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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.
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.
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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.
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
placenta provides the exchange of gas and nutrient
four shunts in fetaI circuIation: 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
. Mixed Oxygenation Defects
Classifications of CHD
1. Defects with increased pulmonary blood flow -ASD, VSD, PDA
-Opening between atria -late childhood/early adulthood S/sx: cyanosis(CHF), dyspnea, fatigue, failure to thrive, split S2 x: Abx, surgery 1-3 yo Cx: endocarditis, heart failure !ostop: monitor arrhythmia, administer antibiotics -Atrial septal defect -Similar to a ventricular septal defect, this is a hole that occurs when the septum separating the right and left atria doesn't close properly. -This allows blood from the left atrium to flow into the right atrium, instead of into the left ventricle and on to the aorta and the rest of the body. -The defect can cause several complications, including arrhythmias, heart failure, stroke and, in rare cases, pulmonary hypertension. -Minor cases may cause no symptoms and may not require treatment. -Larger defects may require surgical closure or cardiac catheterization
Ventricular Septal Defect
Opening in ventricular septum S/sx: respi infections, failure to thrive, dyspnea, fatigue, pansystolic murmur x: close spontaneously otherwise surgery <2 yo Cx: pulmonary HPN, endocarditis, heart failure !ostop: monitor arrhythmia, administer antibiotics -Ventricular septal defect -Sometimes called a hole in the heart most common congenital heart defect occurs when the septum, the muscular wall separating the right and left ventricles, fails to fully form -The hole allows oxygen-rich blood to leak from the left ventricle into the right ventricle, instead of moving into the aorta and on to the body. -Too much blood may flood the lungs. -This defect can lead to heart failure, excessive blood pressure in the lungs (pulmonary hypertension), infections of the heart (endocarditis), irregular heartbeats (arrhythmias) and delayed growth. -Small holes may heal on their own or cause no symptoms. Larger holes may require surgical repair by stitching together or covering with a patch.
Patent Ductus Arteriosus
Aorta to pulmonary artery Common in prematurity, high altitude, maternal rubella females S/sx: clubbing, dyspnea, "machinery like murmur (2nd-3 rd CS) Cx: heart failure, endocarditis, pulmonary artery stasis/HPN x: ndomethacin, surgery -Patent ductus arteriosus -Before birth, a temporary blood vessel called the ductus arteriosus connects the pulmonary artery and the aorta. -This allows blood to bypass the lungs because oxygen is delivered to the fetus through the placenta and umbilical cord. -The temporary vessel normally closes within a few hours or days of birth since the lungs take over. -f it remains open (patent), some blood that should circulate through the body is misdirected to the lungs. -This defect can cause heart failure or endocarditis. n infants, it can be closed with medications. n older children and adults, plugs, coils or surgery can be used to close the vessel.
CYANOTIC HEART DISEASE
1. TetraIogy of FaIIot (TOF)
S/sx: cyanosis, clubbing, dyspnea, fatigue, squatting, "Tet spells, failure to thrive, systolic murmur, polycythemia Cx: thromboembolism, CVA x: O2, knee-chest position, surgery 1-2 yo !ostop: monitor for arrhythmia
TetraIogy of FaIIot -This defect is a combination of four (tetralogy) congenital abnormalities. -The four defects typically are 1. Ventricular septal defect (VSD), 2. Pulmonary stenosis, 3. An aorta overriding both ventricles, and a thickened right ventricular wall 4. (Right ventricular hypertrophy).
-They usually result in an insufficient amount of oxygenated blood reaching the body. -Complications of tetralogy of Fallot ( fuh-LOE) include cyanosis sometimes called "blue baby syndrome," since the lips, fingers and toes may have a bluish tinge from lack of oxygen , clubbing of fingers as well as poor eating, inability to tolerate exercise, arrhythmias, delayed growth and development, and stroke. -Surgical repair of the defects is required early in life. -Tet spells- irritability, pallor and blackouts or convulsions, -CLUBBNG N TETRALOGY OF FALLOT -CLUBBNG OF THE FNGERS
1. TetraIogy of FaIIot (TOF) x: Blalock Taussig: anastomose SC and pulmo art. - avoid BP and venipuncture in right arm
2. Transposition of the Great VesseIs
-Aorta from R ventricle -Pulmonary a. from L ventricle -Males S/sx: cyanosis, murmurs x: PGE for PDA, Balloon catheter to create ASD, definitive surgery 1 wk-3 mos
Transposition of the great vessels/ arteries -With this defect, the positions of the aorta and the pulmonary artery (the great arteries) are reversed (transposed). -The aorta arises from the right ventricle instead of the left and the pulmonary artery arises from the left ventricle instead of the right. -This creates a circulatory pattern that prevents nourishing oxygenated blood from reaching the body. -This condition would quickly be fatal to a newborn except it's generally accompanied by another defect commonly a septal defect or patent ductus arteriosus that does allow oxygen-rich blood to get to the body. Surgical repair is usually necessary shortly after birth.
. TotaI AnomaIous !uImonary
Venous Return Pulmonary vein drain to SVC or R atrium PDA or foramen ovale essential S/sx: cyanosis, fatigue CX: R heart failure x: 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 OBSTRUCTVE DEFECT Coarctation of the Aorta Cx: chronic HPN x: surgery !ostop: monitor abdominal pain, antihypertensives
Coarctation of the aorta
This is a narrowing (coarctation), or constriction, in a portion of the aorta. Coarctation forces the heart to pump harder to get blood through the aorta and on to the rest of the body. This defect can cause several life-threatening complications, including severe hypertension, aortic aneurysm, dissection or rupture, endocarditis, brain hemorrhage, stroke, heart failure and premature coronary artery disease. Repair is typically recommended before age 10, either by surgically removing the affected portion or widening it through balloon angioplasty and placement of a stent. COARCTATON OF THE AORTA Ndx: neffective cardiopulmonary and peripheral tissue perfusion related to impaired cardiac function Proper positioning to maintain respiration Promote rest to conserve energy Quiet activities and stimulation Anticipate needs Administer prescribed drugs COARCTATON OF THE AORTA Activity intolerance r/t effects of congenital heart defect and dyspnea Rest periods Adequate nutrition small frequent feedings iron supplementation
2. !ULONIC STENOSIS Obstruction of blood flow from the right ventricle to the pulmonary artery PULMONC VALVE Backflow of blood towards the right ventricle Right Ventricle has to PUMP HARDER to push the blood to the pulmonary artery for Oxygenation RGHT VENTRCULAR ENLARGEMENT RGHT-SDED CONGESTVE HEART FALURE
. AORTIC STENOSIS nvolves 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.
. AORTIC STENOSIS Obstruction of flow to the AORTA AORTC VALVE Backflow of blood towards the LEFT VENTRCLE Left Ventricle has to PUMP HARDER to push the blood to the AORTA for distribution of oxygenated blood LEFT VENTRCULAR HYPERTROPHY with Regurgitation of oxygenated blood back to the LUNGS LEFT-SDED CONGESTVE HEART FALURE (Respiratory Signs) O Truncus arteriosus -This is a defect in which the normally distinct pulmonary artery and aorta merge into one single great vessel (truncus) arising from the right and left ventricles. n addition, there's usually a large ventricular septal defect, essentially turning the right and left ventricles into a single chamber. -This allows oxygenated and unoxygenated blood to mix. Too much blood may flow to the lungs, flooding them and making it difficult to breathe. -t can also result in life-threatening pulmonary hypertension. Surgery is needed to close the septal defect with a patch and to separate the pulmonary arteries from the trunk. -A conduit is placed to connect the right ventricle to the pulmonary artery. Because the conduit doesn't grow with the child, repeat surgery may be necessary over time. Truncus arteriosus HypopIastic Ieft heart syndrome n this condition, the left side of the heart is underdeveloped (hypoplastic), including the aorta, aortic valve, left ventricle and mitral valve. As a result, the body doesn't receive enough oxygenated blood. n the first few days after a baby is born, the ductus arteriosus remains open (patent), allowing normal circulation, so the baby may seem fine initially. But when the ductus arteriosus naturally closes, signs and symptoms begin, including a bluish cast to the skin from lack of oxygen, difficulty breathing and poor feeding. This condition may be accompanied by an atrial septal defect. Treatment options for this life-threatening condition are a heart transplant or a multistage surgical procedure done during the first few years of life. Hypoplastic left heart syndrome AtrioventricuIar canaI defect This is a combination of defects, including a large hole in the center of the heart and a single common valve instead of the separate tricuspid and mitral valves. Also called atrioventricular septal defect, this defect is classified by whether it's only partial, involving only the upper chambers of the heart, or complete, in which blood can travel freely among all four chambers of the heart. Both forms allow extra blood to circulate to the lungs, causing the heart to enlarge.The condition is often associated with Down syndrome. nfants may also have trouble breathing and not grow well. Surgery is often done in infancy to close the hole and reconstruct the valves.
Before puberty, peaks 4 yo EtioIogy: unknown; autoimmune S/sx: spiking fever x 5 days, bilateral conjunctivitis, reddened pharynx, dry lips, strawberry tongue, cervical lymphadenopathy, peripheral edema, erythema and desquamation, truncal rash, arthritis
Mucocutaneous Lymph Node Syndrome !atho: Respi infection immune complex systemic vasculitis ( coronary artery) > aneurysm and M Dx: clinical x: Salicylates and mmunoglobulins
KAWASAK DSEASE
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 KAWASAK
Nursing easures:Protect edematous areas Record intake and output Offer soft food Administer prescribed medication Rheumatic Fever Autoimmune Grp A Beta hemolytic strep 6-15 yo, peaks 8 yo 1-3 wks after untreated infection
Rheumatic Fever
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
RHEUMATC FEVER
gmt: 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
RHEUMATC FEVER
Nursing Care Monitor vital signs Provide adequate nutrition Promote safety to prevent chorea related injuries Respiratory Anatomy & Physiology The respiratory system consists of two main parts- the upper and the lower tracts
Most frequent infectious disease in children Average of 10-12 colds/ year ncubation period- 2-3 days
The COMMON COLDS ACUTE NASOPHARYNGTS (CORYZA) Most frequent infectious disease in children Average of 10-12 colds/ year ncubation period- 2-3 days
The COMMON COLDS
ETIOLOGIC AGENT 1. Rhinovirus - most common cause 2. Parainfluenza virus 3. Respiratory syncitial virus (RSV) UPPER RESPRATORY TRACT NFECTONS 4. Adenovirus 5. nfluenza virus 6. Coxsackie virus SGNS 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
TREATENT 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
TREATENT & ANAGEENT
!HARYNGITIS
1. antibiotics- 10 day-course of oral antibiotics (Pen G or Clindamycin) 2. high fluid intake 3. relief of pain
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 %ubal 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 -difficulty of swallowing (dysphagia) painful swallowing (odynophagia) -fever - lethargy -mouth breathing -difficulty hearing (Eustachian tube) -halitosis -sleep apnea
TREATENT
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 TONSILLECTOY
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
TONSILLECTOY !ost -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 TONSLLECTOMY 4. Provide appropriate teaching . nstruct 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. E!ISTAXIS 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 apply pressure to the side of the nose with your fingers, may have ice compress E!ISTAXIS 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 nflammation of epiglottis ("cherry-red") Hemophilus influenza type B 2-7 yo Pathophx: upper respiratory infection inflammation of epiglottis
EpigIottitis >an acute , severe inflammation of the epiglottis.( flap of tissue that covers the opening to larynx to keep out food and fluids) > it is considered an emergency because the swollen epiglottis can't rise and allow the airway to open. > This emergency situation occurs most commonly in children between 3 and 6 years of age. Causes: 1. Bacterium H-nfluenza type b 2. pneumococci, streptococci - most common cause 3. echovirus 4.respiratory syncitial virus
E!IGLOTTITIS
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. E ! I G L O T T I T I S NURSE ALERT!!! " Never illicit gag reflex-may cause complete obstruction
- nflammation & narrowing of the larynx, trachea, and major bronchi. Most common form of croup & usually affects children younger than 5 years old. - one of the most frightening diseases of early childhood for both parents and children. Tends to occur at night & recur with respiratory tract infections. - common cause is viral infection usually parainfluenza virus, influenza virus.
signs and symptoms
1.Gradual onset from upper respiratory tract infection , which progresses to signs of distress. 2. Hoarseness 3. low grade fever 4. barking cough at night 5. inspiratory stridor 6. Retractions 7.Severe respiratory distress 8. Restlessness& rritability 9. Wheezing, rales, rhonchi, & localized areas of diminished breath sounds
NURSING ANAGEENT Assess for airway obstruction by evaluating respiratory status. Note color, respiratory effort, evidence of fatigue, & VS. provide warm, moist environment-give o2 to alleviate hypoxia -Keep emergency equipment ( tracheostomy & intubation tray) near the bedside. give corticosteroids & epinephrine (nebulizer) - reduce inflammation and bronchodilation intravenous hydration
Nursing dx: neffective airway clearance related to edema
TubercuIosis 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 !OSITIVE !!D TEST Classification of TB Class TB exposure (+) exposure Class TB infection (+) exposure and PPD Class TB disease active TB or 3 or more of criteria - Exposure, s/sx, (+) tuberculin test,xray, sputum exam, culture Class V 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, painlesss lymphadenopathy Treatment: 1.Intensive NH ( isoniazid), Rifampicin, PZA ( Pyrazinamide) x 2 mos
2.aintenance NH, Rifampicin x 4 mos
!rimary Anti TB Drugs
Rifampicin = SE = orange colored urine, G upset, Jaundice, Renal failure, thrombocytopenia Primary Anti TB Drugs Isoniazid (INH) = ( Bacteriostatic) inhibits ( Bactericidal ) kills Used prophylactically to patients (+) of PPD SE = Rashes (give anti-histamine); Peripheral neuritis ( Give Vit B6- Pyridoxine)50 mg; Jaundice; Psychosis Pyrazinamide ( PZA) SE = Hyperuricemia ( inc uric acid) Mx: nc fluid intake 4 Ethambutol = 15-20mg/day SE = Optic neuritis ( dec visual acuity) Give Vit. B6(Pyrdoxine) 5 Streptomycin SE = Ototoxicity, 8 th cranial nerve damage ( Tinnitus, dizziness, N&V) 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 gmt: surfactant replacement, O2, ventilation, supportive care Decreased surfactant lungs collapse -nc pulmonary resistance -blood shunts through F.O. and D.A. -poor lung perfusion and gas exchange -further decrease in surfactant -hypoxia -acidosis
BRONCHIAL ASTHA
chronic, reversible , obstructive airway disease, characterized by wheezing. t 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 gE from B lymphocytes gE + 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 ncreased 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: Liquify secretions Easily expectorate and drain secretions Relieve spasms Decrease swelling of airways
Nsg Dx: mpaired 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 Status Asthmaticus Progression of attack unresponsive to therapy Preceding upper respiratory tract infection, allergen, cigarette smoke HR and RR inc, dec breath sounds, cyanosis x: cont B2 agonist and V steroid, O2, coughing, fluids, monitor and O, ET T is not enough to have a good mind;
the main thing is to use it well -Rene Descartes- Thank you!
GastrointestinaI Disorders
Diagnostic Tests Barium or Gastrografin Swallow used to examine the esophagus Gastrografin and barium facilitate imaging through X-rays, but Gastrografin is less toxic if it escapes from the G tract
Nursing Interventions: -Explain the procedure to the child and his parents. -Maintain the child on NPO starting at midnight before the test. -Tell the child that he must hold still during the X-ray. -After the test, monitor bowel movements for excretion of barium. Monitor G function. -Upper G maging -Upper G series -Swallowed Barium moves into the esophagus, stomach, and duodenum to reveal abnormalities. -Barium outlines stomach walls and delineates ulcer craters and filling defects. -Small bowel series An extension of the upper G series Visualizes Barium flowing through the small intestine to the ileocecal valve
Nsg ImpIication:
-Explain the procedure to the child and his parents. -Tell the child that he must hold still during the X-ray. -Make sure the lead apron is properly placed around the genital area. -After the test, monitor bowel movements for excretion of barium. -ncrease fluid intake to allow excretion of barium ( note: chalky bowels ) Monitor G function. Barium Enema Allows X-ray visualiztion of the colon.
Nsg ImpIication: - Explain the procedure to the child and his parents. -Usually, the child will follow a liquid diet for 24 hours before the test. -Bowel preparations are administered before the examination. -Tell the child that X-rays will be taken on a test table and that he must hold still. -Cover the genital area with a lead apron during X-ray. -Stool Specimen -Examined for suspected G bleeding, infection, or malabsorption -Tests include the Guaiac test for occult blood and microscopic tests for ova, parasites and fat
Nsg ImpIication: -Obtain the specimen in the correct container. -Be aware that the specimen may need to be transported to the laboratory immediately or placed in the refrigerator.
Fiberoptic Testing
Esophagogastroduodenoscopy a fiber-optic scope is inserted to allow direct visual inspection of the esophagus, stomach and duodenum Proctosigmoidoscopy the rectum and distal sigmoid colon are inspected directly Colonoscopy the descending, transverse and ascending colon are inspected directly
Nsg ImpIication: - Explain the procedure to the child and his parents. Obtain written, informed consent. A mild sedative may be administered before the examination. The child may be kept on NPO starting at midnight before the test. The child may be placed on a liquid diet for 24 hours before the examination or require enemas and laxatives until clear. GI Intubation To empty the stomach and intestine To aid in the diagnosis and treatment To decompress obstructed areas To detect and treat G bleeding To administer medications or feedings NI: Maintain accurate intake and output records Record the amount, odor and consistency of gastric drainage every 4 hours. When irrigating the tube, note the amount of normal saline solution instilled and aspirated Check for fluid and electrolyte imbalances. Provide good oral and nasal care. Make sure the tube is secure but that it isn't causing pressure on the nostrils.
CIeft Lip and !aIate
-Failure of fusion of maxillary and median nasal process -hereditary -unilateral/bilateral Males x: surgery - Cheiloplasty Rule of 10's- AGE=10 wks, WT=10 lbs, HgB=10 gm CIeft !aIate -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 mx: Adequate nutrition; sips of fluid between feeding in semi-upright position; use rubber tipped syringe Direct the formula away from the cleft & toward the side & back of the mouth to prevent aspiration. Provide special nipples or feeding devices ( ex. Soft pliable bottle with soft nipple with enlarged opening)( Breck) Feed the infant slowly & burp frequently to prevent excessive swallowing of air & regurgitation. Prevent ear and upper respiratory tract infection
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 concern Nursing Care
Postop monitor respiratory distress d/t edema, hemorrhage Use mist tent , if prescribed, to minimize edema, liquefy secretions & minimize distress. Suction mucus and blood gently Use cup Use elbow restraints to maintain suture line integrity. Remove them every 2 hours Position side lying or back in cleft lip to avoid injury to the operative side; prone in cleft palate to facilitate drainage.
TracheoesophageaI FistuIa -Communication of the esophagus and trachea maternal hydramnios and prematurity S/sx: coughing, choking, cyanosis, dyspnea, excessive secretion, abdominal distention Dx: Ba swallow -Gastrointestinal anomalies -EA is a condition in which the proximal and distal portions of the esophagus do not communicate. -TEF is an abnormal communication between the trachea and esophagus -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 !reop -Suction regularly -Elevate the head -Gastrostomy feeding -hydration -O2
Nursing care !ostop -Observe for respiratory distress -Proper positioning avoid hyperextension of neck -Continue suction -Prevent wound infection -Provide pacifier
Hirschsprung's Disease
AgangIionic megacoIon -Absence of innervation to a bowel segment usually rectosigmoid colon -No peristaltic activity in affected area
Hirschsprung's Disease Familial 4x males ( esp w/ down's syndrome) Dx: Ba enema, biopsy ( pull through ) x: colostomy, surgery Nursing Care !re op 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
Nursing Care !ostop -Observe for abdominal distention -Small frequent feedings after NGT removal -Colostomy care -Assist parents to cope with children's feeding problems
HIRSCHS!RUNG'S DISEASE Ndx: Constipation r/t reduced bowel function mbalanced nutrition, less than body requirements r/t reduced bowel function ntussusception
Ndx: Pain r/t abnormal abdominal peristalsis Risk for deficient fluid volume r/t bowel obstruction DX: Barium enema for dx & therapeutic treatment tool ( reduction by hydrostatic pressure) Sonogram reveals " coiled spring " X: surgery Nursing Care -Provide comfort measures - pacifier for infants -NPO -Adequate hydration via V therapy -Promote parent-infant bonding
!yIoric Stenosis
Gastrointestinal anomalies
!yIoric stenosis Circular muscle surrounding pylorus hypertropies and block gastric emptying . S/sx : Projectile vomiting( blood tinged ,not bile ) olive- shaped mass in RUQ, visible peristaltic waves gt: Surgical [ pyloromyotomy, fredet ramstedt procedure Nsg gt : !reop : recognize s/sx VF, high fowler's place right side after feeding !ostop : resumed feeding 4-6H discharged : within 72H 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 Nursing care Hydration Pacifier may give thickened feedings on upright position then NPO just before surgery Monitor and O, weight, and vomiting !ostop
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
-Malabsorption syndrome that occurs when the mucosa of the proximal small intestine is sensitive to gluten ( a protein found in BROW wheat, rye, oats, barley) inability to absorb fat, thus steatorrhea ( fatty stools), 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)
CeIiac Disease !athophysioIogy:
-ntolerance 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. Cx: Lymphoma of the small intestine
CeIiac 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. CeIiac Disease anagement: = hydration, gluten free diet, vitamin & Fe supplementation , AVOD: cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some chocolates, some ice cream, donuts, pies, hotdogs, CeIiac Disease Foods aIIowed: 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 x: 'E' surgery
DIA!HRAGATIC 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 Post op: SemifowIers -Maintain warm, humidified envt lung fluid drainage -Suction prn -Chest pptx -NPO prevent pressure on diaphragm
Necrotizing EnterocoIitis
-nflammatory disease of the bowel with increased incidence in preterm & other high risk infants due to intestinal ischemia, colonization of pathogenic bacteria, & substrate( formula feeding) in the intestinal lumen !athophysio: -Mucosal cells lining the bowel wall is damaged >>diminished blood supply to these cells causes death to the tissue>>( stops secreting protective, lubricating mucus>> thin , unprotected bowel wall is attacked by proteolytic enzymes>>bowel continues to swell & break down>> gas forming bacteria invades the damaged areas to produce intestinal penumatosis ( presence of air in the submucosal surfaces of the bowel S/sx: abdomen tense and distended, stool (+) for occult blood, > 2 ml gastric residual, bradycardia, apnea Dx: abdominal xray gmt: d/c feeding, V or TPN, Antibiotic, colostomy, surgery for perforation
InguinaI Hernia
-Protrusion of a section of a bowel into the inguinal ring Males Cause: when there is an increase in intraabdominal pressure S/sx: painless lump in the groin Cx: bowel strangulation x: surgery <1 yo !ost op Nursing care: - wound care - assess circulation in the leg
uscuIoskeIetaI Disorders -Clubfoot (Talipes) -Ankle-foot disorders Types: Varus inward rotation Valgus outward rotation Calcaneous upward rotation or dorsiflexion Equinus downward rotation or plantarflexion -Males -Unilateral more common
Talipes Equinovarus (plantar flexion and medial deviation) 95%
S/sx: foot cannot be manipulated by passive exercises into correct position x: cast and splint, surgery then casting and corrective shoes ( Dennis browne )
CongenitaI Hip DyspIasia -mperfect hip development affecting femoral head and acetabulum -Female -Unilateral more common -nc frequency w/ breech delivery S/sx: -limited abduction of affected hip -shortening of leg on affected side ( Galeazzi / Allis sign ) -asymmetric thigh and gluteal folds -buttocks on affected side will flatten on prone -pelvis dips on normal side when standing on affected leg ( Trendelenburg ) -palpable click ( Ortolani's click)
Endocrine Disorder
Cystic Fibrosis
-Autosomal recessive ( abnormality of the long arm of chromosome 7) -Chronic multisystem disorder of the exocrine glands characterized by abnormally thick pulmonary secretions. -There is a marked electrolyte change in the secretions of the sweat glands ( chloride concentration of sweat is 2 to 5x above normal ) -Resulting in the inability to transport small molecules across cell membranes leading to dehydration of cells in the airway & pancreas & dried secretions. -Affects lungs, pancreas, intestines and sweat glands, salivary glands, reproductive tract. TerminoIogies: Exocrine glands that deliver their secretions to an epithelial surface either directly or through a duct or to the secretions such glands produce. Endocrine ductless glands of the body whose secretions pass directly from the gland into the interstitial tissues from which they are diffused into the blood or lymph to be carried to other parts of the body where they affect the functioning of other organs. EX. Pituitary, thyroid, adrenals, ovaries, testes, & islets of langerhans in the pancreas. econium iIeus obstruction in the ileum of the newborn caused by tenacious meconium ( meconium plug syndrome) Dx: > "Sweat test (Sodium Chloride 2-5x the normal), >absence of pancreatic enzymes, >immunoreactive trypsinogen in blood > stool analysis steatorrhea > xray patchy atelectasis & generalized obstructive emphysema. x: chest physiotherapy, antibiotics, pancreatic enzymes, vitamins, lung or pancreas transplant
CYSTIC FIBROSIS Ndx:
-mbalanced nutrition, less than body requirements r/t inability to digest fats neffective airway clearance r/t inability to clear mucus from the respiratory tract Nursing Care -Hi calorie, Hi CHON, moderate fat diet -Nebulization and physiotherapy -Frequent Position changes when in bed -Oral care -Adequate rest and comfort
Acute GIomeruIonephritis -nflammation of glomeruli of kidney Follows infection with streptococcus 10-14 days 5-10 yo Males S/sx: sudden onset of edema and hematuria ( urine is tea or cola colored), proteinuria, hypertension Dx: urinalysis and 24 hour urine hypoalbuminemia inc ESR, BUN, Creatinine, antistreptolysin O ( an inhibitor of streptolysin or grp A hemolytic streptococci an inc. in the titer indicates a recent streptococcal infection) x: 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 syndrome Nephrotic Syndrome S/sx: proteinuria, edema - periorbital area, hypoalbuminemia, hyperlipidemia Dx: urinalysis and 24 hr CHON, inc ESR x: steroids, immunosupressant NDx: Risk for decreased fluid volume r/t CHON and fluid loss mbalanced nutrition: less than BR r/t CHON and fluid loss Nsg care: -Adequate nutrition, proper diet decrease salt -Weigh daily, monitor and O -Protect edematous areas -Administer prescribed drugs -Health teaching
WiIm'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; Do not palpate x: Nephrectomy, radiotherapy avoid abdominal palpation
HematoIogic Disorders
Iron Deficiency Anemia
nfant's iron supply 4-6 mos Anemia 9-24 mos S/sx: pallor, tachycardia, irritability, Hg < 9 g/dl, susceptible to infection gmt: 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
HemophiIia A nherited interference w/ blood coagulation Factor V (8) Sex linked recessive S/sx: excessive bleeding NB apparent ( circumcision) Pre-school accidents/falls School age bleeding between joints (hemarthroses Adolescent ulcers, hematuria x: factor V transfusion Hemophilia A 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 NDx: Acute pain r/t bleeding into joints HemophiIia B -Christmas Factor -Clotting Factor X (9) -ACUTE LYMPHOCYTC LEUKEMA ( ALL) -Uncontrolled proliferation of WBC -Lymphoblast ( immature lymphocytes ) -Most frequent CA in children -2-16 yo -Males
x: 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 !revent infection -monitor bleeding and transfusion reactions -Provide comfort and pain alleviation -Health teaching -Emotional and psychological support
NeuroIogicaI Disorders
Brain Tumor -Second most common form of cancer in children 1-10 yo, peak 5 yo -Usual location - brainstem or cerebellum TY!ES: Astrocytoma- glial tissue; 5-8 yo Medulloblastoma cerebellum; 5-10 yo; cause compression of 4 th ventricle; most common Brain stem tumor support tissue of neural cells; paralysis of 5 th -7 th , 9 th -10 th CN BRAIN TUOR 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, MR, angiography x: surgery, chemotherapy
Benign FebriIe Seizure - 6 mos - 5 years - fever >/= 38.5C -generalized tonic-clonic -rarely persist > 10 minutes !ostictaI stage - 30-40 % recurrence (+) family history
CONVULSION/SEIZURE Tonic phase (10 secs) eyes open. Elbows flexed. Arms pronated. Legs extended. Teeth clenched. Pupils dilated. Breath held- cyanosis. Bowel or bladder control may be lost at the end of this phase Clonic phase (1-2 min) tremor gives way to violent generalized shaking. Eyes roll backwards and forwards. Tongue may be bitten, tachycardia develops. 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
Status EpiIepticus
-Continual or recurrent seizures lasting 30 minutes or more with no return to normal consciousness -Support and maintenance of vital functions -V administration of diazepam (Valium) or lorazepam (Ativan) -V phenobarbital -Monitor closely -Safety
CerebraI !aIsy
-Damaged motor function d/t anoxic brain injury secondary to infection, perinatal asphyxia, metabolic disorder -Nonprogressive TY!ES: 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 x: 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
HydrocephaIus
-CSF is formed in the first and second ventricles of the brain and then passes through between the aqueduct of Sylvius and the fourth ventricle to empty into the subarachnoid space of the spinal cord where it is absorbed.
Hydrocephalus -mpaired circulation and absorption of CSF -Excess CSF in the ventricles or the subarachnoid space 2 TY!ES: -Obstructive / Noncommunicating there is a block to passage of fluid ( ex: tumor) ( ntraventricular) -Nonobstructive / Communicating fluid can reach the spinal cord ( extraventricular)
!athophysioIogy -Congenital, acquired, or unknown etiology -Obstructive- noncommunicating (99%) -Absorption - communicating HydrocephaIus S/sx: head enlargement, anterior fontanel wide and bulging, scalp veins dilated, broad forehead, sclera shows above iris ( sunset eyes ) , brisk tendon reflexes, spasticity, irritability, lethargy, poor appetite, cracked pot sound on percussion HYDROCE!HALUS Ndx: Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure - monitor vs, head circumference, 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 - V fluids - obtain daily weight X: V! shunt: Ventriculoperitoneal shunt CX: -Peritonitis -Meningitis -Brain abscess Tx: -Antibiotic therapy for infections -Prognosis -f surgically treated with follow-up, 80% survival rate -Highest incidence of mortality within 1 st year of treatment -Surviving children-1/2 have neurologic disabilities and 1/3 are normal
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
S!INA BIFIDA
yeIomeningocoeIe 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 S!INA 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 CP S!INA 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 -Anomalies CNS -Neural tube defect
S!INABIFIDA ( yeIodyspIasia ) failure of bony spine to close spinabifida cystica
Meningocele - sac filled with spinal fluid & meninges.( no neurological deficit ) Myelomeningocele - contain meninges , SF & nerve ( with neurological deficit), seen in lumbosacral
gt : There is no cure for nerve damage due to spina bifida ; Surgery performed within 24 hours after birth to minimize the risk of infection and to preserve existing function in the spinal cord. NI : prevent trauma prevent complication provide adequate nutrition provide sensory stimulation emotional support
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 x: reduce allergen, topical steroids NDx: mpaired skin integrity r/t eczematous lesion Nsg care: Reduce allergen Prevent skin dryness and pruritus
ATO!IC DERATITIS NURSING ANAGEENT
EDS: ANTHSTAMNES, ANTPRURTCS, STERODAL CREAMS -Minimize the risk of infection -Promote skin integrity -Family Health teaching -Cotton fabrics, use mild detergents -Daily baths to hydrate the skin -Use topical moisturizers -Protein Energy Malnutrition
arasmus -Low calorie, low CHON -0-2 yo -(-) edema -"all skin and bone -(+) growth retardation -Apathetic, quiet -Good appetite -nfrequent skin/hair changes -Anemia uncommon
!oisoning -Usually 2-3 yo -Soap, cosmetics, detergents, drugs -Males>females children -Females>males adolescent
: x
1.Determine age wt, type of poison swallowed, time of ingestion, route of poisoning, amount ingested, present condition of child 2.Use syrup of ipecac to induce vomiting except: corrosive, hydrocarbon, px is comatose 3. Activated charcoal then syrup of ipecac 4. Monitor VS 5. refer to hospital/poison control center
!OISONING Acetylsalycilic acid (Aspirin) S/sx: nausea, vomiting, fever, profuse sweating, flushing, hyperthermia, hyperventilation, convulsions, coma x: stabilize airway and breathing -Fluid and electrolyte replacement -Activated charcoal -Alkalinization of urine -hemodialysis
Down's Syndrome Trisomy 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 x: early education and play opportunities