt
restriction, fluid restriction
daily weight and output
 Nephrotic
Syndrome
• Altered glomerular
permeability(autoimmune);
inc permeability to albumin
• 3 yo
• Males
• Minimal change syndrome
• S/sx: proteinuria, edema-
periorbital area,
hypoalbuminemia,
hyperlipidemia
• Dx: urinalysis and 24 hr
CHON, inc ESR
Mx:steroids, immunosupressant

NDx: Risk for decreased fluid volume r/t CHON and

fluid loss
Imbalanced nutrition: less than BR r/t CHON
and fluid loss

Nsg care:
Adequate nutrition, proper diet – decrease salt
Weigh daily, monitor I and O
Protect edematous areas
Administer prescribed drugs
Health teaching
 Wilm’s Tumor
• Malignant tumor of the kidney
• Associated with other anomalies
• 6 mos-5 yo, peaks 3-4 yo
• Good prognosis
• S/sx: abdominal mass, hematuria, low grade
fever, anemia, wt loss
• Dx: CT scan
• Mx: Nephrectomy, radiotherapy
avoid abdominal palpation
Hypospadia/Epispadia

A. Hypospadia B. Epispadia

C. Hypospadia w/ chordee
 UROGENITAL DEFECTS
Hypospadia - common
- chordee - fibrous band

Mx: surgery

Nsg care:
Post op – pain relief
assist parents in coping
 Cryptorchidism
(Undescended
Testis)
• Failure of one or both testes to descend
• Descend up to 6 weeks at birth
• May be d/t dec testosterone

S/sx: right testis more common

Mx: chorionic gonadotrophin hormone

Orchiopexy 1 yo
 Other
Diseases
 Sudden Infant Death
Syndrome
• 1 mo-1 year old, peaks 2-4 mos
• Full term/preterm
• sudden and silent
• the victim seems healthy
• sleeping on prone position
• Theories of causation: abnormalities in the brain
and metabolic disorder
 SIDS
Maternal risk factors - cigarette smoking during
pregnancy, maternal age < 20 yo, poor prenatal
care, low weight gain, anemia, use of illegal drugs
and alcohol, low socioeconomic status

Newborn risk factors – cyanosis, tachycardia,

respiratory distress, irritability, hypothermia, poor
feeding
 SIDS
Nsg Dx:
Dysfunctional grieving r/t loss of a child

Management
• assist psychologically - intense grief and
guilt for parents
 Atopic Dermatitis

• 2 mos-3 yo
• R/t food allergy
S/sx: papular and vesicular
skin eruptions w/ erythema,
pruritus, dry,flaky scales
upon healing
Mx: reduce allergen, topical
steroids
NDx: Impaired skin integrity
r/t eczematous lesion
Nsg care: Reduce allergen
Prevent skin dryness and
pruritus
Normal Skin Dry Skin
Tortuous micro-
Smooth micro-relief
relief
Low roughness
High roughness
Regular
Irregular
desquamation
desquamation
 ATOPIC DERMATITIS
• NURSING MANAGEMENT
1. MEDS: ANTIHISTAMINES, ANTIPRURITICS,
STEROIDAL CREAMS
2. Minimize the risk of infection
3. Promote skin integrity
4. Family Health teaching
• Cotton fabrics, use mild detergents
• Daily baths to hydrate the skin
• Use topical moisturizers
 Otitis Media
• Inflammation of the middle ear
• 6-36 mos, 4-6 yo
• S. Pneumoniae, H. Influenzae, M. Catarrhalis
• Follows URTI
S/sx: pain in affected ear, fever
Cx: hearing impairment
Mx: antibiotics, analgesics, antipyretics
NDx: Acute pain r/t inflammatory process
- provide comfort, reinforce completion of
antibiotic, offer liquids and finger food (prev pain
when chewing)
 Diarrhea

Viral – Rotavirus, Adenovirus

Bacterial – Shigella, Salmonella, Cholera
Protozoan – Amoeba

TYPES:
Mild: fever, irritable, 2-10 episodes/day, dry
mucous membranes, tachycardia
- 2.5-5% wt loss
Mx: oral rehydration
 DIARRHEA
Severe: fever, tachycardia, tachypnea, pale and
cool skin, apprehensive/lethargic, obvious s/sx
of dehydration, UO scanty, several episodes of
loose stools
- 5-15% wt loss
Cx: dehydration
Mx: fluid and electrolyte replacement
Dx: Stool exam and culture, Electrolyte
determination
NDx: deficient fluid volume r/t fluid losses in stools
- promote hydration and comfort, Record I and O
Protein Energy Malnutrition
Marasmus Kwashiorkor
Low calorie, low CHON Low CHON
0-2 yo 1-3 yo
(-) edema (+) edema
“all skin and bone” Wasting variable
(+) growth retardation Growth retardation
Apathetic, quiet variable
Good appetite Irritable, moaning
Infrequent skin/hair Poor appetite
changes (+) skin and hair changes
Anemia uncommon (+) anemia
 Poisoning
Usually 2-3 yo
Soap, cosmetics, detergents, drugs
Males>females – children
Females>males – adolescent

Mx:
1. Det age wt, type of poison swallowed, ime
of ingestion, route of poisoning, amt
ingested, present condition of child
 POISONING
2.Use syrup of ipecac to induce vomiting
except:
caustic, corrosive, hydrocarbon, px is
comatose
3. Activated charcoal then syrup of ipecac
4. Monitor VS
5. refer to hospital/poison control center
 POISONING
Acetylsalicilic acid (Aspirin)
S/sx: nausea, vomiting, fever, profuse sweating,
flushing, hyperthermia, hyperventilation,
convulsions, coma

Mx: stabilize airway and breathing

Fluid and electrolyte replacement
Activated charcoal
Alkalinization of urine
hemodialysis
Down’s Syndrome
Trisomy 21

Maternal age >35 yo, paternal age >55

Features: nose is broad and flat, eyelid have an extra

fold of tissue at the inner canthus, palpebral fissure
slants upwards, white specks in iris, tongue
protrudes, back of the head is flat, neck is short,
extra fat pad, low set ears, poor muscle tone, short
thick fingers, simian crease, cognitively challenged
 DOWN’S SYNDROME
Poor immune function
Congenital heart diseases – Ventricular Septal Defect
Cataract
ALL occurs 20x more

Mx: early education and play opportunities

prevention of infection
counseling and support
 Child Abuse
• Non accidental injury
inflicted by an adult
• Physical, emotional,
sexual
• Children grow up to be
abusers themselves
and are violent
• Nsg Resp: treat injury,
report to DSWD, NGO,
Bantay Bata
SIGNS
OF
CHILD
ABUSE
 Substance Abuse
• Use of chemicals
• Improve mental state
• Induce euphoria
• Peer pressure
• Feel more confident
• Adolescent rebellion
 TYPES OF ABUSED
SUBSTANCES
Tobacco - sign of maturity

Alcohol - most frequent

- no stigma

Amphetamines – sense of well being, alertness, self

esteem and wt loss

Anabolic steroids – improves athletic ability

Marijuana – stress reliever bec gives a sense of

well being, altered sensory perception
TYPES OF ABUSED
SUBSTANCES

Hallucinogens – distortions in vision, smell

or hearing

Opiates – physiologic craving

Cocaine – inc VS, dec appetite,

cardiovascular arrest, euphoria,
excitement, hallucinations
 ASSESSMENT OF
SUBSTANCE ABUSE

• Failure to complete homework

• Poor reasoning ability
• Decreased school attendance
• Frequent mood swings
• Deteriorating physical appearance
• Recent change in peer group
• Negative perception of parents
 Nursing
Intervention
• Caution against drug abuse
• Provide counseling
• refer to rehab facilities
Thank
you!