HIGH RISK PEDIATRIC

CONDITIONS AND
DISORDERS
 Newborn
RESPIRATORY
DISTRESS
 RESPIRATORY DISTRESS
SYNDROME (RDS)
SEQUELA OF RDS
• HYPERBILIRUBINEMIA
• RENTROLENTAL FIBROPLASIA
- retinal changes, visual impairment & eventually
blindness, resulting in too high O2 levels during
treatment
• BRONCHOPULMONARY DYSPLASIA (BPD)
- damage to alveolar epithelium of the lungs related to
high O2 concentrations and positive ventilation.
- may be difficult to wean infant from ventilator, but
most recover & have normal x-rays at 6 months to 2
years.
A. Pulmonary condition common in
preterms and characterized by hyaline
membrane formed in the alveoli ca using
atelectatis. HYALINE MEMBRANE
DISEASE
B. Etiologic Factors:
1. Prematurity
2. Hypoxia
3. Acidosis
C. Major Pathologic Finding:
Inadequate surfactant
D. Major signs:
1. Nasal flaring
2. Tachypnea (RR 70/min)
3. See-saw breathing
4. Chest RETRACTIONS
5. Expiratory GRUNTING
E. NURSING CARE:
1. Resuscitate as indicated
2. Suction PRN less than 5 sec/suction time
3. Administer O2 under CPAP (care in O2 to
prevent = RETROLENTAL FIBROPLASIA)
4. Keep warm maintain tempereture
5. Turn gently every q2h to promote lung
expansion
6. Prevent infection
7. Monitor: color, breath sounds, VS with
emphasis on Respiration using SILVERMAN-
ANDERSON INDEX:
a. 5 Signs to evaluate:
i. Upper chest movement: 2pts for SEE-saw
ii. Lower chest retractions: 2 pts for ”MARKED”
iii. Xiphoid process retractions: 2 pts for ”MARKED”
iv. Flaring: 2 pts for ”MARKED”
v. Expiratory grunting: 2 pts for severe expiratory
grunting even on bare ears
b. SILVERMAN score of 10: severe distress
c. SILVERMAN score of 0: normal respirations
 Newborn
HYPOGLYCEMIA
A. Low blood sugar in the newborn
1. Fullterm: <30mg% in the first 72
hours;<45mg% after 72 hours
2. Preterm: <20mg%
3. Normal value in NB: 40-50mg% or 40-
60mg% in 1st day and 50-90mg% after day
1
B. Etiologic Factors:
1. Prematurity and Postmaturity
2. SGA
3. Congenital Defects
4. DM mother
5. Stresses during birth
C. S/Sx
1. Jitteriness
2. Tachypnea, apnea, irregular RR, cyanosis
3. Lethargy, change behavior, absent MORO
Reflex, twitching, tremors
D. Nursing Care:
1. Early Feeding
2. Give oral glucose as indicated
3. Keep warm
4. Evaluate apneic episodes
HYPERBILIRUBINEMIA
A. Increase serum bilirubin in the blood
more than 12-13mg% [NV: 2-6 mg%]
B. Etiologic factors:
1. Prematurity
2. Polycythemia
3. Infection
4. Blood incompatibilities
C. S/Sx
1. Pathologic jaundice – present in the first 24
hrs
2. Lethargy, pallor
3. Enlarge liver
 Management
a. Phototherapy
Guidelines:
-done for bilirubin level > 7mg/dl
a. unclothed the baby
b. baby’s for
-continued eye5-7
shielded
days
c. ten 20-watt daylight or blue
b. Exchange Transfusion
fluorescent at 45 cm from
skin surface OR 16- 18 INCHES
-fullterm bilirubin : 20 mg/dl
d. monitor side effects:
-pre 1. dehydration
term bilirubin : 10-15 mg/dl
2.”bronze-baby syndrome”
E. Nursing care:
1. Early detection
2. Early and frequent feeding
3. Monitor color, urine, stools, serum bilirubin
4. Regular turning
5. Promote bonding
Digestive Disorders
 CHALASIA
A. Abnormal relaxation of the cardiac sphincter of
stomach resulting to NON-PROJECTILE, NON-
BILE, SELF-LIMITING vomiting
B. Etiology: unknown
C. S/SX
1. Vomiting in 1st 3 months of life
2. Regurgitation after feeding
3. Increase hunger
4. Weight loss
5. Dehydration
D. Nursing care:
1. Prevent vomiting
2. Provide psychological support to parents
 Cleft Lip/Palate
1:1000 births
Cleft lip Cleft Palate
Malformation bet.
Maxillary and median nasal Malformation of
process on 5 to 8 wks IUL palatal process on 9
Common in boys to 12 weeks IUL
Genetic tendency
Common in girls
Deficient intake of Folic
Acid
 Cleft Lip/Palate
 Treatment
 Chelloplasty- closure of cleft lip

 Patient should be ten weeks old, weighs 10 lbs

and hemoglobin of at least 10 g (RULE OF 10)
 Palatoplasty- closure of cleft palate (not done if
patient is not yet 10-12 months old
 Positioning: prone on abdomen
 Use paper cup to feed
 Feeding resume 3-4 weeks after repair
 CheiloPlasty
REASONS FOR SURGERY
1. Prevention of nursing and feeding
problems that can retard normal
growth.
2. Rearrangement of the distorted
tissues to make the lip and palate
function normally
 Treatment
CHEILOPLASTY PALATOPLASTY
PreOperative PreOperative
a. feed in high fowler’s a. prepare parents
b. use large-hole nipple b. teach on feeding
or rubber-tipped syringe methods
c. burp frequently PostOperative
PostOperative a. position: side lying
a. maintain patent airway b. prevent trauma or
b. don’t strain suture line injury to suture line
c. prevent crying c. diet : liquid soft
Pyloric Stenosis
*unknown cause
Assessment
a. olive shape
mass under right
rib cage
b. vomiting
c. visible peristalsis
d. failure to thrive
e. dehydration
f. increase hunger
A. Treatment
1. Prevent vomiting
2. Monitor I and O
3. Surgical
a. Pyloroplasty
b. FREDET-RAMSTEDT SURGERIES: creation of
longitudinal incision into the muscles of the
pylorus to create a gaping wound
B. Nursing care:
1. Correct fluid and electrolytes balance
2. Pre-op and Post-op care
 Intussuception
 common : 6
months &
Assessment
older
a. vomiting
 associated
b. “currant-jelly” stool
with cystic
c. abdominal pain
fibrosis &
celiac disease
 Intussuception
Treatment:
Medical : Hydrostatic Reduction
Surgical : Resection with End to End
Anastomosis
Nursing Care
a. maintain fluid & electrolyte
balance
b. prevent vomiting
c. monitor for peritonitis
Hirschsprung’s Disease
 absence of
ganglion cells in
large colon
Assessment
a. delayed passage of
meconium
b.distended abdomen
c. ribbon-like stools
d. vomiting (fecaloid)
e. diarrhea
 Hirschsprung’s Disease
Nursing Care
a. digital rectal evacuation of
feces
b. diet : low-residue
c. do not treat loose stools
d. stool softeners
e. isotonic enema
Surgical Management:
Abdomino-Perineal Pull
 CELIAC DISEASE
(Malabsorption syndrome;
Gluten-Induced Enterophaty)
 ASSESSMENT

Steatorrhea

Chronic diarrhea

Failure to thrive

 Grossly distended abdomen

 Abdominal pain,irritability and vomiting.

 Symptoms of vitamin A,D,E and K deficiency.

 NURSING INTERVENTIONS:

 Monitor gluten free diet

 Provide supplement fat-soluble vitamins
 Provide client teaching and discharge planning
concerning:
a. Gluten-free diet
b. avoidance of infection.
c. importance of adhering to diet
d. importance of long term ff-up management.
Omphalocoele

Gastroschisis
 Omphalocoele
2.5/10,000
high rate of mortality
covered with a sac
Management: Surgical Repair
Nursing Care:
a. Cover sac with sterile gauze & wrap it
with plastic
b. Vital signs monitoring (temperature)
c. Handle infant carefully
 Gastroschisis
1/10,000 live births
excellent survival
no membrane covering
Management: Surgical Repair
Nursing Care:
a. Cover the exposed bowel loosely with
saline soaked pads (no plastic wrap)
b. Vital signs monitoring
c. Handle infant carefully
 Appendicitis
Inflammation of the vermiform appendix
1:500 Population
Peak Age : 10-25 years
Males > Females
Cause:
OBSTRUCTION + Infection
*50-80% due to fecalith
gallstones
tumors
ball of worms
 Assessment
a. Abdominal Pain
b. Nausea & Vomiting
c. Inability to pass gas
d. Fever
e. Right Lower Quadrant Tenderness
f. Increased WBC
g. (+) Psoas & Obturator Sign
PERITONITIS Perforated Appendix!
Increased Fever & Chills
Tachycardia & Tachypnea
Pallor, Restlessness & Irritability
Sudden relief of pain after perforation
 APPENDECTOMY
Surgical removal of appendix
POSSIBLE COMPLICATIONS
a. Excessive bleeding.
b. Surgical-wound infection.
c. Inadvertent injury to the
ureter.
d. Intra-abdominal abscess.
AVERAGE HOSPITAL STAY
 Nursing Care
a. No laxatives, enemas or medicines for pain.
b. ACTIVITY : Bed Rest
c. DIET : NPO
d. Position on the right side or low to semi-
fowler’s position to promote comfort
e. Avoid application of heat in the abdomen
Post-Operative Care :
a. Monitor vital signs & return of bowel sounds
b. Maintain on NPO till bowel function returned
c. Change dressings as prescribed
d. Medications as prescribed
e. WOF: Signs of Infection
Situation: Bobby, a 13-year-old boy, is
being seen in the emergency room
for possible appendicitis.
December 2003

Which of the following would indicate

that Bobby’s appendix has
ruptured?
a. Diaphoresis
b. Anorexia
c. Pain at Mc Burney’s point
d. Apparent improvement (no pain)
TRACHEOESOPHAGEAL
FISTULA AND
ESOPHAGEAL ATRESIA
MOST COMMON TYPE (85%)
H – TYPE, RARE TYPE
 ESOPHAGEAL ATRESIA

 Salivation and drooling  Regurgitation

Inability to insert NGT

TRACHEOESOPHAGEAL FISTULA

 Salivation and drooling  Tracheal irritation

 Abdominal distention

ESOPHAGEAL ATRESIA W/ TRACHEOESOPHAGEAL FISTULA

 Dx Evaluation
1. Maternal Hx of polyhydramios
2. Flat plate x-ray = presence of gas in
stomach and chest
 Sx
1. Primary repair – esophageal anastomosis
and division of fistula
2. Gastrostomy and cervical
esophagostomy
Treatment : End to End Anastomosis
Nursing Care
Pre-Operative
a. NPO post midnight
b. suction secretions PRN
Post-Operative
a. position: HOB elevated 30-45’
b. suction secretions
c. maintain gastrostomy for feeding
When assessing a 2-month old
infant suspected of having
pyloric stenosis, the nurse would
expect which of the following
findings?
a. absence of bowel sounds
b. ribbon-like stools
c. decrease appetite
d. visible peristalsis
Which of the following if done by the
nurse would be appropriate in feeding
a post-palatoplasty patient.
a. feed using a nipple with large
hole
b. give water before feeding
c. use a rubber-tip syringe when
feeding
d. allow the patient to drink from a
cup
Dis Vomiting Assement

Chalasia Non- 1-3 months

projectile,
non-bile
Pyloric Projectile Peristalsis Seen, olive
Stenosis shape mass
Wilms Tumor present Enlarge abdomen
TEA,EA Regurgitation, Inability to insert
drooling NGT
Hirschsprung’s Fecaloid Enlarge abdomen,
Disease ribbon like stool
Intussuception present 6 mons, “currant
jelly” stool
GenitoUrinary

Disorders
 Urinary Tract Infection (UTI)
most common GUT problem
 common : schooler girls
Escherichia Coli
Nursing Care
a. administer medications
b. increase oral fluid intake
c. acidify urine
d. proper hygiene
e. avoid tub baths or bubble baths
NURSING CARE
• Administer antibiotics as ordered.
- prevention of kidney infection/glomerulonephritis.
- obtain cultures before starting antibiotics
• Provide warm baths and allow child to void in water to
alleviate painful voiding.

• Force fluids.
•Provide client teaching and discharge planning
 Undescended Testis
aka “Cryptorchidism”
 common : unilateral
premature infants
 75% descend spontaneously in 1 year
Treatment : Orchipexy
MEDICAL MANAGEMENT
• Whether or not to treat is still controversial.
- If the testes remains in the abdomen, damage to
the testes (sterility) is possible because of
increased body temperature.
• If not descended by age 8-9 mos, chorionic
gonadotropin can be given.
• Orchipexy
- surgical procedure to retrieve and secure testes
placement
- preformed between ages 1-3 years
NURSING CARE
• Advise parents of absence of testes and provide
information about treatment options.
• Support parents if surgery is to performed.

Post-op
• Avoid disturbing the tension mechanism.
- will be in place for about 1 week.
• Avoid contamination of incision.
 Wilms’ Tumor
“Nephroblastoma” “Renal
Embryoma” “Birch-Hirschfeld
Tumor”
Incidence :
a. Highest : 3-4 years of
life
b. Uniform : 5-15 years
Etiology:
a. Hereditary
b. Sporadic
 Wilms’ Tumor
Assessment: Initial : Asymptomatic
a. Abdominal Pain
b. Fever
c. Hematuria (25%)
d. Hypertension
e. Dysuria, Polyuria, Vomiting, Malaise
Diagnosis:
a. IVP : Enlarged kidney & distorted pelvis
b. Aortography : Arterial supply of tumor
c. Ultrasound, CT Scan
Treatment: Surgery, Chemotherapy, Radiation
- surgery within 24-48 hours of admission
to remove the tumor affected kidney,
and the adjacent adrenal glands
- postoperative radiation therapy
- chemotherapy (dactinomycin, vincristine,
adriamycin, cyclophosphamide)
- BP monitoring
- DO NOT PALPATE THE ABDOMEN!
 Wilms’ Tumor
Nursing Care: DO NOT PALPATE Abdomen!
a.Handle and bathe carefully to prevent trauma
b. Monitor blood pressure
c. Begin teaching family about chemotherapy and
radiation therapy
Postoperative
a. Monitor blood pressure carefully
b. Monitor intake and output to assess kidney
function
c. Encourage child to turn, cough, and deep breathe
d. Teach parents to identify untoward reactions from
chemotherapy and radiation therapy
 Nephrotic Syndrome
 caused by a lot of factors
 problem : increase glomerular
basement membrane permeability
Assessment
a. protenuria (>2 gm/day)
b. hypoprotenemia (<2.5 g/dl)
c. hyperlipidemia (>200 mg/dl)
d. edema
e. anorexia, vomiting
 Plasma CHON enter the renal tubule

Excreted in urine

PROTEINURIA

Oncotic pressure

Plasma volume

HYPOVOLEMIA

Release of RENIN & ANGIOTENSIN BP

Secretion of aldosterone Release of ADH

Reabsorption General shift
Reabsorption of H2O & Na in distal of H2O of plasma into
tubule interstitial
spaces
MASSIVE EDEMA
 Nephrotic Syndrome
Treatment
a. corticosteroids
b. diuretics
c. antibiotics
Nursing Care
a. provide bed rest
b. diet : high protein, low sodium, fats
c. avoid IM injections
d. fluids maintained at 20 cc/kg/day
e. protect from known sources of
infection
NURSING CARE
• Provide bed rest.
- Conserve energy.
- Find activities for quiet play.
• Provide high CHON, low sodium diet during edema phase
only.
• Maintain skin integrity.
- Don’t use Band-Aids.
- Avoid IM injections
- medication is not absorbed in edematous tissue.
• Obtain morning urine for CHON studies.
• Provide scrotal support.
• MIO, V/S and WOD
• Administer steroids to suppress autoimmune response as
ordered.
• Protect from known sources of infection.
 Acute Glomerulonephritis
 immune-complex disease
 self-limiting, resolves in 14 days
 caused by beta hemolytic
streptococcus
Assessment
a. hematuria (100%)
b. edema (98%)
c. hypertension (82%)
d. anorexia
e. lethargy
 Nephrotic Syndrome Glomerulonephritis
Caused by a lot of factors Post-Strep GN
Increased permeability of Decreased glomerular
GBM to protein filtration rate
Edema Hematuria
Massive Proteinuria Hypertension
Transient elevation of BP Edema
Control edema Bed Rest
Diet:low Na, high protein Diet: low Na
Skin Care Monitor neuro status & VS