Child Health Final

Child Development: Chapters 1,5,6,21 &22 (3 questions)

General Trends in Height & Weight Gain During childhood
Birth weight doubles by the first 4-7 months
Birth weight triples by end of the first year
Birth weight quadruples by the age of 2.5 years
Birth height increases by 50% by end of 1st year
Height at age 2 years is about 50% of eventual adult height
How to help them with the milestone
Ericksons Stages:
Trust vs. mistrust (0-1 years)
Autonomy vs. shame and doubt (1-3 years)
Initiative vs. guilt (3-6 years)
Industry vs. inferiority (6-12 years)
Identity vs role confusion (12-18 years)
Role of Play In Development
Content of Play
o Social-affective Play
Infant takes pleasure in relationships with people
o Sense Pleasure Play
Nonsocial stimulating experience that originates from
objects in the environment. Anything that can
stimulate their senses
o Skill play
Repeating an action over and over again
o Unoccupied behavior
Focusing attention momentarily on anything that
strikes their interest
o Dramatic/Pretend Play
Begins in late infancy (11-13 months). Is the
predominate form of play in preschool children
o Games
Imitative games: pat-a-cake
Formal games: ring-around-a-rosy
Competitive games: board games
Social Character of Play
o Onlooker Play

Children watch what other children are doing, but do

not enter into play
Solitary Play
Interest is centered on their own activity. Play with
toys alone, different from those used by others in
their same area
Parallel Play
Children play independently but among other
children
Associative Play
Children play together and are engaged in a similar
or even identical activity, but there is no
organization, division of labor, leadership assignment
or mutual goal
Cooperative Play
Play is organized, and children play in a group with
other childrenthere is a goal for this type of play

Chapter 6 focuses on assessing a Child and How to

communicate with them
How to administer medication?
Nutrition: breast milk (no feeding until feed they start siting
up); if breastfeed they need iron and vitamin D.
DO WE NEED TO KNOW PIAGET COGNITIVE THEORY? PAGE 71
(Maybe? She does not remember if there are Piaget questions
on the final)

Infectious disorders/Communicable Diseases: Chapters 14 (2

questions)
Communicable Disease:
Identification of the infectious agent is of primary importance to prevent
exposure of susceptible individuals
Prodromal symptoms = symptoms that occur between early manifestations of
the disease and its overt clinical syndrome
Can be prevented through immunizations and hand-washing, as will as
standard precautions
Nursing Alert:
If a child is admitted to the hospital with an undiagnosed exanthema (skin
eruption) strict Transmission-Based Precautions (Contact, Airborne, and
Droplet) and Standard Precautions are instituted until diagnosis is confirmed.
Childhood communicable disease requiring these precautions include:
diphtheria, chickenpox, measles, TB, adenovirus, Haemophilus influenza type

b, influenza, mumps, Mycoplasma pneumonia infection, pertussis, plague,

strep pharyngitis, pneumonia, and scarlet fever.
When lotions with active ingredients such as diphenhydramine in Caladryl are
used, they are applied sparingly, especially over open lesions, where
excessive absorption can lead to drug toxixity, Use these lotions with caution
in children who are simultaneously receiving an oral antihistamine. Cooling
the lotion in the refrigerator beforehand often makes it more soothing on the
skin than at room temperature.

Chicken Pox:

Transmission:
Direct Contact, droplet airborne spread
Clinical Manifestations
Prodromal Stage
o Slight fever
o Malaise
o Anorexia
o Rash highly pruritic (begins as macule papule vesicle)
Distribution
o Centripetal spreads to face and proximal extremities (sparse on
distal limbs and areas exposed to less heat)
Constitutional s/s
o Fever
o Irritability from pruritus
Nursing Consideration/Treatment
Airborne and contact precautions (negative air pressure room)
Keep child at home until vesicles have dried and crusty (usually 1 week
after onset)
Incubation 2-3 weeks
Give bath and change clothes and linens daily
Administer topical calamine lotion (intact or dried lesions)
Keep childs finger nails short and clean-apply mittens if child scratches
Teach child to apply pressure to itchy area instead
DO NOT use Aspirin
Childhood Immunization for prevention
Make give acyclovir to someone to prevent it from them getting it really bad
Measles (Rubeola): **
Transmission:
Direct contact, with droplets of infected person
Airborne
Clinical Manifestations:
Prodromal (catarrhal) stage
o Fever
o Malaise in 24 hours followed by
Coryza
Conjunctivitis
Koplik Spots (small irregular red spots with minute, bluish
white center first seen on the mucosa)
Symptoms gradually increase until second day after rash
appears
Rash
o Appears 3-4 days after onset of prodromal stage

Starts on face then spreads downward

After 3-4 days assumes brownish appearance and fine desquamation
occurs
o Isolation until 5th day of first appears
o 4 days prior to rash
Constitutional s/s
o Anorexia
o Abdominal pain
o Malaise
o Generalized lymphadenopathy
Nursing Considerations/Treatment
Airborne precautions
Isolation until 5th day
Rest
Antipyretics for fever
Eye care
o Dim lights if photophobia is present
o Clean eyelids with warm saline to remove secretions or crust
o Do not rub eyes
Coryza, cough
o Cool mist vaporizer
o Petrolatum layer around nares to protect skin
o Fluids and soft bland foods

Skin care
o Clean, use tepid baths prn
Prevention:
Childhood immunization and Vitamin A supplementation
o
o

Erythema Infectiosium
Transmission
Respiratory secretions and blood
Clinical Manifestations
Rash appears in 3 stages
o Stage 1
Slapped face on the cheeks
Leaves within 1-4 days
o Stage 2
Maculopapular red spots appear, symmetrically distributed in
upper and lower extremities
Proximal distal
o Stage 3
Subsides, but reappears with sun, heat or cold
Nursing Considerations/Treatment
Isolation only needed if child is hospitalized or with aplastic crisis
Respiratory isolations if in hospital
NO pregnant females
Antipyretics, analgesics and anti-inflammatory drugs
After they break out of rash, they are not contagious

Rosella Infantum

Transmission
o Possibly acquired from saliva of health adultno reported contact with
infected
o Incubation 5-15 days
o Limited to children <3 years of age
Clinical Manifestations
o Persistent high fever, while child appears well
o Rash
Discrete rose-pink macules or maculopapules 1st on TRUNK
spread to NECK, FACE and EXTREMETIES
Nonpruritic
Fades on pressure (blanchable)
Last 1-2 days
o Associated S/S
Cervical and post auricular lymphadenopathy
Inflamed pharynx
Cough
coryza
Nursing Considerations/Treatment
o Teach parents measures to reduce fever, and dosage on antipyretics
to prevent overdose
o If child is prone to seizures, discuss appropriate precautions and
possibility of recurrent febrile seizures.

Mumps
Transmission:
Direct contact with or droplet spread from an infected person
Agent: paramysovirus
Saliva from infected person
Incubation 2-3 weeks
Clinical Manifestations:
Fever
Headache
Malaise
Followed by parotitis
Nursing Considerations/Treatment:
Droplet and Contact Precautions; maintain isolation during period
May cause orchitis and meningoencephalitis
Encourage rest and decreased activity until swelling subsides
Encourage fluids and soft bland diet foods, avoid chewing
Apply hot or cold compresses to neck
To relieve orchitis provide warmth and local support with tight fitting
underpants (can lead to sterility for males)
Painful for them to chew
German Measles (Rubeola)
Agent: Rubella virus
3 day measles (kids recover during 3 days)
Droplet precautions
Avoid contact with pregnant women
Vaccine given at 15 months

Clinical Manifestations

Prodromal Stage
o low grade fever
o headache
o malaise
o anorexia

o
o
o
o

mild conjunctivitis
coryza
sore throat
cough

Rash
o

1st appears on face rapidly appears downward to neck, arms,

trunk, legs
o By the end of first day, body disappears in the same order it began
Nursing Consideration/Treatment
Droplet precautions
Antipyretics and analgesics
Child should be completely recovered in 3-4 days
Avoid contact with during pregnancy (teratogenic effect on fetus)
The child receives the immunization NOT the mother

Scarlet Fever
Group A strep
Droplet Precautions until 24 hours after initiation
Incubation period: 3-5 days (with symptoms beginning on the 2nd day)
Complications: Peri-tonsillar and retropharyngeal abscess & carditis
Rash appears within 12 hrs everywhere, except face
Clinical Manifestations
Abrupt high fever
Abdominal pain
Increased pulse
Halitosis
Vomiting
First day: white strawberry
tongue
Headache
Third day: Red Strawberry
Chills
tongue
Malaise

 Nursing Considerations/Treatment
Antibiotics
Encourage rest during febrile time
Relive discomfort of sore throat with analgesics, gargles, lozenges antiseptic throat sprays and cool mists
Encourage fluid intake
Begin with sift diet when child can eat
Discard toothbrush, avoid sharing drinks and eating utensils
The child receives the

Conjunctivitis (Pink Eye)

Pink eye is caused by many things
In NBs chlamydia, gonorrhea, or Herpes
Infants can by sign of tear duct obstruction
Infections and is HIGHLY CONTAGIOUS
Clinical Manifestations
Itching
Purulent drainage
Inflamed Conjunctivitis
Crusting eyelids
Nursing Considerations
Keep eye clean
Remove accumulated secretions wiping the inner canthus downward and outward away from the opposite eye
Warm, moist compresses, such as clean washcloth wrung out with hot tap H2O
Instill medication after cleansing eye
Instruct the child to refrain from rubbing the eye and to use good hand-washing technique

NURSING ALERT
Signs of serious conjunctivitis include reduction or loss of vision, ocular pain, photophobia, exophthalmos (bulging
eyeball), decreased ocular mobility, corneal ulceration, and unusual patters of inflammation. Refer patient to HCP if they
have any of these signs
Stomatitis
Caused by Herpes virus
Inflammation of the oral mucosa

May be infectious or non-infectious

May be caused by local or systemic factors.
Canker Sore
Cold Sores or Fever Blisters
Treatment Management:
Relief & prevention of the spread of Herpes Virus
Good hand washing is a must!
Wear gloves when examining lesions.

Health Promotion: Chapter 10,12,16 & 17 (10 questions) (LOOK AT)

Health promotion and problems of different age groups

Milestones: Look at TABLE 10-1 page 310-314

Also look at the infant separation/anxiety and stranger fear
Teething
Discipline (box pg33)
Injury prevention
Immunizations (know which ones to give at what age)

Disorder

ADHD

Clinical
Treatment/Teachi
Manifestation
ng
Developmentally
Hyperactive
Drug therapy;
inappropriate degree of BOX 17-2 on page 502 Methyphenidate
inattention,
has the diagnostic
hydrochloride
impulsiveness and
criteria
(Ritalin)
hyperactivity
Dextoamphentamine
sulfate (Dexedrine)
Began on a small dosage
that is gradually
increased
Must be assessed
Pathophysiology

every 6 months for

appropriate growth
and development
milestones
Require a more
structured
environment than
most children
The nurse should help
families identify new
appropriate
contingencies and
reward systems to meet
the childs developing
needs
Encourage consumption
of nutritious snacks in
the evening when the
effects of the
medication are
decreasing, and serving
frequent small meals
with healthy on the
go snacks are helpful
interventions
Sleeplessness is
reduced by
administering
medication early in
the day

 Avoid caffeine
because decreases
the efficacy of the
drug

Chronic Illness in Children: Chapter 18 (2 questions)

Impact of Childs Chronic Illness or disability

Page 540
BOX 18-4 page 542 Supporting siblings of children with special needs

The child with special Needs

BOX 18-6 (Coping Patterns Used By Children with Special Needs (page 545)

The child who is terminally ill or dying

Page 540 BOX 18-2 adaptive tasks of parents having children with chronic conditions

Cognitive Disorders: Chapter 19 (2 questions)

Cognitive Impairment (page 572)
Down Syndrome (Page 577)

Respiratory Disorders: Chapter 23 (5 questions) (LOOK AT)

Disease
Pathophysiology
Clinical
Treatment/
Manifestations
Teaching

Nasopharyngitis Aka the common cold

Rhinovirus (winter &

spring)

Younger children
Fever

Irritability

Restlessness

Poor feeding and decrease

fluid intake
Nasal mucus
V/D
Older children
Dryness & irritation of nose
& throat
Nasal d/c
Sneezing

Muscle aches

Cough
Physical
Assessment:
Edema
Vasodilation of the mucosa

Managed at home
Antipyretics
Rest
Decongestants & cough
suppressants DO NOT
GIVE if <6 years (For
decongestants the
book actually says you
can give, but be
cautions for children
over 12 months, so she
said she wont ask a
question about it)
Elevate the HOB
Suctioning and
vaporization (saline
nose drops & gentle
suction with a bulb
syringe before feeding
and sleep time maybe
useful
Increase fluids
Infection of control
(proper PPE)
Prevention: avoid contact
with infected person, and
hygiene
Parents are instructed to
notify HCP if any of the
following s/s
Refusal to take oral
fluids and decreased

urination
Evidence of earache
Respirations faster than
50-60 bpm in a toddler
or older child
Persistent cough or
exacerbating cough
Wheezing
Restlessness and poor
sleep patterns
Nursing Alert
Parents are cautioned
regarding OTC
combination cold
remedies because
these often include
acetaminophen.
Careful calculation of
both the
acetaminophen given
separately and the
acetaminophen in
combination
medications is
necessary to avoid an
overdose
Airway maintenance is
priority
Providing adequate
respiratory exchange
Maintain hydration (PO or
IV)

Laryngotracheso Part of the croup syndrome Slowly progressive

Affects children <5 years Stridor
bronchitis
Cause by Para-influenza,
RSV and influenza A&B
Inflammation of mucosa
lining of the larynx and

Suprasternal retractions
Barking or seal-like
cough
Increasing respiratory

Pharyngitis

trachea causing
distress and hypoxia
Watch for dehydration:
narrowing of the airway Can progress to
Weigh diaper over a 24
Will go to bed and wake up
respiratory acidosis,
hour period
with a bad cough
respiratory failure, and Should be 1mL/kg/hr.
death
> 6 months, >30kg
NURSING ALERT:
should be 30 mL/hr.
Early signs of impending High humidity with cool
airway obstruction
mist
include increased
Oxygenation status thru
pulse and respiratory
pulse oximetry
rate; substernal and
Nebulizer treatments:
intercostal retractions;
Epinephrine
flaring nares and
increased restlessness Steroids (IM prefer) slow
release from muscle
Cold humidify air
tissue vs. oral they with

clear a lot fater

Strep throat
Younger children Throat culture to rule out
GABHS
GABHS
Fever
If streptococcal infection is
At risk for rheumatic fever General malaise
present oral penicillin is
& acute
Dysphagia
prescribed,
glomerulonephritis
Abdominal pain
erythromycin for

Physical
children allergic to PCN
assessment:
Obtain a throat swab
Mild-to-moderateculture
hyperemia
Instruct parents on

administering antibiotics,
Older children
Cold or warm compresses
Fever (may reach 40C 104
to the neck,
F)
Warm saline gargles
Headache
Manage pain with
Anorexia

Epiglottitis

Serious obstructive
inflammatory process
occurs predominantly
children 2-5 yrs.
Caused by H influenza
Abrupt onset
Emergency NEEDS for
ASAP

acetaminophen or
Dysphagia
ibuprofen
Abdominal pain

Offer
cool liquids or ice
Vomiting
chips
Physical

Children
consider
Assessment;
infectious
to others at
Mild to bright red,
the onset of symptoms
edematous pharynx
and up to 24 hours
Hyperemia of tonsils and
after the initiation of
pharynx, may extended to
antibiotic therapy,
soft palate and uvula
replace toothbrush after
Often abundant follicular
have been taking
exudate that spreads and
antibiotics for 24 hours
coalesces to form
DRUG ALERT
pseudomembrane on
Never administer
tonsils
Penicillin via IV, it may
Cervical glands enlarged
cause an embolism, or
and tender
toxic reaction
w/insuring deaths in
minutes instead
administer IM to
decrease localized
reaction and pain.
3 predictive
NURSING ALERT:
that
observations:
Throat inspection
in Cough
should be attempted
only when immediate
Drooling
endotracheal
Agitation
intubation can be

performed
Child goes to be

When
epiglottis is
asymptomatic to
suspected the nurse
awaken later

Croup Syndrome Affect larynx, trachea

RSV (AND
BRONCHOLITIS)

complaining of sore
should not attempt to
throat and pain on
visualize epiglottis
swallowing
directly with tongue
depressor or take a
Stridor (aggravated when
throat culture but refer
supine)
to the child for medical
High fever
evaluation
Rapid pulse and

Start
IV infusion
respiration
Continuous monitoring of
Tripod position
respiratory status and

pulse oximetry
ABGs if child is intubated
Prevention HIb vaccine

Hoarseness

Barking cough
Inspiratory stridor

bronchi

Ie. Are epiglottis, laryngitis,

larngotracheobronchitis
(LTB) and tracheitis
Respiratory syncytial virus. Initial:
Treat the symptoms
Most common cause of
Rhinorrhea (1st)
Contact precautions
bronchiolitis
Pharyngitis
RSV affects the epithelial
Cough, sneezing
cells of the respiratory
Wheezing
tract. The ciliated cells
Possible ear or eye
swell, protrude into the
drainage
lumen, and lose their cilia
Intermittent fever (1st)
Bronchiolar mucosa swells
With progression of
and lumina are
illness:
subsequently filled with
Increased coughing and
mucus and excaudate
wheezing
walls of the bronchi and

Asthma

Cystic Fibrosis

bronchioles are infiltrated Tachypnea and

Intraluminal obstruction
retractions
leads to :
cyanosis
Hyperinflation
Severe illness:
Emphysema
Tachypnea >70 bpm
Atelectasis
Listlessness
Apneic spells
Poor air exchange
Poor breath sounds
Chronic inflammation
Dyspnea
disorder of the airways
Wheezing
Characterized by:
Coughing
Recurring symptoms
Airway obstruction
Bronchial hyperresponsiveness

Inherited autosomal
recessive trait
Mechanical obstruction
caused by the
increased viscosity of
mucous gland
secretions
Affects other organs

Meconium ileus
Abdomen distention
Vomiting
Failure to pass stool
Rapid development of
dehydration
GI

TX
Short acting medication:
B2 agonist
Anticholinergic
Systemic corticosteroids
Long acting medication:
Inhaled corticosteroids
Cromolyn sodium &
nedocromil
Long acting b2 agonist
Methylxanthines
Leukotrines modifiers

Diet: High caloriecdiet

with high fat
Treat and prevent
pulmonary infections
Flutter muscu clearance
device
High frequency chest

compression
Large, bulky, loose, foul
Broncholdilator
stool
medication
Eat a lot (early in
Replacement of
disease)
pancreatic enzymes
Lose appetite (later in
given with meals and
disease)
snacks (take extra
Weight loss
enzymes when high fat
Marked tissue wasting
foods are eaten)
Failure to grow
NURSING ALERT
Distended abdomen
Signs of
Thin extremities
pneumothorax are
Yellow or pale brown skin
usually nonspecific
Deficient in vitamins
and include
A, D, E, K
tachycardia,
anemia
dyspnea, pallor, and
Lungs
cyanosis. A subtle
drop in O2 saturation
Wheezing
(increased by
Dry non-productive
pulseoximetry) may
cough
be a early sign of
Increased dyspnea
pneumothorax
Paroxysmal cough

Obstructive emphysema

and patchy areas of

atelectasis
Barrel-shaped chest
Cyanosis
Clubbing
Bronchitis and

bronchopneumonia

Medications associated with respiratory dysfunction (action & adverse effects):

SIDS-pg 401:

GI Disorders: Chapter 24 (5 questions)

Disease
Pathophysiolo
Clinical
Therapeutic Management
gy
Manifestation
Hirschspr Congenital
Table 24-3
Surgery
ung
abnormality
NB
Removal of the aganglion portion of
Disease Results in obstruction Failure to pass
the bowel to remove obstruction,
from inadequate
restore normal motility and preserve
meconium within 24motility of part of the
function of external sphincter
48 hours
intestine
Soave endorectal pull-through: pulling
Refusal to feed
Aka: aganglionic
the end of the normal bowel through
Biolous vomiting
the muscular sleeve of the rectum;
megacolon
Abdominal distention
Complication: constipation
Mutations of RET
Infancy
(enterocolitis) and fecal incontinence
proto-oncogene have Growth failure
Diet low in fiber, high calorie, high
been found
Constipation
protein
In the majority of
Abdominal distention Anorectal myomectomy: for very short
cases aganglionosis
Episode of diarrhea and segment diseases
is restricted to the
vomiting
Prior to surgery child is stabilized with
internal sphincter,

Signs
of
enterocolitis:
rectum and part of
fluid and electrolyte replacement
explosive, watery
the sigmoid colon
Preop
diarrhea, fever,
Absence of ganglion
Make sure that physical status is good,
appears significantly ill

cells in the intestines

that results in loss of
rectosphincteric

reflex and an
abnormal

microenvironment of

cells of the affected

intestine
Absence of these cells

results in a lack of
enteric nervous
system stimulation,
which decreases the
internal sphincters
ability to relax
Contraction of
abnormal bowel
Lack peristalsis
Loss of
rectosphincteric
reflex

if not treat with enemas; a low fiber,

Childhood
high calorie and high protein diet or
Constipation
TPN in severe cases
Ribbon-like, foul
Decrease bacterial flora with
smelling stools
antibiotics and colonic irrigations
Abdominal distention
using antibiotic soln
Visible peristalsis
In children: empty bowels with saline
Easily palpable fecal
enemas and decrease bacterial flora
mass
with oral or systemic antibiotics and
Undernourished anemic
colonic irrigations (bowel cleansing)
appearance
Emergency preop care includes:

monitor vital signs for signs of shock,

fluid, electrolyte replacement, plasma
or blood derivatives and observe for
symptoms of bowel perforation such
as fever, increasing abdominal
distention, vomiting increased
tenderness, irritability, dyspnea and
cyanosis
Infants: no prep needed
Measure abdominal circumference
with a paper tape measure (level of
umbilicus or widest part of abdomen;
can leave the tape measure
underneath the child)
2 step process to let the abdomen rest
(only if it is really distended, the
mega-colon you need to allow it to
undisteneded

Cleft lip or Facial malformation

Cleft
that occurs during
Palate
embryonic
development
Most common
congenital
deformities
Clefts of the lip (CL)
and palate (CP) can
occur alone or
together
Most are caused by
genetics and
environmental
factors
Exposure to
teratogens such as
alcohol, cigarette

Post-op:
Stoma care when there is a colostomy
To prevent contamination of an
infants abdominal wound, place
diaper below dressing
A Foley catheter may be placed to
divert urine away from abdomen
Listen for bowel sounds, make sure
they are passing gas
Discharge care
Teach parents about colonostomy care
Apparent at birth Surgical correction of Cleft Lip
Sometimes seen Occurs 2-3 months
on ultra sounds Rule of ten: 10 weeks old, 10lbs, hgb
of 10
Tennison-Randall triangular flap (Z
plasty)
Millard rotational advancement
technique
Nasoallveolar may be used to bring
cleft segments together prior to
surgery
Surgical Correction of Cleft Palate
Occurs between 6-12 months
Veau Wardill-Kilner VY pushback
procedure
Furlow double opposing Z plasty
May need a 2nd surgery to improve

smoking,
anticonvulsants,
steroids and
retinoids are
associated with
higher risk
The severity of CP has
an impact on
feeding; the infant is
unable to create
suction in the oral
cavity that is
necessary for
feeding (ability to
swallow is normal)

velopharyngeal for speech.

Nursing teaching highest priority
is learning how to feed their
infants and
CL may interfere with the infants
ability to achieve an adequate
anterior lip seal; no difficulty
breastfeeding, use wide based
bottles
CP reduces the infants inability to
suck, which interferes with
breastfeeding and traditional bottle
feeding
Positioning in an upright position, with
head supported by caregivers hand
when feeding
Suction is impaired in infants with CP,
using the specific bottles that like
Special Needs Feeder, Pigeon Bottle,
etc,
Infants with clefts tend to swallow
excessively, so it is important to
pause during feedings and burp
infant
Preop
Teach parents how to use alternative
methods for feeding ie syringe
Postop
Protecting op site

Esophage Rare malformations

al Atresia
that represent a
with
failure of the

For CL use petroleum jelly

For CL, CP or CL/P elbow
immobilizers may be used to
prevent the infant from rubbing the
suture line (applied after surgery7/10days)
Recommendation of syringe for
feeding
Analgesia for pain and to prevent
restlessness
Feeding resumed when tolerate
Upright or infant seat position is
helpful
Avoid the use of suction or other
objects in mouth: tongue
depressors, thermometers,
pacifiers, spoons, or straws
Older child: blenderized or soft diet;
no toast, hard cookies, and potato
chips
Long Term
Speech therapy
Development of healthy personality
and self-esteem
Tooth problems, so they will need to
see a orthodontics
Box 24-9
As a nurse, if you suspect this you will
be there for the 1st feeding and
Excessive frothy
administer water in a medicine cup
mucus from nose

Tracheoes
ophageal

esophagus to
develop as a
continuous passage
and the trachea &
esophagus to
separate into distinct
structures
Can occur alone or
both
Cause is unknown
When a mother had
polyhydraminose
(excessive amnioc
fluid in sac), thats
when you would
suspect it

and mouth
3 Cs of

tracheoesophage
al fistula:

Coughing
Choking
Cyanosis
Apnea

Increased
respiratory
distress during
feeding
Abdominal
distention
Suspected in

cases of
polyhydramnios
(excessive fluid in
the amniotic sac)

to look for the 3Cs

If its there stop giving them the water
baby stays NPO and
As a nurse you want to maintain
patent airway, prevention of
pneumonia, gastric blind pouch
decompression, supportive therapy
and surgical repair of anomaly.
When EA with TEF is suspected, the
infant is immediately deprived of
oral intake, IV fluids are initiated
and the infant is positioned to
facilitate drainage of secretions
and decrease the likelihood of
aspiration
Mouth and pharynx suctioned
frequently because of accumulated
secretions
Double-lumen catheter placed into the
upper esophageal pouch and
attached intermittent or
continuous low suction
Infants head kept upright
(30degrees) to help with removal of
fluid collected in the pouch and
prevent aspiration of gastric content
Antibiotics if there is concern of
aspiration of gastric content
Surgery:

 thoracotomy
for infants who are not stable enough
2 stages: 1) involves gastrostomy,
ligation of the TEF and constant
drainage of esophageal pouch 2)
esophageal anastomosis done weeks
later
Thorascopic repair of EA/TEF
If tracheomalacia is present (when
dilated proximal pouch compresses
the trachea early in fetal life),
surgical intervention would be
aortopexy or stent replacement.
Clinical manifestation are: barking
cough, stridor, wheezing, recurrent
respiratory tract infections, cyanosis
and sometimes apnea
NURSING ALERT: Any infant who has
an excessive amount of frothy
saliva in the mouth or difficulty
with secretions and unexplained
episodes of apnea, cyanosis or
oxygen desaturation should be
suspected of having an EA or TEF and
referred and referred immediately for
medical evaluation.
Preop
Nursing interventions include:
respiratory assessment, airway

management, thermoregulation, fluid

and electrolyte management and PN
support
Suctioning
Positioning: preferably supine
(sometimes prone) with head
elevated on an inclined at least
30 degrees. This helps minimize
reflux of gastric secretions at the
distal esophagus into the trachea and
bronchi
Until surgery the blind pouch is kept
empty by intermittent or continuous
suction through an indwelling
catheter passed orally or nasally

Postop
Infant returned to radiant warmer or
isolette
Double-lumen catheter is attached to
low-suction or gravity drainage
PN is provided
Gastrostomy tube (if they have one) is
returned to gravity drainage until
feeding is tolerated
24-36 pain management
Tracheal suction only done using a
premeasured catheter with extreme
caution to avoid injury to the suture

line
Make sure infant is able to swallow
without feeding
Special problems
Problems such as pneumonia,
atelectasis, pneumothorax and
laryngeal edema
Respiratory difficulty reported ASAP
Monitored for anastomotic leaks as
evidence by purulent drainage, chest
tube drainage, increased WBCs and
temperature instability
Esophagestomy: care for skin because
it becomes irritated by moisture from
the continuous discharge of saliva.
Frequent removal of drainage and
application of layer protective
ointment may remedy the problem
Esophageal replacement, nonnutritive
sucking is provided by a pacifier, to
allow the infant to develop mature
sucking patterns
Some patients with EA/TEF require
periodic esophageal dilation on an
outpatient basis
Tracheomalacia is a complication

Hypertro Occurs when the

phic
circumferential

Pyloric
muscle of the pyloric
Stenosis
sphincter becomes
thickened, resulting
in elongation and
narrowing of the
pyloric channel

It produces an outlet
obstruction and
compensatory

dilation, hypertrophy
and hyperperistalsis
of stomach

Develops first 2-5

weeks of birth
Causes projectile
vomiting,
dehydration,

metabolic alkalosis
and growth failure
Genetic predisposition
Circular muscle of the
pylorus thickens as a
result of hypertrophy
and hyperplasia
(increased mass).

This produces sever

narrowing of the
pyloric canal

Box 24-11
Preop
Projectile vomiting
Restoring hydration and electrolyte
balance, metabolic alkalosis must be
May be ejected 3-4 ft
corrected
from child when in a
side-lying position or 1 NPO receive IV fluids with glucose and
foot when in supine
electrolyte replacement
position
Assess: Vital signs, skin mucous
Occurs shortly after
membranes, and daily weight
feeding, but may not Stomach decompress with an NG tube,
occur for several hours
the nurse must ensure the tube is
Nonbilious vomitus
patent and functioning properly. Also
that may be blood
responsible for measuring and
tinged
recording the type and amount of
drainage
Infant hungry, avid
Postop
feeder, eagerly
accepts a second
IV fluids administered until the infant is
feeding after vomiting
taking and retaining adequate
episode
amounts by mouth
No evidence of pain or Monitoring same things that were
discomfort other than
assessed
hunger
Observed for responses to the stress of
Weight loss or failure
surgery and for evidence of pain
to gain weight
Surgical incision is inspected for
Signs of dehydration
drainage or erythema and any signs of
Distended upper
infection, report ASAP
abdomen
Feedings usually being 4-6 hours postReadily palpable oliveop
shaped tumor in
Teach parents how to care for incision
epigastrium just to the Observation and feeding recordings are

Intussus
ception

between stomach
right of the umbilicus
and duodenum,
Visible gastric
causing partial
peristaltic waves that
obstruction of lumen
move from left to right
across the epigastrium
Children ages
Sudden acute

3months-3years
abdominal pain
Common in children Child screaming and

with cystic fibrosis

drawing knees into
chest
Unknown cause
Child appearing normal
Occurs when one
and comfortable
segment of the
between episodes of
bowel telescopes
pain
into another
segment, pulling the Vomiting
mesentery with it
Lethargy
The mesentery is
Passage or red, current
compressed and
jelly-like stools (mixed
angled resulting in
with blood and mucus)

lymphatic and
Tender, distended
venous obstruction
abdomen
As edema from
Palpable sausageobstruction increases
shaped mass in
pressure increases.
upper right

When pressure
quadrant
equals arterial
Empty lower right
pressure, arterial
quadrant (dance sign)

blood flow stops Eventual fever,

results in ischemia
prostration and other

important

Assess children with severe colicky

abdominal pain combined with
vomiting, which is a significant sign
NURSING ALERT: The classical traid s/s:
abdominal mass, abdominal pain,
and bloody stools. Children might
initially be seen screaming, irritable,
lethargy, vomiting, diarrhea or
constipation, fever, dehydration and
shock. Can be life threatening, the
nurse should be aware of alternative
presentations, observe the child
closely, and refer them for further
evaluation.
Treatment consists of radiologist-guided
pneumonia (air enema) with or
without water-soluble contrast or
ultrasound guided hydrostatic
(saline) enema.
IV fluids, NG decompression and
antibiotic therapy may be used before
hydrostatic reduction
Laparoscopic surgery that involves
manually reducing the invagination
and when indicated, resecting any

and pouring of
signs of peritonitis
mucus into the
Fetal position in pain
intestine + leaking of
blood and mucus
into intestinal
lumen resulting in
currant jelly-like
stools

Celiac
Characterized by
Impaired Fat absorption
Disease
villous atrophyin the Steatorrhea

(excessively large,
small bowel in

nonviable intestine
Look at stool, if stool is normal then no
further procedure; however, if stool
remains jelly-bloody like then surgery
is required
NURSING ALERT: Passage of
normal brown stool usually
indicates that intussusception has
reduced itself. This is
immediately reported to the HCP,
who may chose to alter the dx
and therapeutic care plan.
Preop
NPO
Lab test: CBC and urinalysis
Pre-anesthetic sedation
Nurse monitors all stools
Post-op
Assess: vital signs, sutures and
dressings, return of bowel sounds
After hydrostatic reduction the nurse
observes passage of water soluble
contrast material and stool patterns;
reoccurrence is possible
Reoccurrence is treated with
conservative reduction techniques
Corn and rice become substitute grain
foods
Advise child and patients to read labels

response to the

protein gluten
It is a permanent
intestinal intolerance
to dietary wheat
gliadin and related

proteins that
produces mucosal
lesions in genetically

susceptible

individuals

Exact cause is
unknown, accepted

that it is an

immunologically

mediated small
intestine enteropathy
Gluten is found in
wheat, barley, rye
and oat grains
When individuals are
unable to digest the
gliadin component of
gluten, an
accumulation of toxic
substance that is
damaging to the

pale, oily, frothy stools

carefully
Exceeding foul-smelling Diet requires a wheat-barley, and rye
stools
free diet
Impaired nutrient
A diet high in calories and proteins with
absorption
simple carbohydrates such as fruits
Malnutrition
and vegetables, but low in fat
Muscle wasting
Avoid high fiber foods, such as: nuts,
(especially prominent
raisins, raw vegetables and raw fruits
in legs and buttocks)
with skin until inflammation has
Anemia
subsided
Anorexia
Abdominal distention
Behavioral changes
Irritability
Uncooperativeness
Apathy
Celiac crisis: Acute,
sever episodes of
profuse watery
diarrhea and vomiting.
May be precipitated
by:
Infections (especially
GI)
Prolonged fluid and
electrolyte depletion

mucosal cells occur Emotional disturbance

Damage to the

mucosal of the small

intestine leads to
villous atrophy,
hyperplasia of the
crypts, and
infiltration of the
epithelial cells with
lymphocytes
Villous atrophy leads
to malabsorption
caused by reduced
absorptive surface
area
Genetic predisposition

Congenital/cardiac Disorders: Chapter 25 (6 questions)

Pathophysiology
Clinical
Manifestations

Congestive Heart Inability of the heart to

pump an adequate
Failure

amount of blood to the

systemic circulation at

Impaired Myocardial
Function
Tachycardia
Sweating

Nursing
Consideration/Te
achings
Administer digoxin. But
first check the apical
pulse. Do not
administer if to an

normal filing pressures to

meet demands
In children, it occurs
secondary to structural
abnormalities that result
in increased blood volume
and pressure within the
heart
Right-sided failure = R
ventricle is unable to
pump blood effectively
into the pulmonary artery,
resulting in increases
pressure in the R atrium
and systemic venous
circulation
Left-sided-failure = L
ventricle is unable to
pump blood into the
systemic circulation,
resulting in increases
pressure in the L atrium
and pulmonary veins. The
lungs become congested
with blood, causing
elevated pulmonary
pressures and pulmonary
edema

Decreased urinary
output
Fatigue
Weakness
Restlessness

Anorexia
Pale, cool extremities
Weak, peripheral pulses
Decreased BP

Gallop rhythm
Cardiomegaly
Pulmonary Congestion
Tachypnea
Dyspnea
Retractions (infants)

Flaring nares
Exercise intolerance
Orthopnea
Cough, hoarseness
Cyanosis

Wheezing
Grunting
Systemic Venous
Congestion

Weight gain (best way to

determine HF in
child/infant)
Hepatomegaly
Peripheral edema
(especially periorbital)

infant if the pulse is

<90-110 bpm; and
young children if the
pulse is <70 bpm
Monitor afterload
reduction by measure
BP before and after ACE
administration
Assess serum
electrolytes and renal
function
Clustering treatment to
minimize unnecessary
stress
Monitor temperature
because hyperthermia
or hypothermia
because it increases the
need for oxygen
Skin breakdown from
edema is prevented
with a change of
position every 2 hours
Reduce Respiratory
Distress, through
careful assessment,
positioning and oxygen
administration which
can reduce respiratory
distress

 Ascites
Neck vein distention

Endocarditis

Antibiotics given to
reduced the chance of
getting a respiratory
tract infection
The nurse seeks
measures to enable the
infant to feed easily
without excess fatigue
and to increase the
caloric density of the
formula
Assist in measures to
promote fluid loss
Is an infection of the
Onset usually insidious Administration of highinner lining of the heart Unexplained fever (low
doses of antibiotics IV
(endocardium),
2-8 weeks
grade and intermittent)
generally involving the Anorexia
Take blood cultures
valves
periodically
Malaise
Mainly caused by staph Weight loss
Prophylactic antibiotics
or strep
therapy 1 hour before
Characteristic findings
certain procedure that
caused by extra cardiac
increase risk
emboli formation
Splinter hemorrhages Notify the dentist, if
the child gets any
(thin black nails) under
dental procedure
nails
Oral care needs to be
Osler nodes (red,
maintained to reduced
painful intradermal
the chance of
nodes found on pads
bacteremia from oral
of phalanges)

Hypoxia

Kawasaki
Disease

Painless hemorrhagic

areas on palms and

soles
Petechiae on oral
mucous membranes
May be present
Hear failure
Cardiac dysrhythmias
New murmur or
change in previously
existing one
A reduction in tissue
Cyanosis

oxygenation that results Desaturated venous

from low oxygen

blood
saturation and PaO2
Clubbing
and results in impaired Hypercyanotic spells

cellular processes

Polycythemia
(increased blood cells)
Acute systemic vacuities Child must have fever
of unknown cause
for more than 5 days
along with 4-5 clinical
Occur in children in
criteria
younger than 5 years of

Changes in the

age
extremities: in the
Initial stage of the

acute phase edema,

illness, is extensive
erythema of the
inflammation of the

palms and soles; in

arterioles, venules and
the subacute phase,
capillaries occurs,
periungual
causing many of the s/s

infection
The nurse teaches that
any unexplained fever,
weight loss, or change
in behavior (lethargy,
malaise, anorexia) must
be brought to the HCPs
attention

Keep child hydrated

Place infant-chest
position when having
hypercyantoic spells
Pulmonary hygiene
Treat pulmonary
infections aggressively
High does of IV gamma
globulin (IVGG) along
with aspirin and then
antiplatelets
Monitor heart function
I&O
Daily weights
Assess for signs of heart
failure
Symptoms relief:

 Can cause formation

of coronary artery
aneurysms in some
children

Congenital Heart Defects:

Defect w/
Atrial
increased
Septal
pulmonary
Defect
blood flow
(ASD)

Pathophysiol opening in the

ogy
septum between
the atriums
blood from L atrium
(high pressure)

desquamation
(peeling) of the
hands and feet
Bilateral conjunctival
injection
(inflammation)
without exudation
Changes in the oral
mucous membranes,
such as erythema of
the lips,
oropharyngeal
reddening; or
strawberry tongue
Polymorphous rash
Cervical
lymphadenopathy
(one lymph node > 1.5
cm)

Ventricle
Septal
Defect
(VSD)

Cool clothes
Unscented lotions
Soft loose clothing
Mouth care
Clear liquids
Soft foods
Quiet environment

Teach parents
about CPR

Atrioventric
ular Canal
Defect

Patent
Ductus
Arteriosus
(PDA)

Opening in the
Incomplete fusion of Failure of the fetal
septum between
the endocardial
ductus arteriosus
the ventricles
cushions
(artery
connecting the
L-to-R shunt is
Consists of low ASD
aorta &
caused by the flow
with a high VSD

flows into the R

of blood from L
A large AV valve
atrium (low
ventricle (high
that allows blood
pressure) causes
pressure) to R
to flow between
flow of oxygenated
ventricle (low
all 4 chambers
blood into the R
pressure).
Most common defect
side of heart
Increased pressure in
in children with
the R ventricle
Down Syndrome
causes the
muscle to
hypertrophy
Spontaneous
closure most
likely occurs
during the 1st
year of life in
children having
small or moderate
defects (usually by
4 years)
Might be noticed
2-8 weeks

Clinical
Asymptomatic
Manifestatio Acyonotic
ns
Fatigue easily

Heart failure is
common
Acyonotic

Moderate to
severe heart
failure
If asymptomatic
follow child and
watch for it to close

pulmonary artery)
to close w/in the
first week
Allows blood to flow
from the Aorta to
Pulmonary Artery
This shunt usually
closes at 12-72
hours; 2-3 weeks
seals shut
L R shunt
Causes an increase
workload of the L
side of heart,
increase in
pulmonary
vascular
congestion &
potentially
increase in in R.
ventricular
pressure and
hypertrophy
NSAIDS will cause
it to premature
closure
Asymptomatic
Signs of heart
failure
Acyontoic
May hear a heart
murmur at birth

Treatment/Te Pericardial patch or Procedures

achings
Darcon patch
Procedures
Patient receives lowdose of aspirin for 6
months

on its own
and when they
come for a follow
Mild cyanosis
up you might not
increases with
hear anything
crying
High risk for
pulmonary vascular
obstructive disease
Results going from
aorta pulmonary
artery
Widened pulse
pressure
Bounding
pulse

Procedures
Indomethacin
(ibeuprofen)
promotes closure
You dont want it to
close in utero only
when the baby is
born
NSAIDs promote
opening, and
indomethacin
promotes closure

Obstructive
Coartatation of
Aortic Stenosis
Pulmonic
Defects
the Aorta
Stenosis
Pathophysiology Aorta is narrowed
Narrowing of aortic valve Narrowing of the

closer to the ventricles

entrance of the
pulmonary artery
Causes resistance of
Resistance to blood flow
blood flow in the L
ventricle, and
causes R ventricular
pulmonary vascular
hypertrophy
congestion (pulmonary Can reopen foramen
edema)
ovale, shunting of
unoxygenated blood
into the L atrium
Clinical
Increase BP upper
Leads to heart failure
Asymptomatic
Manifestations
extremities, low BP
NB
Cyanosis
in lower extremities Decrease CO (hard for
Heart failure
Bounding pulses in
blood to come out)
Decrease of CO (severe
arms
Faint pulses
cases)
Weak or absent
Hypotension
Cardiomegaly
femoral pulses
Tachycardia
Cool lower extremities
Poor feeding
Hear failure signs
syncapy (pass out)
Since L side is working
Children
harder, it may cause L Exercise intolerance
ventricle hypertrophy
Chest pain
May go unnoticed if the
Dizziness when standing
PDA does not close
for a long time
OLDER KIDS:
Systolic ejection murmur
Dizziness
may be present
Headaches
Fainting
nosebleeds
Increased pressure
proximal (head and
upper extremities)
Decreases distal
pressure (body and
lower extremities)

Treatment/
Teachings

prostaglandin E to
keep the PDA open
Balloon angioplasty

If they have severe Balloon angioplasty

moderate they need to
avoid competitive or
intense sports because
it can lead to sudden
death
Balloon angioplasy

Decreased
Pathophysiology
Clinical
Treatment/Teachi
Pulmonary Blood
manifestations
ng
Flow
Tetraology of 4 defects in 1
Cyanotic
Blalock Taussing Shunt
Fallot
VSD
bluespells or tet
Different procedures
spells (knee to chest
PS
position)
Overriding aorta

clubbing
R Ventricular
hypoxia
hypertrophy
shunt direction depends
on the difference
between pulmonary
and systemic vascular
resistance
unoxygenated blood to
the body

Mixed Defects
(Mixed Blood)

Transposition of
the Great

Truncus
Arteriosus

Hypoplastic L
Heart Syndrome

Arteries/Great
Vessels
Pathophysiology Oxygenated blood
Blood ejected from the L
goes back and fourth
and R ventricles enters
unless there is
the common trunk so
another defect that
that pulmonary and
allows the blood to
systemic circulation are
go to the other side,
mixed
the child can be okay
Blood goes towards
for a while
the lungs since the
Pulmonary artery
pressure in the lungs is
leaves the R
lower.
ventricle
Aorta leaves the R

ventricle

Clinical
Cyanotic
heart failure

Manifestations Heart failure

poor feeding

cardiomegaly
poor growth

lung congestion
fatigue
hypoxemia
cyanosis
poor growth

activity intolerance

Treatment/Teachi prostaglanding E
procedures (preferably
ng
(keeps it open)
within the first month of

Underdevelopment of L
side of heart results in
hypoplastic L ventricle
aortic atresia
An ASD or patent
foramen ovale allows
blood to flow from L
atrium-to-R atrium and
R ventricle-to-out to
pulmonary artery
lungs aorta
systemically
Gives lungs extra blood
Pulmonary congestion
Mild cyanosis
Signs of heart failure
until PDA closes
Once PDA closes
progressive
deterioration with
cyanosis and decreases
CO
Pulmonary congestion
It is a step procedure,
more than 1 procedure

 procedure

life)

will occur

Medications:
Digitalis glycosides (digoxin) improve contractility (read page 839 Family-Centered Care for
Administering)
o NURSING ALERT: Infants rarely receive more than 1 ml (50 mcg or 0.05 mg) of digoxin in one
does; a higher dose is an immediate warning of a dosage error. To ensure safety, compare the
calculation with another staff members calculation before giving the drug
o Measure the elixir in the dropper and stresses the level mark as the meniscus of the fluid that
is observed at eye level.
Angiotensin-converting enzyme (ACE ) inhibitors reduce the afterload on the heart, which makes it
easier for the heart to pump
o Monitor BP before and after administration and observe symptoms of hypotension and notify
HCP if BP is low
o Careful assessment of serum electrolytes and renal function
Beta-Blockers decrease in heart rate, decreases BP and decreases vasodilation
o Monitor BP
o Side effects: dizziness, headaches and hypotension
Diuretics eliminate excess H2O and salt to prevent accumulation
o Furosemide (Lasix):
Drug of choice
Causes excretion of Cl- and K+
o Cholrothizide (Diuril):
can cause hypokalemia, acidosis with large doses
o Spironolactone (Aldactone):
weak diuretic
K+ sparing effect
Takes several days to take effect


Clinical Consequences of Congenital Heart Disease

Care of children after Cardiac Interventions

Monitor BP
Montior

Hematologic Disorders: Chapter 26 (4 questions

Disorder
Pathophysiology
Clinical
Manifestation
Leukemia (ALL Cancer of the lymphoid
Malaise and Fatigue
classifications
progenitor, affecting B or Fever
)
T cells
Bleeding gums
Most common in children Lymphadenopathy
3-7
Splenomegaly
Overproduction of WBCs, Petechiae
but count is low
Weight Loss
These cells do not
Meningitis
deliberately attack,
Anorexia
instead cellular
destruction happens by Dyspnea

Nursing Management

Use of chemotherapeutic agents: induction

therapy, CNS prophylactic therapy,
intensification therapy and maintenance
therapy
Prepare child and family for dx and
therapeutic procedure
Relieve pain, narcotics are adjusted or
titrated and administered around the
clock for best control of pain
Prevent complication of
myelosuprression caused by

infiltration and
subsequent competition
for metabolic elements

chemotherapeutic agents:
Infection: secondary to neutropenia;
Nurse must use all measure to control
transfer of infection, monitored for sites of
infection and elevation in temperature, IV
antibiotics given; adequate protein-caloric
intake provides child with better host
defense against infection and increases
tolerance of chemo therapy. Use of a
private room, restrictions of all visitors
and health personal with active infection,
and strict, hand-washing technique with
an antiseptic solution.
NURSING TIP: The child is not
immunized against live viral vaccines
(measles, rubella, mumps) until the
immune system is capable of
responding appropriately to the
vaccine. Most institutions have
individual guidelines regarding
vaccinations in children undergoing
immunosuppressive therapy.
Hemorrhage: prevented or controlled by
administration platelet concentrates or
platelet-rich plasma; avoid skin punctures,
aseptic techniques are used for IM shots,
bone marrow injections; Mouth care is
important; perennial care due to certain
drugs making it more likely to cause
ulcerations; avoid injuries that cause

bleeding; platelet transfusion during

active bleeding episodes
Anemia: due to replacement of bone
marrow by leukemic cells; blood
transfusion may be necessary during
induction therapy
Only experience nurses should administer
chemotherapeutic agents, because of the
risk of severe cellular damage
NURSING TIP: Chemotherapeutic
drugs must be given through a freeflowing IV line. The infusion is
stopped ASAP if any sign of
infiltration (pain, stinging, swelling
or redness at the cannulation site)
occurs. When chemo and
immunologic agents are given, the
child be observed for 20 mintues
after the infusion for signs of
anaphylaxis (cyanosis, hypotension,
wheezing, severe urticarial)
Emergency equipment (especially BP
monitor bag valve mask) and
emergency drugs (especially oxygen,
epi, antihistamine, aminophylline,
corticosteroids, and vasopressors)
must be available. If reaction is
suspected, the drug is discontinued,
the IV line is flushed with saline, and
the childs vital signs and

subsequent responses are

monitored.
Managing problems with Drug Toxicity:
N/V: administer antiemetic such as
serotonin-receptor antagonist
(ondansetron..); administer antiemetic
before chemotherapy
Anorexia: NG tube feeding or parenteral
nutrition for significant nutritional
problems
Mucosal Ulceration: bland, moist, soft
diet, use a sponge toothbrush or cottontipped applicator, frequent mouth washes
with NS, use local anesthetics or w/out
alcohol; Stomatitis dental hygiene; Rectal
ulcers prevented by toilet hygiene, stool
softeners, avoid rectal thermometers and
suppositories to prevent trauma
NURSING TIP: Viscous lidocaine is not
recommended for young children; if
applied to the pharynx, it may depress
the gag reflex, increasing the risk of
aspiration. Seizures have been rarely
associated with the use of oral viscous
lidocaine, most likely as a result of rapid
absorption into the bloodstream via the
oral lesion.
Neuropathy: stool softeners and laxatives
for severe constipation, maintain good
body alignment if pt on bed rest use

Lymphomas
Lymphomas are the 3rd
(Hodgkin and
most common group of
Non-Hodgkins
malignancies in kids and
Disease
adolescents
A group of neoplastic
diseases that arise from
the lymphoid and

Increased lymph
nodes

footboard to prevent foot drop, safety

measures during ambulation because of
parenthesis, soft or liquid diet for jaw pain
Hemorrhagic Cystitis: can be prevented
by increases fluids, frequent voiding ASAP
when urge arises, administering drug
early in the am, and administering mensa
(an agent that protects the bladder) as
ordered
NURSING TIP: if signs of cystitis occur,
such as burning or bleeding on urination,
prompt medical evaluation is needed.
Alopecia: warning patient prior, wear a
soft cotton cap, hair regrows within 3-6
months
Moon Face: caused by steroid therapy,
reassure pt that it will go back to normal
once drugs are stopped
Mood Changes: feelings range from wellbeing and euphoria to depression and
irritability

Treatment is chemotherapy for

children = Non-Hodgkin
And for Hodgkins it is chemo and
radiation. Chemo is for children
younger than 3 radiation can be used
on children older than 3.
Similar to treatment therapy above

Sickle Cell

Disease (SCD)

hematopoietic systems
Divide into two
HL originates in the
lymphocytes and mainly
involves the lymph
system
Metastasizes to nonnodal
or extralymphatic sites:
spleen, lover, bone
marrow and lungs.
Includes all the those
hereditary disorders
whose clinical,
hematologic and
pathologic features are
related to the presence
of HbS.
SCA is a type of SCD
Most common genetic
disease world wide

Pallor, jaundice

Splenomegaly

Leg ulcers
Priapism
Delayed puberty

Infection

Acute pain crisis from

infractions of the lung,
kidney, spleen, or
femoral head will also
have fever
Blindness

Stroke
Malnutrition

SCD (first 2 years):

Dactylitis

Record I&O including IV fluids

Childs weight should be taken on
admission to compare to baseline for
evaluating hydration
Be aware of signs of ACS and CVA
ACS signs:
Wheezing
Hypoxia
Chest pain
Fever
Cough
Tachypnea
CVS signs:
Neurological impairment
Paralysis
Vital signs & BP monitor closely for
impeding shock

Severe anemia
leukocytosis

Narcotics given around the clock

NURSING TIP: One simple yet

graphic way to demonstrate the effect of
sickling is to roll rounded objects, such as
marbles or beads, through a tube to
stimulate normal circulation and then roll
pointed objects such as screws or jacks,
through the tube. The effect of sickling
and clumping of the pointed object is
especially noticeable at bend or slight
narrowing of the tube

NURSING TIP: Advise patient to be

particularly alert to situations in which
dehydration may be a possibility, such as
hot weather, and to recognize early signs
of reduced intake such as decreased
urinary output (ei. Fewer diapers) and
increased thirst.

NURSING TIP: Report signs of the

following:

ACS Acute chest syndrome:

Sever chest, back or abdominal pain
Fever of 38.5 C (101.3 F)

Gastriurinary Disorders: Chapter 27 (5 questions)

Cough
Dyspnea, tachypnea
Retractions
Declining oxygen saturation
(oximetery)
CVA cerebrovascular accident
Severe unrelieved headaches
Severe vomiting
Jerking or twitching of the face, legs or
arms
Seizures
Strange, abnormal behavior
Inability to move an arm or leg
Stagger or an unsteady walk
Stutter or slurred speech
Weakness in the hands, feet or legs
Changes in vision

Disorder

Urinary
Tract
Infection

Pathophysiology

Predisposing Factors:
Short female urethra close to
vagina and anus
Incomplete emptying bladder,
they have stasis: allows any
bacteria that come from the
urethra to grow
Stasis of reflux, when the
child voids, urine backflows
up the ureters and then flows
back down into the empty
bladder. It sits in the bladder
and then bacteria from the
urethra grow and the next
time the child voids it
happens again, except that
now the urine that was in the
bladder goes into the ureters,
and can then go into the
kidneys.
Over distention of bladder
Concentrated urine
Constipation
E.coli 80%
The key to prevention UTI is to

Clinical
Manifestatio
n
Box 27-1

Neonatal Period
(birth-1month):

Poor feeding
Vomiting
Failure to gain

weight

Rapid respiration

(acidosis)
Respiratory distress

Spontaneous
pneumothorax or
pneumomomediast

inum
Frequent urination
screaming on

urination
Poor urine stream
Jaundice
Seizures
Dehydration
Enlarged kidneys or
bladder

Infancy (1-24

Nursing
Management
antibiotic therapy should be
administered once
pathogen is identified
Several antibiotics are
specifically used to treat
UTIs:
Penicillins
Sulfonamide
Cephalosporin
Nitrofurnatoion
Surgical correction for
primary reflux or bladder
neck obstruction
When a UTI is suspected
collect a specimen (cleanvoided specimen)
In infants and young children
suprapubic aspiration of
urine or sterile
catheterization should be
done in infants and young
children who are seen with
high fever
Increase fluid intake
Children who have recurrent

maintain adequate blood

supply to the bladder wall by
avoidance of over distention
and higher bladder pressure
NURSING ALERT: a child
who exhibits the following
should be evaluated for
UTI:
Incontinence in a toilet
trained child
Strong smelling urine
Frequency or urgency

NURSING TIP: Check the

diaper every half hour.
This increases the
opportunity for observing
the stream for such
findings as straining or
fretting before voiding
begins, signs of
discomfort before and
during urinating, starting
and stopping the stream
intermittently, and
frequent dripping of small
amounts of urine.

months)
Poor feeding
Vomiting
Failure to gain
weight
Excessive thirst
Frequent urination

Straining or
screaming on
urination
Foul-smelling urine
Pallor
Fever

Persistent diaper
rash
Seizures (with or
without fever)
Dehydration
Enlarged kidney and
bladder

Childhood (2-14
years)
Poor appetite
Vomiting
Growth failure
Excessive thirst
Enuresis,

incontinence,

UTI might be given low dose

antibiotics, given at
bedtime to allow the drug
to remain in the bladder.

Prevention:
Wipe front to back
Avoid tight clothing or
diapers; wear cotton
panties rather than nylon
Check for vaginitis and
pinworms, especially if child
scratches between legs.
Avoid holding urine;
encourage child to void
frequently, especially
before long trips or other
circumstances in which
toilet facilities are not
available
Empty bladder completely
with each void. Have the
child double void (void
wait a few minutes, and
void again). Severe cases
may require clean
intermittent catheterization
or biofeedback instruction
Avoid straining during

Nephrotic
Syndrome

Characterized by increased
glomerular permeability to
plasma protein, which results
in massive urinary protein

loss.

Rare in children younger than 6

months
Uncommon infants younger
than 1 year

Unusual after 8 years

Most common between 2-7
years of age
A loss of protein reduces the
serum albumin level

frequent urination
defecation and constipation
Painful urination
Encourage generous fluid
intake
Swelling face

Seizures

Pallor

Fatigue
Blood in urine
Abdominal or back
pain
Edema
Hypertension
Tetany (intermittent
muscle spasms)

Refer to chart
Refer to chart below
below

Edema
Complications:
Proteinuria
Rarely do children develop
Hypoalbuminemia
renal failure with oliguria
that significantly alters fluid
Hypercholestolemia
and electrolyte imbalance
in the absence of
resulting in hyperkalemia,
hematuria and HTN
acidosis, hypocalcaemia, or
Hallmark is
hyperphosphatemia
massive

Cerebral
complications
proteinuria
(higher than 2+ on
urine dipstick)
GFR is usually

Acute

Glomerulon
ephritis

(hypoalbuminemia),
decreasing colloidal osmotic
pressure in the capillaries.
As a result the vascular
hydrostatic pressure exceeds
the pull of the colloidal
osmotic pressure, causing
fluid to accumulate in the

interstitial spaces (edema)

and body cavities, particularly
in the abdominal cavity

(ascites).
Shift of fluid from the plasma
to the interstitial spaces
reduces vascular fluid
(hypovolemia), which in turn
stimulates the reninangiotensis system and the
secretion of antidiuretic
hormone and aldosterone
NURSING TIP: Another strategy
for obtaining a daily urine
protein is to place cotton balls
in the diaper at night before
bedtime and then squeeze
them out in the morning

May be a primary event or

manifested by a systemic
disorder

normal or high
Serum protein
concentration is
low
Serum albumin
significantly
reduced
Plasma lipids
elevated
Complications:
Circulatory
insufficiency
secondary to
hypervolemia and
thermo-embolism
Infections that may
be seen in children
with NS include:
peritonitis, cellulitis
and pneumonia
and require prompt
recognition

Refer back to
question 1 above
Oliguria

Treated at home if:

Urine output is ok

 Most cases are post-infection

and have been associated

with pneumococcal,

streptococcal, and viral

infection.

Can occur at any age

Affects early school aged

children with peak age onset
of 6-7 years
Uncommon in children younger
than 2 years

Can occur after a strep

infection with certain strains
Immune complexes are

deposited in the glomerular

basement membrane.

The glomeruli become

edematous and infiltrated

with polymorphonuclear
leukocytes, which occlude
capillary lumen

The resulting decrease in

plasma filtration results in an
excessive plasma and
interstitial fluid volumes,
leading to circulatory

congestion and edema.

HTN due to fluid retention and
renin production

Edema
BP is okay
HTN

Circulatory
Treated in a hospital if:
congestion
A lot of edema
Hematuria
HTN
Proteinuria
Gross hematuria

oliguria
Sometimes they
only have a history
of mild cold
Onset appears after
an average of 10
days
Urinalysis of acute
phase shows
Hematuria
Proteinuria
They usually both
parallel each other
3+ or 4 +
Gross discoloration
of urine reflects
RBC and
hemoglobin
content
Microscopic reveals
many RBC,
leukocytes,
epithelial cells, and

Wilms
Tumor

granular and RBC

casts
Bacteria is not seen
in urine

nephroblastoma
Abdominal swelling:
most common malignant renal Firm
and intra-abdominal tumor of Non-tender
childhood
Confined to one side
more commonly to occur in
(L)
African Americans
Hematuria (less
peak age of dx is 3 years
than one fourth of
probably arises from malignant
cases)
, undifferentiated cluster of
Fatigue and malaise

primordial cells capable of

HTN (occasionally)
intitiating the regeneration an Weight loss
abnormal structure
Fever

FAVORS the LEFT kidney.

Manifestations
Test used for diagnosis: X-ray,
resulting from
ultrasounds, CT, CAT scan,
compression of
bone marrow biopsy
tumor mass
STAGES OF WILMS TUMOR Secondary
Stage I: tumor is limited to
metabolic

kidney and completely

alteration from
resected
tumor or

Nursing Alert: To reinforce

the need for cautions post a
sign on the bed that reads:
DO NOT PALPATE
ABDOMEN. Careful
bathing and handling are
also important in
preventing trauma to the
tumor site
Once confirmed, surgery is
scheduled ASAP 24-48
hours upon admission
As a nurse it is important to
prep parents and children
within this 24-28 hour
period: simple, repetitive
and focused (not much
time)
BP is monitored because HTN
from excess renin
production is possible

 Stage II: tumor extends

beyond kidney but is
completely resected
Stage III: Residual nonhematogenous tumor is
confined to abdomen
Stage IV: heamatogenous
metastases; deposits are
beyond stage III, namely, to
lung, liver, bone and brain
Stage V: bilateral renal
involvement is present at
diagnosis

metastasis
Prep parents about
If metastasis
chemotherapy side effects
symptoms of lung
before surgery and children
involvement:
after; ie alopecia (hair loss)
Dyspnea
Tumor affected kidney and
adjacent adrenal gland are
Cough
removed
SOB
A large trans-abdominal
Chest pain
incision is performed
Great care is needed to keep
the encapsulated tumor
intact, because if ruptured
it can spread to abdomen,
lymph and bloodstream
Contralateral kidney is
carefully inspected for
evidence of disease or
dysfunction
Regional lymph nodes are
inspected
Biopsy performed when
indicated
Any involved structures are
removed
If both kidneys are involved,
then radiotherapy or
chemotherapy can be done
before surgery to decrease
the size of the tumor

 May be possible to perform a

partial nephrectomy on the
opposite side
Bilateral nephrectomy is
considered last resort if a
transplant donor is
available
The duration of therapy last
6-15 months
Post op care:
Nurse must carefully monitor
GI activity, because the
child is at risk for
vincristine-induced ileus,
radiation-induced edema,
and post surgical adhesion
formation
Bowel movement
Bowel sounds
Distention
Vomiting
Pain
Nurse must also monitor
BP
Urinary output
Signs of infections
Institutes pulmonary hygiene
to prevent postop
pulmonary complications

 Acute Renal When kidneys are suddenly

Specific:
Failure
unable to regulate the volume Oliguria
and composition or urine
Anuria uncommon
appropriately in response to
(except in
food and fluid intake
obstructive
The featured principal is
disorders)
oliguria, associated with
Nonspecific
azotemia, metabolic acidosis,
(may

Radiotherapy indicated for

children with large tumors
Chemotherapy for all stages
The duration of therapy
ranges from 6-15 months
Offer emotional support to
parents, the stage of the
tumor is confirmed at this
time
NURSING ALERT: Prompt
detection and treatment
of any genitourinary s/s
are mandatory. Children
with solitary kidney
should be assessed and
advised on the need for
protective equipment
before engaging in
contact, collision or
limited contact activities
Monitor fluid balance
Monitor vital signs 4-6 hours
Observe for complications
continuously
Blood transfusion is only
recommended if hgb drops
below 6g/dL
May require dialysis
Usually admitted to ICU,

and diverse electrolyte

disturbances

Not common in childhood

Usually reversible

Severe reduction of GFR, an

elevated BUN level, and

significant reduction in renal

blood flow
Clinical course is variable and
depends on cause
In reversible ARF, there is a
period of severe oliguria, or a
low-output phase, followed by
an abrupt onset of diuresis, or
a high-output phase, and then
a gradual return (or toward)
normal urine volumes
In many cases the infant or

child is already critically ill

with precipitating disorder,
and the explanation for

development of oliguria may

or may not be readily
apparent
Diminished urinary output and
lethargy in a child who is
dehydrated, is in shock, or

develop):
Nausea
Vomiting
Drowsiness
Edema
HTN

Manifestation
s of
underlying
disorder or
pathologic
condition

Complication
s:
Hyperkalemia: No
extra K+

HTN:
antihypertensive
drugs
Anemia:
transfusion only

recommended if
hgb is below 6 g/dL

Seizures:
antiepileptic drugs

because they require

intensive care.
Limiting fluid intake requires
ingenuity on the caregiver
to cope with the child that
is really thirsty
Rationing the daily fluid
intake in small amounts of
fluid served in containers
that give the impression of
larger volumes is one
strategy.
Older children who
understand the rationale of
fluid limits can help
determine how their daily
ration should be.
When nourishment is
provided via IV route,
careful monitoring is
important to prevent fluid
overload.
Maintaining optimal thermal
environment
Reducing any elevation of
body temperature
Reducing restlessness and

has recently undergone

surgery should be evaluated

for possible ARF
NURSING ALERT:
Diminished urinary output
and lethargy in a child
who is dehydrated, is in
shock, or has recently
undergone surgery should
be elevated for possible
ARF.
NURSING ALERT: Any of the
following signs of

hyperkalemia constitute
an emergency and are
reported immediately

Serum K+
concentrations in

excess of 7 mEq/L

Presence of
electrocardiographic

abnormalities, such as
prolonged QRS
complex, depressed ST
segment, high peaked T
waves, bradycardia or
heart block

anxiety are used to

Cardiac failure: r/t
decreased the rate of tissue
hypervolemia, tx
catabolism
by reducing fluid
volume, with water Children = anxious and
frightened
and sodium
Infants = restless and
restriction and
irritable
administration of
If the child is able to
diuretics
tolerate food, you want
QUALITY
high carbohydrates, high
PATIENT
fat, and low protein.
OUTCOMES: During oliguria phase =
no sodium, chloride, or
Underlying cause of
potassium, unless there
ARF identified and
are other larger, ongoing
treated
loses
Water balance

maintained
HTN controlled
Provide dietary that
Electrolyte balance
provides sufficient
maintained
calories and protein
Diet maintains

calories while
Limit phosphorous, salt
minimizing tissue
and potassium
catabolism,

Observe for evidence

metabolic acidosis,
hyperkalemia, and
of accumulated waste

uremia
Significant lab
measurements
during renal
shutdown that
serve as a guide
for therapy are
BUN, serum
creatinine, pH,
sodium, potassium,
and calcium.

products

Encourage intake of
carbs and foods high in
calcium

nifestation

Clinical

Nephrotic
Syndrome

Box 27-2 pg 914

Weight gain
Puffiness of face
(facial edema)
Especially around
the eyes
Apparent on
arising in the
morning
Subside during
the day
Abdominal
swelling (ascites)
Pleural effusion
Labial or scrotal
swelling
Edema of
intestinal
mucosa, possibly
causing:
Diarrhea
Anorexia
Poor intestinal
absorption
Ankle or leg

Acute
glomerulonephr
itis
Box27-3 pg 915
Edema
Especially
preorbital
Facial edema
more prominent
in the morning
Spreads during
the day to
involve
extremities and
abdomen
Anorexia
Urine
Cloudy, smoky
brown
(resembles tea
or cola)
Severely
reduced volume
Pallor
Irritability
Lethargy
Child appearing
ill

swelling
Irritability
Easily fatigued
Lethargic
BP normal or
slightly decreased
Susceptibility to
infection
Urine alterations:
Decreased
volume
Frothy (full of
mass around
mucous)
General Info:
Nephrotic
syndrome is a
clinical stat that
includes massive
proteinuria,
hypoalbuminemia
, hyperlipiidemia
and edema

Child seldom
expresses
specific
complaints
Older children
complaining of
Headaches
Abdominal
discomfort
Dysuria
Vomiting
possible
Mild to severely
elevated blood
pressure

Nutritional Therapy:

Low-salt diet
Severe cases = fluid

Moderate sodium
restriction and
fluid if child has
HTN and edema


Nursing
Management

restriction

Edema complications =
diuretic therapy initiated to
provide temporary relief

from edema
Due to severe protein loss =
infusion 25% of albumin is
used
Acute infections = tx with
antibiotics

st
1 line of therapy =
corticosteroids
Starting dose for
prednisone is usually 2
mg/kg/day for 6 weeks;
followed by 1.5 mg/kg
every other day for 6 weeks
Side effects: weight gain,
rounding of face, behavior
changes, and appetite
changes. Long term:
hirsutism, growth
retardation, cataracts, HTN,
gastrointestinal bleeding,
bone demineralization,
infection & hyperglycemia.
About 2/3 of children have a

During periods of
oliguria K+ is
restricted
A record of
daily weight is
the most
useful in for
assessing fluid
balance
Acute HTN is
anticipated and
identified early
BP is taken 4-6
hours; HTN and
diuretics are
used
Antibiotics used to
treat children
with evidence of
strep infection,
to help with
spreading it to
others
Note volume and
character of
urine

relapse
Children with fluid
Monitor fluid retention and
restriction,
excretion (I&O)
especially those
Collection bags (but its
with severe
irritating to skin)
edema, or those
Applying diapers or
who have lost
weighing wet pads may be
weight are
necessary
observed for
Place cotton balls in diaper
signs of
at night before bedtime and
dehydration
then squeeze them out in Assessment of
the morning)
appearance for
Urine samples of albumin
signs of cerebral
Daily weight
complications
Measurement of abdominal
If a child has
girth (middle abdomen)
edema, HTN and
Assessment of edema (ie,
gross hematuria
increased or decreased
they may be
swelling around the eyes and
subject to
dependent areas); degree of
complications;
pitting, and the color and
therefore,
texture of skin are part of
seizure
nursing care
precautions and
Vital signs monitored to detect
IV equipment
any early signs of
should be
complications such as shock
included in care
or an infective process

 Because they are on

corticosteroids they are at

risk for infections (especially
URI); therefore child must be
kept warm and dry, active
and protected from contact
with infected individuals.
Vital signs monitored to
detect early signs
Appetite is lost, so the nurse
with the help of others needs
to formulate an attractive
diet for child, with minimal
salt during the edema phase,
and while the child is on
steroid therapy. You want to
serve foods that the child
likes, because remember you
want them to eat!!!! Just
dont add salt (or very
minimal
Fluid restriction is limited to
short-term use during
massive edema
Help them find activities that
they like; steroids cause

plan.
No added salt in
diet
If fluid restriction
is prescribed, the
amount should
be evenly
divided
throughout the
waking hours
Activities should
be planned to
allow for
frequent rest
periods and
avoidance of
fatigue
Teach parents how
to treat edema
and how to care
for child at home
Health supervision
is continued
throughout the
week followed by
monthly visits for
urinalysis

irritability and moods swings

Teach parents
How to detect signs of
relapse and to call for
changes of treatments
How to test the urine for
albumin
Administer medication
Provide general care
Child needs to stay away
from infected individuals at
school
Unless, protein in urine is
severe or parents are not
able to care for child, home
health care is preferred

evaluation

Increased intercranial Pressure: Chapter 28

Chapter 28: Child with Cerebral Dysfunction 6 Questions

Clinical Manifestations of ICP (box 28-1)

Infants:

Tense, bulging fontanel

Separated cranial sutures-enlarged head *
Macewen (cracked-pot) sign
Irritability and restlessness *
Drowsiness

Increased sleeping
High pitched cry *
Increased frontoocipital circumference
Distended scalp veins *
Poor feeding *

 Crying when disturbed

Eyes: setting-sun sign *
Children:
Headache *
Decline in school performance
Nausea (sometimes) *
Diminished physical activity and motor performance
Forceful vomiting *
Increased sleeping
Diplopia, blurred vision *
Inability to follow simple commands
Seizures *
Lethargy
Indifference, drowsiness
Late S/S in infants and children

Glasgow Coma Scale:

Coma assessment that consists of 3-part assessment eye opening, verbal response and motor response
A score of 15 is the best unaltered level of consciousness (LOC)
A score of 3 is the worse score- extremely decrease LOC

Neuro Examination:
Vital Signs
Skin
Eyes:
Doll Head Maneuver:
Rotate the childs head quickly to one side and to the other.
Normal response: eyes move in the opposite direction
Caloric test (aka oculovestibular test):
Only do when child is unconscious
Irrigate the external auditory canal with 10ml of ice water for 20 seconds
Elicited with childs head up (HOB 30 degrees)
Normal response: movement of eyes toward the side of stimulation
NURSING ALERT(S)
The sudden appearance of a fixed and dilated pupil(s) is a neurologic emergency
Any tests that require head movement are not attempted until after cervical spine injury has been ruled out
The caloric test is painful and is never performed on a child who is awake or on an individual with a ruptured tympanic
membrane

Motor Function
Posturing:
Flexion
Extension
Reflexes:
NURSING ALERT
3 key reflexes that demonstrate neurologic health in young infants are the: Moro, tonic neck and withdrawal reflexes
Procedures:
Lumbar puncture is contraindicated when there is a suspicion of ICP
Nursing Care of the Unconscious Child
Emergency measures are directed toward ensuring
o Patent airway (breathing) and circulation
o Treating shock (stabilizing the spine)
o Reduce ICP
Continual observation of LOC
DRUG ALERT:
When opioids are used, bowel elimination must be closely monitored because of the potential constipating effect. Stool
softeners should be given with laxatives as needed to prevent constipation
NURSING ALERT
o Respiratory obstruction and subsequent compromise leads to cardiac arrest. Maintaining an adequate, patent
airway is of the utmost importance
NURSING ALERT:
o The HOB is elevated to 30 degrees, and the child is positioned, so that the head is maintained in midline to
facilitate venous drainage and avoid jugular compression. Turning side to side is contraindicated because of the
risk of jugular compression.

Hypoxia and the Valsalva maneuver can increase ICP

Suctioning in contraindicated, unless it is necessary; Make sure it is brief and preceded by hyperventilation with 100%
O2. If suctioning, oxygenate prior to suctioning. Suctioning should be brief. Increase in intrathoracic abdominal pressure
will be transmitted to the cranium. Avoid neck vein compression
Make sure to watch for overhydration, it can cause cerebral edema

Antipyretic agents are usually not effective, therefore external cooling should be used, which consists of evaporation
(sponge baths), conduction (ice packs, cooling blankets), convection (fans), and radiation (skin exposure)
Mouth care is performed at least 2X a day, because the mouth tends to get dry coated with mucus. Clean teeth with soft
toothbrush or clean with gauze-saturated saline. Chap stick for lip (make sure it is not an oil based product.
NURSING ALERT:
o The eyes should be examined regularly and carefully for early signs of irritation or inflammation. Artificial tears
or a lubricating ointment is placed in the eyes every 1-2 hours. Eye dressings may be necessary to protect
the eyes from possible damage

HEAD INJURY:
3 major causes: Falls, Motor Vehicle Injuries and Bicycle or sports related injuries
Contrecoup = know that a child can have injury on the opposite side of injury

Clinical Manifestations (BOX 28-3)

Minor Injury:
May or may not lose consciousness
Irritability
Transient period of confusion
Pallor
Somnolence
Vomiting (one or more episodes
Listlessness
Signs of progression:
Altered mental status (difficulty arousing
Development of focal lateral neurologic signs
child)
Marked changes in vital signs
Mounting agitation
Sever Injury:
Signs of increased intracranial pressure (box
Hemiparesis
28-1)
Quadriplegia
Bulging fontanel (infant)
Elevated temperature
Retinal hemorrhages
Unsteady gait
Extraocular palsies (especially CNIII)
papilledema
Associated Signs
Scalp trauma

Other injuries (to extremities)

Major complications of Heady Injury

Hemorrhage
Infection
Cerebral Edema
Herniation
Bradycardia
Decreased motor response to command
Decreased sensory response to painful stimuli
Alterations in pupil size and reactivity
Extension or flexion posturing
Cheyne-Strokes respiration
Papilledema
Decreased consciousness
Comma

NURSING ALERT (S)

Posttraumatic meningitis should be suspected in children with increasing drowsiness and fever who also have basilar
skull fractures
Children with subdural hematoma and retina hemorrhages should be evaluated for the possibility of child abuse,
especially shaken baby syndrome
Stabilize a childs spine after head injury until spinal cord injury is ruled out
Deep, rapid, periodic or intermittent and gasping respirations; wide fluctuations or noticeable slowing of the pulse: and
widening pulse pressure or extreme fluctuations in BP are signs of brainstem involvement.. Note that the marked
hypotension may represent internal injuries
Observation of asymmetric pupils or one dilated, nonreactive pupil in a comatose child is a neurologic
emergency
Bleeding from the nose or ears needs further evaluation, and watery discharge from the nose (rhinorrhea) that is
positive for glucose (as tested with Dextrostix) suggest leaking of CSF from skull fracture

Nursing Considerations/Treatment
NPO or restricted to clear liquids, until vomiting does not occur

IV fluids for comatose child, or continuously vomiting

Daily weight
I&Os
Serum osmolality to detect early s/s of: H2O retention, excessive dehydration, and states of hypertonicity or hypotonicity
Neurological assessment, most important is LOC assessment; try to have by one single observer, so they can
notice any slow changes
Safety Measures: side rails up, seizure precautions
Provide a quiet environment
Provide sedation and analgesic for child
Report any seizure
Document drainage of any orifice
Suture for lacerations
Antiepileptic for seizures
Antibiotics if lacerations or CSF leakage

NURSING ALERT:
Suctioning through the nares is contraindicated because of the risk if the catheter entering the brain parenchyma
through a fracture in the skull
Teaching
Check child every 2 hours, if child is asleep wake them up
s/s of increased ICP
no narcotics or pain medication, report HCP
Vomiting could be a sign of ICP, contact HCP

Bacterial Meningitis
Prevention:
Immunization of Hib
Nursing Consideration:
Keep room quiet
Keep environmental stimuli to a minimum
HOB slightly elevated
Side lying positioning

Evaluate for pain (acetaminophen with codeine); Careful to evaluate patient for a fever before administration, because
this can the fever go away and a fever is an indicator of infection
Vital signs
Promote adequate fluid and nutritional status
Observation of VS, neurological signs, LOC, I&Os
Frequent assessment of open fontanels
Maintaining IV infusion for antibiotic therapy
Isolation Precautions
NURSING ALERT:
A major priority of care of a child suspected of having meningitis is to administer antibiotics ASAP. The child is
placed on respiratory isolation for at least 24 hours after initiation of antimicrobial medication

Endocrine System: Chapter 29 (5 questions)

Type 1: destruction of pancreatic beta cells, which produce insulin; this

usually leads to absolute insulin deficiency.
o Abrupt onset
o <20 years
o 3Ps: polyuria, polydipsia, polyphagia and underweight; others: blurred
vision and fatigue
Type 2: usually arises because of insulin resistance in which the body fails
to use insulin properly combined with relative (rather than absolute) insulin
deficiency
o Gradual onset
o Adults, but increasing in children
o Presenting symptoms may be r/t long term complications, overweight
Nursing Considerations/Treatment
Type 1 replacement of insulin that the child can not produce
Types of insulin:
o Rapid acting: (Novolog, Lispiro)
Onset 15 minutes
Peak 30-90 min
Duration
o Short aciting (Novolin R.)
Onset 30 min
Peak 2-4 hours
Duration
Administer 30 mintues before meals
o Intermediate-acting (Novolin NPH)
Onset 2-6 hours
Peak 4-14 hours
Duration 14-20 hours
o Long-acting (Lantus)
Onset 6-14 hours
Peak 10-16 hours (no peak)
Duration All day
Nursing Consideration/Treatment:
NURSING ALERT:
Hypoglycemic episodes most commonly occur before meals or when the
insulin effect is peaking
Hypoglycemic s/s: pallor, tremulosness, palpations, , sweating, hunger,
weakness, dizziness, headache.etc REMEMBER cold and clamy give some
candy
o Give a 10-15 g simple carb (1 TBS of sugar) , followed by a complex
carb and a protein (slice of bread or cracker and protein such as PB or
milk
Glucagon functions by releasing stored glycogen from the liver and requires
about 15-20 minutes to elevate the blood glucose levels
o
Teaching
Timing of food consumption must be regulated to correspond to the timing
and action of the insulin prescribed
Extra food is needed for increased activity

Concentrated sweets are discouraged

Fat is recommended to be reduced to 30% or less of total caloric requirement
Intake of dietary fiber
Exercise lowers blood glucose levels, if exercised is unplanned one can
compensate by providing extra snack. If person is exercising consistently
then insulin can be reduced

Integumentary System: Chapter 30 (3 questions)

Relief of pruiurits by cooling the affected area and increasing the skin pH with
cool baths or compresses and alkaline applications (baking soda baths)
Clothing and bed linen should be soft and lightweight to decrease the irritant
from friction and stimulation
Keeping fingernails short and trimmed reduce the risk for secondary infections
Antipyretic medications can be prescribed for sever itching, especially if it
disrupts rest
NURSING ALERTS
Application of heat tends to aggravate most conditions and its use is usually
reserved for reducing inflammatory process, such as folliculitis and cellulitis
Signs of wound infections are
o Increased erythema,
o Purulent exudate
especially beyond the
o Pain
would margin
o Increased temperature
o Edema
o
Do not put anything in a wound that you would not put in an eye. The safest
solution is normal saline
Advise parents that the yellow gel forming under hydrocolloid dressings may
look like pus and has a distinct odor (somewhat fruity) but is normal leakage
Provide written instructions and demonstrate to parent the correct amount of
topical medication to apply. If more than one prescription is applied, mark the
containers with numbers so the parents remember the correct order of
application. Stress that more is not necessarily better with some medications
such as steroids
IV drugs are more likely to cause a reaction than oral drugs, Stop the drug but
maintain the infusion with normal saline

Neuroskeletal System: Chapter 31 (2 questions)

Immobilization:

Inactivity leads to a decrease in the functional capabilities of the whole body

as dramatically as the lack of physical exercise leads to muscle weakness
Most of the pathological changes that occur during immobilization arise from
decreased muscle strength and mass, decreased metabolism, and bone
demineralizations
The daily stress on bone created by motion and weight bearing maintain the
balance between bone formation and reabsorption
Nursing Care/ treatment
Systems that can be affected secondarily circulatory, respiratory, renal,
muscular, GI systems
With long-term immobilization there may be neurological impairment, and
changes in electrolytes (especially calcium), nitrogen balance, and the general
metabolic rate
Prevent skin breakdown placed on a pressure-reduction mattress to prevent
skin breakdown,
Can use the Braden Q scale in the assessment for pressure ulcer development
for children at risk for kin breakdown
Antiembolism stockings or intermittent compression devices
Anticoagulant therapy
Diet: high protein, high caloric foods are encourage to prevent negative
nitrogen balance if there is anorexia due to decrease in GI mobility
Nasogastric or gastrostomy feedings or IV fluids may be needed to maintain
nutrition
When possible upright position
Have child associate with others by increasing environmental stimuli and
allowing social contact with others
Use dolls or stuffed animals to illustrate and explain immobilization methods
Have them participate in their own care

Growth Plate (Physeal) Injuries

It is the weakest point of the cartilage; therefore it is a frequent site of

damage during trauma. It is important because it may affect future bone
growth.
Clinical Manifestation (BOX 31-2)
Signs of injury:
Generalized swelling
Deformity
Pain or tenderness
Diminished functional use of
affected limb or digit
May also demonstrate:
Bruising
Crepitus (grating sensation at a
fracture site)
Severe muscular` rigidity
NURSING ALERT
A fracture should be strongly suspected in a small child who refuses to walk or
crawl
Nursing Consideration/Treatment

Goal:
o To regain alignment and length of the bony fractures (reduction)
o To retain alignment and length (immobilization)
o To restore function to the injured parts
o To prevent further injury and deformity
Fractures are splinted or casted to immobilize and protect the injured
extremity
EMERGENCY TREATMENT (pg. 1059):
o Determine the mechanism of injury
o Assess the 6Ps
o Move the injured part as little as possible
o Cover open wounds with sterile or clean dressing
o Immobilize the limb, including joints above and below the fracture
site; do not attempt to reduce the fracture or push protruding bone
under the skin.
o Use a soft splint (pillow or folded towel) or rigid splint (rolled
newspaper or magazine)
o Uninjured leg can serve as a splint for leg fracture if no splint is
available
o Reassess neurovascular status
o Apply traction if circulatory compromise is present
o Elevate the injured limb if possible
o Apply cold to the injured area
o Call emergency medical services or transport to medical facility
NURSING ALERT:
Compartment syndrome is a serious complication that results from
compression of nerves, blood vessels, and muscle inside a closed space. The
injury may be devastating, resulting in tissue death, and this requires
emergency treatment (fasciotomy). The 6Ps of ischemia from a vascular, soft
tissue, nerve, or bone injury should be included in an assessment of any
injury:

o
o
o
o
o
o

Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Pressure

The Child in a Cast

Cast Application:
Consider the childs developmental stage before
o Preschool: use a plastic doll or stuffed animal to explain procedure
o Let them know what to expect: like that it will get warm during
application
o Use distracting methods: like blowing bubbles, asking them questions
that focus on them etc
Turn child every 2 hours to help dry body cast evenly
Support a plaster cast with a pillow, and handle with palms of hands
Hot spots felt or foul smelling odor can indicate infection

NURSING ALERTS:
Heated fans or dryers are not used because they cause the cast to dry on the
outside and remain wet beneath or cause burns from heat conduction by way
of the cast to the underlying tissue
Observations such as pain (unrelieved by pain medication 1 hour after
administration, especially with passive ROM), swelling, discoloration (pallor,
cyanosis) of the exposed portions, decreased temperature, paresthesia, or the
inability to move the distal exposed part(s) should be reported ASAP. Pallor,
paralysis, and pulselessness are late signs.
LOOK at Family Centered Care-Cast Care PG 1061
Feeding a child in a hip-spica cast supine with head elevated;
Children in spica cast usually find prone position easier for self feeding
Cast Removal
Explain what the child should expect, tickling sensation and heat may be felt.
Reassurance that it will be okay, let them keep cast at the end (if they want
to)
Teach them that they can use mineral oil or lotion to remove particles left
behind.

evelopmental Dysplasia of the Hip:

A spectrum of disorders related to abnormal development of the hip that may
occur at any time during fetal life, infancy or childhood.
Diagnostic Testings (LOOK at pg 1069):
Ortonali
o Involves abducting the thighs to test for hip subluxation or dislocation
o With clunk elicited (infants < 4 weeks)
o Positive test hip reduced by abduction
Barlow Test
o Thighs are adducted
o Positive test hip is dislocated by adduction

Clinical Manifestations:
Infants
Asymmetry of gluteal and thigh
Shortening of the limb on the
folds
affected side
Limited abduction (as seen in
Broadening of the perineum (in
flexion)
a bilateral dislocation)
Apparent shortening of the
Decreased hip abduction
femur (level of knee flexion)
Older Infants:
Affected leg appears shorter than the other
Telescoping or piston mobility of joint-head femur felt to move up and down in
buttock when extended thigh is pushed first toward childs head and then
pulled distally
Trendelenburg sign-When child stands first on one foot and then on the
other (holding onto a chair, rail) bearing weight on affected hip, pelvis tilts
downward on normal side instead of upward, as it would with normal stability
Greater trochanter prominent and appearing above a line from anterosuperior
iliac spine to tuberosity of ischium
Marked lordosis and waddling gait (bilateral hip dislocation)

 Nursing Consideration/Treatment
Major problem is the maintenance of the device and adaptations with child
and/parent
NB-6months
Pavlik Harness,
o Hip in an abducted, reduced position
o Worn continuously until the hip is proved stable on clinical and
ultrasound examination, usually for 6-12 weeks
o Since infants grow rapidly, the straps should be checked weekly for
adjustments (parents are not allowed to adjust it)
o Removing depends on the providers recommendation, which will be
based on the deformity and family level of understanding
o Skin care to prevent breakdown are very IMPORTANT
Always put on undershirts (or a shirt with extension that close
at the crotch) under the chest straps and put knee socks under
the foot pieces to prevent the straps from subbing the skin
Check frequently (at least 2-3X a day) for red areas under the
straps and the clothing
Gentle massage healthy skin under the straps once a day to
stimulate circulation, In general avoid lotions and powders,
because they can cake and irritate the skin
Always place the diaper under the straps
Other devices are used for adduction contracture is present
When there is difficulty maintain stable reduction, a hip spica cast is used and
changed periodical to accommodate the childs growth.
Duration of treatment on the development of the acetabulum, but is usually
accomplished within the 1st year
6-24 months
Surgical closed reduction is performed
Spica cast for almost 12 weeks OR a abduction orthosis may be used
Open reduction is performed if hip remains unstable
Older Children
More difficult to accomplish in this age group, the older the child gets the
harder it is to reconstruct
Requires several procedures, and complete reconstruct
NURSING ALERT:
The former practice of double or triple diapering for DDH is not recommended
because there is no evidence to support its efficacy.

Clubfoot

A complex deformity of the ankle and foot that includes forefoot adduction,
midfoot supination, hindfoot varus, and ankle equinus
Nursing Consideration/Treatment
Goal is to achieve: painless, plantigrade, & stable foot
Ponseti method; Serial casting is stared right after birth
Weekly gentle manipulation and serial long-leg cast allow for gradual
repositioning of the foot.
Extremities are casted until maximum correction is achieved can take 6-10
weeks
Then tenotomy is performed

Then long-leg cast is performed and left for 3 weeks

Ponseti sandals or straight-laced shoes placed in abduction are then
fitted to prevent recurrence
Inability to achieve normal foot alignment after casting and tenotomy
indicates the need for surgical intervention

Parent Teaching:
Understand the importance of regular cast changes, and the role they play in
the long-term effectiveness of the therapy
Teach parent care of the cast appliances

Osteogenesis Imperfecta
Osteoporosis syndrome in children
Heterogeneous inherited disorder of connective tissue
Defective periosteal bone formation and reduced cortical thickness of
bones

Nursing Consideration/Treatment
Primarly supportive
Bisphiosphonate therapy with IV pamidronate to promote increased bone
density and prevent fractures has become standard therapy for many children
(however, long bones are weekend by prolonged treatment
Lightweight braces and splints help support limbs, prevent fractures and help
to get around
Physical therapy
Surgery to treat manifestations

Parent Teaching
Require careful handling to prevent fractures: supported when being turned,
positioned, moved, held. Never hold by the ankles when diapered, instead lift
by the buttocks or support with pillow
Education regarding childs limitation, and suitable activities
Occupational planning
Genetic counseling
NURSING ALERT:
Children with multiple fractures should be screened for OI. The possibility that
non-accidental trauma is the cause of the fracture in children must be
carefully elevated by a multidisciplinary team

Slipped Capital Femoral Epiphysis

Spontaneous displacement of the proximal femoral epiphysis in a posterior

and inferior direction
Develops before or during accelerated growth (puberty)
Clinical Manifestation (BOX 31-8)
Very often obese (body mass index >95%)
Limp on affected side
Possible inability to bear weight because of sever pain

Pain in groin, thigh or knee

o May be acute, chronic or acute-on-chronic
o Continuous or intermittent
Affected leg is externally rotated
Loss of abduction and internal rotation as severity increases
Shortening of lower extremity
Nursing Consideration
Non-weight bearing to prevent further slippage
Surgery within 24 hours of dx (depends on the surgeon
Surgical pinning in situ involves the placement of a single pin or multiple pin s
and scres through the femoral neck osteotomy for deformity
Hip arthroscopy before situ pinning in shown to decrease pain and allow early
hip movement
Postsurgical care includes NON-WEIGHT bearing with CRUTCH AMBULATION
until painless ROM
Postop care involves hemodynamic stabilization and assessment for
complication
NURSING ALERT:
Children with hip issues such as Legg-Calve-Perthes or SCFE often present
with groin, thigh or knee pain. This is often because of referred pain and is
anatomically related to the obturator nerve. Any time a child presents with
groin, thigh, or knee pain a complete hip examination is paramount to rule out
underlying hip pathology

Osteomyelitis

Infectious process in the bone tissue

Can be caused by hematogenous sources and exogenous sources

Clinical Manifestations
General
o Possible history of
o Restlessness
trauma to affected bone
o Elevated Temperature
o Child appears very ill
o Rapid Pulse
o Irritability
o Dehydration
o
Local
o Tenderness
o Involved extremity held
o Increased warmth
in semi flexion
o Surrounding muscles
o Diffuse swelling over
tens and resistant to
involved bone
passive movement
o Involved extremity
painful, especially on
movement
o
o Nursing Consideration/Treatment
Collect culture
Start empiric antibiotics
When the infectious agent is identified, continue antibiotic treatment for 3-4
weeks (6 wks-4 months sometimes)
Monitor hematologic, renal, hepatic, ototoxic side effects

To prevent antibiotics-associated diarrhea in some children, administer a

probiotic
Position comfortably with affected limb supported
Temporary splint or cast may be applied
Avoid weight-bearing in the acute phase
Child may require long-term pain medication to deal with bone pain
Carful observation of IV equipment and site (PICC line can be inserted for long
term antibiotics)
Implement standard precautions: wound care to prevent infection
Provide child with activities for those confined to bed for some time during the
acute phase, but may be allowed to move on a stretcher or wheelchair if
isolation is not necessary. Mainly the child will have complete bed rest and
immobility of limb
o
o
o

Juvenile Idiopathic Arthritis (Juvenile Rheumatoid

Arthritis)

A chronic autoimmune inflammatory disease causing inflammation of joints

and other tissue with an unknown cause
Chronic inflammation of the synovium with joint effusion and eventual erosion,
destruction, and fibrosis of the articular cartilage
Chronic and acute uveitis can cause permanent vision loss if undiagnosed
and not aggressively treated; Uveitis is unique to JIA
o
o Clinical Manifestations
Arthritis tends to wax and wane
Loss of mobility in affected
(increase and then decrease);
joints
s/s increase with stressors
Warm to touch, usually
Joint deformity
erythema
Functional disability
Tender to touch in some cases
Stiffness
Growth retardation
Swelling


Nursing Consideration/Treatment
GOAL: control pain, preserve joint ROM, minimize effects of inflammation
such as joint deformity and promote normal growth and development
Drugs therapy (opioid analgesics are usually avoided):
o NSAIDs
Teach parent not to give on an empty stomach
o Methotrexate (in combination with NSAIDs)
Monitor CBC and liver function
Patient education on birth defects
Teach teens to avoid alcohol
o Corticosteroids
PO, IV, eye drop for UVEITIS
Teach about long term effects: Cushing syndrome, osteoporosis,
increased infection risk, glucose intolerance, cataracts and
growth suppression
o Biologic agents
Teach about Side effects: increased risk for infection, rare
reports about demyelinating disease and pancytopenia, and
allergic reaction
Because of the infection risk, evaluate child for TB exposure
Physical and Occupational Therapy
Caloric intake needs to match energy needs to avoid weight gain, if child is
inactive
Sleep and rest
Firm mattress, electric blanket, or sleeping bag helps provide warmth, comfort
and rest
Nighttime splints to help maintain ROM (splint should not be painful or impede
sleep)
Well-child care to assess growth, development, and immunization
requirements needs to be coordinated between the primary care provider and
rheumatologist
Seek medical attention ASAP for other illnesses (like URI) to prevent arthritis
flare ups
School nurse should be aware, and notified of childs condition (child needs to
take medication and, come in to rest if needed)
A formal school hearing may be necessary to obtain an Individualized
Education Program, ensured by public law, which includes intensive school
modifications
Moist heat is best for relieving pain and stiffness
Bathtub with warm water
Also daily whirlpool bath, paraffin bath or hotpacks prn for acute swelling and
pain
hotpacks applied using a bath towel wrung out after being immersed in hot
water or headed in a microwave oven-apply to area and cover with plastic for
20 minutes
painful hands or feet can be immersed in a pan of warm water for 10 minutes
2-3 X daily
pool therapy best and easiest for exercise
You want the child to perform ADLs on their own; therefore, advise to use
helpful devices, self-adhering fasteners, tongs for manipulating difficult

objects, grab bars installed in bathrooms for safety, and raised (higher) toilet
seat
Parent Teaching
Begin the day by waking up the child early, administering medication and
then letting them sleep for an hour
Take a hot bath (or shower)
Perform a simple ritual of limbering-up-exercise
Exercise, heat and rest are spaced throughout the day

 Neuromuscular System: Chapter 32 (4 questions)

Cerebral Palsy:
Group of permanent disorders of the development of movement and posture, causing activity limitation, that are
attributed to non-progressive disturbances that occurred in the developing fetal or infant brain
Other medical disorders associated: mental impairment, seizures or epilepsy, growth problems, impaired vision or
hearing and abnormal sensation or perception
Many develop the condion during prenatal development or childbirth, very few afterwards

Nursing Considerations/Treatment
Supportive
Since jaw control in often compromised, more normal control can be achieved if the feeder provides
stability of the oral mechanism from the side or front of face
Safety precautions are implemented, such as having child wear protective helmets if they are subject to falls or capable
of injuring their heads on hard objects
Home and environment should be adapted to their need to prevent bodily harm
Administer appropriate immunizations to prevent childhood illnesses and protect against respiratory infection: influenza,
pneumonia
Dental problems, dental care is very important
Federally approved safety restraint should be used at all times in cars, and recommended for them to ride in the back of
car in a rear facing position
Physical, speech and occupational therapy
Use devices that will help with ADLs, and make sure the patient does as much as possible. Since they might get tired
offer frequent rest periods.
Nursing Alert:
Mobile infant walkers are discouraged in children with CP. They pose a risk for injury

Spina Bifida:
Midline defects involving failure to the osseous (bony) spine to close
Can be prevented if the mother takes folic acid (should be taken by all females of who are capable of getting pregnant

Nursing Consideration/Treatment
Assess infant for level of neurological involvement

Movement of extremities or skin response, especially an anal reflex that might provide clues to the degree of motor or
sensory impairment
Observation of urinary output
Abdominal distention revealing bladder distention
The head circumference is measured daily and the fontanels are examined for sings of tension or bilging
Infant is placed in an incubator or warmer so temperature can be maintained without clothing or covers that might
irritate the spinal lesion
When an overhead warmer is use, dressings over defect requires more moistening, because of the dehydrating effects of
radiation heat
Sterile normal saline, moist, nonadherent dressing over defect
Sac must be carefully cleansed if it becomes soiled or contaminated
Positioning the child is important; the child must be kept in the prone position to minimize tension on the sac and
the risk for trauma; prone with hips slightly flexed and supported to reduce tension on the defect. Put a pad between the
knees to counteract hip subluxation
Turn infants head for feedings
Prone position is maintained after surgical closure, although many neurosurgeons allow a side-lying or partial side lying
position
Children with SB are at high risk for developing latex allergies, because of repeated exposure to latex products during
surgery and procedures-need a latex free enviornment

NURSING ALERT:
Observe for early signs of infection, such as temperature instability (axillary), irritability, and lethargy, and for signs of
increased intracranial pressure, which might indicate developing hydrocephalus.

Duchenne Muscular Dystrophy

Most severe and most common muscular dysfunction in childhood
Inherited as an X-linked recessive trait and the single-gene defect
High mutation rate with a positive family history in 65%
Genetic counseling
Early onset, usually between 3-7 years of age
Progressive muscular weakness, wasting and contractures
Calf muscle hypertrophy in most patients
Loss of independent ambulation by 6-12 years of age

 Slowly progressive, generalized weakness during teenage years.

Clinical Manifestations:
Relentless progression of muscle weakness, possible death from respiratory or cardiac failure
Waddling gait
Lordosis
Frequent falls
Gower sign: child turns onto side or abdomen; flexes knees to assume a kneeling potions; and then with knees
extended, gradually pushes torso to an upright position by walking the hands up the legs
Enlarged muscles especially calves, thighs and upper arms; feel usually firm or woody on palpation
Later stage: profound muscular atrophy
Mental deficiency
Complications:
o Contracture deformities of hips, knees, and ankles
o Disuse atrophy
o Cardiomyopathy
o Obesity and at times under nutrition
o Respiratory compromise and cardiac failure

EXAM 4 child ?
drink milk if shaky, dizzy
chicken legSIADH
lay supine after a shunt
candida albicansanal lesions and redness.
inflamed jointsleg calve
dont give Aspirin to varicella/chickenpox child
DDH select all that apply 3 answers
osteogenesis imperfecthomeschool child to prevent injury
Seizure meds-dont abruptly stop