PEDIATRIC NURSING

By: Daryl Joel C. Dumdum, RN

Growth and Development

Growth
Increase in size of a structure.

Development
Maturation of structures

Cephalocaudal
Head to Toe

Proximo-Distal
Trunk to Peripheries

Phylogeny
Development or evolution of a species or group

Ontogeny
Development of an individual within a species

Rates of Development
Fast Growth Periods
INFANCY and ADOLESCENTS

Slow Growth Periods

TODDLER THROUGH SCHOOL AGE

FETAL and INFANCY

The Head and neurologic tissue grow faster than other tissues

TODDLER and PreSCHOOL

The trunk grows more rapidly than other tissues

The limbs Grow most during School age periods The trunk grows faster than other tissue during adolescence

Theorists
Sigmund Freud ( Psychosexual Theory) 0-1 - ORAL STAGE 1-3 - ANAL STAGE 3-6 - PHALLIC STAGE 6-12- LATENCY STAGE 12 and Above - GENITAL SAGE

ERIK ERIKSON (PSYCHOSOCIAL)

0-1 INFANCY 1-3 TODDLER 3-6 PRESCHOOL 6-12 SCHOOL AGE 12-18 ADOLESCENT 18-35 Early Adult 35-60 Middle Adult 60 and above Late Adult Trust vs mistrust Autonomy vs shame Initiative vs guilt Industry vs inferiority Identity vs role confusion Intimacy vs Isolation Generativity vs stagnation Ego Integrity vs Despair

Jean Piaget (COGNITIVE)

0-2 Sensorimotor
Reflexes, repetition of acts

2-4 Preconceptual
Egocentrism, use of symbols, magical thinking

4-7 intuitive/ preoperational

Cause and effect

7-11 Concrete operations 11-15 Formal Operations

Reality & Abstract thought

MEASUREMENT TOOLS
Chronological Age -Assessment of developmental tasks related to birth date Mental age-assessment of cognitive development

Denver Developmental age

IQ

Growth Parameters

Generalized assessment tool. Measures gross motor, fine motor, language, and personalsocial development from newborn to 6 yrs Does not measure intelligence Bone Age: x-ray of tarsals and carpals Growth charts

Neonate Birth to 1 month

Weight increases weekly by 5-7oz (142198g)for first 6 months Length; grows 1 inch monthly for the first 6months Head Growth: equal to or slightly larger than the chest. Increases by inch monthly for the first 6moths Brain Growth: Increase in size about 2/3 adult size at 1year and 90% adult size at 2 years

Neonate Birth to 1 month

Behavior is reflex controlled Flexed extremities Can lift head slightly off bed when in prone Hearing and touch are well developed at birth Sight not fully developed until 6 years Differentiate darkness from light at birth Rapidly develops clarity of vision within 1 foot Fixates on moving objects

Neonate Birth to 1 month

Cries to express displeasure Smiles indiscriminately Receives gratification through sucking Makes throaty sounds

1-4 months
Posterior fontanel closes Moro Reflex and Tonic neck reflex begins to fade Gains Head control: Balances head in sitting position Rolls from back to side Begins voluntary hand-mouth activity Begins to be able to coordinate stimuli from various sense organs Hearing: locates sound by turning and visually searching

1-4 months
Vision: beginning hand eye coordination Prefers human face Follows objects at 180 Accommodation is equal to adult Crying becomes differentiated at 1 month
Decreased during awake periods Ceases when parent is in view

Vocalization distinct from crying at 1 month

Squeals to show pleasure at 3 moths Coos, babbles, laughs, vocalizes when smiling

SOLITARY PLAY
BIRTH to 4 months
Provide variety of brightly colored objects, different sizes and textures Hang mobiles within 8-10 inches of infants face Expose to various environmental sounds; use rattles, musical toys.

5-6 months
Birth weight doubles at 6 months Eruption of teeth begins
Lower incisor first Causes increased saliva and drooling Enzyme released during teething causes diarrhea, facial skin irritation Slight fever

Intentional rolling over Supports weight on arms Creeping Can grasp and let go voluntarily Transfers toys from one hand to another

5-6 months
Sits with support Hearing: can localize sounds above and below the ear Vision: smiles at own mirror image and responds to facial expressions of others Taste: sucking needs have decreased and cup weaning can begin; chewing, biting and taste preference begin to develop Vocalization: begins to imitate sounds Socialization: recognizes parents, stranger anxiety begins to develop

5-6 months
SOLITARY PLAY
Provide brightly colored toys to hold and squeeze Allow infant to splash in bath Provide crib mirror

Begins to imitate Can find partially hidden objects

7-9 months
Teething continues Sits unsupported; goes from prone to sitting position Crawls Pulls self to standing position Develops finger-thumb opposition (pincer grasp) Preference for dominant hand evident Can fixate on small objects Beginning to develop depth perception
7 months: upper central incisor 9 months: upper lateral incisor

7-9 months
Begins to understand object permanence, searches for dropped objects Reacts to adult anger; cries when scolded Imitates simple acts and noises Responds to simple commands Vocalization: verbalizes all vowels and most consonants Socialization: increased stranger anxiety and anxiety over separation from parent Exhibits aggressiveness by biting at times Understands the word NO

10-12 months
Birth weight triples Length: 50% increase over birth length Head and chest circumference equal Teething
Lower lateral incisors erupt Average of 8 deciduous teeth

Creeps with abdomen off floor Walks with help or cruises May attempt stand alone Can sit down from upright position Weans from bottle to cup

10-12 months
Able to discriminate simple geometric forms Able to follow rapidly moving objects Vocalization: imitates animal sounds, can say 4-5 words but understands many more (ma, da) Socialization: begins to explore surroundings Play games such as pat-a-cake, peek-a-boo Shows emotions such as jealousy, affection, anger, fear Recognizes objects by name Looks and follows pictures in book Shows more goal-directed actions

1-3 years
Slow growth Primary dentition (20 teeth) completed by 2 years Develops sphincter control necessary for bowel and bladder control Walks alone by 18 months Climbs stairs and furniture by 18 months Runs fairly well by 2 years Jumps from chair or step by 2 years Balances on one foot Rides tricycle

3-5 years
Permanent teeth may appear late in preschool
Molars behind last temporary teeth

Walks upstairs with alternating feet by 3 yrs Walks downstairs using alternate feet by 4 years Stands on 1 foot by 3 years Hops on 1 foot by 4 yrs

3-5 years
Skips and hops on alternate feet by 5 years Balances on 1 foot with eyes closed by 5 years Throws and catches ball by 5 years Jumps off 1 step by 3 years Jumps rope by 5 years Hands dominance is established by 5 years Builds a tower of blocks by 3 years Ties shoes at 5 Copies a circle by 3 yrs Copies squares, traces a diamond by 4 yrs Copies a diamond and triangle , print letters and numbers at 5 Handles scissors well at 5 years old.

6-12 years
Slow growth continues Dentition
Loses first primary teeth at about 6 years By 12 years has all permanent teeth except final molars

Vision completely mature Gross motor skills: children are very energetic, develops greater strength Develops smoothness and speed in fine motor control

12 yrs old
Girls
Increase in size of breast & genitalia Appearance of axillary & pubic hair Menarche

Boys
Deepening of voice Development of muscle Increase in size of penis & testes Production of viable sperm

12-18
Adolescence
Play - continuation of competitive play Fear - of obesity - of replacement from friends - of death - of acne Significant Development
They have distinctive odor

 Nocturnal emission/ wet dreams are present Sperm is viable by the age of 17 Testes & scrotum increases at age 17 Breast & female genitalia increases until the age of 18

Characteristics
Idealistic Rebellions Performance Conscious of body image

 Adventure some Smoking Alcoholism Drug addiction Premarital sex

Interventions for the ill or hospitalized Child

Speak in quiet, pleasant tones Use words appropriate to age Do not explain more than necessary Always explain what you are going to do and its purpose Be honest; do not lie about whether something will hurt Do not make a promise you know you cant make Do not threaten, if necessary, punish the act not the child Never shame the child by using terms like baby or sissy

Interventions for the ill or hospitalized Child

Involve parents in child care Promote independence Allow choices where possible, but do not use yes/no questions unless you can accept a no answer Teach parents to anticipate next stage of development If parents cannot stay with the child, encourage them to bring in a favorite toy, pictures of family members, or to make a tape to be played for the child

Interventions for the ill or hospitalized Child

PLAY
Is a way to solve problems, becomes enculturated, express creativity, decreases stress in the environment, prepare for different situations, sublimate sensations, enhance fine and gross motor development as well as social development Make play appropriate for mental age and physical disease Use multisensory stimulation

Interventions for the ill or hospitalized Child

Provide toys safe for mental age Offer play specific to age groups
Infants and Toddler: enjoys repetition, solitary play, parallel play Preschooler: likes to role play and make believe play. Associative play School age: likes groups, organized activities (to enhance sharing) cooperative play, group goals with interaction

Preparation for procedures

Allow the child to play with the equipments to be used but provide safety Demonstrate procedure first on a doll Teach the child skills that will be needed after the procedure and provide time for practice Desensitize the child Describe sensations to be felt by the child postprocedure Parents can often be helpful in preparing the child for the procedure, but needs to be prepared as well Inadequate preparation results in heightened anxiety that may result in regressive behavior, uncooperativeness, or acting out

Failure to Thrive (FTT)

A condition in which a child fails to gain weight and is persistently less than the 5th percentile on growth charts When related to inorganic cause it is usually due to disrupted maternal - child relationship Other pathology especially absorption and hormonal dysfunctions must be ruled out first before a diagnosis of FTT can be obtained

Failure to Thrive (FTT)

Growth and development delay usually improve with appropriate stimulation S/S
Sleep disturbances: voluntary regurgitation and reswallowing History of parental isolation and social crisis with inadequate support systems Delayed growth and development Disturbed maternal and- infant interaction

Failure to Thrive (FTT)

Nursing Interventions: Provide consistent care Teach parents positive feeding techniques. Maintain face to face posture with the child Talk to child encouragingly during feeding Involve parents in care Provide supportive environment Give positive feedback Demonstrate and reinforce responding to childs cues

Child Abuse
Physical, emotional, or sexual abuse of children; may result from intentional and nonaccidental actions or may be from intentional and nonaccidental acts of omission (neglect) In sexual abuse 80% of children know their abuser Adults who abuse are more likely victims of abuse also Only 10 % of abusers have serious psychologic disturbance, but most have low self-esteem, little confidence and low tolerance to frustrations

Child Abuse
Abuse is most common among toddlers as they exercise autonomy and parents may sense loss of power Assessment findings:
No history to explain injury Delay in seeking medical attention History changes with repetition Injury not consistent with injury Skin injuries (bruises, burns, lacerations)

Child Abuse
Injury may show outline of instruments use and may be in varying stages of healing Musculoskeletal injuries, fractures, sprains, dislocations, CNS injuries like subdural hematoma, retinal hemorrhage Abdominal Injuries may include lacerated liver, ruptured spleen Observation of parents and child may reveal interactional problem

Child Abuse
NURSING INTERVENTIONS: Attend to physical needs of the child first Report suspected child abuse to appropriate agency Encourage parents to express feelings concerning abuse, hospitalization, and home situation Provide education Initiate referrals for long term follow-up (community agencies, pediatric and mental heath clinics)

SIDS (Sudden Infant Death Syndrome)

Sudden death of any young child that is unexpected by history and in which thorough postmortem examination fails to demonstrate adequate cause of death Cannot be predicted, cannot be prevented Peak age: 3 months ; 90% by 6 months Usually occurs during sleep; there is no struggle and death is silent Diagnosis made at autopsy

SIDS (Sudden Infant Death Syndrome)

Although cause is unknown, chronic hypoxemia and apnea are suggested factors ASSESSMENT:
Incidence higher in preterm infants, twins or triplets, low birth weight infants Infants with abnormalities in respiration, feeding, or other neurologic symptoms at higher risk

SIDS (Sudden Infant Death Syndrome)

NURSING INTERVENTIONS:
Nursing care is directed at supporting parents/family Provide a room for the family to be alone if possible. Stay with them; prepare them for how infant will look and feel ( baby will be bruised and blanched due to pooling of blood until death was discovered; also cold) Let parents say goodbye to the baby (hold, rock)

SIDS (Sudden Infant Death Syndrome)

Reinforce that death was not their fault Provide appropriate support referrals; clergy, significant others Explain how parents can receive autopsy results Notify Family physician or pediatrician.

Death and Dying

Parental Response
Major life stress event Initially parents experience grief in response to potential loss of child Responses might include shock and disbelief, denial, guilt, and depression May have long term disruptive effects on family system
Stress may result to divorce Behavioral problems

Death and Dying

Childs Response
Child concepts to death depends on mental age Infants and toddler
Live only in present Are concerned only with separation from mother and being alone and abandoned

Preschooler
See death as temporary, a type of sleep or separation

Death and Dying

School age
Have a concept of time, causality, and irreversibility (but still questions it)

Adolescents
Are thinking about the future and knowing that they can not participate May express anger at impending death May find it difficult to talk about death May wish to plan own funeral May wish to write something for friends and family

NURSING IMPLICATIONS
Communicating with dying child
Use the child's own language Do not use euphemisms Do not expect an immediate response Never give up hope Do not leave the child Do not whisper in the room Touch is therapeutic Continue reading favorite stories of the child Lat parents participate

Who ha!
The nurse has assessed four children of varying ages; which one requires further evaluation?
1. a 7-month old who is afraid of strangers 2. A 4 year old who talks to an imaginary playmate 3. A 9 yr old with enuresis 4. A 16 yr old who had nocturnal emissions

All right!
The nurse is caring for a 5 year old child who has leukemia and is now out of remission and not expected to survive. The child says to his mother, will you take care of me when I am dead the way you do now? The childs mother asks the nurse how to respond. The nurse s response should be based on which of the following understanding of the childs behavior?
1. 2. 3. 4. The child is denying that he has a terminal problem The child may be hallucinating Children of this stage do not understand the finality of death Most 5 yr old children have a great fear of mutilation

Grabeh na to!
When Child abuse is suspected, the nurse knows that abusive burns will
1. 2. 3. 4. Have a number of scars Have identifiable shapes Display an erratic pattern Be on one side of the body

Todo na talaga!
The Nurse is talking with a mother of a one year-old child in a well baby clinic. Which statement the mother makes indicates a need for more instruction in keeping the child safe?
1. I have some syrup of ipecac at home in case my child ever needs it 2. I put all medicines on the highest shelf in the kitchen 3. We have moved all the valuable vases and figurines out of the family room 4. My husbund put the gates up at the top and bottom of the stairs

YEYE! BONEL!
The presence of what condition would necessitate a change in the standard immunization schedule for a child?
1. 2. 3. 4. Allergy to eggs Immunosuppression Congenital defects Mental Retardation

Common Pediatric Disorders

Autosomal Dominant
Allele responsible for the disease is dominant Only one parent needs to pass on the gene. Examples:
Huntingtons chorea Myotonic muscular dystrophy Night blindness

Genetic Counselling: 50% chance with each pregnancy that the child will have the disease or disorder

Common Pediatric Disorders

Autosomal Recessive
Allele responsible for disease will not result ihn expression if the other allele in the pair is dominant Both parents must pass on the genes Examples:
Cystic fibrosis PKU Sicke cell anemia Albinism Tay- Sachs

Common Pediatric Disorders

Genetic Counselling:
25% chance with each pregnancy of haing a child with the disorder 50% chance with each pregnancy of having a child who is a carrier of the disease but will not manifest the symptoms. 25% chance with each pregnancy of having a child will neither have the disease nor be a carrier.

 Sex - linked ( X-linked) Inheritance

Inheritance of characteristics located on X and Y chromosomes Examples:
Color blindness Baldness Hemophillia A and B

Genetic Counselling
If a woman is a carrier and her partner does not have the disorder
50% chance that her son will have the disorder

 50% chance her daugther will become a carrier If a man has a sex-linked disorder, all his daughters will be carriers but none will manifest the disease.

Chormosome Disorders
Down Syndrome
Caused by an extra chromosome 21 ( total of 47)

Assessment Findings
Head and Face
Small head, flat facial profile, broad flat nose Small mouth, normal- size protruding tongue Low Set ears

Extremities
Short Thick Fingers and hands

Chormosome Disorders
Simian creases ( Single crease along palms) Muscle weakness, lax joints

Associated anomalies and disorders

Congenital heart defects GI structural defects Increase incidence of leukemia Increased Incidence of Respiratory infection Visual defects

Mental Retardation

Chormosome Disorders
Nursing Interventions
Provide parent education concerning
Increased susceptibility to respiratory infection Nutritional Needs Medication Administration if necessary

Promote developmental progress Provide genetic counselling

Fluid And Electrolyte, Acid Base Balance

Dehydration
Isotonic Dehydration
Water and electrolytes loss are proportionate

Hypotonic dehydration
Electrolytes deficit exceeds water loss

Hypertonic Dehydration
Water loss exceeds electrolyte loss

Diarrhea
A change in consistency and frequency of stools Caused by bacteria and viruses, parasites, poisons, inflammation, malabsorption, allergies, etc Leads to metabolic acidosis Also causes loss of bicarbonate and potassium

Diarrhea
Signs/ Symptoms
Frequent stools with abdominal cramping Decreased urine output, decreased tears and saliva, dry mucous membranes, dry skin with poor turgor In children less than 18 mos. Depressed anterior fontanel Increased Pulse Rate and decreased BP Sunken Eyes High pitched cry

Diarrhea
Nursing Interventions
NPO to rest bowel if ordered Administer IV Fluids as ordered Resume Oral feeding slowly Provide skin care Monitor lab results Isolation if infectious Anti - diarrheal drugs

Vomiting
Differs from spitting up (dribbling of undigested formula, often with burping) If prolonged may result in metabolic alkalosis or aspiration Nursing Interventions:
Treat the underlying cause Hydration Assess amount of vomitus, frequency, and nature

Vomiting
Prevent complications Administer anti-emetic Medications
Trimethobenzamine HCl ( Tigan) Promethazine HCl (Phenargan)

Nuerologic Disorder

HYDROCEPHALUS Increased amount of CSF within the ventricles of the brain May be caused by obstruction of CSF flow or by overproduction or inadequate reabsorption of CSF Classification
NONCOMMUNICATING/OBSTRUCTIVE
obstruction within the ventricles such as congenital malformation, neoplasm, or hematoma inadequate absorption of cerebrospinal fluid (CSF) resulting from infection, trauma, or obstruction by thick arachnoid membrane or meninges

COMMUNICATING/CONGENITAL

Clinical findings 1. Increasing head size in the infant because of open sutures and bulging fontanels 2. Prominent scalp veins and taut, shiny skin 3. "Sunset" eyes (sclera visible above iris), bulging eyes, and papilledema of retina 4. Head lag, especially important after 4 to 6 months 5. Increased intracranial pressure: projectile vomiting not associated with feeding, irritability, anorexia, high shrill cry, seizures 6. Damage to the brain because increased pressure decreases blood flow to the cells, causing necrosis

Therapeutic interventions 1. Relief of hydrocephalus

a. Removal of the obstruction if that is the cause b. Mechanical shunting of fluid to another area of the body-ventricular peritoneal shunt: catheter passed subcutaneously to the peritoneal cavity; revised as necessary

2. Treatment of complications 3. Management of problems related to effect on psychomotor problems

Nursing Care of Infants and Children with Hydrocephalus

A. Assessment 1. Head circumference/fontanels 2. Signs of increased intracranial pressure B. Analysis/Nursing Diagnoses 1. Altered family process related to having a seriously ill child 2. Risk for infection related to shunt 3. Risk for injury related to increased intracranial pressure 4. Risk for skin breakdown related to immobility

Planning/Implementation 1. Prevent breakdown of scalp, infection, and damage to spinal cord

a. Place the infant in a Fowler's position to facilitate draining of fluid; infant should be positioned flat postoperatively with no pressure on shunted side b. When holding the infant, support the neck and head c. Observe shunt site (abdominal site in peritoneal procedure) for infection

2. Monitor for increasing intracranial pressure

a. Carefully observe neurologic signs b. Measure head circumference c. Use minimal sedatives or analgesics, which can mask symptoms d. Check the valve frequently for patency

Promote adequate nutrition

a. Monitor for vomiting, irritability, lethargy, and anorexia, because these will decrease the intake of nutrients b. Perform all care before feeding to prevent vomiting; hold infant if possible c. Observe for signs of dehydration

4. Keep eyes moist and free of irritation if eyelids incompletely cover corneas

5. Postoperative nursing care: similar to that for cardiac surgery with the addition of: a. Place the infant or child on bed rest after surgery, with minimal handling to prevent damage to shunt b. Support parents (1) Continued shunt revisions are usually necessary as growth occurs (2) Usually very concerned about developmental delay c. Observe for brain damage by recording milestones during infancy d. Teach parents (1) Pumping of the shunt, if indicated, to maintain patency (2) Signs of increasing intracranial pressure and infection (3) Evidence of dehydration

SPINA BIFIDA 1. Failure of posterior vertebral arches to fuse during embryonic development 2. Causes: idiopathic, sibling with neural tube defect, radiation, viral, environmental factors 3. 85%= lower thoracic lumber or sacral area, 15% = upper thoracic & cervical regions TYPES 1. SPINA BIFIDA OCCULTA 2. SPINA BIFIDA CYSTICA 2.1. MENINGOCELE 2.2. MYELOMENINGOCELE

SPINA BIFIDA MEDICAL MANAGEMENT 1. SURGERY: CLOSURE OF SAC, SHUNT, ORTHOPEDIC PROCEDURES 2. DRUG THERAPY: Antibiotics 3. Immobilization ASSESSMENT FINDINGS 1. Examine the defect for size, level, tissue covering & CSF leakage 2. Motor/sensory involvement 3. Bowel & bladder function: NEUROGENIC BLADDER

SPINA BIFIDA

DIAGNOSTIC TEST 1. PRENATAL: ALPHAFETOPROTEIN NURSING INTERVENTIONS 1. Prevent trauma to the sac: covering, positioning, keeping dryness, antibiotics ) 2. Prevent complications ( hydrocephalus, neurogenic bladder, immobilization )

CEREBRAL PALSY 1.Neuromuscular disorders resulting from damage to or altered structure of the part of the brain responsible for motor function 2. Causes 3. 2.1. PRENATAL: genetic, trauma or anoxia to mother 2.2. PERINATAL: drugs at delivery, precipitate delivery, fetal distress, breech deliveries with delay 2.3. POST NATAL: kernicterus or head trauma

CEREBRAL PALSY
MEDICAL MANAGEMENT 1. DRUG therapy: anti-anxiety, skeletal muscle relaxants, local nerve blocks 2. PT/OT 3. Speech/audiology therapy 4. Surgery ASSESSMENT FINDINGS
Spasticity Athetosis Ataxia Tremors Rigidity

CEREBRAL PALSY
ASSOCIATED PROBLEMS a. Mental retardation b. Hearing loss c. Defective speech touch, perception d. Dental anomalies e. Orthopedic problems f. Visual disabilities g. Disturbances of body image, h. Feelings of worthlessness

NURSING INTERVENTIONS 1. Obtain a careful pregnancy, birth, and childhood history 2. Limit stimulation 3. Assist in ADL, demonstration of procedure is essential 4. Provide a safe environment ( safety helmet, padded crib ) 5. PT

Meningitis
A. Most common CNS infection of infants and children B. Inflammation of the meninges by viral or bacteria that travel via the cerebrospinal fluid

Classification: culture of cerebrospinal fluid used to help identify organism 1. Bacterial: caused by pus-forming bacteria, especially meningococcus, pneumococcus, and influenza bacillus
2. Tuberculous: caused by tubercle bacillus 3. Viral or aseptic: caused by a wide variety of viral agents

Clinical findings 1. Opisthotonos: rigidity and hyperextension of the neck 2. Headache 3. Irritability and high-pitched cry 4. Signs of increased intracranial pressure 5. Fever, nausea, and vomiting 6. Meningococcal meningitis: petechiae and purpuric skin rash
Therapeutic intervention - massive doses of intravenous antibiotics

Children with Meningitis A. Assessment 1. Fever 2. Headache, irritability 3. Vomiting 4. Seizures 5. Nuchal rigidity

B. Analysis/Nursing Diagnoses 1. Altered family processes related to having a child with a serious illness
2. Risk for infection related to presence of infective organisms 3. Risk for injury related to presence of infection

C. Planning/Implementation 1. Provide for rest 2. Decrease stimuli from the environment (control light and noise) 3. Position on the side with head gently supported in extension 4. Institute respiratory isolation 5. Maintain fluid balance because of meningeal edema a. Record intake and output carefully b. Correct any deficits c. Monitor IV fluid d. Daily weights 6. Provide emotional support for parents, since child usually becomes ill suddenly 7. Administer antibiotic therapy as prescribed 8. Observe for complications such as septic shock and circulatory collapse

D. Evaluation/Outcomes 1. Child shows decreasing severity of illness 2. Family verbalizes fears regarding child's prognosis

CardioVascular Disorder

CONGENITAL HEART DEFECTS

Acyanotic Heart Defects

Oxygenated blood is shunted from the systemic to pulmonary circulation ( left to right shunt) and blood leaving the aorta is completely oxygenated

Cyanotic Heart Defects

Unoxygenated blood is shunted from the right to the left side of the heart where it mixes with oxygenated blood

Acyanotic Heart Defects

Atrial Septal Defect ( ASD )
Abnormal opening in the septum between left and right atria, causing a left to right shunt

Ventricular Septal Defect (VSD)

Opening in the septum between ventricles, causing a left - to - right shunt

Patent Ductus Arteriosus (PDA): Failure to close at birth

Acyanotic Heart Defects

Coarctation of the Aorta
Narrowing of the Aorta usually just beyond the left subclavian artery

Pulmonary Stenosis Aortic Stenosis Endocardial Cushion defects

ATRIAL SEPTAL DEFECT

Four types
Ostium secundum defect Ostium primum defect Sinus venosus defect Coronary sinus septal defect

Manifestations
prominent right ventricular cardiac impulse palpable pulmonary artery pulsations Mitral valve prolapse
In patients with mitral valve prolapse, an apical holosystolic or late systolic murmur often is heard radiating to the axilla.

Management
Cardiac catheterization surgical closure

NURSING: Oxygenation Emotional Support Education

Ventricular Septal Defect

A ventricular septal defect (VSD), which is a hole between the 2 lower chambers of the heart, may occur as a primary anomaly with or without additional major associated cardiac defects VSD is a developmental defect of the interventricular septum whereby a communication exists between the cavities of the two ventricles.

Manifestations
Infants with small defects
Normal vital signs Clear lungs Absence of jugular venous distension (JVD), hepatomegaly, or edema Mildly hyperactive precordial impulse Second heart sound (S2): S2 may be obscured entirely by the holosystolic murmur, which is well localized at the left sternal border.

Manifestations
Infants with large VSDs

Cyanosis Clubbing Erythrocytosis Prominent RV lift, maximal in xiphoid region, revealed on palpation Very short or no systolic murmur S2 - Loud, palpable, single, or closely split S3 of right ventricular origin - May be present Squatting in 15% of patients

Hemoptysis: Hemoptysis occurs in 33% of patients (never in patients <24 y); it occurs in 100% of patients by age 40 years and contributes to cause of death.

Management
Furosemide in a dosage of 1-3 mg/kg/d in 2 or 3 divided doses is used. Long-term furosemide treatment results in hypercalcemia and renal damage and electrolyte disturbances. Increase the caloric density of the feedings. Captopril in a dosage of 0.1-0.3 mg/kg 3 times daily can be useful to reduce systemic afterload. Digoxin in a dosage of 5-10 mcg/kg/d may be indicated if diuresis and afterload reduction do not relieve symptoms adequately

Patent Ductus Arteriosus

The ductus arteriosus is normally patent during fetal life. This patency is promoted by continual production of prostaglandin E2 (PGE2) by the ductus. Prostaglandin antagonism, such as maternal use of nonsteroidal anti-inflammatory medications, can cause fetal closure of the ductus arteriosus. This can be associated with severe fetal cardiovascular compromise. Normally, functional closure of the ductus arteriosus occurs by about 15 hours of life in healthy infants born at term. This occurs by abrupt contraction of the muscular wall of the ductus arteriosus, which is associated with increases in the partial pressure of oxygen (PO2) coincident with the first breath.

Manifestations
The apical impulse is laterally displaced. A thrill may be present in the suprasternal notch or in the left infraclavicular region. The first heart sound (S1) is typically normal. The second heart sound (S2) often is obscured by the murmur

MANAGEMENT
Surgical ligation

Cyanotic Heart Defects

Tetralogy of fallot
Pulmonary stenosis Coarctation of the Aorta Ventricular Septal Defect Right Ventricular Hypertrophy

Symptoms Depends on the degree of pulmonary stenosis

Cyanotic Heart Defects

ASSESSMENT S/SX= CYANOSIS, Polycythemia, clubbing of digits, poor growth, squatting, risk for blood clots, CHF( LEFT SIDE ) A.3. NURSING INTERVENTIONS a.3.1. Dont interfere when squatting a.3.2. Organize care a.3.3. Administer oxygen a.3.4. Meet needs quickly a.3.5. Use soft nipple for feeding a.3.6. Provide careful skin care a.3. 7. Antibiotic prophylaxis

RHD
Caused by GABHS Signs and symptoms
Fever Migratory poly arthritis Malnourished

Treatment:
Aspirin Sumapen Supportive

Disorder of the Hematologic System

SICKLE CELL ANEMIA

A. Autosomal disorder affecting hemoglobin B. Defective hemoglobin causes red blood cells to become sickle shaped and clump together under reduced oxygen tension; initially fetal hemoglobin prevents sickling

MEDICAL MANAGEMENT b.1. Drug therapy: UREA, ANALGESIC/NARCOTICS( avoid aspirin ), ANTIBIOTICS b.2. Exchange/blood transfusion b.3. Hydration b.4. Bed rest b.5. Surgery

SICKLE CELL ANEMIA

ASSESSMENT FINDINGS 1. Abdomen ( first sign: colic ) 2. Lower extremities ( hand-foot syndrome, ulcers) 3. Spleen ( splenomegaly ) 4. Bones ( osteoporosis ) 5. Nervous system ( CVA ) 6. Kidneys ( infarts, enuresis ) 7. Heart ( Heart failure = hemosiderosis ) 8. Genitals (impotence)

SICKLE CELL ANEMIA

Vasoocclusive crisis (pain episode): most common and nonlifethreatening
a. Results from sickled cells obstructing blood vessels, causing occlusion, ischemia, and potential necrosis b. Symptoms include fever, acute abdominal pain (visceral hypoxia), hand-foot syndrome, priapism, and arthralgia without an exacerbation of

SICKLE CELL ANEMIA

2. Splenic sequestration crisis a. Results from the spleen pooling large quantities of blood, which causes a precipitous drop in blood pressure and ultimately shock b. Acute episode occurs most commonly in children between 8 months and 5 years of age; can result in death from anemia and cardiovascular collapse c. Chronic manifestation is termed functional asplenia

SICKLE CELL ANEMIA

3. Aplastic crisis: diminished red blood cell production a. May be triggered by a viral or other infection b. Profound anemia results due to rapid destruction of red blood cells combined with a decreased production 4. Hyperhemolytic crisis: increased rate of red blood cell destruction a. Characterized by anemia, jaundice, and reticulcytosis b. Rare complication that frequently suggests a coexisting abnormality such as glucose-6phosphate dehydrogenase deficiency

SICKLE CELL ANEMIA

5. Stroke: sudden and severe complication with no related illnesses a. Sickled cells block the major blood vessels in the brain b. Repeat strokes in 60% of children who have experienced previous one 6. Chest syndrome: clinically similiar to pneumonia 7. Overwhelming infection a. Streptococcus pneumonia b. Haemophilus influenzae type B

SICKLE CELL ANEMIA

DIAGNOSTIC TEST d.1. Sickle cell test d.2. Sickledex d.3. Hgb electrophoresis

NURSING INTERVENTIONS 1. Hydration & oxygenation 2. Avoid tight clothing 3. Bed rest 4. Correct metabolic acidosis 5. Decrease emotional stress

SICKLE CELL ANEMIA

Therapeutic interventions 1. Prevention of sickling phenomenon
a. Adequate oxygenation b. Adequate hydration c. Administration of hydroxyurea to limit sickling a. Rest b. Hydration/electrolyte replacement c. Pain management d. Antibiotic therapy e. Blood products

2. Treatment of crisis

SICKLE CELL ANEMIA

Assessment 1. Vital signs 2. Neurologic signs 3. Vision/hearing 4. Location and intensity of pain

. Analysis/Nursing Diagnoses

SICKLE CELL ANEMIA

1.

Body image disturbance related to: a. Retarded growth and maturation b. Limited activity tolerance c. Chronic illness

2. Fear related to: a. Unfamiliar environment b. Separation from support system 3. Pain related to tissue ischemia
4. Altered tissue perfusion (cardiovascular) related to decreased oxygen tension

Planning/Implementation 1. Prevent crisis

SICKLE CELL ANEMIA

a. Avoid infection, dehydration, and other conditions causing strain on body, which precipitates a crisis; prophylactic use of pneumococcal, meningococcal, and Haemophilus flu vaccines b. Avoid hypoxia: treat respiratory tract infections immediately c. Avoid dehydration
(1) May cause a rapid thrombus formation (2) Daily fluid intake should be calculated according to body weight (130 to 200 ml per kilogram [2 to 3 oz per pound]) (3) During crisis, fluid needs to be increased, especially if the child is febrile

 2. During crisis provide for:

a. Adequate hydration (may need IV therapy) b. Proper positioning, careful handling c. Exercise as tolerated (immobility promotes thrombus formation and respiratory problems) d. Adequate ventilation e. Control of pain; use narcotics; schedule to prevent pain f. Blood transfusions for severe anemia

SICKLE CELL ANEMIA

 3. Provide for genetic counseling

a. Disorder mostly of blacks; can be found in Mediterranean people b. Parents need to know the risk of having other children with trait or disease c. If both parents are carriers, each pregnancy has 25% chance of producing a child with the disease d. Screen young children for the disorder, since clinical manifestations usually do not appear before 6 months of age

SICKLE CELL ANEMIA

. Evaluation/Outcomes 1. Child reports minimal pain 2. Child verbalizes feelings about disease process 3. Child demonstrates positive body image 4. Child does not exhibit signs of sickling

SICKLE CELL ANEMIA

HEMOPHILIA

TYPES

b.1. Hemophilia A: Factor VIII b.2. Hemophilia B: Christmas disease/factor IX deficiency b.3. Hemophilia C: Factor XI deficiency ASSESSMENT FINDINGS 1. Prolonged bleeding after minor injury 2. Bruising, hematomas, no petechiae 3. Hemarthrosis 4. Peripheral neuropathies 5. Prolonged PTT, anemia

HEMOPHILIA
NURSING INTERVENTIONS 1. Control acute bleeding episode ( I-C-E ) 2. Provide care for hemarthrosis 3. Administer cryoprecipitate 4. Provide client teaching: prevention of trauma & genetic counselling

Dengue Hemorrhagic Fever /Dengue Shock Syndrome

Caused by Dengue Virus (I,II,III,IV) Vector: Aedes Aegyptii MOT: Mosquito bite Signs/ Symptoms:
Petichial rash Epistaxis Hematemesis Melena DHN

Disorder of the Respiratory System

CYSTIC FIBROSIS
GENERAL INFORMATION 1. Dysfunction of the exocrine glands ( respiratory, GIT, sweat, salivary, pancreas ) 2. Autosomal recessive inheritance 3. Affected organs: ( 1 ) PANCREAS, ( 2 ) RESPIRATORY, ( 3 ) REPRODUCTIVE, ( 4 ) LIVER 4. Fatal disease: average age at death is 20 years MEDICAL MANAGEMENT 1. Pancreatic involvement: promote absorption of nutrients 1.a. Diet modification: predigested formula, high calorie/low fat, high protein 1.b. Pancreatic enzyme supplementation 2. Respiratory involvement: chest physiotherapy, antibiotic

CYSTIC FIBROSIS
ASSESSMENT FINDINGS 1. PANCREATIC INVOLVEMENT ( 1 ) FTT, steatorrhea, meconium ileus, rectal prolapse, voracious appetite, protruding abdomen, vit ADEK deficiencies, anemia ( 2 ) Diagnostic test: DECREASE TRYPSIN, FECAL FAT increase 2. RESPIRATORY INVOLVEMENT ( 1 ) S/SX of respiratory distress, barrel chest, productive cough, pseudomonas infection, clubbing of digits

CYSTIC FIBROSIS
3. ELECTROLYTE INVOLVEMENT ( 1 ) HYPONATREMIA, Salty taste of sweat ( 2 ) PILOCARPINE IONTOPHORESIS SWEAT TEST = 2-5 x normal amount NURSING INTERVENTIONS 1. PANCREATIC INVOLVEMENT 1.1. Pancreatic enzymes with meals 1.2. Provide highcalorie, high carbohydrate & protein, low fat

CYSTIC FIBROSIS
2. RESPIRATORY INVOLVEMENT 2.1. Administer antibiotics 2.2. Administer expectorants, mucolytic 2.3. Avoid cough suppressants 2.4. Breathing exercises, postural drainage 4 times/day 2.5. Provide aerosol treatments, mist tent 3. ELECTROLYTE IMBALANCE 3.1. High sodium intake

Disorder of the GIT

CLEFT LIP AND PALATE

GENERAL INFORMATION
Failure of merging between the medial nasal and maxillary processes at the fifth week of embryonic development, on one or both sides

MEDICAL MANAGEMENT 1. Speech therapist, dentist/orthodontist, audiologist,otolaryngologist, pediatrician 2. Surgical correction 2.1. CHEILOPLASTY( 2 months ) 2.2. PALATOPLASTY ( 18

CLEFT LIP AND PALATE

NURSING INTERVENTIONS D.1 Pre-operative CHEILOPLASTY 1. Proper positioning in feeding 2. Burp frequently 3. Use a large-holed nipple 4. Use a rubber-tipped syringe 5. Gavage feeding 6. Finish feeding with water 7. Provide SFF

 D.2 Post-operative CHEILOPLASTY 1. Maintain patent aiway 2. Assess color, monitor amount of swallowing 3. DO NOT PLACE IN PRONE POSITION 4. Anticipating childs needs 5. Use elbow restraints 6. Keep suture line clean 7. Provide pain control relief

 D.3. Pre-operative PALATOPLASTY 1. Infant should be weaned to cup before surgery D.4. Post-operative PALATOPLASTY 1. POSITION ON SIDE 2. Have suction available 3. Prevent injury or trauma to

PYLORIC STENOSIS

GENERAL INFORMATION

MEDICAL MANAGEMENT b.1. Noninvasive: thickened feedings b.2. Surgery: Pyloroplasty

also known as infantile hypertrophic pyloric stenosis (IHPS), is the most common cause of intestinal obstruction in infancy. It occurs secondary to hypertrophy and hyperplasia of the muscular layers of the pylorus.

ASSESSMENT FINDINGS 1. Olive-size bulge under right rib cage 2. FTT 3. Projectile vomiting 4. Dehydration 5. DIAGNOSTIC TEST: UGIS, Serum electrolytes, Hematocrit

PYLORIC STENOSIS
NURSING INTERVENTIONS D.1. PRE-OPERATIVE 1. Administer replacement fluids 2. Prevent vomiting ( give thickened feeding, high fowlers position, place on right side after feeding ) 3. Prevent aspiration D.2. POST-OPERATIVE 1. Advance DAT 2. Place on right side after feeding 3. Monitor I & O, signs of infection

INTUSSUSCEPTION GENERAL INFORMATION

a segment of intestine invaginates into the adjoining intestinal lumen, causing a bowel obstruction.

A. Telescoping of one portion of the intestine into another; occurs most frequently at the ileocecal valve B. Males affected two times more frequently than females C. Usually occurs between 3 to 12 months of age

INTUSSUSCEPTION

Classification 1. Ileocecal: invagination at the ileocecal valve; most common type 2. Ileoileal: one part of ileum invaginates on another section of the ileum 3. Colocolic: one part of the colon invaginates on another section of the colon

Clinical findings 1. Healthy, well-nourished infant or child who wakes up with severe paroxysmal abdominal pain, evidenced by kicking and drawing legs up to the abdomen 2. One or two normal stools, then bloody mucus stool ("currant jellylike stool) 3. Palpation of sausage-shaped mass 4. Other signs of intestinal obstruction usually present

MEDICAL MANAGEMENT
1. Barium enema to reduce telescoping 2. Surgery ( if with Peritonitis )
Medical reduction by hydrostatic pressure (barium enema) Surgical reduction; sometimes with intestinal resection

Children with Intussusception

Assessment 1. Sudden, acute, intermittent abdominal pain 2. Vomiting 3. Red "currant jelly-like" stools 4. Tender, distended abdomen

INTUSSUSCEPTION Planning/Implementation 1. Same as for any abdominal surgery 2. Make provisions for frequent parental visits because the problem usually occurs when the child is 6 to 8 months of age and separation anxiety is acute

Evaluation/Outcomes 1. Child does not show physiologic manifestation of pain 2. Family can verbalize feelings about the illness 3. Child consumes sufficient nutrients for growth 4. Child does not exhibit signs of dehydration

Analysis/Nursing Diagnoses 1. Pain related to invaginating bowel 2. Altered family processes related to having a child with life-threatening illness 3. Altered nutrition: less than body requirements related to: 4. Risk for fluid volume deficit related to:
a. Vomiting b. Diarrhea a. Decreased intake b. Increased peristalsis

CELIAC DISEASE
Absorptive disorder of the GI tract

MEDICAL MANAGEMENT 1. Diet therapy: BROW free/glutenfree 2. TPN ASSESSMENT FINDINGS 1 Steatorrhea 2. Chronic diarrhea 3. FTT

CELIAC DISEASE
4. Distended abdomen, muscle wasting 5. Abdominal pain, listlessness 6. Vit A,D,E,K deficiency 7. Diagnostic test: ( 1 ) PANCREATIC ENZYMES & SWEAT CHLORIDE TEST ( 2 ) Jejunal & duodenal biopsy: ATROPHY OF MUCOSA NURSING INTERVENTIONS 1. Monitor gluten-free diet 2. Provide fat-soluble vitamins

Hirschsprung Disease
Absence of aganglionic nerve in the portion of the colon Characteristic sign:
Ribbon-like stool Symptoms, same as pyloric stenosis

Management:
Resection of the colon Colostomy

Disorder of the Renal System

NEPHROSIS/NEPHROTIC SYNDROME
PATHOPHYSIOLOGY 1. PROTEINURIA 2. HYPOALBUMINEMIA 3. EDEMA 4. HYPERLIPIDEMIA MEDICAL MANAGEMENT 1. DRUG THERAPY: Steroids, antibiotics, diuretics, Antimetabolites ( Cytoxan ) 2. Bed rest 3. Diet: HIGH PROTEIN, LOW SODIUM

NEPHROSIS/NEPHROTIC SYNDROME
ASSESSMENT FINDINGS 1. Anorexia, vomiting, diarrhea, malnutrition 2. Pallor, lethargy 3. Hepatomegaly NURSING INTERVENTIONS 1. Bed rest 4. I & O and weight monitoring 2. Diet 5. Protect from known sources of infection 3. Maintain skin integrity 6. Provide scrotal support

Pediatric Oncology

LEUKEMIA
GENERAL INFORMATION TYPES b.1. ACUTE LYMPHOCYTIC LEUKEMIA ( ALL ) b.2. ACUTE NONLYMPHOCYTIC LEUKEMIA ( ANLL ) MEDICAL MANAGEMENT 1. Diagnosis: blood studies, bone marrow biopsy 2. Treatment stages a. Induction: intense & potentially life threatening b. CNS prophylaxis c. Maintenance: 2 to 3 years

LEUKEMIA
ASSESSMENT FINDINGS 1. BLOOD: ANEMIA, BLEEDING, INFECTION 2. Enlarged lymph nodes 3. Enlarged spleen & liver 4. Abdominal pain with weight loss & anorexia 5. Bone pain NURSING INTERVENTIONS 1. Provide care for client receiving chemotherapy, radiation therapy 2. Support for family & child

WILMS TUMOR/NEPHROBLASTOMA

GENERAL INFORMATION

is the most common type of kidney cancer in children. About 90% of kidney cancers in children are Wilms tumors.

MEDICAL MANAGEMENT 1. Nephrectomy( 24-48 hours of diagnosis ) 2. Radiation therapy 3. Chemotherapy: Vincristine, Daunorubicin, Doxorubicin ASSESSMENT FINDINGS 1. Mother notices MASS while bathing or dressing child; nontender, midline near liver 2. Hypertension, hematuria, anemia 3. Diagnostic test: IVP

WILMS TUMOR/NEPHROBLASTOMA NURSING INTERVENTIONS 1. DO NOT PALPATE ABDOMEN 2. Handle carefully when bathing 3. Provide care for a client post nephrectomy 4. Provide care for a client receiving chemotherapy, radiation therapy

HODGKINS LYMPHOMA

is a cancer that starts in lymphatic tissue. Lymphatic tissue includes the lymph nodes and related organs that are part of the body's immune and blood-forming systems. MEDICAL MANAGEMENT

GENERAL INFORMATION

1. DIAGNOSIS: Lymphangiogram, biopsy( REEDSTERNBERG CELLS ), splenectomy 2. RADIATION THERAPY, CHEMOTHERAPY ASSESSMENT FINDINGS 1. Enlarged nodes in lower cervical region; nodes are NONTENDER, PAINLESS, FIRM & MOVABLE 2. Recurrent, intermittent fever

HODGKINS LYMPHOMA
3. Night sweats 4. Weight loss, malaise, lethargy 5. Pruritus NURSING INTERVENTIONS 1. Provide care for child on chemotherapy, radiation therapy 2. Protect from infection if splenectomy is performed 3. Provide support for child/adolescent parents

POISONING

Poisoning
A. Ingestion of a toxic substance or an excessive amount of a substance B. More than 90% of poisonings occur in the home C. Highest incidence occurs in children under 4 D. Improper storage is the major contributing factor to poisonings

Poisoning
A. Assessment 1. Vital signs 2. Need for respiratory or cardiac support 3. Treat other symptoms such as seizures 4. See Clinical Findings under type of poisoning

Analysis/Nursing Diagnoses 1. Altered family processes related to sudden hospitalization and emergency aspects of illness 2. Fear related to sudden hospitalization and treatment (multiple injections for lead poisoning) 3. Risk for injury related to sources of toxic substances in the environment 4. Risk for injury related to presence of toxic substance in the body 5. Risk for poisoning related to immature judgment of child

Poisoning

C. Planning/Implementation 1. Terminate the exposure

a. Empty the mouth of pills, plant parts, or other material b. Thoroughly flush eyes with tap water if they were involved c. Flush skin and wash with soap and soft cloth d. Remove clothing, especially if pesticide, acid, alkali, or hydrocarbon involved e. Bring the victim into fresh air if an inhalation poisoning f. Give water to dilute ingested

Poisoning

Poisoning
2. Identify that a poisoning has occurred
a. Call the local poison control center, emergency facility, or physician for immediate advice regarding treatment b. Save all evidence of poison (container, vomitus, urine, etc.) c. Be alert to signs and symptoms of potential poisoning in absence of other evidence

Poisoning
3. Do not induce vomiting
a. If the person is comatose, in severe shock, or convulsing or has lost the gag reflex; these conditions can increase the risk of aspiration b. If the poison is a low-viscosity hydrocarbon; once aspirated,it can cause a severe chemical pneumonitis c. If the poison is a strong corrosive (acid or alkali), emesis of the corrosive redamages the mucosa of the esophagus and pharynx

Poisoning
4. Remove the poison
a. Dilute with water b. Induce vomiting except as contraindicated by administering ipecac syrup (for 6- to 12month-olds give 10 ml of ipecac syrup with 8 to 12 oz of water, for 1- to 2-year-olds give 15 ml of ipecac syrup with 8 to 16 ounces of water; over 12 years of age give 30 ml of ipecac syrup with 16 ounces of water); if vomiting does not occur repeat once in 20 minutes for those over 12 months of age; for those under 12 months of age ipecac is not repeated

Poisoning
c. Administer activated charcoal 1 g per kg 30 to 60 minutes after inducing vomiting d. Prepare appropriate equipment for potential medical use, such as gastric lavage 5. Whether vomiting is spontaneous or induced, prevent aspiration a. Keep the child's head lower than the chest b. When alert, place the head between the legs

Poisoning
6. Observe for latent symptoms and complications of poisoning
a. Monitor vital signs b. Treat as appropriate (e.g., institute seizure precautions, keep warm and position correctly in case of shock, reduce temperature if hyperpyretic)

7. Support the child and parent

a. Keep calm and quiet b. Do not admonish or accuse the child or parent of wrongdoing

Poisoning
8. Teach prevention of poisoning
a. Assess possible contributing factors in the occurrence of an accident, such as discipline, parent-child relationship, developmental ability, environmental factors, and behavior problems b. Institute anticipatory guidance for possible future accidents based on the child's age and maturational level c. Refer to a visiting nurse agency for evaluation of the home environment and the need for safety measures d. Provide assistance with environmental manipulation when necessary

Poisoning
e. Educate the parents regarding safe storage of all substances f. Teach children the hazards of ingesting nonfood items without supervision

g. Caution against keeping large amounts of drugs on hand, especially children's varieties
h. Discourage transferring drugs to containers without safety caps i. Discuss problems of discipline and children's noncompliance

Poisoning . Evaluation/Outcomes

1. Child recognizes and does not ingest harmful substances 2. Child is treated without complications 3. Child receives medication with minimal distress

4. Toxin is eliminated from body

5. Child expresses feelings and concerns 6. Parents express confidence in care 7. Parents and child have knowledge concerning prevention of future poisoning

 A. One of the most common drugs taken by children 1. Toxic dose 150 mg/kg body weight 2. Therapeutic use of 150 mg/kg/day for several days has resulted in toxicity

Acetaminophen Poisoning

 Clinical findings - symptoms of overdose

1. Profuse diaphoresis 2. Nausea and vomiting 3. Pallor 4. Weakness 5. Pain in right upper quadrant 6. Slow, weak pulse 7. Confusion 8. Decreased urine output 9. Jaundice 10. Coagulation abnormality 11. Coma 12. Liver failure

Acetaminophen Poisoning

 Therapeutic interventions 1. Induce vomiting with ipecac syrup, lavage 2. Administer IV fluid 3. Administer an antidote (acetylcysteine)

Acetaminophen Poisoning

Specific Nursing Care of Children with Acetaminophen Poisoning A. Identify ingested substance and amount B. Monitor the electrocardiograph C. Measure intake and output D. Measure and record the vital signs frequently E. Obtain blood for hepatic and renal function tests F. Support the child and family

Acetaminophen Poisoning

Salicylate Toxicity and Poisoning Toxic dose: 300 to 500 mg per kilogram of body weight or 7 adult aspirins (28 baby aspirin) for a 9-kg (20-lb) child

Salicylate Toxicity and Poisoning

Clinical findings

1. Mild salicylate toxicity (items i to k are of little value in small children)

a. Diaphoresis b. Nausea c. Vomiting d. Dehydration e. Delirium f. Oliguria g. Hyperpnea h. Hyperpyrexia i. Ringing in the ears j. Dizziness k. Disturbances of hearing and vision

Salicylate Toxicity and Poisoning

2. Salicylate poisoning
a. Hyperventilation: confusion, coma b. Metabolic acidosis: anorexia, sweating, increased temperature c. Bleeding, especially if chronic ingestion

 C. Therapeutic interventions 1. Induce vomiting, gastric lavage, activated charcoal, saline cathartics 2. IV fluids 3. Vitamin K if bleeding 4. Peritoneal dialysis in severe cases

Lead Poisoning (Plumbism)

Data Base A. A prevalent, significant, preventable health problem that causes neurologic and intellectual damage from even low levels of lead B. Blood lead concentration should be less than 10 mg per 100 ml of blood C. Associated with increased levels of lead in the environment and pica
1. Most common source is lead-based paint 2. Soil, dust, or drinking water with lead 3. Parental occupations, hobbies

Lead Poisoning (Plumbism)

D. Clinical findings (chronic ingestion)
1. Loss of weight, anorexia 2. Abdominal pain, vomiting 3. Constipation 4. Anemia, pallor, listlessness, fatigue 5. Lead line on teeth and long bones 6. Protein in urine as a result of proximal tubular damage 7. Behavioral changes (impulsiveness, irritability, hyperactivity, or lethargy) 8. Headache, insomnia, joint pains 9. Brain damage, convulsions, death

 E. Therapeutic interventions 1. Objective: reduce concentration of lead in the blood and soft tissue by promoting its excretion and deposition in bones a. Calcium disodium edetate (Calcium Disodium Versenate, calcium EDTA) (1) Urine lead content monitored; peak excretion in 24 to 48 hours (2) Adverse effects: acute tubular necrosis, malaise, fatigue, numbness of extremities, GI disturbances, fever, pain in muscles and joints b. Dimercaprol (BAL) (1) Generally used in conjunction with calcium disodium edetate (2) Adverse effects: local pain at the site of injection; may cause persistent fever in children receiving therapy; rise in blood pressure accompanied by tachycardia after injection

 c. d-penicillamine
(1) Oral chelating agent (2) Increases urinary excretion, but less effective than calcium EDTA (3) Adverse effects: transient decrease in white blood cells and platelets; rash; enuresis; abdominal pain

2. Prevention of further ingestion

Specific Nursing Care of Children with Lead Poisoning A. Determine environmental exposure B. Screen children at risk by recognizing clinical findings, especially behavior changes C. Plan preparation of the child and rotation of injection sites if therapeutic intervention includes IM chelating agents; warm moist applications may relieve discomfort of injections D. Observe child carefully and closely E. Plan discharge and follow-up care of the child F. Prevent future lead poisoning by parental and child education, appropriate environment, and supervision of child and siblings