1. CARDIO<br />CONGENITAL HEART DISEASE<br />Acyanotic diseases<br />Pulmonary circulation and systemic circulation are not connected<br />If there is a connection, the pressure is higher in the left side than in the<br />right side<br />PATENT DUCTUS ARTERIOSUS<br />Most common congenital heart defect<br />Symptoms depend on size of the vessel and age of the child<br />May have no symptoms; indication may be a murmur<br />Increasing dyspnea, full bounding pulse, wide pulse pressure<br />Spontaneous closure after infancy rarely occurs<br />Without treatment – life expectancy short<br />ATRIAL SEPTAL DEFECTS<br />10% of all forms of congenital heart disease<br />Allows oxygenated blood returning from the lungs to pass into the right<br />atrium<br />VENTRICULAR SEPTAL DEFECT<br /> constitute 20% of all forms of CHD<br /> allows systemic venous and oxygenated arterial blood to mix<br /> may produce no symptoms at all<br /> require no specific treatment and often close spontaneously<br />COARCTATION OF THE AORTA<br /> narrowing of the lumen of the aorta<br /> may be an isolated defect or associated with other cardiac malformation<br /> Assessment: measure BP in both arms and a leg and to assess the pulse<br />in both upper and lower extremities<br /> surgical repair – only permanent treatment; usually deferred until 3 years<br />of age<br />PULMONIC VALVE STENOSIS<br /> usually do not produce symptoms; typical murmur<br />AORTIC VALVE STENOSIS<br /> mild to moderate asymptomatic; typical murmur<br />CYANOTIC DISEASES<br />TETRALOGY OF FALLOT<br />VSD<br />Overriding of the aorta<br />Pulmonary valve stenosis<br />Enlarged right ventricular wall<br />Assessment:<br />Primary sign – cyanosis<br />Hypoxic spells – usually initiated by crying<br />Fainting – due to cerebral hypoxia<br />Stunted growth, clubbed fingers and toes<br />Squatting position – characteristic position to relieve dyspnea<br />Implementation<br />Decrease hypoxic spells – do not permit child to cry<br />Place in knee chest position<br />O2 as needed<br />TRANSPOSITION OF THE GREAT VESSELS<br /> aorta arises from the right ventricle<br /> degree of cyanosis depends on the abnormal connections<br />Assessment:<br /> cyanotic at birth<br /> develop polycythemia risk for emboli and thromboses<br /> may develop CHF or pulmonary vascular obstructive<br />Implementation:<br /> require emergency medical treatment<br /> cardiac catheterization<br /> ballool atrial septostomy <br />TRICUSPID ATRESIA<br /> condition in which tricuspid valve did not form<br /> no opening between the right atrium and right ventricle<br /> 2% of congenital heart defects<br /> profound cyanosis and dyspnea at birth<br /> emergency catheterization with balloon atrial septotomy<br />TOTAL ANOMALOUS VENOUS RETURN<br /> condition in which all the pulmonary venous blood returns to the heart<br /> cyanosis and severe respiratory distress<br /> emergency surgical intervention<br />TRUNCUS ARTERIOSUS<br /> single vessel arising from the ventricles just above a large VSD<br /> retarded growth; enlarged liver and heart<br /> usually infants die within the first year<br />CARDIOVASCULAR DEFECTS<br /> Monitor vital signs closely<br /> Monitor respiratory status<br /> Auscultate breath sounds for crackles, ronchi or rales<br /> if respiratory effort is increased, place child in reverse Trendelenburg<br />position<br /> administer humidified oxygen<br /> Monitor for hypercyanotic spells:<br />Place infant in a knee chest position<br />Administer 100% oxygen by mask<br />Administer morphine as ordered<br />IVF as prescribed<br />Assess for signs of CHF<br />Assess peripheral pulses<br />Keep child stress free as possible; allow maximal rest<br />CARDIAC SURGERY<br />Postoperatively:<br /> monitor for signs of discomfort<br /> monitor for signs of sepsis (fever, lethargy, diaphoresis, altered LOC)<br /> Monitor lines, tubes or catheters ; remove promptly<br /> administer pain medications; note effectiveness<br /> encourage rest periods<br /> facilitate parent-child contact as soon as possible<br />Home Care<br /> omit activities in which child could fall for 2-4 weeks<br /> avoid crowds for 2 weeks after discharge<br /> no added salt diet<br /> do not put creams, lotions or powders on the incision site<br /> child may return to school 3rd week after discharge<br /> no physical education for 2 months<br /> follow up after 2 weeks<br /> avoid immunizations, invasive procedure and dental visits for 2 months<br /> advise parents regarding importance of dental visit every 6 months<br /> inform dentist of cardiac problem<br /> instruct parents to call MD if with coughing, tachypnea, cyanosis, diarrhea<br />CONGESTIVE HEART FAILURE<br /> inability of the heart to pump sufficiently to meet the metabolic demands<br />of the body<br /> infants – most commonly caused by congenital heart defects<br /> combination of both left sided and right sided heart failure<br /> goal of treatment: to improve cardiac function, remove accumulated fluid<br />and sodium, decrease cardiac demands, improve tissue oxygenation<br />Assessment:<br /> tachycardia<br /> tachypnea<br /> profuse scalp sweating especially in infants<br /> fatigue and irritability<br /> sudden weight gain<br /> respiratory distress<br />Implementation:<br /> monitor vital signs closely and for early signs of CHF<br /> monitor for respiratory distress<br /> monitor I and O; weigh diapers<br /> Monitor daily weight to assess for fluid retention; weight gain of 0.5 kg<br />( 1 lb /day)<br /> monitor for facial or peripheral edema , auscultate lung sounds<br /> elevate HOB<br /> maintain neutral thermal environment to prevent cold stress in infants<br /> administer cool, humidified oxygen <br /> organize nursing activities to allow uninterrupted sleep<br /> maintain adequate nutritional status<br /> provide rest; decrease environmental stimuli<br /> feed when hungry and soon after awakening<br /> infant should be well rested before feeding<br /> provide small, frequent feedings<br /> administer sedation<br /> administer digoxin<br /> check with physician parameters for witholding digoxin<br />Note that infants rarely receive more than 1 mL (50 ug or 0.05 mg) of digoxin<br /> Administer diuretics; monitor for hypokalemia<br /> administer potassium supplements<br /> monitor serum electrolytes<br /> restrict fluid in acute stages<br /> check with physician regarding sodium restriction; infant formulas have slightly <br />more sodium than does breast milk<br />Home care Instructions for Administering Digoxin<br /> administer 1 hr before or 2 hrs after feeding<br /> do not mix medication with food or drink<br /> if the child vomits, do not administer a second dose<br /> if more than 2 consecutive doses have been missed, notify MD; do not <br />increase or double the dose for missed doses<br /> keep the medication in a locked cabinet<br /> if the child becomes ill, notify MD<br />RHEUMATIC FEVER<br /> an inflammatory autoimmune disease<br /> affects connective tissue of the heart, joints, subcutaneous tissues and<br />blood vessels of the CNS<br /> most serious complication – RHD affecting the cardiac valves<br /> presents 2-6 weeks following an untreated Group A beta hemolytic strep<br /> Jones criteria<br />Asssessment:<br /> signs of carditis: SOB, edema of the face, abdomen or ankles, precordial pain<br /> signs of polyarthritis: edema, inflammation of the large joints, joint pain<br /> erythema marginatum: macular rash on trunk and extremities<br /> subcutaneous nodules<br /> fever<br /> elevated ASO<br /> elevated ESR<br /> elevated CRP <br />Implementation:<br /> Assess vital signs<br /> Control joint pain and inflammation with massage<br /> Febrile phase – provide bed rest<br /> limit physical exercise in child with carditis<br /> Administer antibiotics (penicillin) as prescribed<br /> administer salicylates and anti-inflammatory agents<br /> Instruct parents about the importance of follow up and need for<br />antibiotic prophylaxis for dental work, infection, invasive procedures<br /> advise child to inform the parents if anyone in school develops a <br />strep throat infection<br />KAWASAKI DISEASE<br /> known as mucocutaneous lymph node syndrome<br /> acute systemic inflammatory illness<br /> unknown cause<br /> cardiac involvement – most serious complication<br />Assessment:<br /> fever<br /> conjunctival injection<br /> red throat<br /> Swollen hands, rash, enlargement of the cervical lymph nodes<br />Implementation:<br /> monitor temperature frequently<br /> assess heart sounds and rhythm<br /> assess extremities for edema, redness, desquamation<br /> monitor mucus membrane for inflammation<br /> weigh daily<br /> administer IV immune globulin<br /> instruct parents in the administration of prescribed meds<br />aspirin – need to monitor bleeding<br />GASTROINTESTINAL SYSTEM<br />Physiology of DIGESTIVE SYSTEM<br /> Mechanical functions of digestion immature at birth<br /> No voluntary control over swallowing until 6 weeks<br />Stomach capacity decreased<br />Relaxed sphincter contributes to tendency to regurgitate<br />Liver functions immature throughout infancy<br />Gastric acidity low in infants rises until age 10<br />Digestive processes are mature by toddlerhood<br />Assessment:<br />Presenting problem <br />a. Vomiting<br />b. Abnormal bowel habits: diarrhea, constipation, bleeding<br />c. Weight loss, failure to thrive<br />d. Pain<br />Nutritional history<br />Physical Examination:<br /> General appearance:<br />a. Height and weight<br />b. Measure mid arm circumference<br />c. Observe color: jaundice<br /> Mouth: dentition<br /> Abdomen<br />a. Skin integrity<br />b. Abdominal distension; visible peristaltic waves<br />c. Inspect for hernias<br />d. Auscultate bowel sounds ( every 10-30 seconds)<br />e. Palpate for tenderness<br />f. Liver span (inferior edge palpated 1-2 cm below RCM)<br />g. Spleen (felt on inspiration 1-2 cm below left costal margin)<br />DISORDERS OF THE TEETH<br />DENTAL CARIES<br /> erosion of the enamel and dentine of teeth<br /> results from combination of fermenting sugars and starched <br />and acid forming organisms<br />Prevention:<br /> dental hygiene<br /> regular dental hygiene<br /> good nutrition<br /> fluoridation<br />CLEFT LIP AND CLEFT PALATE<br /> 1 in 1000 births<br /> multifactorial<br /> common among children with chromosomal abnormalities<br /> results from failure of the embryonic structures of the face to unite<br /> may occur separately or may combine to produce a single unilateral<br />or bilateral cleft from the lip through the soft palate<br /> interfere with the child’s capacity to meet oxygenation and<br />nutritional needs <br /> may seriously hamper normal bonding process of children with parents<br />Assessment:<br /> facial abnormality visible at birth<br />- cleft lip or palate or both, unilateral or bilateral<br /> difficulty sucking<br /> inability to form airtight seal around nipple<br /> formula/milk escapes through nose in infants with cleft palate<br /> predispose to infection – communication between mouth and nose<br /> difficulty swallowing<br /> abdominal distension – air swallowing<br />Management:<br /> team approach<br /> otolaryngologist, audiologist, pediatrician, dentist, orthodontist, speech therapist<br /> Surgical correction:<br />early correction – prevent speech defects<br /> Cheiloplasty <br /> correction of cleft lip<br /> unite edges to allow lips to be both functional; aesthetic reasons<br /> performed usually at age 2 months<br />Cleft palate repair<br /> not done until age 18 months – anticipation for speech development<br /> child should be weaned and able to take liquids from a cup before<br />palate repair<br />NURSING INTERVENTION:<br />Cleft Lip (PreOP)<br /> feed in upright position<br /> burp frequently<br /> press cleft lip together with fingers – to encourage sucking and to strengthen muscles<br />if unable to suck, use a rubber tipped syringe; drip onto side <br />of mouth<br /> finish feeding with water to wash away formula in palate area<br /> provide small, frequent feedings<br /> provide emotional support for parents<br />Post OP: Cleft Lip repair<br /> maintain patent airway<br /> monitor amount of swallowing to detect hemorrhage<br /> do not place in prone position or with pressure on cheeks<br /> avoid any tension on suture line<br /> avoiding straining on suture line<br /> prevent crying<br /> keep child comfortable and contented<br /> use elbow restraint<br /> keep suture line clean – clean after each feeding with saline, peroxide or water to remove crusts<br /> pain relief<br />Nursing Intervention: Preop cleft palate repair<br /> prepare parents to care fro child after surgery<br /> instruct concerning feeding methods and positioning<br />Post Op cleft palate repair<br /> position on side for drainage of blood<br /> have suction available <br /> prevent injury or trauma on suture line<br />Use cups only for liquids; no bottles<br /> avoid straws, utensils, popsicle sticks, chewing gum<br /> provide soft toys<br />Use elbow and wrist restraints<br />Provide liquid diet initially soft normal diet<br />Give water after each feeding to clean suture line<br />Hold and cuddle <br />ESOPHAGEAL ATRESIA and TRAACHEOESOPHAGEAL FISTULA<br />Esophageal atresia<br /> congenital defect; upper segment of the esophagus ends in a blind<br />pouch<br />TEF<br /> defect in which embryonic structures fail to divide into a separate esophagus and trachea<br /> opening between the two structures<br /> usually occur together<br />Assessment:<br /> copious oral and nasal secretions –first sign of a defect<br /> choke or cough<br /> when suctioning or gavage is attempted – catheter cannot pass<br /> into stomach<br />Medical and Surgical intervention<br /> prevention of aspiration<br /> drainage tube may be placed in the blind pouch – to suction secretions<br /> esophageal atresia – medical emergency<br />- end to end anastomoses<br /> feeding tube maybe inserted into the stomach through gastrostomy until repair heals<br />Nursing intervention:<br /> provide nutrition<br />Provide gastrostomy tube feeding until anastomosis site has healed<br /> start oral feedings when infant can swallow well<br /> promote respiratory function<br />1. position properly<br />PYLORIC STENOSIS<br /> narrowing of the outlet of the stomach<br /> caused by excessive growth of circular muscles that surrounds the pylorus<br /> hypertrophy develops over 4-6 weeks of life when symptoms begin to appear<br /> more common in Caucasian; first born, full term boys<br />Assessment:<br /> olive size bulge under right rib cage<br /> vomiting – projectile; non bilous<br /> peristaltic waves during and after feeding<br /> failure to thrive<br /> dehydration<br /> diagnostic tests:<br />a. UGIS – narrowing of diameter of pylorus<br />b. Decreased serum Na, K, Cl<br />c. Increased Hct<br />d. Metabolic alkalosis<br />Nursing intervention: Preop<br /> replace fluids and electrolytes<br /> prevent vomiting<br />Give thickened feedings<br />High Fowler’s<br />Place on right side after feeding<br />Minimize handling<br />Strict I and O, daily weights, urine sp gravity<br />Nursing Intervention: post Op<br />Advance diet as tolerated<br />Place on right side after feeding<br />Observe incision for signs of infection<br />Provide client teaching and discharge planning<br />INTUSSUSCEPTION<br /> telescoping of bowel into itself <br /> ileocecal region<br /> edema, necrosis of bowel, obstruction<br /> most common at age 6 months<br /> more in boys than in girls<br /> associated with cystic fibrosis<br />Assessment:<br /> piercing cry<br /> severe abdominal pain (pulls leg up)<br /> vomiting of bile stained fluid<br /> bloody mucus in stool<br /> “currant jelly” stool<br />Management:<br />1. barium enema<br />2. surgery<br />Nursing Intervention:<br />1. provide routine pre and post op care<br />2. monitor for peritonitis<br />HIRSCHSPRUNG’S DISEASE<br /> absence of autonomic parasympathetic ganglion cells in large intestines<br /> results in decreased motility in that portion of the colon and signs of functional obstruction<br />Assessment:<br /> failure or delay in passing meconium<br /> abdominal distension<br /> failure to pass stool<br /> temporary relief following rectal exam<br /> loose stools – only liquid can pass thru<br /> ribbon like stools<br /> nausea, anorexia, fecal vomiting<br /> weight loss, failure to grow<br /> volvulus – bowel twists upon itself<br /> diagnostic tests: rectal biopsy – confirms presence of aganglionic cells<br />Nursing intervention:<br /> enema as ordered<br />A. Mineral oil or isotonic saline<br />Do not use water or soap suds – water intoxication<br />Use volume appropriate to weight of child<br />infants – 150-200ml<br />children – 250-500 ml<br /> administer TPN as ordered<br />Provide low residue diet<br /> provide client teaching and discharge teaching<br />Colostomy care<br />Low residue diet<br />IMPERFORATE ANUS<br /> during embryonic life – membrane that separates the rectum and anus is absorbed<br /> absorption fails to occur -> imperforate anus<br /> anus appear as a dimple<br /> fistula may be present – rectovaginal, rectourethral<br />Assessment:<br /> inspection of anus, check rectum for patency<br /> insert rectal thermometer<br /> absence of stool during 1st 24 hours<br /> development of a distended abdomen<br />Intervention:<br /> surgery<br />anoplasty – if possible<br />temporary colostomy<br /> if with distension – nasogastric suction<br />Nursing intervention:<br /> keep operative site clean<br /> observe infant for signs of hypovolemic shock and infection<br /> if anoplasty heals – regular dilatation of anus to prevent stricture<br /> colostomy care<br />a. Kept clean<br />b. zinc oxide<br /> after surgery – side lying or prone with hips elevated<br />CELIAC DISEASE<br /> malabsorption syndrome characterized by intolerance of gluten,<br />found in rye, oats, wheat and barley<br /> familial disease<br /> more common in Caucasians<br /> cause unknown<br /> flat mucosal surface and atrophy of villi of the intestine<br /> reduced absorptive surface -> marked malabsorption of fats<br />Assessment:<br /> steatorrhea<br /> chronic diarrhea<br /> failure to thrive<br /> distended abdomen<br /> abdominal pain, irritability, listlessness, vomiting<br /> symptoms of ADEK deficiency<br /> diagnostic tests:<br />1. pancreatic enzymes<br />2. jejunal or duodenal biopsies<br />Management:<br /> diet therapy<br /> gluten free diet<br /> TPN in children<br />Nursing Intervention:<br /> gluten free diet (BROW – Barley, Rye, Oatmeal, Wheat)<br /> supplemental fat soluble vitamins<br /> client teaching<br />1. gluten free diet<br />2. importance of reading the label<br />3. avoidance of infection<br />4. adhering to diet even if symptoms are controlled<br />5. importance of long term follow up<br />APPENDICITIS<br /> inflammation of the appendix<br /> ischemia, gangrene, rupture, peritonitis – if untreated<br /> school age children – most common<br /> due to mechanical obstruction or anatomic defects<br />Assessment:<br /> diffuse pain RLQ<br /> nausea, vomiting<br /> guarding of abdomen<br /> rebound tenderness<br /> decreased bowel sounds<br /> fever<br /> diagnostic tests:<br />1. CBC<br />2. elevated acetone in urine<br />Nursing Intervention:<br /> antibiotics/ antipyretics as ordered<br /> no enemas<br /> no heating pads<br /> routine preop care<br /> post op care:<br />semi-Fowler’s position<br />Monitor NGT<br />Monitor penrose drains<br />PARASITISM<br /> roundworms, pinworms<br />Assessment:<br /> pinworms – anal itching, disturbed sleep<br /> roundworms – colic , abdominal pain, lack of appetite, weight loss<br />Nursing intervention:<br /> obtain stool culture<br /> observe all excreta for worms<br /> Scoth tape swab <br /> instruct parents to change clothing, bed linens, towels and launder in hot water<br /> instruct all family members to scrub hands and fingernails prior to eating and after using toilet<br />DIABETES MELLITUS<br /> most common endocrine disease of children<br /> onset maybe any age<br /> type 1 IDDM<br /> risk of complication is high – retinopathy, neuropathy, nephropathy,<br />skin changes, predisposition to infection<br />Assessment:<br /> rapid onset<br /> polyuria, polydipsia, polyphagia, fatigue<br /> weight loss<br /> ketoacidosis<br />-Dry flushed skin<br />Management:<br /> insulin<br /> diet therapy<br /> exercise<br /> prevention of complications<br />Nursing intervention:<br /> administer insulin as ordered<br /> force fluids without sugar<br /> monitor blood glucose levels daily<br /> observe for hypoglycemia: behavior changes, sweating<br /> provide client teaching<br />a. Daily regimen for home care<br />b. Urine and blood glucose monitoring<br />c. Nutrition management<br />d. Effects of infection and exercise on CHO metabolism<br />e. Prevention of acute and chronic complications<br />RESPIRATORY SYSTEM<br />EPIGLOTTITIS<br /> inflammation of the epiglottis<br /> H. influenzae Type b ; Strep pneumoniae<br /> age 2-5<br /> abrupt onset; winter<br /> considered an emergency situation<br />Assessment:<br /> fever<br /> sore, red and inflamed throat<br /> drooling, difficulty of swallowing<br /> inspiratory stridor<br /> muffled voice<br /> nasal flaring<br />Implementation<br /> maintain patent airway<br /> assess respiratory status and breath sounds<br /> use of accessory muscles; presence of stridor<br /> assess temperature<br /> do not attempt to visualize the posterior pharynx or obtain throat culture<br /> lateral neck film<br /> do not force child to lie down<br /> do not restrain<br /> administer antibiotics; IV fluids <br /> cool mist oxygen<br /> high humidification <br /> have resuscitation equipment available<br /> immunization<br />LARYNGOTRACHEOBRONCHITIS (LTB)<br /> inflammation of the larynx, trachea, bronchi<br /> most common type of croup; maybe viral or bacterial<br /> parainfluenza virus<br /> gradual onset ; preceded by URI<br />Assessment:<br /> fever<br /> irritability and restlessness<br /> hoarse voice<br /> inspiratory stridor and suprasternal retractions<br /> crackles and wheezing<br /> cyanosis<br />Implementation:<br /> patent airway<br /> vital signs<br /> elevate HOB<br /> humidified oxygen; IVF<br /> nebulized epinephrine<br /> resuscitation equipments available<br />BRONCHITIS<br /> infection of the major bronchi<br /> assessment: cough, worse at night; becomes productive in 2-3 days<br /> Implementation:<br />Monitor for respiratory distress<br />Increased fluid intake<br />Acetaminophen<br />BRONCHIOLITIS/RESPIRATORY SYNCYTIAL VIRUS (RSV)<br />Inflammation of the bronchioles; production of mucus that occludes<br />bronchiole tubes and small bronchi<br />RSV – highly communicable, usually transferred by hands<br />Assessment:<br />URI<br />Lethargy, poor feeding, tachypnea<br />Expiratory wheezes and grunt<br />Diminished breath sounds<br />The child with RSV:<br /> isolate in a single room or place with same patient<br /> good handwashing<br /> nurses caring for these children do not care for other high risk children<br /> wear gowns when soiling may occur<br /> ribavirin – may be aerosol<br /> nurses wearing contact lenses must wear goggles – ribavirin may dissolve<br />contact lenses<br />PNEUMONIA<br /> inflammation of the alveoli<br /> inhalation of causative agent bloodstream<br /> Primary atypical pneumonia – most common cause of pneumonia between 5-12 years<br />Implementation:<br /> antimicrobial therapy<br /> oxygen<br /> cool humidification<br /> encourage child to lie on the affected side<br /> isolation procedures as needed<br /> antipyretics<br /> IVF; liberal fluid intake<br />ASTHMA<br /> chronic inflammatory disease of airways<br /> commonly caused by physical and chemical irritants common symptoms – coughing in the absence of respiratory infection,<br />especially at night<br />Assessment:<br /> episodes of wheezing, breathlessness, dyspnea, chest tightness<br /> SOB, cough, wheezing<br /> child speaks in short, broken phrases<br /> retractions<br /> exercise induced bronchospasm<br /> severe spasm or obstruction<br />Implementation<br /> continuously monitor respiratory status<br /> administer quick-relief (rescue) medication<br /> initiate an IV line; prepare to correct dehydration, acidosis or electrolyte imbalance<br />Medications<br />Quick relief<br />To treat symptoms and exacerbations<br />Short acting b2 agonists<br />Anticholinergics – for relief of acute bronchospasm (ipratropium bromide)<br />Long term control<br />Corticosteroids<br />Long acting b2 agonist<br />Long acting bronchodilator<br />Nebulizer, MDI<br />Used to deliver many medications<br />Non-CFC (chlorofluorocarbon) – albuterol<br />Chest physiotherapy<br />Includes breathing exercises <br />Home care measures:<br /> instruct in measures to eliminate allergens<br /> avoid extremes of environmental temperature<br /> avoid exposure to individuals with a viral infection<br /> instruct the child in how to recognize early symptoms <br /> instruct the child in the cleaning of devices used for inhaled medications<br /> keep immunization up to date<br />OTITIS MEDIA<br /> Infection of the middle ear occuring as a result of a blocked eustachian<br />tube, preventing normal drainage<br /> common complication of ARI<br /> infants and children more prone – ET shorter, wider, straighter<br />Assessment:<br /> fever<br /> irritability and restlessness<br /> rolling of head from side to side<br /> pulling or rubbing the ear<br /> earache; signs of hearing loss<br /> purulent ear discharge<br /> otoscopic exam<br />Intervention<br /> Encourage fluids<br /> upright position when feeding<br /> avoid chewing – increases pain<br /> have the child lie with the affected ear down<br /> instruct on appropriate technique to clean drainage from the ear with<br />sterile cotton swabs<br /> administer analgesics and antibiotics (10-14 days)<br /> screening for hearing loss<br /> otic medications <br />If younger than age 3 – auditory canal is straightened by pulling the pinna<br />down and back<br />If older than 3 years – pull pinna up and back<br />Myringotomy<br />Insertion of tympanoplasty tubes into the middle ear to equalize pressure<br />and keep ear aerated<br />Keep ears dry<br />Earplugs should be worn during bathing, shampooing, swimming<br />TONSILLECTOMY AND ADENOIDECTOMY<br />Assessment:<br /> persistent or recurrent sore throat<br /> enlarged bright red tonsils ; with exudates at times<br /> dysphagia<br /> mouth breathing; unpleasant mouth odor<br /> fever; cough<br />Preop:<br /> assess for presence of infection<br /> assess bleeding and clotting studies<br /> assess for loose teeth<br /> prepare the child for a sore throat<br />Postoperatively:<br /> Position – prone or side lying to facilitate drainage<br /> have suction equipment available<br /> monitor for signs of hemorrhage<br /> may give apply ice collar<br /> discourage coughing or clearing the throat<br /> provide clear, cool, noncitrus and non carbonated drinks<br /> avoid milk products intially – will coat the throat<br /> avoid red liquids<br /> do not give child any straw, forks, or sharp objects<br /> administer paracetamol as ordered<br /> instruct parents to notify MD if bleeding, persistent earache or fever occurs<br /> instruct parents to keep child away from crowds until healing occurred<br />HEMATOLOGIC SYSTEM<br />LEUKEMIA – the most frequent type of childhood cancer<br />Brain tumors – 2nd<br />Etiology: <br /> 1. Environmental<br />Viruses<br />Familial/genetic<br />Host factors<br /> STAGES OF TREATMENT<br />INDUCTION<br />Goal: to remove bulk of tumor<br />Methods: surgery, radiotherapy, chemotherapy, BM transplant<br />Effects: often the most intensive phase<br />Side effects are potentially life threatening<br />CONSOLIDATION<br />Goal: to eliminated any remaining malignant cells<br />Methods: chemo/radio<br />Side effects will still be evident<br />MAINTENANCE<br />Goal: to keep the child disease free<br />Chemotherapy <br />This phase may last several years<br />OBSERVATION<br />Goal: to monitor the child at intervals for evidence of recurrent<br />disease and complications of treatment<br />Method: treatment is complete<br />Child may continue in this stage indefinitely<br />LATE EFFECTS OF TREATMENT<br />Impaired growth and development<br />CNS damage<br />Impaired pubertal development<br />Development of secondary malignancy<br />Psychologic problems related to living with a life threatening disease and complex treatment regimen<br />NURSING INTERVENTION<br />Help child cope with intrusive procedures<br />Provide information geared to developmental level and emotional<br />readiness<br />Explain what is going to happen, why it is necessary, how it will feel<br />Allow child to handle to handle and manipulate equipments<br />Allow child some control in situations<br />- positioning, selecting injection site<br />Support child and parents<br />Maintain frequent clinical conferences to keep all informed<br />Always tell the truth<br />Acknowledge feelings and encourage child/family to express them<br />Provide contact with another parent or support group<br />Minimize side effects of treatment<br />Skin breakdown<br />Keep clean and dry; wash with warm water; no soaps or creams<br />Do not wash off radiation marks<br />Avoid all topical agents with alcohol<br />Do not use heating pads or hot water bottle<br />Bone marrow suppression<br />Provide frequent rest periods<br />Avoid crowds<br />Evaluate any potential site of infection<br />Monitor temperature<br />Avoid use of aspirin<br />Select activities that are physically safe<br />Nausea and vomiting<br />Administer antiemetic at least half an hour before chemotherapy<br />Eat light meal prior to administration of therapy<br />Administer IVF if needed<br />Alopecia<br />Reduce trauma of hair loss<br />Buy wig before hair falls out<br />Discuss various head coverings <br />Avoid exposing head to sunlight<br />Nutrition deficits<br />Establish baseline<br />Provide high calorie, high protein<br />5. Developmental delay<br />Facilitate return to school as soon as possible<br />Discuss limit setting, discipline<br />LEUKEMIA<br /> most common form of childhood cancer<br /> peak 3-5 years<br /> proliferation of abnormal wbc that do not mature beyond the blast phase<br /> blast cells – infiltrate other organs – liver, spleen, lymph tissue<br />Types:<br />Acute Lymphocytic leukemia (ALL)<br />80-85% <br />Acute<br />75% chance of surviving<br />Acute nonlymphocytic leukemia<br />Includes granulocytic and monocytic types<br />60-80% will obtain remission<br />30-40% cure rate<br />Assessment:<br />anemia, weakness, pallor, dyspnea<br />Bleeding, petecchiae, spontaneous bleeding, ecchymoses<br />Infection, fever, malaise<br />Enlarged lymph node<br />Enlarged spleen and liver<br />Bone pain<br />Management:<br />diagnosis: blood studies, BMA<br />Treatment stages<br />Induction<br />CNS prophylaxis<br />Maintenance<br />Nursing Intervention:<br />Provide care for the child receiving chemo and radiotherapy<br />Provide support for the family/child<br />Support child during painful procedures<br />Use distraction, guided imagery<br />Allow the child to retain as much control as possible<br />Administer sedation prior to procedure as ordered<br />Sickle Cell Disease<br /> hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin (HgbS)<br /> HgbS sensitive to changes in the oxygen content of the red blood cell<br /> Risk factors: African American<br /> Insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow<br /> The sickling response – reversible under adequate oxygenation<br /> Sickle cell crises – vaso-occlusive crisis, splenic sequestration, aplastic crisis<br />Assessment:<br />Vaso-occlusive crisis<br />Most common type of crisis<br />Caused by stasis of blood with clumping of the <br />cells in microcirculation, ischemia and infraction<br />Fever, pain and tissue engorgement<br />Splenic sequestration<br />Pooling of blood in the spleen<br />Profound anemia, hypovolemia, shock<br />Aplastic crisis<br />Caused by the diminished production and increased destruction of RBCs, triggered by viral infection or the depletion of folic acid <br />Profound anemia and pallor<br />Implementation:<br /> Administer oxygen and blood transfusions<br /> administer analgesics<br /> maintain adequate hydration and blood flow with IV normal saline as prescribed and with oral<br />fluids<br /> Assist the child to assume a comfortable position so that the child keeps the extremities extended<br />to bed no more than 30 degrees<br /> avoid putting strain on painful joints<br /> encourage consumption of a high calorie, high protein diet with folic acid supplementation<br /> administer antibiotics as prescribed<br /> Monitor for signs of increasing anemia and shock (pallor, vital sign changes)<br /> <br />IRON DEFICIENCY ANEMIA<br /> Iron stores are depleted, resulting in a decreased supply of iron for the manufacture for the <br />manufacture of hemoglobin in RBCs<br /> Results from blood loss, increased metabolic demands, syndromes of GI malabsorption, dietary<br />inadequacy<br />Assessment:<br /> pallor<br /> weakness and fatigue<br /> irritability<br />Implementation:<br /> Increase the oral intake of iron<br /> Instruct the child and parents in food choices that are high in iron<br /> Administer iron supplements as prescribed<br /> Liquid iron prep stains – stains teeth; with straw<br /> side effects of iron therapy<br />APLASTIC ANEMIA<br /> a deficiency of circulating erythrocytes resulting from the arrested development of RBCs within the bone marrow<br /> causes: exposure to toxic agents, viruses, infection, autoimmune disorders, allergic states<br /> definitive diagnosis: BMA<br /> Therapeutic management: blood transfusions, splenectomy, corticosteroids, immunosuppressive therapy, bone marrow transplantation<br />Assessment<br /> Pancytopenia <br /> Petecchiae, purpura, bleeding, pallor, weakness, tachycardia and fatigue<br />Implementation:<br /> Blood transfusion<br /> corticosteroids and immunosuppresives<br /> splenectomy<br /> bone marrow transplant<br /> Medic Alert bracelet<br />HEMOPHILIA<br /> x linked recessive trait<br /> Hemophilia A – deficiency of Factor VIII<br /> Hemophilia B – deficiency of factor IX<br /> Males inherit hemophilia from their mothers and females inherit the carrier status from their<br />fathers<br />Assessment:<br /> prolonged bleeding after minor injury<br />At birth after cutting cord<br />Following circumcision<br />Following IM immunization<br />Increase bruising as child learns to crawl and walk<br /> abnormal bleeding in response to trauma <br /> joint bleeding – pain, tenderness, swelling limited range of motion<br /> tendency to bruise easily<br /> prolonged PTT<br /> normal BT, PT, platelet count<br />Implementation:<br /> prepare to administer Factor VIII concentrate /cryoprecipitate<br />Thaw slowly<br />Gently rotate bottle<br />Infuse immediately; deteriorates at room temperature<br /> monitor for bleeding<br /> monitor for joint pain; immobilize the affected extremity if joint pain occurs<br /> assess neurological status ( child at risk for IC bleed)<br /> monitor urine for hematuria<br /> Control bleeding by immobilization, elevation, application of ice; apply pressure (15 mins)<br />for superficial bleeding<br /> instruct parents regarding activities of the child<br /> avoidance of contact sports<br />BETA THALASSEMIA MAJOR<br /> Cooley’s anemia<br /> autosomal recessive disorder<br /> characterized by reduced production of one of the globin chains in the synthesis of hemoglobin<br /> incidence highest in Mediterranean descent<br />Assessment:<br /> severe anemia<br /> pallor<br /> failure to thrive<br /> hepatosplenomegaly<br /> microcytic, hypochromic RBCs<br />Implementation<br /> Instruct the administration of folic acid (Vit B9)<br /> administer blood transfusion as prescribed<br /> Monitor for iron overload<br /> iron overload – chelation therapy with deferoxamine<br /> genetic counseling<br />IDIOPATHIC THROMBOCYTOPENIC PURPURA<br /> increased destruction of platelets with resultant platelet count less than 100,000/mm3<br /> characterized by petechiae and ecchymoses of skin<br /> exact mechanism unknown<br /> often preceded by a viral illness<br /> spleen not enlarge<br />Assessment:<br /> petechiae: spider web appearance of bleeding under the skin due to small size of platelets<br /> ecchymosis<br /> blood in any body secretions, bleeding from mucus membranes, nosebleeds<br /> diagnostic test: platelet count decreases, anemia <br />Management:<br /> steroids and immunosuppressives<br /> platelet transfusion<br /> surgery; splenectomy<br />Nursing Intervention<br /> control bleeding<br />Administer platelet transfusion as ordered<br />Apply pressure to bleeding sites as needed<br />Position bleeding part above heart level if possible<br />Prevent bruising<br />Protect from infection<br />Measure normal circumference of extremities for baseline<br />Administer meds orally, rectally or IV rather than IM; hold pressure on site for 5 mins<br />Avoid aspirin<br />Provide client teaching and discharge planning<br />Pad crib and playpen<br />Provide soft toys<br />Provide protective headgear during toddlerhood<br />Use soft toothbrush<br />Avoid contact sports<br />INTEGUMENTARY SYSTEM<br />ECZEMA<br /> atopic dermatitis - often the first sign of an allergic predisposition in a child<br /> usually manifests during infancy<br />Asssessment:<br /> erythema, weeping vesicles that rupture and crusts<br /> severe pruritus; scratching causes thickening and darkening<br /> dry skin, sometimes urticaria<br />Intervention:<br /> topical steroids<br /> antihistamines<br /> coal tar preparation<br /> colloid baths<br /> diet therapy: elimination of offending food<br />Nursing Intervention:<br /> avoid heat and prevent sweating<br /> check materials in contact with child’s skin (sheets, lotions, soap)<br /> avoid frequent baths<br /> avoid use of soap<br /> provide lubricant immediately after bath<br /> administer topical steroids as ordered<br /> use cotton instead of wool<br /> keep child’s nails short; use elbow or glove restraints if needed<br /> apply wet saline or Burrow’s solution compresses<br />DIAPER RASH<br /> contact dermatitis<br /> plastic/rubber pants and linings of disposable diapers<br />exacerbate the condition by prolonging contact with<br />moist, warm environment<br /> skin further irritated by acidic urine<br />Assessment:<br /> erythema/excoriation in the perineal area<br /> irritability<br />Nursing intervention:<br /> keep area clean and dry; clean with mild soap and water after each stool and soon as child urinates<br /> take off diaper and expose area to air during the day<br /> client teaching:<br />Proper hygiene<br />Avoid use of plastic pants or disposable diapers with a plastic lining<br />Avoid commercially prepared diaper wipes containing alcohols<br />Avoid cornstarch; good medium for bacteria<br />MUSCULOSKELETAL SYSTEM<br />Care of the child with a Cast<br /> if cast is of plaster – will remain wet for at least 24 hrs<br /> use only the flats of their hands to move children<br /> casts must remain open to the air until dry<br /> casted extremities are elevated to help blood return and reduce swelling<br /> Initial chemical hardening reaction may cause a change in an infant’s body<br /> Choose toys too big to fit down cast<br /> do not use baby powder near cast – medium for bacteria<br /> prepare for anticipated casting by having child help apply cast in a doll<br />Diagnoses and interventions:<br />Potential for alteration in tissue perfusion related to constriction of cast<br />Check color, sensation and motion distal to the cast every half hour<br />Check pedal or radial pulse<br />Check for tightness by slipping finger under edge; if impossible – cast is too tight<br />Ask child to move toes or fingers<br />Elevate casted extremity<br />Potential for alteration in skin integrity<br />Remove plaster flakes from skin<br />Handle wet cast carefully so as not to cause indentations<br />Expose wet cast to air to hasten drying<br />Support heavy cast with sling or pillow to decrease pressure of cast edges<br />Check cast for foul or musty odors<br />Potential for fear and loneliness<br />Encourage expression of feelings<br />Provide diversional play<br />Encourage friends and family to visit children as often <br />Provide educational opportunity for children confined for long periods<br />Potential for knowledge deficit of family<br />Encourage discussion of feelings and fears<br />Provide information and reassurance as appropriate<br />Involve family in child’s care in hospital<br />Prepare family for some emotional regression<br />CONGENITAL HIP DISLOCATION<br /> displacement of the head of the femur from the acetabulum<br /> present at birth although not always diagnosed<br /> familial disorder<br /> unknown cause; may be fetal position in utero<br /> acetabulum is shallow and the head of femur is cartilaginous at birth<br />Assessment:<br /> maybe unilateral or bilateral<br /> limitation of abduction (cannot spread legs to change diaper)<br /> Ortolani’s click<br />With an infant supine, bend knees and place thumb on bent knees,<br />fingers at hip joint<br />Bring femur 90degrees to hip, then abduct<br />Palpable click – dislocation<br />Barlow’s test<br />With infant on back, bend knees<br />Affected knee will be lower because the head of the femur dislocates<br />towards the bed of gravity<br />additional skin folds with knees bent<br /> when lying on abdomen, buttocks of affected side will be flatter<br /> Trendelenburg test – if child can walk<br />Have child stand on affected leg only<br />Pelvis will dip on normal side as child attempts to stay erect<br />Management:<br />Goal : to enlarge and deepen the socket<br />Early treatment: positioning the hip in abduction with the head of the femur in the acetabulum and maintaining it in position for several months<br />Traction and casting (hip spica)<br />Surgery<br />Nursing intervention:<br /> Maintain proper positioning: keep legs abducted<br />Use triple diapering<br />Use Frejka pillow splint (jumperlike suit to keep legs abducted)<br />Place infant on abdomen with legs in “frog” position<br />Use immobilization devices<br />Provide adequate nutrition<br />Provide sensory stimulation<br />Client teaching and discharge planning:<br />CLUBFOOT (Talipes)<br /> abnormal rotation of foot at ankle<br />Varus – inward rotation; bottom of feet face each other<br />Valgus – outward rotation<br />Calcaneous – upward rotation; would walk on heels<br />Equinas – downward rotation; would walk on toes<br />Most common – talipes equinovarus<br />Assessment: <br /> foot cannot be manipulated by passive exercises into correct position<br />Management:<br /> exercises<br /> casting<br /> Denis Browne splint (bar shoe)<br /> surgery and casting<br />Nursing Intervention:<br /> perform exercises as ordered<br /> provide cast care<br /> child who is learning to walk must be prevented from trying to stand; apply restraints if necessary<br /> provide diversional activities<br /> provide skin care<br /> client teaching<br />SCOLIOSIS<br /> lateral curvature of the spine<br /> most commonly in adolescent girls<br /> familial pattern; associated with other nueromuscular condition<br /> idiopathic majority<br />Assessment:<br /> failure of curve to straighten when child bends forward with knees straight and arms hanging down feet<br /> uneven bra strap marks<br /> uneven hips<br /> uneven shoulders<br /> asymmetry of rib cage<br /> xray: reveals curvature<br />Management:<br /> stretching exercises<br /> Milwaukee brace – worn 23 hours/day for 3 years<br /> plaster jacket vest<br /> spinal fusion<br />Nursing Intervention:<br /> teach/encourage exercise<br /> provide care for the child with Milwaukee brace<br />Child wears brace 23 hours/day<br />Monitor pressure points<br />Promote positive body image with brace<br />Provide cast care<br />Assist with modifying clothing for immobilization devices<br />Adjust diet with decreased activity<br />Provide client teaching and discharge instructions<br />Exercise<br />Cast care<br />Correct body mechanics<br />Alternative education for long term hospitalization<br />Availability of community agencies<br />JUVENILE RHEUMATOID ARTHRITIS<br /> systemic, chronic disorder of connective tissue<br /> autoimmune reaction<br /> results from eventual joint destruction<br /> affected by stress, climate and genetics<br />Types:<br />Monoarticular JRA<br />Fewer than 4 joints involved (usually legs)<br />Asymmetric<br />Good prognosis<br />Mild signs of arthritis<br />Polyarticular JRA<br />Multiple joints affected<br />Symmetrical<br />Involvement of TMJ<br />Remissions and exacerbations<br /> poor prognosis<br />Systemic disease with polyarthritis (Still’s disease)<br />Fever, rash, LADP, anorexia, weight loss<br />Exacerbations and remissions<br />Assessment:<br />No specific diagnostic tests<br />ESR, ASO, RF- not specific<br />Intervention<br />Drugs: ASA, corticosteroids<br />NSAIDS<br />Physical therapy – strengthening muscles, preventing deformities<br />Splints – used for knees, wrists and hands – to reduce pain and prevent <br />or reduce flexion deformities<br />Nursing intervention:<br /> Assess joints for pain, swelling, tenderness<br /> promote maintenance of joint mobility<br />a. ROM exercises<br />b. Isometric exercises<br /> change position frequently; alternate sitting, standing, lying<br /> promote comfort and relief<br /> provide firm mattress<br /> maintain proper body alignment<br /> keep joints mainly in extension, not flexion<br /> cold treatments: in acute episodes<br /> focus on child’s strength<br />GENITOURINARY SYSTEM<br /> Nephrons continue to develop after birth<br /> GFR is 30% below adult level at birth<br /> reaches normal level by age 2 years<br /> tubular function immature at birth; reach adult level<br />by age 2 years<br /> urethra shorter in children and more prone to ascending<br />infection<br />UNDESCENDED TESTES (Cryptorchidism)<br /> unilateral or bilateral absence of testes in scrotal sac<br /> testes normally descend at 8 months of gestation<br /> increased incidence in those with genetic disorder<br /> 75% will descend spontaneously by age 1 year<br />Assessment:<br /> unable to palpate testes in scrotal sac<br />Management:<br /> if testes remains in abdomen, damage to testes is possible because of increased<br /> chorionic gonadotropin<br /> orchipexy: surgical procedure to retrieve and secure testes placement; performed between ages 1-3 yrs<br />Nursing Management:<br /> provide treatment options<br /> support parents if surgery will be done<br /> post op: avoid disturbing the tension mechanism<br /> avoid contamination of incision<br />HYPOSPADIAS<br /> urethral opening located anywhere along the ventral surface of penis<br />Assessment:<br /> urinary meatus misplaced<br /> inability to make straight stream of urine<br />Management:<br /> minimal defects – no intervention<br /> neonatal circumcision delayed, tissue maybe needed for corrective repair<br /> surgery at age 3-9 months<br />Nursing Intervention:<br /> diaper normally<br /> provide support for parents<br /> post op: check pressure pressure dressing <br /> monitor catheter drainage<br />PHIMOSIS<br /> an abnormal narrowing of the foreskin so that it cannot be retracted over the glans penis<br /> may be present at birth or may develop as a result of poor hygiene with accumulation of smegma<br />Management:<br /> Prevention – regular pulling the foreskin back and cleaning<br /> circumcision<br />Nursing intervention:<br /> circumcision care:<br />Close observation for bleeding<br />Ice application<br />Administration of analgesics<br />ENURESIS<br /> involuntary passage of urine after the age of control is expected (4 years)<br /> types:<br />Primary – in children who have never achieved control<br />Secondary: in children who have developed complete<br />control<br />May occur anytime but most frequent at night<br />More common in boys<br />No organic cause<br />Etiologic possibilities:<br />Sleep disturbances<br />Delayed neurologic development<br />Immature development of bladder<br />Psychologic problems<br />Assessment:<br />PE normal<br />History of repeated voluntary urination management:<br /> bladder retention exercises<br /> drug therapy<br />TCA – imipramine<br />Anticholinergics<br />Nursing Intervention:<br /> Provide information/counseling to family:<br />Confirm that this not conscious behavior and that the child is not purposely misbehaving<br />Assure parents that they are not responsible and that this is a relatively common problem<br />Involve child in care; give praises and support with small accomplishments<br />Age 5-6 years – can strip wet beddings<br />Age 10-12 years – can do laundry and change bed<br />Avoid scolding and belittling the child<br />EXSTROPHY OF THE BLADDER<br /> congenital malformation ; nonfusion of abdominal <br />and anterior walls of the bladder during embryologic<br />development <br /> anterior surface of bladder lie open on abdominal wall<br />Assessment:<br /> Associated structural changes<br />Prolapsed rectum<br />Inguinal hernia<br />Widely split symphysis<br />Rotated hips<br />Associated anomalies<br />Epispadias<br />Cleft scrotum or clitoris<br />Undescended testes<br />Chordee (downward deflection of the penis)<br />Management:<br /> reconstructive surgery<br /> urinary diversion<br /> delayed until 3-6 months<br />Nursing intervention: Preop:<br /> Provide bladder care; prevent infection<br />Keep area as clean as possible<br />Change diaper frequently; keep loose fitting<br />Wash with mild soap and water<br />Cover exposed bladder with vaseline gauze<br />Postop:<br /> Design play activities to foster toddler’s need for autonomy <br />- child will be immobilized for extended period of time<br />Prevent trauma; as child gets older and more mobile,<br />trauma is more likely<br />NEPHROTIC SYNDROME<br /> autoimmune process <br /> structural alteration of glomerular membrane <br /> results in increased permeabilityb to plasma proteins<br /> course: exacerbations and remissions over a period of months to years<br /> commonly affects preschoolers; boys>girls<br />Assessment:<br />Proteinuria<br />Hypoproteinemia<br />Hyperlipidemia<br />Dependent edema<br />Puffiness around the eyes in morning<br />Ascites<br />Scrotal edema<br />Ankle edema<br />anorexia, vomiting, diarrhea<br />Pallor, lethargy<br />Hepatomegaly <br />Management:<br /> drug therapy<br />Corticosteroids<br />Antibiotics<br />Thiazide diuretics<br />Nursing Intervention:<br />Provide bed rest<br />Conserve energy<br />Find activities for quiet play<br />Provide high protein, low sodium diet – during edema phase<br />Maintain skin integrity<br />Avoid IM injections – meds not absorbed in edematous tissues<br />Obtain morning urine for protein studies<br />Provide scrotal support<br />Monitor I and O, vital signs <br />Daily weight<br />Administer as ordered<br />Protect from sources of infection<br />ACUTE GLOMERULONEPHRITIS<br /> immune complex disease<br /> beta hemolytic strep<br /> More frequently in boys; 6-7 years<br /> resolves in 14 days<br /> self limiting<br />Assessment:<br />History of strep infection (URTI or impetigo)<br />Edema, anorexia, lethargy<br />Hematuria or dark colored urine<br />Fever<br />Hypertension<br />Diagnostic tests:<br />Urinalysis – rbc,wbc,protein, cellular casts<br />Urine specific gravity increased<br />BUN, crea increased<br />ESR elevated<br />Hgb, Hct decreased<br />Management:<br /> antibiotics<br /> Antihypertensives<br /> digitalis – if with CHF<br /> fluid restriction <br /> peritoneal dialysis – if severe renal complication occurs<br />Nursing Management:<br />1. Monitor I and O, BP<br />Weigh daily<br />Provide diversional activity<br />Provide client teaching and discharge planning<br />Medication administration<br />Prevention of infection<br />Signs of renal complications<br />Importance of long term follow up<br />WILM’S TUMOR (NEPHROBLASTOMA)<br /> large, encapsulated tumor that develops in the renal parenchyma,<br /> more frequently in left kidney<br /> originates during fetal life<br /> peak age : 1-3 years<br />Assessment:<br /> non tender mass, usually midline near liver<br /> hypertension<br /> hematuria<br /> test: IVP<br />Nursing intervention:<br />Do not palpate abdomen – to avoid dissemination of CA cells<br />Handle child carefully when bathing and giving care<br />Provide care for the client with a nephrectomy<br />Provide care for the child receiving chemotherapy<br />MALFORMATIONS OF THE NERVOUS SYSTEM<br />Cranial Defects:<br />Craniosynostosis<br /> one or more of the sutures close too soon<br />ICP increases; interfeeres with normal brain growth MR<br />Assessment: <br />suture lines of the skull manually palpated <br />Radiographs are made to confirm<br />Microcephaly<br />The brain fails to grow<br />May be due to a chromosomal defect or from drugs, toxins or radiation<br />MR <br />Hydrocephalus<br />Imbalance of CSF absorption or production<br />caused by malformations, tumors, hemorrhage, infection, trauma<br />Types:<br />Communicating – impaired absorption within arachnoid space<br />Non-communicating – obstruction of CSF flow within the ventricular system<br />Assessment:<br />Infant – increased HC<br />Macewen’s sign – cracked-pot sound on percussion of bones of head<br />Anterior fontanel tense, bulging<br />Scalp veins dilated<br />Frontal bossing, sunsetting eyes<br />Child – behavior changes<br />Headache, nausea and vomiting<br />Ataxia, nystagmus<br />Surgical Implementation: Hydrocephalus<br />Goal: to prevent further CSF accumulation by bypassing the blockage and<br />draining the fluid from the ventricles to a location where it may be <br />reabsorbed<br />VP Shunt – CSF drains into the peritoneal cavity from the lateral ventricle<br />AV shunt – CSF drains into the right atrium<br />PostOP Care:<br />Keep child flat as prescribed – to avoid rapid reduction of intracranial fluid<br />Observe increase ICP – if present, elevate HOB 15-30 deg<br />Monitor for infection<br />Measure HC<br />Monitor I and O<br />Provide comfort measures; administer medications (diuretics, antibiotics, or anticonvulsants)<br />Toddler – headache and anorexia earliest common signs of shunt malfunction<br />SPINA BIFIDA<br /> CNS defect that occurs as a result of neural tube failure to <br />close during embryonic development<br /> defect closure usually done during infancy<br />Types:<br />Spina bifida occulta<br />Posterior vertebral arches fail to close in the lumbosacral area<br />Spinal cord intact; not visible<br />Meninges not exposed on the skin surfaces<br />Meningocoele<br />Protrusion involves meninges and a sac-like cyst<br />Lumbosacral area<br />Myelomeningocoele<br />Protrusion of meninges, CSF, nerve roots, portion of spinal cord<br />Sac covered by a thin membrane may rupture or leak<br />Neuro deficit evidence<br />Assessment:<br />Depends on spinal cord involvement<br />Visible spinal defect<br />Flaccid paralysis of legs<br />Altered bladder and bowel function<br />Implementation:<br /> Evaluate sac; measure lesion<br /> neuro check<br /> monitor for increase ICP<br /> measure HC; assess fontanelles<br /> Protect the sac<br />1. Cover with sterile, moist (normal saline) non-adherent<br />dressing<br />2. Change dressing every 2-4 hours <br /> Place prone position<br /> head is turned to one side for feeding<br /> diapering may be C/I until defect repaired<br /> Aseptic technique<br /> Watch for early signs of infection<br /> Administer antibiotics<br /> Administer anticholinergics – improve urinary continence<br /> Administer laxatives , antispasmodics<br />MENINGITIS<br /> infectious process of the CNS caused by bacteria and viruses<br /> acquired as a primary or as a result of complications<br /> diagnosis – CSF analysis (increase pressure, cloudy CSF, high protein, low glucose<br /> bacterial or viral<br />Assessment:<br /> signs and symptoms vary depending of age group<br /> fever, chills<br /> vomiting, diarrhea<br /> poor feeding or anorexia<br /> altered LOC<br /> bulging anterior fontanel<br /> nuchal rigidity<br />Implementation:<br /> isolation; maintain for at least 24 hours after antibiotics are initiated<br /> administer antibiotics as prescribed<br /> monitor VS and neuro status<br /> Monitor I and O<br /> assess nutritional status<br /> determine close contacts of the child with meningitis<br />SEIZURE DISORDERS<br /> Sudden transient alterations in brain function resulting from excessive levels of electrical activity in the brain<br />Assessment:<br /> obtain information from parents about the time of onset, precipitating events and behavior before and after the seizure<br /> seizure precautions:<br />Raise side rails<br />Pad side rails<br />Place waterproof mattress on bed<br />Instruct child to swim with companion<br />Alert caregivers to the need for special precautions<br />Emergency Treatment for Seizures:<br /> Ensure patency of airways<br /> If the child is standing or sitting, ease the child down to the floor<br /> place pillow or folded blanket under the child’s head<br /> loosen restrictive clothing<br /> clear area of any hazards<br /> if vomiting occurs, turn child to one side<br /> do not restrain child; do not place anything in the child’smouth<br /> Remain with the child until fully recovers<br /> Prepare to administer medications<br />CEREBRAL PALSY<br /> disorder characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal motor system<br /> spastic type- most common<br />Assessment:<br /> extreme irritability and crying<br /> feeding difficulties<br /> stiff and rigid arms and legs<br /> delayed gross development<br /> abnormal motor performance<br /> alterations of muscle tone<br /> abnormal posturing<br /> persistence of primitive reflexes<br />Implementattion:<br /> early recognition<br /> PT, OT, speech therapy, eduaction and recreation<br /> assess the child’s developmental level and intelligence<br /> early intervention<br /> encourage communication and interaction with the child on a functional level<br /> provide safe environment<br /> position upright after meals<br /> provide safe, appropriate toys for age and developmental level<br />