Pediatric Nursing-Course Audit

PEDIATRIC NURSING
Care of the Child and Family

By: MARITES A. ROSAPAPAN, RN
Developmental Theorists
Maslows Hierarchy of Needs (1954)
Erik Erikson - Psychosocial Theory

Jean Piaget - Cognitive Theory
Principles:
Maslows Hierarchy of Needs
An individuals needs are depicted in ascending levels on the hierarchy Needs at one level must be met before one can focus on a higher level need
Levels of Maslows Hierarchy of Needs:

Physiologic/Survival Needs Safety and Security Needs Affection or Belonging Needs Self-esteem/Respect Needs Self-actualization Needs
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TRUST VS. MISTRUST

Birth - 1 year World/Self is good Basic needs met Met = happy baby Unmet = crying, tense, clinging Stranger Anxiety Separation Anxiety
Photo Source: Del Mar Image Library; Used with permission
AUTONOMY VS. SHAME & DOUBT

1 3 years
Sense of control Exerts self/will Pride in self-accomplishment Negativism Ritualism/Routines Parallel play
INITIATIVE VS. GUILT

3 6 years
Can-do attitude Behavior is goal-directed and imaginative Play is work Be careful with criticism
INDUSTRY VS. INFERIORITY

6 12 years Mastery of skills Peers in both play and work Rules important Competition Predictability
IDENTITY VS. ROLE CONFUSION

12 -18 years Sense of I Peers are very important Independence from parents Self-image
Piagets Cognitive Theory

Development of Thought Processes:
0 2 years:Sensorimotor 2 7 years: 7 11 years: Preoperational Concrete Operations
11 years + :
Formal Operations
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SENSORIMOTOR
Birth - 2 years
Reflexive behavior leads to intentional behavior
Egocentric view of world Cognitive parallels motor development Object Permanence
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PREOPERATIONAL THOUGHT
2 - 7 years
Egocentric thinking Magical thinking Dominated by self-perception Animism No irreversibility Thoughts cause actions
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CONCRETE OPERATIONS
7 - 11 years
Systematic/logical Fact from fantasy Sense of time Problem solve Reversibility Cause & effect Humor
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FORMAL OPERATIONS
11 years - Adult
Abstract thinking Analyze situations New ideas created Factors altering this: Poor comprehension Lack of education Substance abuse
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Infant Physical Tasks

Physical Tasks: 0 - 6 months:
Fastest growth period Gains 5-7 oz (142-198 g) weekly for 6 months Grows 1 inch (2.5 cm) monthly for 6 months Head circumference is equal to or larger than chest circumference Posterior fontanel closes at 2-3 months* Obligate nose breathers* Vital signs: HR and RR faster and irregular* Motor: behavior is reflex controlled
sits with or without support at 6 mo* rolls from abdomen to back Sensory: able to differentiate between light and dark hearing and touch well developed
TOYS = Mirror, Music, Mobile

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Infant Physical Tasks

Physical Tasks 6 - 12 months:
Gains 3-5 oz (84-140g) weekly for next 6 months
* triples weight by 12 months Gains 1/2 in (1.25 cm) monthly for next 6 months Teeth begin to come in Motor: Intentional rolling over from back to abdomen* Starts crawling and pulling to a stand* Develops pincer grasp* Sits without support by 9 months* Sensory: Can fixate on and follow objects Localizes sounds
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Infant Psychosocial Tasks

Vocalizations:

Distinction in cry at 1 month Coos at 3 months Begins to imitate sound at 6 months babbles Verbalizes all vowels at 9 months Can say 45 words at 12 months
Social smile at 2 months Demands attention & social interaction at 4 months Stranger anxiety & comfort habits begin at 6 months* Separation anxiety develops at 9 months*
Socialization:
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Infant Cognitive Tasks

Neonates
Reflexes only Recognizes faces Smiles and shows pleasure Discovers own body and surroundings Begins to imitate
1-4 months
5-6 months
7-9 months
Searches for dropped objects *Object Permanence begins Responds to simple commands Responds to adult anger Recognizes objects by name Looks at and follows pictures in books
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10-12 months
Physical Tasks:

Toddler
Slow growth period Gains 11 lbs (5 kg) Grows 8 inches (20.3 cm) Anterior fontanel closes at 12 - 18 months* Primary dentition (20 teeth) complete by 2 years Develops sphincter control toilet training possible*
Walks alone by 12 - 18 months* Climbs and runs fairly well by 2 years Rides tricycle well by 3 years
Motor Tasks:

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Toddler Cognitive Tasks

Follows simple directions by 2 years Uses short sentences by 18 months *favorite words no and mine = Autonomy Knows own name by 12 months, refers to self Achieves object permanence Uses magical thinking Uses ritualistic behavior Repeats skills to master them and decrease anxiety Egocentric thinking - thoughts cause actions
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Toddler Psychosocial Tasks

Increases independence
Able to help with dressing self Temper tantrums (autonomy)
Beginning awareness of ownership (me and mine)

Shares possessions by 3 years Vocabulary increases to over 900 words
Toilet training
Fears: separation anxiety, loss of control
TOYS = Push-pull toys, large blocks
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Preschooler
Physical Tasks:
Slow growth rate continues Weight increases 4-6 lbs (1.82.7 kg) a year Height increases 2 inches (5-6.25 cm) a year Permanent teeth appear Walks up & down stairs Skips and hops on alternate feet Throws and catches ball, jumps rope Hand dominance appears Ties shoes and handles scissors well Builds tower of blocks
Motor Tasks:
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Preschooler Cognitive Tasks

Can only focus on one idea at a time Begins awareness of racial and sexual differences Develops an understanding of time
Learns sequence of daily events Able to understand some time-oriented words

Begins to understand the concept of causality Has 2,000 word vocabulary Is very inquisitive and curious
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Preschooler Psychosocial Tasks

Becomes independent Gender-specific behavior is evident by 5 years Egocentricity changes to awareness of others Understands sharing Aggressiveness and impatience peak at 4 years Eager to please and shows more manners by 5 years Behavior is goal-directed and imaginative
Play is work*
TOYS = Dolls, Dress-up, Imagination
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Preschooler Psychosocial Tasks

Fears: about body integrity (Fear & Injury) are common Magical and animistic thinking allows illogical fears to develop* Observing injuries or pain of others can precipitate fear Able to imagine an event without experiencing it Guilt and shame are common*
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School-age
Physical Tasks:
Slow growth continues Weight doubles over this period Gains 2 inches (5 cm) per year At age 9, both sexes are the same size At age 12, girls are bigger than boys Very limber but susceptible to bone fractures Develops smoothness & speed in fine motor skills Energetic, developing large muscle coordination, stamina & strength Has all permanent teeth by age 12

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School-Age Cognitive Tasks

Period of Industry:
Likes to accomplish or produce Interested in exploration & adventure Develops confidence Rules become important*
Concepts of time and space develop:

Understands causality, permanence of mass & volume Masters the concepts of conservation, reversibility, arithmetic and reading Develops classification skills Begins to understand cause and effect*
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School-Age Psychosocial Tasks

School occupies half of waking hours; has cognitive and
social impact on child

Morality develops Peer relationships start to be developed Enjoys family activities Has increased self-direction - tasks are important Has some ability to evaluate own strengths & weaknesses Enjoys organizational activities (sports, scouts, etc.)* Modesty develops as child becomes aware of own body*
TOYS = Board games, computer games, learning activities

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Adolescent
Physical tasks:
Period of rapid growth Puberty starts Girls: height increases 3 inches/year Boys: growth spurt around 13-yrs-old height increases 4 inches/year weight doubles between 12-18 yrs Body shape changes: Girls have fat deposits in thighs, hips & breast, pelvis broadens Boys become leaner with a broader chest

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Adolescent
Sexual Development
Girls
Breasts develop Menses begins First 1 2 years infertile
Boys
Facial Hair growth Voice changes Enlargement of testes at 13 yrs Nocturnal emission during sleep Reaches reproductive maturity with viable sperm at 17 yrs
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Adolescent Cognitive Tasks

Develops abstract thinking abilities
Often unrealistic Sense of invincibility = risk taking behavior* Capable of scientific reasoning and formal logic Enjoys intellectual abilities Able to view problems comprehensively
ACTIVITIES = Music, video games, communication with peers

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Adolescent Psychosocial Tasks

Early Adolescent: Prone to mood swings Needs limits and consistent discipline Changes in body alter self-concept Fantasy life, daydreams, crushes are normal
Middle Adolescent: Separate from parents

Identify own values and define self* Partakes/conforms to peer group/values*
Increased sexual interest

May form a love relationship Formal sex education begins
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Adolescent Psychosocial Tasks

Late Adolescent: Achieves greater independence* Chooses a vocation Finds an identity* Finds a mate Develops own morality Completes physical and emotional maturity Fears: Threats to body image acne, obesity Rejection Injury or death, but have sense of invincibility The unknown
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Lets Review
A 10 month-old baby was admitted to the pediatric unit. Each time the nurse enters the room the baby begins to cry. The most appropriate action by the nurse would be to:
A. Complete all procedures quickly in order to decrease the amount of time the baby will cry. B. Ask another nurse to assist you with the babys care. C. Distract the baby. D. Encourage the parent to stay by the bedside and assist with the care.
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Lets Review
A 6 month-old is admitted to the pediatric unit for a 3 week course of treatment. The infants parents cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of an infant?
A. Telling the parents that frequent visits are unnecessary. B. Placing the infant in a room away from other children. C. Assigning the infant to different nurses for varied contacts. D. Assigning the infant to the same nurse as much as possible.
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Lets Review
Which child is most likely to be frightened by hospitalization?
A. 4 month-old admitted with a diagnosis of bronchiolitis. B. 2 year-old admitted with a diagnosis of cystic fibrosis. C. 9 year-old admitted with a diagnosis of abdominal pain. D. 15 year-old admitted with a diagnosis of a fractured femur.
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Infant Nutrition
Birth 6 months:
Breast milk is most complete diet Iron-fortified formulas are acceptable No solid foods before 4 months*
6 - 12 months:
Breast milk or formula continues* Diluted juices can be introduced Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats Finger foods at 9-10 months Chopped table foods at 12 months

Gradual weaning from bottle/breast No honey (risk for botulism)
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Toddler Nutrition

Able to feed self autonomy & messy! Appetite decreases- physiologic anorexia Negativism may interfere with eating Needs 16 20 oz. milk/day Increased need for calcium, iron, and phosphorus risk for iron deficiency anemia Caloric requirements is 100 calories/kg/day No peanuts under 3 years of age (allergies)* Do not restrict fats less than 2 years of age* Choking is a hazard (no nuts, hot dogs, popcorn, grapes)*
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Preschooler Nutrition
Caloric requirements is 90 calories/kg/day
May demonstrate strong taste preferences 4 years old picky eaters 5 years old influenced by food habits of others
Able to start social side of eating
More likely to try new foods if they assist in food preparation

Establish good eating habits - obesity
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School-Age Nutrition
Caloric needs diminish, only need 85 kcal/kg
Foundation laid for increased growth needs

Likes and dislikes are well established Junk food becomes a problem
Busy schedules breakfast is important

Obesity continues to be a risk Nutrition education should be integrated into
the school program

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Adolescent Nutrition
Nutritional requirements peak during years of maximum growth:
Age 10 12 in girls Age 14 16 in boys Food intake needs to be balanced with energy expenditures
Increased needs for:

Calcium for skeletal growth Iron for increased muscle mass and blood cell development Zinc for development of skeletal, muscle tissue and sexual maturation
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Adolescent Nutrition
(continued)
Eating and attitudes towards food are primarily family/peer centered
Skipping breakfast, increased junk food, decreased fruits, veggies, milk Boys eat foods high in calories. Girls under-eat or have inadequate nutrient intake.
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Lets Review
The nurse recommends to parents that popcorn and peanuts are not good snacks for toddlers. The nurses rationale for this action is:
A. B. C. D. They are low in nutritive value. They cannot be entirely digested. They can be easily aspirated. They are high in sodium.
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Lets Review
Nutrition is an important aspect of health promotion for the infant. Priority information to give the parents concerning infant nutrition would include (check all that apply):
A. Restrict the fat intake of the infant to help reduce the chances of an obese child. B. Breast or infant formula must be continued for the first year. C. Encourage the use of a pacifier for non-nutritive sucking needs. D. Introduction of solid foods should begin at 4-6 months.
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Lets Review
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Wh2ich of the following statements, if made by the mother, would require a need for further instruction? a. "It is okay to give my child white grape juice for breakfast." b. "My child can have a grilled cheese sandwich for lunch." c. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." d. "For a snack, my child can have ice cream."
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Play is the work of Children

Enhances Motor Skills Enhances Social Skills Enhances Verbal Skills Expresses Creativity Decreases Stress
Helps Solve Problems

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Appropriate Play Activities

Infants - Solitary Play, stimulation of senses (music, mirror)
Toddler - Parallel Play, make believe, locomotion (push-pull toys), gross & fine motor, outlet for aggression & autonomy
Preschooler - Associative Play, Imaginary Playmate, dramatic & imitative, gross & fine motor School Age - Cooperative Play, rules dominate play, team games/sports, quiet games/activities, joke books Adolescent - Group activities predominate, activities involving the opposite sex in later years
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Preparation for Procedures

Allow child to play with equipment Demonstrate procedure on doll for young child Use age-appropriate teaching activities Describe expected sensations Use simple explanations Clarify any misconceptions Involve parents in comforting child Praise/reward child when finished
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Communicating with Children

Provide a trusting environment Get down to childs eye level Use words appropriate for age Always explain what you are doing
Always be honest
Allow choices when possible Allow child to show feelings/talk
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Lets Review
The single most important factor for the nurse to recognize when communicating with a child is:
A. B. C. D. The childs chronological age. Presence or absence of the childs parents. Developmental level of the child. Nonverbal behaviors of the child.
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Health Promotion
Childhood Immunizations Well child check-ups Nutrition Screenings throughout childhood
(APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis)
Health Teaching
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Immunizations
Primary prevention of many communicable diseases Vaccines safety MMR vaccine and autism (no correlation) Reactions (pre-medicate with Tylenol) Live attenuated vaccines (MMR, Varicella) Weakened form of disease Body produces immune response Contraindicated in immunosupressed individuals Inactivated (killed virus/bacteria or synthetic) 1st dose only primes system- immunity develops after 3rd
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Injury Prevention & Safety Issues

Accidents are the leading cause of death in
infants and toddlers (falls, burns, poisons) Toddlers and Preschoolers drowning School-age and adolescents motor vehicle accidents and firearms 90% of all accidents are preventable! Safety education is the answer
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Injury Prevention
Methods of Injury Prevention Understanding and Applying Growth and Developmental Principles Anticipatory Guidance Childproofing the environment Educating caregivers and children Legislation Precipitating Factors
Potential Outcomes
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Pediatric Poisonings
Highest incidence occurs in children in 2-year-old age group and under 6 years of age Major contributing factor improper storage, allowing children to play with bottles rattling of pills, drink syrups, toxic portion of plants.
Teach parents about proper storage Knowledge of plants in household, and keep away from infants and children who might chew
Emergency treatment depends on agent ingested

Teach parents to have poison control number available Refer to appropriate method according to substance ingested
First Intervention is to call POISON CONTROL CENTER
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Types of Poisonings
Lead Poisoning
Salicylate Poisoning
Acetaminophen Ingestion
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Major environmental health concern Found in older homes (built before 1978), leadcontaminated soil, water through lead pipes, lead-based paint in ceramics products, Mexican candies made in lead containers Body rapidly absorbs lead specially in periods of rapid growth most harmful to children under 6 years Absorbed in GI tract and accumulates in bones, brain, kidneys Low levels in blood can cause behavioral/learning problems, mid-levels anemia-like symptoms and skeletal growth interference, and high levels can be fatal from CNS edema and encephalopathy Diet high in fat, low in iron & calcium can increase lead absorption Intervention=teaching for prevention. If blood level 45, chelation therapy is needed monitor kidney function during treatment.
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Lead Poisoning
Salicylate Poisoning
Can be acute or chronic ingestion S/S = nausea, disorientation, vomiting, dehydration,
hyperpyrexia, oliguria, coma, bleeding tendencies, tinnitus, seizures Nursing interventions = activated charcoal, sodium bicarbonate for metabolic acidosis, external cooling measures for hyperpyrexia, anticonvulsant and seizure precautions (think patient safety!), vitamin K for bleeding, possible hemo (NOT peritoneal) dialysis
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Acetaminophen Poisoning
Most common drug poisoning in children Acute ingestion S/S start as nausea, vomiting, pallor, sweating
hepatic involvement (jaundice, confusion, coagulation problems, RUQ pain) Treatment is activated charcoal first, then the antidote N-acetylcysteine (Mucomyst) PO every 4 hours for 17 doses after a loading dose given
Always assess Level of Consciousness (LOC) before administering PO med!

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Lets Review
Which would be the best approach for gastric emptying in a lethargic 18-month-old who ingested antihistamine tablets an hour ago?
A. B. C. D. Diluting toxic substance with water or milk Administering naloxone (Narcan) Gastric lavage Administering ipecac syrup
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Physical Assessment of Infant

Assessment is NOT in the head-to-toe manner When quiet, auscultate heart, lungs, abdomen Assess heart & respiratory rates before temperature Palpate and percuss same areas Perform traumatic procedures last Elicit reflexes as body part examined Elicit Moro reflex last Encourage caretaker to hold infant during exam
Distract with soft voice, offer pacifier, music or toy
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Physical Assessment of Toddler

Inspect body areas through play count fingers and
toes Allow toddler to handle equipment during assessment and distract with toys and bubbles Use minimal physical contact initially Perform traumatic procedures last Introduce equipment slowly Auscultate, percuss, palpate when quiet Give choices whenever possible
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Physical Assessment of Preschooler

If cooperative, proceed with head-to-toe If uncooperative, proceed as with toddler Request self undressing and allow to wear underpants Allow child to handle equipment used in assessment Dont forget magical thinking Make up story about steps of the procedure Give choices when possible If proceed as game, will gain cooperation
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Physical Assessment of School-Age Child

Proceed in head-to-toe May examine genitalia last in older children Respect need for privacy remember modesty! Explain purpose of equipment and significance Teach about body function and care of body
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Physical Assessment of the Adolescent

Ask adolescent if he/she would like parent/caretaker

present during interview/assessment Provide privacy Head-to-toe assessment appropriate Incorporate questions/assessment related to genitals/sexuality in middle of exam Answer questions in a straightforward, noncondescending manner Include the adolescent in planning their care
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Fever
Causes Often unknown, may be due to dehydration,
most often viral induced Danger in infants is febrile seizures most common between 3 months to five years. The seizure is a result of how quickly the temperature rises. Hydration (20mls/kg is formula for bolus) Antipyretics acetaminophen or ibuprofen Cooling measures avoid shivering
Tepid bath Remove excess clothing and blankets Cooling blankets/mattresses
NO ICE PACKS!
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Pediatric Differences
Fluid & Electrolyte
Percent Body Water compared to Total Body Weight:
Premature infants: 90% water Infants: 75 - 80% water Child: 64% water
Higher percentage of water in extracellular fluid in infants Infants and toddlers more vulnerable to fluid and electrolyte disturbances Concentrating abilities of kidneys not fully mature until 2 years Metabolic rate is 2-3 times higher than an adult Greater body surface area per kg body weight than adults; dehydrates more quickly
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Dehydration
Types:
Isotonic Most common; salt and water lost. Greatest threat Hypovolemic Shock Hypotonic Electrolyte deficit exceeds water deficitphysical signs more severe with smaller fluid losses Hypertonic Water loss higher than electrolyte Vomiting leads to metabolic alkalosis Diarrhea leads to metabolic acidosis
LAB WATCH: monitor sodium, potassium, chloride, carbon dioxide, BUN, and creatinine
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Assessment of Dehydration
Skin gray, cold, mottled, poor to fair, dry or clammy Delayed capillary refill Mucous membranes/lips dry Eyes and fontanels sunken No tears present when crying Pulse and respirations rapid Irritability to lethargy depending on cause and severity, not responsive to parent and/or environment
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Daily weight, I/O Assess hydration status Assess neurological status Monitor labs (electrolytes) Rehydrate with fluids both PO and IV (20 mls/kg of NS) Diet progression: Pedialyte modified Bread-RiceApple Juice-Toast (BRAT) Diet-for-age (DFA) Skin care for diaper rash Stool output (Amount, Color, Consistency, Texture ACCT) HANDWASHING!

Dehydration: Nursing Interventions
Priorities: fluid replacement & assess for S/S of shock

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Diarrhea
Often specific etiology unknown, but rotavirus is most common cause of gastroenteritis in infants and kids Dont forget contact precautions!! Leading cause of illness in children younger than 5 May result in fatality if not treated properly History very important Treatment aimed at correcting fluid imbalance and treating underlying cause Metabolic acidosis = blood pH < 7.35
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Vomiting
Often result of infections, improper feeding techniques, GI blockage (pyloric stenosis), emotional factors Management directed toward detection, treatment of cause and prevention of complications Metabolic alkalosis = blood pH >7.45
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Lets Review
The most appropriate type of IV fluid to infuse in treatment of extra-cellular dehydration in children is:
A. B. C. D. Isotonic solution. Hypotonic solution. Hypertonic solution. Colloid solution.
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Lets Review
Which laboratory finding would help to identify that a child experiencing metabolic acidosis?
A. B. C. D. Serum potassium of 3.8 Arterial pH of 7.32 Serum carbon dioxide of 24 Serum sodium of 136
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Pain Assessment: Infants

Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness
Examples: FLACC scale, NIPS scale
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Pain Assessment: Toddlers

Toddlers may have a word that is used for pain (owie, booboo, ouch or no); be sure to use term that toddler is familiar with when assessing. Can also use FLACC scale, or Oucher scale (for older toddlers)
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Pain Assessment: Preschoolers

Think pain will magically go away May deny pain to avoid medicine/injections Able to describe location and intensity of pain FACES scale, poker chips and Oucher scale may be used
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Pain Assessment: Older Children

Older children can describe pain with location and intensity
Nonverbal cues important, may become quiet or withdrawn
Can use scales like Wongs FACES scale, poker chips, visual analog scales, and numeric rating scales
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Lets Review
The nurse begins a full assessment on a 10 yearold patient. To ensure full cooperation from this patient it is most important for the nurse to:
A. Approach the assessment as a game to play. B. Provide privacy for the patient. C. Encourage the friend visiting to stay at the bedside to observe. D. Instruct the child to assist the nurse in the assessment.
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Lets Review
During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development?
A. Babies progress at different rates. Your infants development is within normal limits. B. If she is pulling up, you can help her by holding her hand. C. Shes a little behind in her physical milestones. D. You can strengthen her leg muscles with special exercises to make her stronger.
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Lets Review
When assessing a toddler identify the order in which you would complete the assessment:
1. 2. 3. 4. Ear exam with otoscope Vital signs Lung assessment Abdominal assessment
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Lets Review
When assessing pain in an infant it would be inappropriate to assess for:
A. B. C. D. Facial expressions Localization of pain Crying Extremity movement
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Genetic Disorders
7 Principles of Inheritance g Autosomal Dominant g Autosomal Recessive g Sex-linked (X-linked) Inheritance g Chromosome Alterations 7Downs Syndrome 7Tay-Sachs Disease
Nursing intervention is supporting parents and resources
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Autosomal Dominant
50% chance offspring will be affected
Normal Parent Affected Parent a a A a
Aa affected
Aa affected
aa normal
aa normal
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Autosomal Recessive
Only child who receives two altered genes Heterozygous Parent Heterozygous Parent develops the disease
A a A a
AA normal
Aa carrier
Aa carrier
aa affected
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X-linked Dominant
When the father is affected, all daughters Normal Mother Affected Father are affected, sons are not
X X XX Affected daughter XY Normal son XX Affected daughter XY Normal son X Y
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X-linked Dominant
When the mother is affected, daughters and sons may be affected
Affected Mother Normal Father X X XX Affected daughter XY Affected son XX Normal daughter XY Normal son X Y
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X-linked Recessive When the father is affected, all daughters will

carry the trait
X Normal Mother X XX Carrier Daughter XY Normal son XX Carrier Daughter Xy Normal son X Affected Father Y
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When the mother is carrier, the daughter will carry the trait, and the son may be affected
Carrier Mother Normal Father X X XX Carrier Daughter XY Affected son XX Normal Daughter Xy Normal son X Y
X-linked Recessive
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Downs Syndrome
Most common cause of cognitive impairment (moderate to severe) 1 in 600 live births Risk factor- pregnancy in women over 35 yrs old Cause - extra chromosome 21 (faulty cell division) Causes change in normal embryogenesis process resulting in:
Cardiac defects, GI conditions, Endocrine disorders, Hematologic abnormalities, Dermatologic changes
Physical features: small head, flat facial profile, broad flat nose,
small mouth, protruding tongue, low set ears, transverse palmar creases, hypotonia
* Feeding is often a problem in infancy *

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Tay-Sachs Disease
Occurs predominately in children of Eastern European Jewish ancestry Fatal Disease - death usually occurs before age 4 Autosomal recessive inheritance Degenerative brain disease Caused by absence of hexosainidase A from body tissue Symptoms: progressive lethargy in previously healthy 2-6 months old
infants, loss of milestones, visual acuity, seizures, hyper-reflexia, posturing, malnutrition, dysphagia
Diagnosis: Classic cherry red spot on macula, enzyme measurement in
serum, amniotic fluid, white cells
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Lets Review
The infant with Downs Syndrome is closely monitored during the first year of life for which condition?
A. B. C. D. Thyroid complications Orthopedic malformations Cardiac abnormalities Dental malformations
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Neurosensory System
Rapid head growth in early childhood Bones are not fused until 18-24 months
Size and Structure:
Function:
Autonomic Nervous System is intact - neurons are completely myelinized by 1 year Infants behavior initially reflexive, but are replaced with purposeful movement by 1 year
Infants demonstrate a dominance of flexor muscles

Motor development occurs constantly in head to toe progression
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Neurosensory System
Eye and Vision:
Changes in development of eye and eye muscles *strabismus normal until 6 months
Vision function becomes more organized

Papilledema rarely occurs in infants due to expansion of fontanels with increased ICP
Ear and Hearing:

Hearing fully developed at birth Abnormal physical structures may indicate genetic problems
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The Neurosensory System

Disorders of the Nervous System 3 3 3 3 3 Hydrocephalus Spina Bifida 3 Reyes Syndrome Seizures Cerebral Palsy (CP) Meningitis
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Hydrocephalus
Develops as a result of an imbalance of production and absorption of CSF The increase of CSF causes increased ventricular pressure, leading to dilation of the ventricles, pressing on skull Signs/Symptoms of Increased ICP: Poor feeding and vomiting Bulging fontanel, head enlargement, separation of sutures Lethargy, irritability, restlessness, not responsive to parents CHILD - Headache, vomiting, diplopia, ataxia, papilledema Seizures
A childs head with an open fontanel (under 2 years old) has the ability to expand and better compensate for the increased intracranial pressure.
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Ventriculoperitoneal (VP) Shunts

Relief of hydrocephalus Prevention/treatment of complications Management of problems related to psychomotor development Surgical intervention: ventriculoperitoneal (VP) shunt
One-way pressure valve releasing
CSF into peritoneal cavity where it is reabsorbed

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General Nursing Interventions

Monitor Neuro Status

Decrease ICP

Determine baseline Assess LOC Assess motosensory Pupil checks Vital signs, Head circ
Seizure precautions Fall precautions Possible restraints Determine LOC ac
Provide Patient Safety
Cluster care/ stress Quiet environment HOB 30-45 degrees Appropriate position (head midline, no hip flexion, no prone) Medications(pain meds,corticosteroids, diuretics, stool softeners, antiinfectives, anticonvulsants)
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General Nursing Interventions

Maintain Adequate Cerebral Perfusion
Maintain airway Monitor oxygenation and apply O2 PRN Monitor temperature and administer antipyretics PRN Maintain normovolemia Monitor I/O Assess perfusion
Maintain Nutritional & Fluid Needs

Determine swallow ability prior to POs NGT feedings may be necessary Dietary consult PRN Daily weight Monitor lab results
Psychosocial Support
Child Life consult Teaching
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Spina Bifida:
Occulta and Cystica
(meningocele and myelomeningocele) Etilogy is unknown, but genetic & environmental factors considered. Maternal intake of folic acid Exposure of fetus to teratogenic drugs The severity of clinical manifestations depend on the location of the lesion. T12 - flaccid lower extremities, sensation, lack of bowel control and dribbling urine S 3 and lower - no motor impairment Other complications may occur. Hydrocephalus (80-90%) Orthopedic issues such as scoliosis, kyphosis, club foot Urinary retention Skin breakdown/Trauma
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Spina Bifida
Nursing Interventions
Sterile dressing pre/post-op Monitor VS, S/S infection Use latex free items Avoid stress on sac - prone position only, especially pre-op; no supine until incision healed Monitor for S/S intracranial pressure (ICP) Interventions to ICP Encourage touch & talk Social service consult
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Reyes Syndrome
A true pediatric emergency - cerebral complications may reach an irreversible state. Vomiting & change in LOC to coma Acute encephalopathy with fatty degeneration of the liver causing fluid & electrolyte imbalances, metabolic acidosis, hypoglycemia, dehydration, and coagulopathies.
Most frequently seen in children recovering from a viral illness during which salicylates were given.
Therapeutic management is intensive nursing care and maintaining adequate cerebral perfusion, &ICP. Increased ICP secondary to cerebral edema is major contributing factor to morbidity and mortality.
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Seizures
Febrile seizures are the most common in children, caused by by a RAPID elevation in temperature, usually above 102. Most children do not have a second febrile seizure episode and only about 3% develop epilepsy. Focus of care is on patient safety, cause of fever and education of parents for home care. Remember basic CPR during seizures airway before oxygen Seizure precautions: Suction, oxygen, padded rails
Infants often have subtle seizures with only occular movements or some extremity movements.
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Cerebral Palsy (CP)

1.5 - 5 in 1,000 live births
Neuromuscular disorder resulting from damage or altered structure of part of the brain
Caused by a variety of factors: Prenatally - genetic, trauma, anoxia Perinatally - fetal distress, drugs at delivery, precepitate
or breech delivery with delay Postnatally - kernicterus or head trauma
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Cerebral Palsy
(continued)
Spasticity - exaggerated hyperactive reflexes Athetosis - constant involuntary, purposeless, slow writhing motions Ataxia - disturbances in equilibrium Tremor - repetitive rhythmic involuntary contractions of flexor and extensor muscles Rigidity - resistance to flexion and extension
Associated Problems: Mental retardation, hearing loss, speech defect, dental & orthopedic anomalies, GI problems and visual changes
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Cerebral Palsy: Nursing Interventions

Safety
Feed in upright position Seizure precautions Ambulate with assistance if able Medication administration
Special Needs
Nutritional needs include increased calories, assist with feeds, possible GT feeds. Speech, Occupational and Physical therapies
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Bacterial Meningitis
Infectious process of CNS causing inflammation of meninges and spinal cord. ISOLATION IS MANDATORY Signs and symptoms include those of increased ICP plus photophobia, nuchal rigidity, joint pain, malaise, purpura rash, Kernigs and Brudinskis signs Can occur at any age, but often between 1 month-5 years Most common sequele: hearing and/or visual impairments, seizures, cognitive changes Diagnostic confirmation is done by lumbar puncture and CSF is cloudy with increased WBCs, increased protein, and low glucose Nursing Interventions include: appropriate IV antibiotics and meds for increased ICP as well as interventions to decrease ICP
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Causes of Blindness
Genetic Disorders:
Tay-Sachs disease Inborn errors of metabolism
Perinatal: prematurity, retrolental fibroplasia

Postnatal: trauma, childhood infections, Juvenile Arthritis
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Causes of Deafness
Conductive:
Interference in transmission from outer ear to middle ear from chronic OM
Sensorineural:
Dysfunction of the inner ear Damage to cranial nerve VIII from rubella, meningitis or drugs
110
Lets Review
Which test would confirm a diagnosis of meningitis in children?
A. B. C. D. Complete blood count Bone marrow biopsy Lumbar puncture Computerized Tomography (CT) scan
111
Lets Review
In performing a neurological assessment on a patient which data would be most important to obtain?
A. B. C. D. Vital signs. Head circumference. Neurologic soft signs. Level of consciousness (LOC).
112
Lets Review
A neonate born with myelomeningocele should be maintained in which position pre-operatively? A. B. C. D. Prone. Supine. Trendelenberg. Semi-Fowler.
113
Lets Review
The nurse witnesses a pediatric patient experiencing a seizure. The primary nursing intervention would be:
A. Careful observation and documentation of the seizure activity. B. Maintain patient safety. C. Minimize the patients anxiety. D. Avoid over stimulation and promote rest.
114
Lets Review
Which assessment finding in an infant first day post-op placement of a ventriculoperitoneal (VP) shunt is indicative of surgical complications?
A. B. C. D. Hypoactive bowel sounds. Congestion in upper airways. Increasing lethargy. Incisional pain.
115
Cardiovascular System: Pediatric Variances

Cardiac arrest is related to prolonged hypoxemia
Heart Rate (HR) higher Cardiac Output depends on HR until heart muscle is fully
developed (around 5 years of age)

Innocuous (benign) murmurs Sinus arrhythmias normal in infants Congenital defects present at birth the greater the
defect, the more severe the clinical manifestations (S/S)

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FETAL CIRCULATION
117
Cardiovascular System: Changes from Fetal Circulation

Fetal Circulation - Pattern of Altered Blood Flow Normal Circulatory Changes at Birth: Oxygenation takes place in Lungs Structural changes occur: * Ductus venosus constricts by 3-7 days becomes ligamentum venosum * Foramen ovale closes within first weeks * Ductus arteriosus functional closure at 24 hours, anatomic closure 1-3 weeks
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Cardiovascular System: Changes from Fetal Circulation

Abnormal Circulatory Patterns After Birth
Abnormal openings between the pulmonary

and systemic circulations can disrupt blood flow. Blood will follow the path of least resistance -Left side of heart has greater pressure, so . . . Blood normally shunted from left to right Obstructions to pulmonary blood flow may cause right to left shunting of blood
119
NORMAL HEART ANATOMY BLOOD FLOW
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The Cardiovascular System

Y Care of the Child with Congestive Heart Failure
Y Congenital Heart Defects Increased Pulmonary Blood Flow Decreased Pulmonary Blood Flow Obstruction to Systemic Blood Flow Y Acquired Heart Disease
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Goals of Nursing Care with Congenital Heart Disease

Y Reduce workload-Improve cardiac function Y Improve respiratory function Y Maintain nutrition to meet metabolic demands
and promote growth Y Prevent infection and support/instruct parents
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Congestive Heart Failure Review

COMPENSATORY RESPONSES
Tachycardia, especially at rest Diaphoresis Fatigue Poor Feeding Failure to Thrive (FTT) Exercise Intolerance Decreased Peripheral Perfusion Pallor and/or Cyanosis Cardiomegaly
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CLINICAL MANIFESTATIONS-CHF
PULMONARY
Tachypnea Dyspnea Wheezes Crackles Retractions Nasal Flaring Cough
SYSTEMIC
Edema (facial) Sudden weight gain Decreased Urine Output Hepatomegaly Splenomegaly Jugular Vein Distention (JVD, children) Ascites
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CHF: Focused Review Nursing Interventions

Therapeutic Management
Improve cardiac function Digitalization; Infant dose calculated 1000micrograms=1mg, ACE inhibitors Diuretics, fluid restrictions, daily weights, I/O Decrease tissue demands Promote rest, minimize stress Increase tissue oxygenation Oxygen Nutrition Nipple feeds vs. gavage or GT, highercalorie feeds
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GENERAL NURSING INTERVENTIONS

Improve Cardiac Function Decrease Cardiac Demands Medicate Promote rest Cardiac glycosides Minimize Stress (Digoxin) Monitor VS (temp) Promote Fluid Loss Reduce Respiratory Distress Medicate HOB elevated Furosemide Possible supplemental Spironolactone oxygen Clorothiazide Maintain Nutrition Fluid Restriction Nipple vs. Gavage/GTT Daily Weight Higher-calorie feeds (more than 20 cals/oz) Monitor I/O
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Increased Pulmonary Blood Flow (Acyanotic)

Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)

Patent Ductus Arteriosus (PDA)
CHF Feeding intolerance Activity intolerance Poor growth, failure to thrive Frequent Pulmonary Infections due to boggy lungs
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Decreased Pulmonary Blood Flow (Cyanotic)

Pulmonary Stenosis Tetralogy of Fallot Transposition of the Great Vessels
Assessment findings/Compensatory mechanisms
Oxygen desaturation Varying degrees of cyanosis Polycythemia
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Decreased Pulmonary Blood Flow (Cyanotic)
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Obstruction to Systemic Blood flow

Aortic Stenosis
Coarctation of the Aorta Think perfusion issues -Diminished or unequal pulses -Poor color
-Delayed capillary refill time

-Exercise intolerance
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Obstruction to Systemic Blood flow
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Rheumatic Fever
Acquired Heart Disease Inflammatory disorder involving heart, joints, connective tissue, and the CNS Peaks in school-age children Linked to environmental factors and family history
Thought to be an autoimmune disorder: Commonly preceded by a Strep Throat

Prognosis depends upon the degree of heart damage Rest important in recovery priority intervention in acute stage Strep prophylaxis for 5 years or throughout adolescence
133
Hematologic System: Pediatric Variances

All bone marrow in a young child is involved in the formation of blood cells.
By puberty, only the sternum, ribs, pelvis, vertebrae, skill, and proximal epiphyses of femur and humerus are involved in blood cell formation. During the first 6 months of life, fetal hemoglobin is gradually replaced by adult hemoglobin.
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The Hematologic System

Disorders of Red Blood Cells Iron Deficiency Anemia Sickle Cell Anemia
Disorders of Platelets/Clotting Factors Idiopathic Thrombocytopenia Purpura (ITP) Hemophilia
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IRON DEFICIENCY ANEMIA

Most common nutritional anemia in childhood Severe depletion of iron stores resulting in a low HGB level Decreased O2 to tissues = fatigue, headache, pallor, increased heart rate Occurs after depletion of iron stores in body (6-9 mo of age) Most likely to occur during rapid physical growth and low iron intake
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IRON DEFICIENCY ANEMIA

Often occurs as a result of increased milk intake Lab results show low HGB, HCT, MCV, MCH, MCHC, iron, ferritin Teach parents proper nutrition
Meat, spinach, legumes, sweet potatoes,
egg yolks, seafood Calcium inhibits iron, Vitamin C enhances iron absorption
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Sickle Cell Disease
PATHOLOGY
Normal RBC has a flexible, round shape RBC w/HbS has a normal shape until its O2 delivered to
tissue, then sickle shape occurs Stiff, non-pliable cant flow freely Trapped in small vessels = causes vaso-occlusions, tissue ischemia and infarctions painful episodes, most common area is joints Hemolysis of RBC- lifespan down to 20 days Compensatory mechanism is increased reticulocytes
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Sickle Cell Disease

ACUTE FEBRILE ILLNESS High mortality rate <5 years old Splenic dysfunction begins at 6 mo old Prophylactic PCN BID at 2-3 mo old Monitor for Infection Temp > 101.5 Respiratory S/S SPLENIC SEQUESTRATION Highly vascular Susceptible to injury/infarction Occurs 6 mo-3yrs Pallor, fatigue, abd pain, splenomegaly, CV compromise Treatment: IV fluids, PRBCs
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Sickle Cell Disease: Nursing Interventions

GENERAL NURSING CARE Hydration is Priority!
Fluid Bolus & maintenance + 1/2
Oxygen - to decrease sickling of of cells Pain Management

Assess frequently/appropriately IV Morphine q3-4 hr, PCA Non-pharmacological methods
HOME MANAGEMENT Pain Control Fluids Teaching Early Identification of infection Immunizations Avoid dehydration
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Idiopathic Thrombocytopenic Purpura (ITP)

Acquired hemorrhagic disorder characterized by
thrombocytopenia and purpura Cause is unknown, but is to believed to be an auto-immune response to disease-related antigens Usually follows an URI, measles, rubella, mumps, chickenpox Greatest frequency is between 2-8 years of age Platelet count is below 20,000 Therapeutic management is supportive with safety concerns. Activity is usually restricted. Acute presentation therapy can include prednisone, IV immunoglobulin, or Anti-D antibody (causes a hemolytic anemia to rid the body of the antibody-coated RBCs) Chronic ITP will involve a splenectomy.
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Hemophilia
Group of genetic bleeding disorders of which there is a deficiency of a clotting factor Most common are Factor VIII (A) & Factor IX (B) Bleed LONGER not faster Clinical manifestations: prolonged bleeding, bruising, spontaneous hematuria Management: replacement of missing clotting factor (recombinant factor VIII concentrate), cryoprecipitate, DDAVP NSAIDS (aspirin, Indocin) are contraindicated, they inhibit platelet function Regular non-contact exercise/physical therapy is encouraged
142
Hemophilia
COMPLICATIONS Bleeding into muscle tissue Hemarthrosis can cause joint pain & destruction
Acute Treatment is rest, ice,
elevation, ROM
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Lets Review
When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is much greater than that found in the childs leg. The nurse reacts to these findings in which way?
A. B. C. D. Charts the findings and realizes they are normal. Suspects the child may have coarctation of the aorta. Suspects the child may have Tetralogy of Fallot. Notifies the physician and alerts the surgery team.
144
Lets Review
A 1-month-old infant is being admitted for complications related to a diagnosed ventricular septal defect (VSD). Which physicians order should be questioned by the nurse?
A. Blood pressure every 4 hours. B. Serum digoxin level. C. Diet: Enfamil 20, nipple 6 oz q2H. D. Supplemental oxygen via nasal cannula prn maintain SaO2 >92%.
145
Lets Review
A nursing intervention most pertinent for the child with hemophilia is:
A. Sedentary activities to prevent bleeding episodes. B. Meticulous oral care with dental floss to prevent infection. C. Warm compresses to bleeding areas to increase absorption. D. Active range of motion exercises for joint mobility.
146
Lets Review
Which is the most appropriate information to teach a parent of a 14 month-old child with iron deficiency anemia?
A. Increase the childs daily milk intake to a minimum of 24 ounces. B. Administer oral iron supplement for the child to drink in a small cup. C. Increase the amount of dark green, leafy vegetables and eggs in the childs diet. D. Encourage the parents to let the child choose foods he prefers.
147
Lets Review
Which strategy is appropriate when feeding the infant in congestive heart failure?
A. Continue the feeding until a sufficient amount of formula is taken B. Bottle feed no longer than 30 minutes C. Feed the infant every 2 hours D. Rock and comfort the infant during feedings
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Respiratory System Pediatric Variances

The airway is smaller and more flexible. The larynx is more flexible and more susceptible to spasm. The lower airways are smaller with underdeveloped
cartilage. The tongue is large. Infants < 6 months old are obligate nose breathers. Chest muscles are not well developed The diaphragm is the neonates major respiratory muscle. Irregular breathing pattern and brief periods of apnea (10 15 secs) are common Abdominal muscles are used for inhalation until age 5-6 yrs. Respiratory rate is higher Increased BMR raises oxygen needs
149
The Respiratory System

Upper Airway Disorders
Tonsillitis Croup Epiglottis Foreign Body Aspiration
Lower Airway Disorders

Bronchiolitis Asthma Cystic Fibrosis
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Tonsillitis
CLINICAL MANIFESTATIONS

IMPLEMENTATIONS
Ease Respiratory Efforts Provide Comfort
Sore throat Mouth breathing Sleep Apnea Difficulty swallowing Fever Throat C&S/Rapid Strep
Warm saline gargles Pain Medication Throat lozenges

Reduce Fever Promote Hydration Administer Antibiotics Provide Rest Patient Teaching Tonsillectomy may be
necessary
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Tonsillectomy
Pre-operative Nursing Care
Monitor Labs (CBC, PT, PTT) Age-appropriate Preparation/Teaching Surgical Consent
Post-operative Nursing Care

Frequent site assessment - visualize! Monitor for S/S of Complications Pain Management Diet (push fluids-no citrus juices or red, advance diet) Patient Teaching
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Croup/Epiglottitis
Infection and swelling of larynx, trachea, epiglottis, bronchi Often preceded by URI traveling downward Causative agent: Viral Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress Most common ages 6 mo-3 yrs LTB form most common
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Acute Epiglottitis
Bacterial form of croup affecting epiglottis LIFE-THREATENING EMERGENCY Wellness to complete obstruction in 2-6 hours Most common in ages 2-5 years Do not examine throat! Have functional emergency equipment at bedside - Priority! Often the child is intubated 4 Ds - Drooling, Dysphagia, Dysphonia, Distressed Inspiratory Effort Lateral Neck X-ray shows thumb sign HIB vaccine has reduced the cases dramatically
154
Croup/Epiglottitis
Maintain Patent Airway Assess and Monitor Ease Respiratory Efforts
Administer Meds Corticosteroids (HHN) Nebulizer treatment of Racemic Epinephrine PRN stridor Antibiotic for epiglottitis
Promote Hydration
Reduce Fever Calm Environment
Promote Rest
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Foreign Body Aspiration

Occurs most often in small children Choking, coughing, wheezing, respiratory difficulty Often it is round food, such as hot dogs, grapes, nuts, popcorn Bronchoscopy often needed for removal Age-appropriate preparation needed for procedure Prevention and parent education is very important
156
Bronchiolitis/RSV
Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur Increased amount of mucus and exudates preventing expiration of air and overinflation of lungs Causative agent in 85% of cases is Respiratory Syncytial Virus (RSV). It is highly contagious - contact isolation must be enforced. Nasal swab or nasal washing obtained for viral panel, including RSV CXR shows hyperinflation and consolidation if atelectasis present Primarily seen in children under 2 years of age Most common in winter and early spring Palivizumab (Synagis)
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Bronchiolitis/RSV
CLINICAL MANIFESTATIONS Nasal Congestion Cough Rhonchi, Crackles, Wheezes Increased RR & SOB Respiratory Distress Fever Poor Feeding IMPLEMENTATIONS Suction priority Bronchodilator via HHN CPT Promote fluids Monitor VS , SaO2, lung sounds & respiratory effort Supplemental oxygen Reduce fever Promote rest HANDWASHING!
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Asthma
CLINICAL MANIFESTATIONS Tachypnea SaO2 below 95% on RA Wheezes, crackles Retractions, nasal flaring Non-productive cough Silent chest Restlessness, fatigue Orthopnea Abdominal pain CXR = hyperinflation INTERVENTIONS Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Ease respiratory efforts Promote hydration Promote rest Monitor labs/x-rays Patient teaching
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Asthma
Administer Medications
Bronchodilator via HHN or MDI with spacer (Albuterol) Peak flows should always be done before and after Tx Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal) Corticosteroid IV or PO (Solu-medrol or Decadron) Antibiotic if precipitated from a respiratory infection
Home Medication Management

Bronchodilator via HHN or MDI with spacer (Albuterol Proventil, Levalbuterol - Xopenex) Inhaled steroids (Beclamethasone - Vanceril) Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal) Leukotriene modifiers PO for long-term control - Singular
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CYSTIC FIBROSIS
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Cystic Fibrosis
1 in 1,500-2,000 live births Dysfunction of the exocrine gland (mucus producing) Multi-system disorder Secretions are thick and cause obstruction and fibrosis of tissue. The clinical manifestations are the result of the obstructive process. Sweat has a characteristic high sodium- Sweat Chloride Test Pancreatic involvement in 85% of CF patients Disease is ultimately fatal. Average age at death: 32 years
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Cystic Fibrosis
PULMONARY MANIFESTATIONS GI MANIFESTATIONS
Initial
Wheezing Dry, non-productive cough
Eventual & Progressive

Repeated lung infections Wet & paroxysmal cough Emphysema/Atelectasis Barrel-chest - Clubbing - Cyanosis
Large, loose, frothy and foul-smelling stools Increased appetite (early) Loss of appetite (later) Weight loss FTT Distended abdomen Thin extremities Deficiency of A,D, E, K Anemia
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Cystic Fibrosis
MANAGEMENT/INTERVENTIONS Airway Clearance - Chest physiotherapy (CPT) Priority Drug Therapy
Bronchodilators - via HHN Mucolytic Agent (Dnase-Pulmozyme) - via HHN Antibiotics - via HHN, IV, or PO Digestive enzymes
Nutrition - needs are at 150% Increased calories and protein - TPN or GT feedings at night Additional fat soluble vitamins Additional salt with vigorous exercise and hot weather Exercise Patient Teaching
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Otitis Media

Acute otitis media (AOM) Infectious process by pathogen Infection can spread leading to meningitis S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane Otitis media with effusion (OME)
Inflammation of middle ear with fluid behind tympanic membrane-no infection Peaks spring and fall (allergies)
Most common childhood illness Inflammation of middle ear Impaired eustachian tube causes decreased ventilation and drainage
Chronic otitis media
Inflammation of middle ear > 3 mo Can lead to hearing loss/delayed speech

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Otitis Media
RISK FACTORS Secondary smoke Formula feeding (positioning) Day care Pacifier > 6 mo old TREATMENT Antibiotics (for AOM) Myringotomy with Pressure Equalizing (PE) tubes INTERVENTIONS Teaching No bottle propping Feeding techniques Medication regimen PAIN MANAGEMENT Fever management Surgery prep if needed
167
Lets Review
The nurses first action in responding to a child with tachypnea, grunting, and retractions is to:
A. Place the child in an upright, semi-fowlers position. B. Apply a pulse oximeter to determine oxygen saturation. C. Assess for further symptoms. D. Call for a stat respiratory nebulizer treatment (HHN).
168
Lets Review
A 3-year-old child is brought to the emergency room with a sore throat, anxiety, and drooling. The priority nursing action is to:
A. Inspect the childs throat for infection. B. Prepare intubation equipment and call the physician. C. Obtain a throat culture for respiratory syncytial virus (RSV). C. Obtain vital signs and auscultate lung sounds.
169
Lets Review
An assessment finding in a child with asthma requiring immediate action by the nurse is:
A. B. C. D. Diminished breath sounds. Wheezing in bronchi. Crackles in lungs. Refusal to take PO fluids.
170
Lets Review
Which sign is indicative of air hunger in an infant?
A. Nasal flaring. B. Periods of apnea lasting 15 seconds. C. Irregular respiratory pattern. D. Abdominal breathing.
171
Lets Review
The priority nursing intervention in caring for the infant with Respiratory Syncytial Virus (RSV) induced bronchiolitis is:
A. Nasopharyngeal suctioning. B. Coughing and deep breathing exercises. C. Administration of intravenous antibiotic. D. Administration of antipyretics for fever.
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Gastrointestinal System
Many GI issues require surgical intervention Nursing interventions will often include general pre and post-op care Bilious vomiting is a sign of GI obstruction and requires immediate intervention Assess stools! Assess hydration status
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Gastrointestinal System Pediatric Variances

Mechanical functions of digestion are immature at birth Liver functions are immature throughout infancy Production of mucosal-lining antibodies is decreased Infants have decreased saliva Infants stomach lies transversely Peristalsis is faster in infants Digestive processes are mature as a toddler The childs liver and spleen are large and vascular Infants and children who vomit bile-colored emesis require immediate attention Gastric acidity is low at birth
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The Gastrointestinal System

8 Altered Connections
3 Esophageal Atresia/Tracheoesophageal Fistula 3 Cleft Lip and Palate
8 Gastrointestinal Disorders
3 3 3
Gastroesophageal Reflux Hirschsprungs Disease Intussusception
3 Pyloric Stenosis 3 Imperforate Anus
Acquired Gastrointestinal Disorders

3 Celiac Disease 3 Appendicitis 3 Parasitic Worms
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ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA
Congenital defects of esophagus EA is an incomplete formation of esophagus TEF is a fistula between the trachea and esophagus Classic 3 Cs - coughing,choking,cyanosis
176
ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA

SIGNS/SYMPTOM
Copious, frothy oral secretions Abdominal distension from air in stomach Look for 3 Cs Confirmed with radiographic studies
TREATMENT
Surgery: either a one- or two-stage repair Pre-op care focuses on preventing aspiration and hydration Post-op care focus is a patent airway, prevent incisional trauma
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Cleft Lip/Palate
May present as single defect or combined Non-union of tissue and bone of upper lip and
hard/soft palate during fetal development CL-failure of nasal & maxillary processes to fuse at 5-8 weeks gestation CP-failure of palatine planes to fuse 7-12 weeks gestation Cleft interferes with normal anatomic structure of lips, nose, palate, muscles depending on severity and placement Open communication between mouth and nose with cleft palate
178
Cleft Lip/Palate
Multidisciplinary care throughout

ESSR method (enlarge, stimulate,
childhood and early adulthood Nutrition is a challenge in infancy

swallow, rest) Risk for aspiration Respiratory distress
Altered bonding is a possibility

179
CLEFT LIP & CLEFT PALATE: Operative Care

Cleft lip surgery by 4 weeks & again at 4-5 yrs Cleft palate surgery at 6-24 months of age, usually
done by 1 year so speech will not be affected Protect suture lines- priority Monitor for infection
Clean Cleft Lip incision
Pain Management Cleft Palate starts feedings 48-hour post-op: Clear and advance to soft diet No straws, pacifiers, spouted cups Rinse mouth after feeding
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GASTROESOPHAGEAL REFLUX Regurgitation of gastric contents back
into esophagus - 50% healthy term babies affected Related to inappropriate relaxation of Lower Esophageal Sphincter (LES) making the LES pressure less than the intra abdominal pressure GER may predispose patient to aspiration and pneumonia Apnea has been associated with GER chance of GER after 12-18 mo old related to growth due to elongation of esophagus and the LES drops below the diaphragm
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GASTROESOPHAGEAL REFLUX
SIGNS/SYMPTOMS
Vomiting/spitting up Gagging during feedings Irritability Arching/posturing Frequent URIs/OM Anemia Bloody stools
DIAGNOSTIC EVAL
History of feedings/PE Upper GI/Barium swallow to eliminate anatomical problems Upper GI endoscopy to visualize esophageal mucosa pH probe study
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GASTROESOPHAGEAL REFLUX: Therapeutic Management

Positioning
Prone HOB 30 Right side
Medications
Prokinetic agents: LES pressure & gastric motility Histamine H-2 antagonists are added if esophagitis : acid Proton Pump Inhibitors if H-2 ineffective:acid Mucosal Protectants
Dietary modifications
Small, frequent feedings, burp often Possibly thicken formula Avoid fatty, spicy foods caffeine, & citrus Surgery: fundoplication Teach
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HIRSHSPRUNGS
Aganglionic megacolon
No ganglion cells at affected area usually at rectum/proximal portion of lower intestine Absence of peristalsis leads to intestinal distension, ischemia & maybe enterocolitis
Treatment
Mild-mod: stool softeners & rectal irrigations Mod-severe: single or 2-step surgery Colostomy with later pull-through
184
HIRSHSPRUNGS
SIGNS/SYMPTOMS Infants Unable to pass meconium stool within 24 hours of life Abdominal distention Bilious vomiting Refusal to feed Failure to thrive Children
Chronic constipation Pellet or ribbon-like stools (foul-
smelling) Vomiting/FTT
NURSING INTERVENTIONS Surgery prep: bowel cleansing, antibiotics, NPO, IVFs, therapeutic play for surgery preparation Infection & Skin Integrity: monitor ostomy/anus Nutrition & Hydration: NGT, NPO then advance to Diet as tolerated, assess bowel function and abdominal status
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INTUSSUSCEPTION
Prolapse or telescoping of one portion of the intestine into another Abrupt onset Usually occurs in 3-24 months of age Sudden abdominal pain Vomiting Red, current jelly stool Abd distention/tender Lethargy Can lead to septic shock
186
INTUSSUSCEPTION
DIAGNOSTIC STUDY Barium or air enema Abdominal ultrasound
TREATMENT Hydrostatic reduction: force exerted using water-soluble contrast and air to push the affected intestine apart Surgical reduction if hydrostatic reduction is unsuccessful

NURSING INTERVENTIONS Monitor for infection, shock, pain Maintain hydration - assess status! Prepare child/parent for hydrostatic reduction teach, consent, NPO, NGT Monitor stools pre & post procedure If surgery: general pre & post-op care
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PYLORIC STENOSIS
Hypertrophy of pyloric sphincter, causing a
narrowing/ obstruction (bands pylorus) Usually occurs between 2-8 weeks of age Infant presents with non-bilious projectile vomiting, and is always hungry Can lead to dehydration and hypochloremic metabolic alkalosis Weight loss
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PYLORIC STENOSIS
DIAGNOSTIC EVAL
History/PE: olive palpated in epigastrum Upper GI (string sign) Abdominal Ultrasound
INTERVENTIONS
Pre-op: NPO, NGT to LIS, hydration, I/O, monitor electrolytes Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule begin w/5cc GW half strength formula Full strength formula
TREATMENT
Surgical Intervention: Pyloromyotomy
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IMPERFERATE ANUS
Anorectal malformations No obvious anal opening Fistula may be present from distal rectum to perineum or GU system Diagnostic Eval: patency of anus in newborn, passage of meconium; ultrasound is suspected Therapeutic Management: manual dilatation for anal stenosis, surgical treatment for malformations Nursing Implementations: pre and post-op care IV fluids, consent, assessing surgical site for infection and monitoring for complications, possible NGT, diet progression, possible colostomy and teaching; preferred post-op condition is sidelying.
190
Celiac Disease
Malabsorption syndrome characterized by intolerance of gluten (rye, oats, wheat and barley)
Familial disease - more common in Caucasians

Thought to be an inborn error of metabolism or an immunological disorder
Reduced absorptive surfaces in small intestine which causes marked malabsorption of fats (frothy, foul-smelling stools)
Child has diarrhea, abdominal distention, failure to thrive Treatment is lifelong low-gluten diet; corn and rice are substituted grain foods
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APPENDICITIS
Inflammation and infection of vermiform appendix, usually related to an obstruction Cause may be bacteria, virus, trauma Ischemia can result from the obstruction, leading to necrosis causing perforation S/S: periumbilical painRLQ pain (McBurneys point), fever, vomiting, diarrhea, lethargy, irritability, WBCs Surgery is necessary If ruptured, often child will receive IV antibiotics for 24 hrs prior to OR Pre-op Care: NPO, pain management, hydration, prep & teaching, consent Post-op Care: routine post-op care, IVF/antibiotics, NPODAT, ambulation, positioning, pain management, wound care, possible drains.
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PINWORM (enterobiasis)
Transmission: oral-fecal Persist in indoors for up to 3 weeks contaminating anything
they contact (toilets, bed linens) S/S: intense perianal itch, sleeplessness, abd pain, vomiting Scotch tape test collects eggs laid by female outside of anus. Must be obtained in am prior to bath or BM. Treatment: *mebendazole (Vermox) for over 2 years of age. Under 2 years of age treatment may be pyrvinium pamoate (Povan) which stains stool and emesis red *All family members must be treated.
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OMPHALOCELE AND GASTROSCHISIS
OVERVIEW Description of lesion Preoperative stabilization Preanesthetic evaluation Anesthetic management Postoperative considerations
GUT DEVELOPMENT
Primitive gut - Divided into 3 regions Foregut- Pharynx, esophagus and stomach Midgut- Small and large intestine Hindgut- Colon and rectum
Abdominal wall- somatic and splanchnic layers of the ceph

lateral and caudal folds
Failure in development of one of these folds can result in

anterior abdominal wall defects
OMPHALOCELE
Greek- omphalos-navel, cele- hernia Absence abdominal wall fascia Herniation abdominal contents Eccentric displacement umbilical cord
Small underdeveloped abdominal cavity

Thin sac covering defect
OMPHALOCELE
Incidence: 1 in 3 - 5,000 Divided into 2 groups Small hernia umbilical cord (<4 cm) Giant Omphalocele (>4 cm with herniated liver)
Associated congenital abnormalities (30-70%)
Gastrointestinal, Genitourinary, central nervous system, congenital heart defe Cardiac defects- seen in 25% of patients (TEF most common)
ASSOCIATED MALFORMATIONS
UPPER MIDLINE SYNDROME
Pentalogy of Cantrell, Sternal defect, Ectopia cordis, Pericardial
and cardiac defects, Diaphragmatic defect, Omphalocele
LOWER MIDLINE SYNDROME

Vesicointestinal fistula, Imperforate anus, Colonic agenesis, Bladder
extrophy, Omphalocele
BECKWITH-WIEDEMANN SYNDROME
Macroglossia, Visceromegaly, Omphalocele
OMPHALOCELE
30- 50% develop hypoglycemia May last for first year of life
Associated mortality
Small defect (30%)
Giant defect (48%)
GASTROSCHISIS
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GASTROSCHISIS
Greek: Gaster-stomach, schisis- cleft Incidence 1 in 50,000
Infarction /atresia bowel common

Infrequent congenital malformations
High association prematurity

Herniated contents (rarely liver) Umbilical cord left defect, Absence sac over herniation Abdominal cavity more developed
GASTROSCHISIS
ISOLATED OMPHALOCELE
umbilical ring
Failure of lateral folds to engulf the midgut and form the
DEVELOPMENT SPECULATIVE
Shaw (Early 1980s) Simple herniation of the cord that r
after completion of the anterior abdominal wall but, befo completion of the umbilical ring.
GLICK (1984)
GASTROSCHISIS
Ultrasound for chronologic in utero development of Gastroschisis
OBSERVATION
27 - Moderate soft tissue mass adjacent to fetal anterior wall, contained in sac 31 - Mass with loops of bowel identified, contained in sac 35 - Free floating bowel in amniotic fluid
CESAREAN SECTION
4 cm wall defect to the right of the umbilical cord, no sac remnant
visible
PREOPERATIVE STABILIZATION
AIRWAY SUPPORT Often intubated in delivery room GASTRIC DECOMPRESSION
Prevent aspiration
Air progressing past pylorus where irretrievable and cause increased difficulty in repair
TEMPERATURE REGULATION
Infant covered with plastic wrap to minimize heat loss
BOWEL CARE
Bowel covered by moist saline dressing, protect from dehydration
Care to be taken not to twist bowel impair vascular integrity
INITIAL RESUSCITATION
Consider hypoglycemia until proven otherwise Dextrose solution at 5-7 mg / kg / min

D20 / D10 / Ringers lactate / 5% albumin
Brain & Heart depend on glucose as major energy substrate Limited hepatic glycogen storage < 2.5 kg
PREOPERATIVE EVALUATION
Inspect the protruding viscera, R/O torsion or angulation of Correct dehydration / hypovolemia / hypoglycemia
Evaluation respiratory system (Chest X-ray)

Cardiac evaluation (EKG, ECHO, especially in Omphalocele)
Temperature stabilization
Evaluation intravascular status
MANAGEMENT
ANESTHETIC MANAGEMENT
Airway Maintenance Monitors
SURGICAL PROCEDURE
Reduction herniated viscera Closure of defect Cardio/respiratory function
SURGICAL PROCEDURE
PRIMARY CLOSURE
Reduced complications
Sepsis,sac dehiscence,prolonged ileus Hypotension,bowel ischemia, anuria, respiratory failure
Increased complication
STAGED CLOSURE
Avoid abdominal viscera compression Allow early extubation
POSTOPERATIVE MANAGEMENT
Lets Review
Which intervention would have the highest priority for the nurse assisting in the feeding of a child post cleft palate repair?
A. Permiting the child to choose the liquids desired. B. Providing diversional activities during feeding. C. Applying wrist restraints. D. Cleansing the mouth with water after each feeding.
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Lets Review
Which food choice by a parent of a child with celiac disease indicates a need for further teaching? A. B. C. D. Oatmeal Rice Cornbread Beef
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Lets Review
Which assessment finding would the nurse find in a child with Hirschsprungs Disease?
A. Current jelly stool B. Diarrhea C. Constipation D. Foul-smelling, fatty stool
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Lets Review
Children with gastroenteritis often receive intravenous fluids to correct dehydration. How would you explain the need for IV fluids to a 3 year-old child?
A. The doctor wants you to get more water, and this is the best way to get it. B. Your stomach is sick and wont let you drink anything. The water going through the tube will help you feel better. C. See how much better your roommate is feeling with his IV! You will get better, too. D. The water in the IV goes into your veins and replaces the water you have lost from vomiting and diarrhea.
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Lets Review
The nurse caring for a child with suspected appendicitis would question which physician order?
A. NPO status B. Start IV fluids of D5 NS at 50 mls/hour C. Complete Blood Count (CBC) D. Apply heating pad to abdomen for comfort
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Anatomy & Physiology Review

The GU system maintains homeostasis of the body (water & electrolytes) Responsible for the excretion of waste products Nephron is the workhorse of the kidney (filter blood at the rate of 125mL/minute)-GFR Renin helps maintain Na & water balance (and B/P) Kidneys produce erythropoeitin which stimulates RBC production in marrow
Genitourinary System
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Genitourinary System
Infants & young children excrete urine at a higher rate related to the increased BMR producing more waste Infant kidneys have function if under stress Infant cant concentrate urine well until 3-6 mo In infants, kidney & bladder are abdominal organs Infant kidneys are less protected because of unossified ribs, less fat padding & large size Young children have shorter urethras Nephrons continue to develop after birth
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Pediatric Variances
The Genitourinary System

Minimum urine outputs by age groups:
INFANTS & TODDLERS 2-3 ml/kg/hr PRESCHOOLERS & YOUNG SCHOOL-AGE 1-2 ml/kg/hr SCHOOL-AGE & ADOLESCENTS 0.5-1 ml/kg/hr
TIP: Bladder capacity in ounces: AGE in years + 2

Example: a 2-year-olds bladder can hold up to 4 ounces or 120 mls
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The Genitourinary System

d Disorders of the Genitourinary System
F F F F Enuresis Nephrotic Syndrome Acute Glomerulonephritis Hemolytic Uremic Syndrome (HUS)
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Glomerulonephritis
Group of kidney disorders that show main focus of injury is the glomerulus It is characterized by inflammation of the glomerular capillaries Acute disorders occur suddenly and resolve completely Acute poststreptococcal glomerulonephritis (APSGN) is the most common type History, presenting symptoms, and lab results establishes the diagnosis of APSGN
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Glomerulonephritis
PAT H OPHYS I OLOGY
Streptococcal Infecti on
Prod uc ing An tib od ie s Ba ct erial Ant ige ns plus A nt ibod ies f orm I mmun e Com plex es & t ra p in Glome ru lus
Infla mmatory Re s po nse

I njury t o Cap illa ry Wa lls
Ineffecti ve Fi l trati on
Prot e in s Pa ss Throu gh De crea sed GFR
Ki dn eys E nl arge
wit h so dium, wa te r, was te
EDE MA
ACUTE RENA L FA IL URE
Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.
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Glomerulonephritis
ASSESSMENT Hematuria Proteinuria Edema: periorbital, ankles Urine Output Hypertension Fatigue Possible fever Abdominal discomfort Labs: +ASO, Bicarb,K BUN, Creat, H & H INTERVENTIONS Monitor Urine (Dipstick) Monitor fluid overload Assess lung sounds/Resp effort Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS Antibiotic, diuretic & antihypertensive medications Promote & provide rest Provide comfort measures Monitor labs
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Nephrotic Syndrome
Kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. There is primary (involving kidney only) and secondary (caused by systemic disease or heavy metal poisoning) NS. Primary is the most common (MCNS). Cause not fully understood-may have an immunologic component. Primary age affected is 2-6 years (boys 2:1) There is no occlusion of glomerular vessels. Loss of immunoglobulins also occur (IgG) Hypovolemia and the severe proteinuria put the child in a hypercoagulable state Treatment is prednisone (2mg/kg/day) for about 4-6 weeks. Remission is obtained when the urine protein is 0-tr for 5-7 days Albumin followed by furosemide may be given for the edema
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Nephrotic Syndrome
PATHOPHYSIOLOGY
Alt erat ion in Glomerulus Damage to Basement Membrane of glomerulus (increased permeabilit y )
Prot einuria (Hy poalbuminemia)
Fluid Shif t I nt rav ascular t o I nt erst itial HYPOVOLEMI A Dec reas ed Renal Blood Flow Triggers Renin Produc tion Causing Increased Aldost erone Reabs orpt ion of Sodium and Wat er ret ent ion Hy perlipidemia
ED EMA
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Nephrotic Syndrome
ASSESSMENT
Proteinuria (3-4+), frothy urine Edema (pitting):periorbital, genitals, lower extremities, abdominal Urine Output (Hypovolemia) Normotensive or hypotensive Fatigue Recent URI, Pneumonia Abdominal Pain/Anorexia Labs:
Albumin Platelets H & H Cholesterol Triglycerides
INTERVENTIONS
Monitor Urine (Dipstick) Monitor edema/dehydration Assess skin integrity/turn often Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS & S/S of infection Administer medications Promote & provide rest Monitor labs HANDWASHING/monitor visitors
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Hemolytic Uremic Syndrome (HUS)

It is the most common cause of acute renal failure (ARF) in children. HUS is characterized by the triad of anemia, thrombocytopenia, and ARF. Most children have associated GI symptoms- almost all are caused by e. coli 0157. Treatment is supportive and based on symptoms. No antibiotics are given; more damage can be caused. Serum electrolytes may be outside of normal limits. Blood transfusions and/or dialysis may be necessary. More than 90% of the children recover with good renal function.
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GAST ROENTERITIS e. coli #0157 Bacter ia Adheres to GI Mucosa Multiplies Releases T oxins
Damages Capillar y Walls
Inflammator y Response
Collection of Fibrin Lipids Platelet Fr agments
Occlusion of Vessels Thr ombocytopenia ( Glomer ular Vessels)
Fr agmented RBC' s Causing Anemia
Decr eased GFR

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Acute Renal F ailur e

ASSESSMENT History: emesis, bloody diarrhea, abd pain, Urine Petechiae, bruises, purpura Edema (possible CHF) Hepatosplenomegaly Altered LOC, seizure Hypertension Fatigue Abdominal discomfort Labs: Lytes may be abnormal BUN Creatinine H&H Platelets INTERVENTIONS Monitor I/O, Daily Weights Evaluate for signs of bleeding Monitor fluid overload/edema Assess for dehydration Monitor VS with neuro checks Seizure Precautions, HOB Diuretic & antihypertensive medications Provide rest/calm environment Provide comfort measures Monitor labs closely
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Enuresis
Involuntary passage of urine in children whose chronological or developmental age is at least 5 years of age Voiding occurs at least twice a week for minimum 3 months More common in boys Alteration in neuromuscular bladder function Often benign and self-limiting Organic factor could be the cause Familial tendency Emotional factor could be considered Therapeutic techniques include: bladder training, night fluid restriction, drugs (imipramine, oxybutynin, DDAVP)
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Lets Review
A clinical finding that warrants further intervention for a child with acute poststreptococcal glomerulonephritis is:
A. B. C. D. Weight loss to 1 pound of pre-illness weight. Urine output of 1 ml/kg per hour. A normal blood pressure. Inspiratory crackles.
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Lets Review
A 3 year-old is scheduled for surgery to remove a Wilms tumor from one kidney. The parents ask the nurse what treatments, if any, will be necessary after recovery from surgery. The nurses explanation is based on knowledge that:
A. B. C. D. No additional treatments are necessary. Chemotherapy may be necessary. Chemotherapy is indicated. Kidney transplant is indicated.
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Lets Review
Fluid balance in the child who has acute glomerulonephritis is best estimated by assessing:
A. B. C. D. Intake and output Abdominal circumference Daily weights Degree of edema
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Lets Review
In evaluating the effectiveness of nursing actions when caring for a child with nephrotic syndrome, the nurse expects to find:
A. B. C. D. A recurrence of pneumonia. Weight gain. Increased edema. Decreased edema.
233
Pediatric Variances Musculoskeletal System

Bone Growth:
Linear growth results from skeletal development Bone circumference growth occurs as new bone tissue is formed beneath the periosteum Skeletal maturity is reached by age 17 in boys and 2 years after menarche in girls (14 yrs) Bone growth affected by Wolffs Law - bone grows in the direction in which stress is placed on it Certain characteristics of bone affect injury and healing Childrens bones are softer and are easily fractured
234
Pediatric Variances Musculoskeletal System

Muscle Growth:
Responsible for a large part of increased body weight The number of muscle fibers is constant throughout life Results from increase in size of fibers and increased number of nuclei per fiber Most apparent in adolescent period
235
The Musculoskeletal System

QDisorders of the Musculoskeletal System
m m m m m m Developmental Dysplasia of the Hip Talipes (Clubfoot) Osteogenesis Imperfecta Scoliosis Muscular Dystrophy Juvenile Rheumatoid Arthritis
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Developmental Dysplasia of the Hip (DDH)

Variety of hip abnormalities shallow acetabulum, subluxation or dislocation Often made in newborn period often appears as hip joint laxity rather than dislocation Ortolani click if < 4 weeks old, older ultrasound needed to diagnose Treatment is Pavlik Harness (abducted position) for newborn to 6 months old monitor for Avascular Necrosis 6-18 months traction followed by spica cast Older children operative reduction Priority nursing interventions are skin care and facilitating normal growth and development
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Talipes (Clubfoot)
Most common type is when foot is pointed downward and inward Often associated with other disorders May be due to decreased movement in utero Treatment requires surgical intervention Serial casting is begun shortly after birth and usually lasts for 8-12 weeks Priority nursing interventions are skin care and facilitating normal growth and development
238
Osteogenesis Imperfecta (OI)

Inherited disorder of connective tissue and excessive fragility of bones Pathologic fractures occur easily Incidence of fractures decrease at puberty related to increased hormones making bones stronger Treatment is supportive: careful handling of extremities, braces, physical therapy, weight control diet, stress on home safety Surgical techniques for correcting deformities and for intermedullary rodding
239
Scoliosis
o Abnormal curvature of the spine (lateral) o Congenital or develops later, most common during the growth spurt of early adolescence (idiopathic) o Diagnosis is made by physical exam and x-rays o Treatment for curvatures < 40 degrees is bracing o Surgical intervention is for severe curvatures internal fixation and instrumentation (Harrington) o Postoperative care includes logrolling, neurologic assessments, pain management, skin care, assessing for paralytic ileus and possible mesenteric artery syndrome o Dont forget the developmental needs of the adolescent
240
Muscular Dystrophy
Duchennes Muscular Dystrophy most common Gradual degeneration of muscle fibers S/S begin to show about 3 years of age difficulties in running and climbing stairs Changes to having difficulty moving from a sitting/supine position Profound muscular atrophy continues, wheelchair by 12 yrs Respiratory and cardiac muscles affected and death is usually respiratory or cardiac in nature Diagnosis made with physical exam, muscle biopsy, EMG, serum studies: AST (SGOT), aldolase, creatine phosphokinase high first 2 years of life Nursing care is to maintain optimal level of functioning and to help the child and family cope with the progression and limitations of the disease
241
Juvenile (Rheumatoid) Arthritis

Inflammatory disease with an unknown cause Occurs in children < 16 years; lasts > 6 weeks Clinical manifestations: stiffness, swelling, and loss of motion in affected joints, tender to touch Therapeutic management includes drug therapy (NSAIDs, SAARDs, cytoxic drugs, corticosterioids), physical and occupational therapy, exercise (swimming), moist heat for pain and stiffness, general comfort measures
242
General Nursing Interventions for Children with Musculoskeletal Dysfunctions (immobility)

Maintain optimal level of functioning Promote general good health Facilitate compliance Facilitate optimal growth and development Maintain skin integrity Safety considerations at home Pain management Support child and family
243
Lets Review
An infant is being treated non-surgically for clubfoot. Which describes a major goal of care for this patient? Prevention of:
A. B. C. D. Skin breakdown Calf atrophy Structural ankle deformities Thigh atrophy
244
Lets Review
The nurse is helping parents create a plan of care for their child with osteogenesis imperfecta. A realistic outcome is for this child to:
A. Have a decreased number of fractures B. Demonstrate normal growth patterns C. Participate in contact sports D. Have no fractures after infancy
245
Lets Review
During acute, painful episodes of juvenile arthritis, a priority intervention is initiating:
A. A weight-control diet to decrease stress on the joints. B. Proper positioning of the affected joints to prevent musculo-skeletal complications. C. Complete bedrest to decrease stress to the joints. D. High-resistance exercises to maintain muscular tone in the affected joints.
246
Pediatric Variances Endocrine System

Growth Hormone: Does not effect prenatal growth Main effect on linear growth Maintains rate of body protein synthesis Thyroid-stimulating hormone (TSH): Important for growth of bones, teeth, brain Secretion decreases throughout childhood and increases at puberty
Adrenocorticotrophic Hormone (ACTH): Activated in adolescent Stimulates adrenals to secrete sex hormones Influences production of gonadotropic hormone
247
The Endocrine System

Disorders of the Endocrine System
8 8 8 8 Type 1 Diabetes Mellitus Congenital Hypothyroidism Growth Hormone Deficiency Precocious Puberty
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Type 1 Diabetes Mellitus Pediatric Considerations

INSULIN
Most children are well-controlled with BID dosing of fast acting (Lispro) short acting (regular) and intermediate acting (NPH, Lente) insulin. There is also Lantis, an insulin that acts a basal. U-20 insulin is also available for infants Insulin pump, pen Honeymoon phase Stress, infection, illness and growth at puberty can increase insulin needs
249

HYPOGLYCEMIC EPISODES
In small children it is more difficult to determine and may just be a behavior change. Treatment is the same simple sugar assess LOC first!
NUTRITION
Carb counting most childrens calories should not be restricted; meal plan might change as child grows. Some sweets may be incorporated into the diet and may help with compliance. 3meals with 3 snacks per day
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EXERCISE
Important for normal growth and development Assists with daily utilization of dietary intake Enhances insulin absorption, so may decrease amount needed Add 15-30 grams of carbs for each 45-60 minutes of exercise Watch for hypoglycemia with strenuous exercise
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DEVELOPMENTAL ISSUES
Infant/Toddler
Autonomy & choices, rituals, hypoglycemia identification difficult
Preschooler
Magical thinking-let them know they did not cause it Use dolls for teaching Urine testing may be done Can choose finger to use for testing
School-age
Very busy with school and activities Likes tasks and explanations Can do self blood testing; injections at age 8-10 years
Adolescents
Peers and body image preoccupation High risk for non-compliance Collaborative health care with parent involvement very important
252
Congenital Hypothyroidism
Thyroid is not producing enough thyroid hormone to meet needs of the body (resulting inoxygen consumption, BMR and protein synthesis) Clinical manifestations: cool, mottled skin, bradycardia, large tongue, large fontanel, hypothermic, hypotonia, lethargy, feeding problems - THINK SLOW! Labs: High TSH, low T4 Decreased brain development will result with cognitive impairments Part of newborn screening Therapeutic management is life-long thyroid hormone replacement (levothyroxine)
253
Growth Hormone (GH) Deficiency

Deficient secretion of growth hormone Definitive diagnosis is made with GH levels (using stimulation testing) under 10mg/ml and x-rays of hand and wrist for ossification levels Treatment is replacement of GH (subcutaneous daily injections) until goals met Nursing care is directed at child and family support Remember to interact and speak to the child at her appropriate developmental level!
254
Precocious Puberty
Manifestations of sexual development in boys younger than 9 years and girls younger that 8 yrs Causes also an early acceleration of growth with closure of growth plates Therapeutic management is directed toward the specific cause, if known The early secretion of sex hormones will be treated with monthly subcutaneous injections of leuteinizing hormone-releasing hormone (LHRH) Priority interventions are directed at psychological support of child and family encourage play with same age peers
255
Lets Review
A child weighing 25 kilograms is being treated with synthetic growth hormone. The recommended dosage range is 0.3 0.7 mg/kg/week. The mother informs the nurse that her child receives 1.25 mg subcutaneously at bedtime 6 times per week. The proper response from the nurse would be:
A. That dose is too high, the doctor needs to be notified. B. You are doing a great job, that is the correct dose for your child. C. The injection should be given intramuscular, not subcutaneous. D. That dose is too low based on your childs new weight.
256
Lets Review
The nurse should include which information in teaching the parents of a recently diagnosed toddler with Type 1 diabetes mellitus?
A. Allow the toddler to choose which finger to use for blood glucose monitoring B. Allow the toddler to assist with the daily insulin injections C. Test the toddlers blood glucose every time she goes out to play D. Let the toddler determine meal times
257
Lets Review
Which is the most appropriate teaching intervention for a nurse to give parents of a 6year-old with precocious puberty?
A. Advise the parents to consider birth control for their child B. Inform the parents there is no treatment currently available C. Explain the importance for the child to foster relationships with peers D. Assure the parents there is no increased risk for sexual abuse.
258
Lets Review
Number in order of priority the following interventions needed while caring for a patient in diabetic ketoacidosis.
_____ Hydration _____ Electrolyte replacement _____ Dietary intake _____ IV Insulin _____ Subcutaneous insulin
259
Pediatric Variances Integumentary System

Evaporative water loss is greater in infants/small children Skin more susceptible to bacterial infections
More prone to toxic erythema

More susceptible to sweat retention and maceration
260
The Integumentary System

Disorders of the Integumentary System
Impetigo Roseola Diaper Rash
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Impetigo
Superficial bacterial skin infection, often secondary from insect bite Highly contagious Late summer outbreak Toddlers & preschoolers Rash is bullous or honeycolored crusted lesions Treatment: topical & systemic antibiotics, comfort measures, teaching, preventing comps
262
Roseola
Transmission: contact with secretions (saliva) Virus 6 - 18 months Fever flu symptoms rose-pink macular rash Fades with pressure Treatment is supportive
263
Diaper Rash
Cause could be fungal in nature; assess mucous membranes for thrush Cause could be due to infrequent diaper changes, an allergic reaction to the diaper product or diarrhea Skin care includes appropriate skin barrier cream/ointment, keeping area dry Teach parents appropriate skin care
264
Medication Administration
Oral Medication Hold infant with head elevated to prevent aspiration Slowly instill liquid meds by dropper along side of the tongue Crush pills and mix with sweet-tasting liquid if permitted, but dont add too much liquid! Allow choices for the child such as which med to take first Flush following gastrostomy or NG tube
265
Factors to consider when selecting IM sites

Age
Weight Muscle development
Amount of subcutaneous fat

Type of drug Drugs absorption rate
266
IM and SQ Meds
Select needle length according to muscle size for IM Infant - should use 1 inch needle Preemies can use 5/8 inch needle Use Z-track for iron and tissue-toxic meds Apply EMLA or other topical anesthetic 45-60 minutes prior to injection May mix medication with lidocaine Some medications may be need to be separated into 2 injections depending on amount
267
Peds IM Injection Sites

Vastus lateralis for infants
Ventrogluteal and dorsogluteal
Dont inject into dorsogluteal until age 3 years - muscle not well developed until child walks and sciatic occupies a larger portion of the area.
Deltoid after 3 years
268
IV Meds
Site may be peripheral or central Administer IV fluids cautiously Always use infusion pumps with infants and small
children Inspect sites frequently (q 1-2 hours) for signs of infiltration Cool blanched skin, puffiness( infiltration) Warm and reddened skin (inflammation)
269
Nose Drops
Instill in one nare at a time in infants because they are
obligate nose breathers.

Suction nare with bulb syringe prior to administration
if nasal congestion present
270
Ear Meds
Pull the ear down and back to instill eardrops in infants/toddler (3 years pull )
Pull the ear up and out to instill in older children ( 3 years pull ) Have medication at room temperature
271
Rectal Medication
Insert the suppository past the anal sphincter Hold buttocks together for a few seconds after
insertion to prevent expulsion of medication

It is a very stressful route for children, and the school-age and adolescent have issues with modesty.
272
Inhalers and Spacers

Shake the inhaler for 2-5 seconds. Position inhaler into spacer (with mask or mouthpiece). After normal exhale, place mask on face or mouthpiece in
mouth both with a good seal. Have child inhale slowly after canister is pressed down . Have child take a few breaths with a spacer and without a spacer have them hold breath for few seconds after medication released. Inhalers without spacers arent placed in the mouth because spacers require a seal around mouthpiece; masks with spacers can be used for infants.
273
MDI with Spacer MDI with Spacer and Mask
274
Lets Review
The nurse would prepare which site for an intramuscular injection to a 11 month-old?
A. B. C. D. Dorsogluteal Deltoid Vastus lateralis Ventrogluteal
275
Pediatric Oncology
Cancer is the leading cause of death from disease in children from 1 - 14 years. Incidence: 6,000 children develop cancer per year 2,500 children die from cancer annually Boys are affected more frequently
Etiologic factors: environmental agents, viruses, host factors, familial/genetic factors

Leukemia is the most frequent type of childhood cancer followed by tumors of the CNS system.
276
Oncology Stressful Events

Treatment is worse than the disease.
1. Diagnosis 2. Treatment - multimodal
3. Remission
4. Recurrence
5. Death
277
Oncology Interventions
8 Surgery 8 Radiation Therapy 8 Chemotherapy 8 Bone Marrow Transplant
278
Stages of Cancer Treatment

1. 2. 3. Induction Consolidation Maintenance
4. Observation
5. Late Effects of Treatment

Impaired growth & development CNS damage Psychological problems
279
Pediatric Oncology
Types of Childhood Cancers
D D D D D D Leukemia Brain Tumors Wilms Tumor Neuroblastoma Osteogenic Sarcoma Ewings Sarcoma
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Leukemias
Most common form of childhood cancer Peak incidence is 3 to 5 years of age
Proliferation of immature WBCs (blasts) May spread to other sites (CNS, testes) Types of Leukemia:
Acute lymphocytic leukemia (ALL) 80-85% of childhood leukemia 95% chance of remission
Acute nonlymphocytic Leukemia (ANLL) 60-80 % chance of remission
Treatment is chemotherapy: prednisone, allupurinol, selected chemotherapeutic agents

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Leukemias
CLINICAL MANIFESTATIONS
Purpura, Bruising Pallor Fever Unknown Origin Fatigue, Malaise Weight loss Bone pain Hepatosplenomegaly Lymphadenopathy
LABS & DIAGNOSTIC TESTS

WBCs (50-100) or Very low WBCs Hgb, Hct, Platelets Blast cells in differential BONE MARROW ASPIRATION LUMBAR PUNCTURE BONE SCAN possible
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Brain Tumors
Second most prevalent type of cancer in children Males affected more often
Peak age 3 - 7 years

Types: Medulloblastoma Astrocytoma Brain Stem glioma Look for S/S of increased ICP and area of brain affected
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Wilms Tumor
Also known as Nephroblastoma
Large, encapsulated tumor that develops in the renal
parenchyma (do not palpate abdomen!)

Peak age of occurrence: 1 - 3 years
Prognosis is good if no metastases- lungs first

Treatment is surgery, chemotherapy and sometimes
radiation
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Neuroblastoma
Highly malignant tumor extracranial
Often develop in adrenal gland, also found in head, neck, chest, pelvis
Incidence: One in 10,000
Males slightly more affected

From infancy to age 4 Often diagnosed after metastasis occurs Treatment includes surgery, chemotherapy and radiation
285
Bone Tumors
Osteogenic Sarcoma: Occurs most often in boys between 10-20 yrs
10-20% 5 year survival rate

Primary bone tumor of mesenchymal cell Treatment:surgery (amputation or salvage) and chemo Ewings Sarcoma: Occurs in boys between 5 - 15 years Primary tumor arising from cells in bone marrow Treatment is radiation and chemotherapy
286
Pediatric Oncology: Nursing Interventions

CHEMOTHERAPY SIDE EFFECTS Leukopenia (Nadir) Thrombocytopenia Stomatitis Nausea/Vomiting Alopecia Hepatotoxicity Nephrotoxicity NURSING INTERVENTIONS HANDWASHING! Monitor visitors Monitor for infection Meticulous oral care Antiemetics ATC Monitor Labs Support/Teaching
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Pediatric Oncology: Nursing Interventions

Supportive care for radiation treatment, focusing on skin care Surgical interventions are based on location and type of surgery
Basic pre and postoperative care
Psychosocial care for patient and family utilize Child Life and Social Services
288
Pediatric Oncology
Teach, teach, teach! Support the child and family Provide resources Be honest Include the child in the care planning
289
Lets Review
In caring for the child with osteosarcoma, it is important for the nurse to inform the child and family of the treatment plan. Which would be appropriate?
A. B. C. D. The affected extremity will have to be amputated. The child will only need chemotherapy. Both surgery and chemotherapy are indicated. Only palliative measures are taken.
290
Lets Review
The nurse assessing a child who is undergoing chemotherapy finds the child to be suffering from mucositis. Which intervention would be the highest priority?
A. Meticulous oral care. B. Obtain dietician consult. C. Place the child on a full liquid diet only. D. Medicate for pain around the clock.
291
Lets Review
The priority nursing intervention in caring for a child with acute lymphocytic leukemia (ALL) during the childs nadir period is:
A. B. C. D. Handwashing. Monitoring lab results. Administering antiemetics. Monitoring visitors.
292
Death & Dying

Childs Response to Death:
Infants & Toddlers:
Do not understand Viewed as a form of separation Can sense sadness in others

Preschooler:
Death is temporary Viewed as sleep or separation
Feel guilty and blames self

Dying children may regress in behavior
293
Death & Dying

School-Age:
Have concept of irreversibility of death Fear, pain, mutilation and abandonment
Ask many questions

Feel death is a punishment May personify death (bogeyman) Will ask directly if they are dying Interested in the death ceremony Comforted by having parents and loved ones with them
294
Death & Dying

Adolescent:
Have an accurate understanding of death Death as inevitable and irreversible May express anger at impending death May find it difficult to talk about death May wish to leave something behind to remember them by May wish to plan own funeral
295
Death & Dying

Parental responses to death:
Major life stress
Experience grief at potential loss of child Related to circumstances regarding childs death (denial, shock, disbelief, guilt) Confronted with major decisions regarding care May have long term disruptive effects on family Bereaved parents experience intense grief of long duration
296
Communicating with the Dying Child and Family

Use childs own language
Dont use euphemisms Dont expect an immediate response
Communicate through touch

Encourage questions and expressions of feelings
Strengthen positive memories

Listen, touch, cry
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Impending Death Care Guidelines

Do not leave child alone
Do not whisper in the room

Touching the child is very important Let the child and family talk and cry
Let parents participate in care as much as they are emotionally capable of doing
Continue to read favorite stories or play the childs favorite music Be aware of the needs of the siblings
298
Lets Review
Which intervention would be most helpful in supporting a dying childs family as they cope with the various decision-making periods of a lengthy terminal illness?
A. Encouraging the parents to take their child home to die. B. Encouraging the parents to go through all of the KublerRoss stages of dying as quickly as possible. C. Referring the childs family to the hospital clergy service as soon as possible. D. Using active listening to identify specific fears and concerns of the childs family members.
299
Types of Child Abuse

M Neglect:
Intentional or unintentional omission of basic needs and support

M Physical Abuse:
Is non-accidental injury to a child by an adult

M Sexual Abuse:
Forced involvement of children in sexual activities by an adult

M Emotional Abuse:
Withholding of affection, use of cruel and degrading language towards a child by an adult
300
Child Abuse
M Reports of M Many of
violence against children has almost tripled since 1976. the abused children are infants.
Red Flags
Fractures in infants Spiral fractures Injuries do not match story told
NURSES ARE MANDATED REPORTERS

301
Child Abuse
Neglect

Physical or emotional maltreatment Failure to thrive Contributing factors may be ignorance or lack of resources Minor or major physical injury (bruising, burns, fractures) May cause death Munchausen by Proxy (MSP) Shaken baby syndrome (SBS) Incest, molestation, child porn, child prostitution May be suspected, but difficult to substantiate Impairs childs self-esteem and competence
302
Physical Abuse

Sexual
Emotional

Child Abuse
Warning Signs

Incompatibility between history of event and injuries Conflicting stories from various people involved History inconsistent with developmental level of child Repeated visits to emergency rooms Inappropriate response from child and/or caregiver Assess: Physical assessment and history of event, observe and listen to caregivers and childs verbal and non-verbal communication Documentation: Complete CAR form and contact Child Protective Services, hospital documentation Support family and child: Social services, resources, teaching

THE CHILDS SAFETY COMES FIRST AND IS THE PRIORITY!

303
Lets Review
In caring for a 4 year-old with a diagnosis of suspected child abuse, the most appropriate intervention for the nurse is:
A. Avoid touching the child. B. Provide the child with play situations that allow for disclosure of event. C. Discourage the child from speaking about the event. D. Give the child realistic choices to feel in control.
304
Lets Review
Which pediatric patient would most necessitate further investigation by the community-based nurse?
A. An adolescent who prefers to spend time with friends rather than family. B. A toddler with dark bruises located on both legs. C. An infant with numerous insect bite marks and diaper rash. D. A preschooler with dirty knees and torn pants.
305
Thank you po!
306

Pediatric Nursing-Course Audit

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PEDIATRIC NURSING

Care of the Child and Family

Erik Erikson - Psychosocial Theory

Maslows Hierarchy of Needs

Levels of Maslows Hierarchy of Needs:

TRUST VS. MISTRUST

AUTONOMY VS. SHAME & DOUBT

Photo Source: Del Mar Image Library; Used with permission

INITIATIVE VS. GUILT

INDUSTRY VS. INFERIORITY

Photo Source: Del Mar Image Library; Used with permission

IDENTITY VS. ROLE CONFUSION

Photo Source: Del Mar Image Library; Used with permission

Piagets Cognitive Theory

Photo Source: Del Mar Image Library; Used with permission

Infant Physical Tasks

TOYS = Mirror, Music, Mobile

Infant Physical Tasks

Infant Psychosocial Tasks

Photo Source: Del Mar Image Library; Used with permission

Infant Cognitive Tasks

Photo Source: Del Mar Image Library; Used with permission

Toddler Cognitive Tasks

Toddler Psychosocial Tasks

Beginning awareness of ownership (me and mine)

TOYS = Push-pull toys, large blocks

Preschooler Cognitive Tasks

Learns sequence of daily events Able to understand some time-oriented words

Preschooler Psychosocial Tasks

TOYS = Dolls, Dress-up, Imagination

Preschooler Psychosocial Tasks

School-Age Cognitive Tasks

Concepts of time and space develop:

School-Age Psychosocial Tasks

social impact on child

TOYS = Board games, computer games, learning activities

Photo Source: Del Mar Image Library; Used with permission

Adolescent Cognitive Tasks

ACTIVITIES = Music, video games, communication with peers

Adolescent Psychosocial Tasks

Middle Adolescent: Separate from parents

Increased sexual interest

Adolescent Psychosocial Tasks

Gradual weaning from bottle/breast No honey (risk for botulism)

More likely to try new foods if they assist in food preparation

Foundation laid for increased growth needs

Busy schedules breakfast is important

the school program

Increased needs for:

Photo Source: Del Mar Image Library; Used with permission

Play is the work of Children

Helps Solve Problems

Appropriate Play Activities

Preparation for Procedures

Communicating with Children

Injury Prevention & Safety Issues

Emergency treatment depends on agent ingested

First Intervention is to call POISON CONTROL CENTER

Always assess Level of Consciousness (LOC) before administering PO med!

Physical Assessment of Infant

Physical Assessment of Toddler

Physical Assessment of Preschooler

Physical Assessment of School-Age Child