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Other Causes
Radiation enteritis
Abdominal tumors
Protein-losing enteropathy (Mntrier disease,
intestional lymphagiectasia)
Viruses
Paravirus
Associated Conditions
Upper respiratory tract infections
Otitis media
Dietary Conditions
Over feeding
Introduction of new foods
episode
Osmotic diarrhea from excess sugar in formula or juice
Medications
Antibiotics
Laxatives
Toxic Causes
Ingestion of heavy metals (arsenic, lead, mercury), or organic phosphates
Functional Causes
Irritable bowel syndrome
Other Causes
Pseudomembranous enterocolitis
Hirschsprung disease
o Vomiting
Localized abdominal pain and vomiting often occur with appendicitis, pancreatitis, or
peptic ulcer disease
A change in the LOC or a headache associated with vomiting indicates a CNS or
metabolic disorder
Forceful vomiting is associated with pyloric stenosis
Cyclic vomiting syndrome- rare disorder characterized by bouts of vomiting that can
last for hours to several days (Unknown cause)
Ondansteron [Zofran) block receptors in the chemoreceptor trigger zone
Metoclopramide [Reglan]- enhance gastroduodenal peristalsis
Promethazine [Phenergan]- compete for H1- receptor sites
Dimenhydrinate [Dramamine]- motion sickness
Poor feeding
Vomiting
Failure to
gain weight
Rapid respirations (acidosis)
Respiratory
distress
Spontaneous pneumothorax or pneunonediastinum
Frequent urination
Screaming
on urination
Poor urinary stream
Jaundice
Seizures
Dehydration
Other abnormalities or
stigmata
o The classic symptoms of UTI are often observed in children more than 2 years of age
o What catches the attention of mothers- crying when the baby goes pee
Foul smelling urine
Urine bag. Clean catch.
Best method in n out straight catch to get a culture
o
o
o
o
o
Objective data
Fever
Hematuria, foul-smelling urine; tender, enlarged kidney
Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria
Facing the wall back to you so you can get a clean catch urine They are more stable and relaxed and labia are open so there is decreased
changes of contamination
Kidney reflux- in babies- anatomic
The higher the BUN the more severe the problem
Renal disease
Increased protein catabolism
Dehydration
Hemorrhage
High protein intake
Corticosteroid therapy
o Glomerulonephritis
Acute Poststreptococcal
Glomerulonephritis
Elevated
Elevated
Primarily periorbital and
peripheral
Common
Mild to moderate
Gross or microscopic
Present
Present
Syndrome
Normal
Normal or decreased
Generalized, severe
Normal or increased
Minimum reduction
Normal
5-7
Normal
Markedly decreased
Elevated
2-3
Absent
Massive
Microscopic or none
Absent
Absent
o Nephrotic Syndrome
o Dialysis
Peritoneal dialysis
Hemodialysis
Hemofiltration
o Adolescents often resent the control and enforced dependence imposed by dialysis
Depression, hostility, or both are common
Withdrawal from peers and social isolation are the rule, and noncompliance with the
therapeutic regimen is not uncommon
o Peritoneal Dialysis
The preferred method of dialysis for children
Slow, gentle process, which decreases the stress on body organs that can occur with the
rapid chemical and volume changes of hemodialysis
Indicated for neonates, children with severe cardiovascular disease, or those who are
poor risks for vascular access
Contraindications
Recent abdominal surgery
Peritoneal adhesions and scarring
A higher rate of infection (peritonitis) is observed with this modality
Catheters for long term use are placed surgically in the OR with the pt under anesthesia
Abdominal cavity acts as semipermeable membrane for filtration
Cerebral Function
o Assessment
Infants and young children: observe spontaneous and elicited reflex responses
Physical examination:
No response to pain,
Altered LOC
Impaired gait
Can not fix a stare
Early signs and symptoms may be subtle
In children there is a modified Glascow Coma Scale
As pressure increases, signs and symptoms become more pronounced and level of
consciousness (LOC) deteriorates (Expected reference range is 10-15 mm Hg)
Clinical Manifestations of Increased Intracranial Pressure (ICP)
Vomiting: with or without nausea
Pupils become progressively sluggish in reaction and eventually become fixed and
dilated
Clinical Manifestations of Increased Intracranial Pressure in Infants and Children
Tense, bulging fontanel
High-pitched cry
Infants
Separated cranial sutures
Distended scalp
veins
Macewen (cracked-pot) sign
Poor feeding
Irritability and restlessness
Crying when
disturbed
Drowsiness
Setting-sun sign
Increased sleeping
Children
Headache
Nausea
Forceful vomiting
Diplopia, blurred vision
Seizures
Indifference, drowsiness
Decline in school performance
Diminished physical activity
Increased sleeping
Lethargy
Inability to follow simple commands
Bradycardia
Coma
Decreased motor response to command
Decreased sensory response to painful stimuli
Alterations in pupil size and reactivity
Extension or flexion posturing
Cheyne-Stokes respirations
Papilledema
Decreased
consciousness
Nursing Care
Patient positioning
Head alignment should be in line with the body
Avoiding hip flexion/extension
Avoid activities that may increase ICP
Coughing
Blowing the nose
Straining (stool softener)
Keep the head of the bed elevated to 30 which will also promote venous drainage
The sudden appearance of a fixed and dilated pupil is a neurosurgical emergency
Eliminate or minimize environmental noise
Suctioning issues - Suction only when necessary
o Skull fracture
Infants are at increased risk of skull fractures from minor trauma
Falls are most common cause of head injury
Linear skull fracture
Single fracture line that starts at the point of maximum impact
and spreads; however they DO NOT cross suture lines
Typically occur in the parietal bone
Comminuted fracture
Multiple associated linear fractures
Result from intense impact
May suggest child abuse particularly if in occipital bone
Depressed fractures
The bone is locally broken, usually into several irregular fragments that are pushed
inward
Should be suspected when a childs head appears misshapen
Open fractures
Result in a communication between the skull and the scalp or the mucosa of the
upper respiratory tract
Risk of CNS infection is increased with open fractures
Compound fractures
Skin laceration overlying the bone fracture
May lead to leakage of CSF (rhinorrhea or otorrhea)
Basilar fractures
Involves bones at the base of the skull in either the posterior or the anterior region
Usually result in a dural tear
Clinical features: CSF rhinorrhea, CSF otorrhea, hemotympanum, Battle sign,
raccoon eyes
Growing fractures
Results from a skull fracture with an underlying tear in the dura that fails to heal
properly
The parietal bone is the most common location
Occurs before 3 years of age
The major complications of trauma to the head are hemorrhage, infection, edema, and
herniation through the brainstem
o The lower the pupil;
The smaller you see the higher the pressure- Bulging fontanels
o Meningitis and hydrocephalous reasons for increased ICP
Neonates
Specific signs
present
Jaundice
Irritability
Seizures
Cyanosis
Respiratory irregularities or apnea
Drowsiness
Weight loss
Complications
If infection extends to the ventricles, thick pus, fibrin, or adhesions may occlude the
narrow passages, thereby obstructing the flow of CSF and causing obstructive
hydrocephalus
Extension of the infection to the areas of the cranial nerves or compression necrosis
from increased pressure may cause deafness, blindness, or weakness or paralysis of
facial or other muscles of the head and neck
Meningococcal sepsis or meningococcemia (Waterhouse-Friderchsen syndrome)
Overwhelming septic shock
disseminated intravascular coagulation
Massive bilateral adrenal hemorrhage
Purpura
REQUIRES IMMEDIATE EMERGENCY TREATMENT
Meningitis in the neonatal period is more likely to cause lifelong impairments,
including moderate to severe developmental delay, blindness, deafness, and epilepsy
Lumbar Puncture
Let them empty their bladder
LMX (4% lidocain) or EMLA cream, topical anesthetics, may be applied to the skin
overlying L3 to L5 to reduce pain before LP. For max effect apply EMLA cream at least
1 hour before the procedure or LMX 30 minutes beforehand
May be sedated with fentanyl (Sublimaze) and midazolam (Versed)
Remain in bed for 4 to 8 hr in a flat position to prevent leakage and a resulting spinal
headache
Therapeutic Management
Isolation precautions
Initiation of antimicrobial therapy
Management of hydration Maintenance of ventilation
Reduction of
increased ICP
ONSET
SEVERE CASES
Malaise
Fever
Dizziness
Apathy
Lethargy
N/V
Ataxia
Tremors
Speech difficulties
High fever
Stupor
Disorientation
Spasticity
Coma (may
Altered mental status
Paralysis
Headaches
Nuchal rigidity
Hyperactivity
Seizures
proceed to death)
Ocular palsies
Seizures
o Therapeutic Management
The goal of treatment of seizure disorders is to control the seizures or to reduce their
frequency and severity, discover and correct the cause when possible, and help the child
live as normal a life as possible
Management of epilepsy has four treatment options:
Drug therapy
The administration of antiepileptic drugs serves to raise this threshold and
prevent seizures
Drug
Carbamazepine
Phenytoin
*Vitamin D and
Provide the appropriate drug or combo of drugs in a dosage that provides the
desired effect without causing undesirable side effects or toxic reaction
Monotherapy remains the tx method of choice for epilepsy
If complete seizure control is maintained on an anticonvulsant drug for 2
years it is safe to be d/c the drug for patients with no risk factors
RF: age > 12 yrs at onset, hx of neonatal seizures, numerous seizures
before control is achieved, and presence of neurologic dysfunction
Dose needs to be decreased gradually
Measurement of blood levels of the drug is important if the seizures continue
once the child is on a therapeutic dose of medication
Some possible causes of low serum blood concentration are noncompliance,
poor absorption, and drug interactions
Dose needs to be increased as the child grows
Common Antiepileptic Medications
Indications
Half-life (hr)
Maintenance
Therapeutic
Adverse
dose
levels
Effects
(mg/kg/day)
(mcg/ml)
Paritial,
14-27 (children)
10-30
4-12
Allergic rashes,
Secondary
8-28 (neonates)
nausea,
generalized
diplopia, blurry
vision,
dizziness,
drowsiness,
hypersensitivity
syndrome,
aplastic anemia
Partial, tonicclonic
5-14 (children)
10-60 (neonates)
(nonlinear
5-8
10-25
(occasionally
lower)
Rashes,
sedation,
nystagmus,
folic acid
supplements
kinetics)
ataxia,
hirsutism,
gingival
hyperplasia,
coarse features,
folate
deficiencies
Do not take w
milk
Valproic acid
Phenobarbital
*Need vitamin
D and folic acid
Ethosuximide
Primary
generalized,
absence,
myoclonic,
akinetic,
febrile, infantile
spasms, some
partial
Neonatal,
febrile, partial,
generalized
tonic-clonic
30-80
50-100 (150 if
tolerated)
Nausea,
tremors, weight
gain, hair loss,
thrombocytope
nia, hepatic
failure,
pancreatitis
36-73
10-40
Sedation,
inattention,
hyperactivity,
irritability,
cognitive
impairment,
rash, rare
hypersensitivity
reactions
Absence,
myoclonic
20-60
15-40
40-100
Nausea,
abdominal
discomfort,
drowsiness,
rash,
leukopenia
Primidone
Partial, simple
and complex;
generalized
tonic-clonic
5-11
12-25
5-12
Clonazepam
Absence,
atypical
absence,
atonic,
myoclonic
20-40
0.1-0.3
0.02-0.08
Sedation,
dysphoria,
irritability,
psychomotor
slowing, rash,
rare
hematologic
and
hypersensitive
reactions
Sedation,
irritability,
tolerance,
ataxia, diplopia
Ketogenic diet
May be effective in controlling seizures
High-fat, low-carbohydrate, and adequate protein diet
Forces the body to shift from using glucose as the primary energy sources to
using fat, and the individual develops a state of ketosis
Rigorous- all foods/liquids must be carefully weighed and measured
Deficient in vitamins/minerals so provide supplements
Potential side effects
constipation
weight loss
lethargy
kidney
stones
Vagus nerve stimulation
Implantable device that reduces seizures in individuals who have not had
effective control with drug therapy
Adjunctive therapy in patients 12 years and older with partial onset seizures
Electrodes tunneled underneath the skin deliver electrical impulses to the
left vagus nerve (CN X)
Precise pattern of stimulation to the left vagus nerve
Activate the device using a magnet at the onset of seizures
Epilepsy surgery
When seizures are caused by a hematoma, tumor, or other cerebral lesion,
surgical removal is the treatment
Incapacitating, refractory seizures
Refractory seizures are usually defined as the persistence of seizures
despite adequate trials of three antiepileptic medications, alone or in
combination
Surgical excision of the epileptogenic focus may not eliminate the need for
drug therapy
o Nursing care
An important nursing responsibility is to observe the seizure episode and accurately
document the event
Record and note any alterations in behavior preceding the seizure and the characteristics
of the episode, such as sensory- hallucinatory phenomena (eg. Aura), motor effects (e.g.
eye movements, muscular contractions), alteration in consciousness, and postictal state
Note the duration of seizures
The more detailed these descriptions, the more valuable they are for assessment
The child must be protected from injury during the seizure
The nurse must remain calm, stay with the child, and prevent the child from sustaining
any harm during
If the nurse is able to reach the child in time, a child who is standing or seated in a chair
(including a wheelchair) is eased to the floor immediately
Placing the child on the side facilitates drainage and helps maintain a patent airway
When feasible, the child is integrated into the environment as soon as possible
Do not move or forcefully restrain the child during a tonic-clonic seizure, and do not
place a solid object between the teeth
o Febrile Seizure
More serious protrusion of membranes and spinal cord through the opening
May have associated paralysis of lower extremities
Adequate nutrition
Accurate observations and charting
Education of the parents
The child will be insensitive to pressure or other sources of tissue injury.
Family must be alert to hot or cold items that could cause thermal injury to tissues
and remember to inspect the skin regularly for signs of pressure
A priority nursing intervention to prevent contractures of the infants lower extremities
(also supposed the infant also have clubfoot and congenital hip dislocation) is to conduct
range-of-motion exercises.
Complications that can be life threatening must be monitored
Meningitis
Pneumonia
UTI
Urological monitoring
Skin care
Potential for latex allergy
Due to multiple surgeries, catheterization, fecal disimpaction, etc. all with use of
latex gloves
Spina Bifida Occulta
May have a tuft of hair, dimple, lipoma, or discoloration at the site
Treatment not necessary unless neuromuscular symptoms appear
neurological problems
o Shunting, called ventriculoperitoneal shunting, is necessary to drain the excess fluid
and relieve the pressure in the brain
This should be done as soon as hydrocephalus is recognized to give the child the
best possible neurological outlook
o Manifestations
Depend upon time of onset and severity of imbalance
Classic signs
Increase in size of head
Eyes rotated downward- Setting-sun sign
Cranial sutures separate to accommodate enlarging mass
Scalp is shiny
Veins are dilated
Macewen Sign- cracked pot sound on percussion
Infant cries when picked up or rocked and quiets when allowed to lie still
Increased ICP
Increased blood pressure
Decrease in pulse rate
Decrease in respirations
High-pitched cry
Unequal pupil size or response to light
Bulging fontanels
Irritability or lethargy
Poor feeding
Infants with hydrocephalus are at risk for vomiting
After feedings infants should be placed in the side-lying position
o Monitoring
Head Circumference- (F.O.C.)
Fontanel tension
Serial ultrasoundsventricle size
FOC or OFC= Frontal Occipital Circumferencemark on head w/ marking pen
o Management
Treatment of excessive CSF (shunt)
Ventriculoperitoneal (VP) shunt :
Provides primary drainage of the CSF from the ventricles to an extracranial
compartment, usually the peritoneum
The valves are designed to open at a predetermined intraventricular pressure
and close when the pressure falls below that level, thus preventing backflow of
fluid
Since it requires repeated lengthening, the ventriculoatrial (VA) shunt (ventricle
to right atrium) is reserved for older children who have attained most of their
somatic growth and children with abdominal pathologic conditions
Revisions are performed when physical signs indicated shunt malformation
Children often need shunt lengthening as body growth occurs
Treatment of complications
Infection
Greatest risk is 1 to 2 months after placement
Spastic (Pyramidal)
In the supine position spasticity is evident by scissoring (legs in crossed position; knees,
hips, and ankles stiff) and extension of the legs, with the feet plantar flexed
A persistent infantile resting and sleeping posture (arms abducted at shoulders, elbows
flexed, and hands fisted) is a sign of spasticity when it remains constant after 4 to 5
months of age
Persistence of primitive reflexes is one of the earliest clues to CP
Persistence or even hyperactivity of the Moro, plantar, and palmar grasp reflex
Possible signs of Cerebral Palsy
Poor head control after 3 months of age
Physical signs
Stiff or rigid arms or legs
Pushing away or arching back
Floppy or limp body posture
Cannot sit up without support by 8 months
Uses only one side of the body, or only the arms to
crawl
Clenched hands after 3 months
Persistence of primitive reflexes such as Moro and
atonic neck past 6 months
Hand preference demonstrated before 18 months
Leg scissoring Supine positioning
Seizures
Sensory impairment (hearing,
vision)
After 6 months of age, persistent tongue thrusting
Extreme irritability or crying
Behavioral signs
Feeding difficulties
Excessive
sleeping
Little interest in surroundings
following:
Physical Therapy
Orthotic Devices
Adaptive equipment
Occupation Therapy
Adaptive equipment
Speech-language Therapy
Special Education
Surgical intervention
Medication Therapy
Behavioral Therapy
Braces
Splints
Casting
Molded orthoses
Scooters, bicycles, and tricycles
Wheelchairs
Boards
Standing devices
Utensils for functional use (e.g. eating, writing)
Switches
Computers
Oral-motor skills
Adaptive communication
techniques
Early intervention programs
Specialized learning programs and support services
in schools
Socialization to promote self-concept development
Orthopedic- tendon transfers, muscle lengthening,
spinal deformities
Neurologic- neurectomies
Selective dorsal rhizotomy
Feeding- gastrostomy
Dental
Medications to treat
Spasticity
Pain
Secondary conditions (seizure disorder,
chronic constipation, UTI, gastroesophageal
reflux)
Primary care of health supervision and acute
childhood illness
Functional (neuromuscular) electrical stimulation
Care Coordination
o Management
Assist the family in devising and modifying equipment and activities
Medication administration (anti seizure meds)
Pharmacologic to Decrease Spasticity in CP
Botulinum toxin type A (Botox)
Baclofen
Oral
Implanted pump for intrathecal administration
Dantrolene sodium (Dantrium)
Diazepam (Valium)
Cast
Spinal or cervical
Total body
Spica- immobilize the hip and knee (bar to keep hips abducted)
complications
Compartment syndrome (accumulation of fluid in the fascia)
Cast syndrome (portion of the duodenum is compressed between the superior and
mesenteric artery and the aorta)
Indentations
Weight
Conformity
Surface
Cost
Stability
Miscellaneous
hardens
Slow drying time increased
Rapid drying time reduces
possibility of indentations or
likelihood of indentation; allows
alterations of intended fit
rapid use
Relatively heavy; bulky; makes it
Lightweight; less bulky; permits
difficult to wear regular clothing
regular clothing to be worn; allows
for greater range of activity
Molds readily to body part
Does not mold easily to some
body parts such as fingers and
toes; may be unsuitable for some
fractures
Smooth exterior; does not snag on Smooth exterior
clothing or scratch furniture
Relatively inexpensive; an
Inexpensive unless Gore Tex
advantage if cast change is
added
anticipated
Relatively stable; cast must be
Some cast material may tolerate
kept dry
being wet or immersed in water
with permission from practitioner
(only those with use of
nonabsorbent synthetic lining);
can be cleaned with small amount
f mild soap and water, dried with
towel followed by blow dryer on
cool or warm setting; takes
considerable time to dry if
immersed
Child may feel uncomfortable
Child may feel uncomfortable
warming or burning sensation
warming or burning sensation
under cast while it dries (chemical under case while it dries
reaction)
Skin under cast may become
irritated
Cast must be protected when
around water (bathing)
Bucks Traction
Russells
Traction
o Nursing Care
Traction used when cant maintain alignment any other way
Traction aligns the injured bone
Skeletal muscles act as a splint
Nursing care: cast/ace bandage/traction:
Check Pain compartment syndrome
Check Pulse
Check Sensation
Check Color
Check Capillary refill
Check Movement
Neuromuscular assessments Q 4 hours
Traction weights checked, hanging free
Traction removed and reapplied Q 4 hours (released to monitor circulation)
Perform skin care Q 4 hours
Provide diversional activities
Skeletal Traction
Neuromuscular assessments Q 4 hours
Know signs of compartment syndrome and report them to the physician
immediately
Maintain traction- never released by the nurse
Prevent skin breakdown
Assess pin sites Q 8 hours of s/s of infection
Manage pain
Maintain good nutrition and elimination
Assess for complications (osteomyelitis, pneumonia, circulatory compromise,
ischemia, and disuse)
Prepare family for discharge
Bracing
Exercise
Surgical intervention for severe curvature (various systems of instrumentation and
fusion)
TLSO Brace
Wear them all the time except when they bathe
Wear a shirt underneath brace to reduce skin irritation
Depends on the severity how long they have to wear the brace
Nursing Care
Nursing care
Perform scoliosis screening
Discuss bracing and exercise
Assess body image and maintain orthotic brace compliance
Surgery when pulmonary function becomes compromised
Preoperative care (explain to child and parents what to expect, tour ICU, and
teach ROM exercises)
Postoperative care (VS, neurological status, fluid balance, pain control, NG tube,
advance diet, chest tube, s/s infection, logrolling, prevent constipation,
discharge teaching, community resources, and encourage adolescent to be as
active as possible)