Module 09-pediatric Nursing

PEDIATRIC NURSING Care of the Child and Family 1

Developmental Theorists  Maslow’s Hierarchy of Needs

(1954)  Erik Erikson - Psychosocial

Theory  Jean Piaget - Cognitive

Theory 2

Maslow’s Hierarchy of Needs

ciples:

individual’s needs are depicted in ascending levels on the erarchy eds at one level must be met before one can focus on a hig el need

ls of Maslow’s Hierarchy of Needs: 

Physiologic/Survival Needs



Safety and Security Needs



Affection or Belonging Needs



Self-esteem/Respect Needs



Self-actualization Needs 3

Erikson’s Psychosocial Theory Birth to 1 year:

Trust vs. Mistrust

1 – 3 years:

Autonomy vs. Shame & Doubt

3 – 6 years:

Initiative vs Guilt

6 – 12 years:

Industry vs. Inferiority

12 – 18 years:

Identity vs. Role Confusion

Young Adults:

Intimacy vs. Isolation

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TRUST VS. MISTRUST • Birth - 1 year – World/Self is good – Basic needs met • Met = happy baby • Unmet = crying, tense, clinging • Stranger Anxiety • Separation Anxiety

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AUTONOMY VS. SHAME & DOUBT 1 – 3 years – Sense of control – Exerts self/will – Pride in selfaccomplishment • Negativism • Ritualism/Routines • Parallel play

Photo Source: Del Mar Image Library; Used with permission

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INITIATIVE VS. GUILT 3 – 6 years – “Can-do” attitude – Behavior is goaldirected and imaginative – Play is work – Be careful with criticism

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INDUSTRY VS. INFERIORITY 6 – 12 years – Mastery of skills – Peers in both play and work – Rules important – Competition – Predictability

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IDENTITY VS. ROLE CONFUSION 12 -18 years – Sense of “I” – Peers are very important – Independence from parents – Self-image

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Piaget’s Cognitive Theory Development of Thought Processes: 30 – 2 years:

Sensorimotor

32 – 7 years:

Preoperational

37 – 11 years:

Concrete Operations

311 years + :

Formal Operations

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SENSORIMOTOR Birth - 2 years – Reflexive behavior leads to intentional behavior – Egocentric view of world – Cognitive parallels motor development – Object Permanence 11

PREOPERATIONAL THOUGHT 2 - 7 years – Egocentric thinking – Magical thinking – Dominated by selfperception – Animism – No irreversibility – Thoughts cause actions Photo Source: Del Mar Image Library; Used with permission

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CONCRETE OPERATIONS 7 - 11 years – – – – – – –

Systematic/logical Fact from fantasy Sense of time Problem solve Reversibility Cause & effect Humor Photo Source: Del Mar Image Library; Used with permission

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FORMAL OPERATIONS 11 years - Adult

– Abstract thinking – Analyze situations – New ideas created – Factors altering this: • Poor comprehension • Lack of education • Substance abuse

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

TOYS = Mirror, Music, Mobile

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Infant Physical Tasks Physical Tasks 6 - 12 months:  Gains 3-5 oz (84-140g) weekly for next 6

months * triples weight by 12 months  Gains 1/2 in (1.25 cm) monthly for next 6 months  Teeth begin to come in  Motor: Intentional rolling over from back to abdomen* Starts crawling and pulling to a stand* Develops pincer grasp* Sits without support by 9 months*  Sensory: Can fixate on and follow objects

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Infant Psychosocial Tasks Vocalizations: • • • • •

Distinction in cry at 1 month Coos at 3 months Begins to imitate sound at 6 months – babbles Verbalizes all vowels at 9 months Can say 4–5 words at 12 months

Socialization: • • • •

Social smile at 2 months Demands attention & social interaction at 4 months Stranger anxiety & comfort habits begin at 6 months* Separation anxiety develops at 9 months*

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Infant Cognitive Tasks Neonates

Reflexes only

1-4 months Recognizes faces Smiles and shows pleasure Discovers own body and surroundings

5-6 months Begins to imitate 7-9 months Searches for dropped objects *Object Permanence begins Responds to simple commands Responds to adult anger

10-12 months

Recognizes objects by name Looks at and follows pictures in books 18

Physical Tasks: • • • • • • •

Toddler

Slow growth period Gains 11 lbs (5 kg) Grows 8 inches (20.3 cm) Anterior fontanel closes at 12 - 18 months* Primary dentition (20 teeth) complete by 2½ years Develops sphincter control – toilet training possible*

Motor Tasks: • • •

Walks alone by 12 - 18 months* Climbs and runs fairly well by 2 years Rides tricycle well by 3 years

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

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Toddler Psychosocial Tasks  Increases independence  Able to help with dressing self  Temper tantrums (autonomy)

 Beginning awareness of ownership (me and mine)  Shares possessions by 3 years  Vocabulary increases to over 900 words  Toilet training  Fears: separation anxiety, loss of control

TOYS = Push-pull toys, large blocks

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Preschooler Physical Tasks: • • • •

Slow growth rate continues Weight increases 4-6 lbs (1.8–2.7 kg) a year Height increases 2½ inches (5-6.25 cm) a year Permanent teeth appear

Motor Tasks: • • • • • •

Walks up & down stairs Skips and hops on alternate feet Throws and catches ball, jumps rope Hand dominance appears Ties shoes and handles scissors well Builds tower of blocks Photo Source: Del Mar Image Library; Used with permission

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Preschooler Cognitive Tasks  Can only focus on one idea at a time  Begins awareness of racial and sexual differences  Develops an understanding of time

• Learns sequence of daily events • Able to understand some time-oriented words  Begins to understand the concept of causality  Has 2,000 word vocabulary  Is very inquisitive and curious

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

TOYS = Dolls, Dress-up, Imagination

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Preschooler Psychosocial Tasks Fears: about body integrity (Fear & Injury) are common Magical and animistic thinking allows illogical fears to develop* Observing injuries or pain of others can precipitate fear Able to imagine an event without experiencing it Guilt and shame are common*

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School-age Physical Tasks:  Slow growth continues  Weight doubles over this       

period Gains 2 inches (5 cm) per year At age 9, both sexes are the same size At age 12, girls are bigger than boys Very limber but susceptible to bone fractures Develops smoothness & speed in fine motor skills Source: Del Mar Image Library; Used with Energetic, developing large Photo permission muscle coordination, stamina & strength Has all permanent teeth by age 12

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School-Age Cognitive Tasks Period of Industry: • Likes to accomplish or produce • Interested in exploration & adventure • Develops confidence • Rules become important*

Concepts of time and space develop: • Understands causality, permanence of mass & volume • Masters the concepts of conservation, reversibility, arithmetic and reading • Develops classification skills • Begins to understand cause and effect* 27

School-Age Psychosocial Tasks  School occupies half of waking hours; has cognitive and

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

TOYS = Board games, computer games, learning activities

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Adolescent Physical tasks:  Period of rapid growth  Puberty starts  Girls: height increases 3

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

Photo Source: Del Mar Image Library; Used with permission

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Adolescent Sexual Development Girls

Boys

Breasts develop

Facial Hair growth

Menses begins

Voice changes

First 1 –2 years infertile

Enlargement of testes at 13 yrs Nocturnal emission during

sleep Reaches reproductive maturity with viable sperm at 17 yrs

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Adolescent Cognitive Tasks  Develops abstract thinking abilities  Often unrealistic  Sense of invincibility = risk taking behavior*  Capable of scientific reasoning and formal logic  Enjoys intellectual abilities  Able to view problems comprehensively

ACTIVITIES = Music, video games, communication with peers

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Adolescent Psychosocial Tasks Early Adolescent: Prone to mood swings Needs limits and consistent discipline Changes in body alter self-concept Fantasy life, daydreams, crushes are normal Middle Adolescent: Separate from parents Identify own values and define self* Partakes/conforms to peer group/values* Increased sexual interest May form a “love” relationship Formal sex education begins

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Adolescent Psychosocial Tasks Late Adolescent:

Achieves greater independence* Chooses a vocation Finds an identity* Finds a mate Develops own morality Completes physical and emotional maturity

Fears:

Threats to body image – acne, obesity Rejection Injury or death, but have sense of “invincibility” The unknown 33

Let’s Review A 10 month-old baby was admitted to the pediatric unit. Each time the nurse enters the room the baby begins to cry. The most appropriate action by the nurse would be to: A. Complete all procedures quickly in order to decrease the amount of time the baby will cry. B. Ask another nurse to assist you with the baby’s care. C. Distract the baby. D. Encourage the parent to stay by the bedside and assist with the care.

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Let’s Review A 6 month-old is admitted to the pediatric unit for a 3 week course of treatment. The infant’s parents cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of an infant? A. Telling the parents that frequent visits are unnecessary. B. Placing the infant in a room away from other children. C. Assigning the infant to different nurses for varied contacts. D. Assigning the infant to the same nurse as much as possible. 35

Let’s Review Which child is most likely to be frightened by hospitalization? A. 4 month-old admitted with a diagnosis of bronchiolitis. B. 2 year-old admitted with a diagnosis of cystic fibrosis. C. 9 year-old admitted with a diagnosis of abdominal pain. D. 15 year-old admitted with a diagnosis of a fractured femur.

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Infant Nutrition Birth – 6 months:  Breast milk is most complete diet  Iron-fortified formulas are acceptable  No solid foods before 4 months*

6 - 12 months:  Breast milk or formula continues*  Diluted juices can be introduced  Introduction of solid foods*(4-6 mo): cereal,

vegetables, fruits, meats  Finger foods at 9-10 months

 Chopped table foods at 12 months

 Gradual weaning from bottle/breast  No honey (risk for botulism) 37

Toddler Nutrition     

   

Able to feed self – autonomy & messy! Appetite decreases- physiologic anorexia Negativism may interfere with eating Needs 16 – 20 oz. milk/day Increased need for calcium, iron, and phosphorus – risk for iron deficiency anemia Caloric requirements is 100 calories/kg/day No peanuts under 3 years of age (allergies)* Do not restrict fats less than 2 years of age* Photo Source: Del Mar Image Library; Used with Choking is a hazard (no nuts,permission hot dogs, popcorn, grapes)* 38

Preschooler Nutrition  Caloric requirements is 90 calories/kg/day  May demonstrate strong taste preferences • 4 years old – picky eaters • 5 years old – influenced by food habits of

others  Able to start social side of eating  More likely to try new foods if they assist in food preparation  Establish good eating habits - obesity

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School-Age Nutrition  Caloric needs diminish, only need 85

kcal/kg  Foundation laid for increased growth

needs  Likes and dislikes are well established  “Junk” food becomes a problem  Busy schedules – breakfast is

important  Obesity continues to be a risk  Nutrition education should be

integrated into

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

Increased needs for: Calcium for skeletal growth Iron for increased muscle mass and blood cell development Zinc for development of skeletal, muscle tissue and sexual maturation

Photo Source: Del Mar Image Library; Used with permission

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Adolescent Nutrition (continued)

Eating and attitudes towards food are primarily family/peer centered Skipping breakfast, increased junk food, decreased fruits, veggies, milk Boys eat foods high in calories. Girls under-eat or have inadequate nutrient intake.

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Let’s Review The nurse recommends to parents that popcorn and peanuts are not good snacks for toddlers. The nurse’s rationale for this action is: A. B. C. D.

They are low in nutritive value. They cannot be entirely digested. They can be easily aspirated. They are high in sodium.

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Let’s Review Nutrition is an important aspect of health promotion for the infant. Priority information to give the parents concerning infant nutrition would include (check all that apply): A. Restrict the fat intake of the infant to help reduce the chances of an obese child. B. Breast or infant formula must be continued for the first year. C. Encourage the use of a pacifier for nonnutritive sucking needs. 44 D. Introduction of solid foods should begin at

Play is the work of Children  Enhances Motor

Skills  Enhances Social

Skills  Enhances Verbal

Skills  Expresses

Creativity  Decreases Stress

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Appropriate Play Activities Infants - Solitary Play, stimulation of senses (music, mirror) Toddler - Parallel Play, make believe, locomotion (push-pull toys), gross & fine motor, outlet for aggression & autonomy Preschooler - Associative Play, Imaginary Playmate, dramatic & imitative, gross & fine motor School Age - Cooperative Play, rules dominate play, team games/sports, quiet games/activities, joke books Adolescent - Group activities predominate, 46 activities involving the opposite sex in later years

Preparation for Procedures • Allow child to play with equipment • Demonstrate procedure on doll for young child • Use age-appropriate teaching activities • Describe expected sensations • Use simple explanations • Clarify any misconceptions • Involve parents in comforting child Photo Source: Del Mar Image Library; Used with • Praise/reward child when permission finished 47

Communicating with Children

 Provide a trusting

environment  Get down to child’s eye

level  Use words appropriate for

age  Always explain what you

are doing  Always be honest  Allow choices when

possible

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Let’s Review The single most important factor for the nurse to recognize when communicating with a child is: A. The child’s chronological age. B. Presence or absence of the child’s parents. C. Developmental level of the child. D. Nonverbal behaviors of the child.

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Health Promotion Childhood Immunizations Well child check-ups Nutrition Screenings throughout childhood (APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis)

Health Teaching

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Immunizations  Primary prevention of many

communicable diseases  Vaccines safety

• MMR vaccine and autism (no correlation) • Reactions (pre-medicate with Tylenol)

 Live attenuated vaccines (MMR,

Varicella)

• Weakened form of disease • Body produces immune response • Contraindicated in immunosupressed individuals

 Inactivated (killed virus/bacteria or

synthetic)

• 1st dose only “primes” system- immunity develops after 3rd

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Injury Prevention & Safety Issues  Accidents are the leading cause of

death in infants and toddlers (falls, burns, poisons)  Toddlers and Preschoolers – drowning  School-age and adolescents – motor vehicle accidents and firearms  90% of all accidents are preventable!  Safety education is the answer

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Injury Prevention  Methods of Injury Prevention • Understanding and Applying Growth and

• • • •

Developmental Principles Anticipatory Guidance Childproofing the environment Educating caregivers and children Legislation

 Precipitating Factors  Potential Outcomes 53

Pediatric Poisonings Highest incidence occurs in children in 2year-old age group and under 6 years of age Major contributing factor – improper storage, allowing children to play with “bottles” – rattling of pills, “drink” syrups, toxic portion of plants.

• Teach parents about proper storage • Knowledge of plants in household, and keep away from infants and children who might “chew”

Emergency treatment depends on agent ingested Teach parents to have poison control number available

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Types of Poisonings Lead Poisoning Salicylate Poisoning Acetaminophen Ingestion 55

 



 

 

Lead Poisoning

Major environmental health concern Found in older homes (built before 1978), lead-contaminated soil, water through lead pipes, lead-based paint in ceramics products, Mexican candies made in lead containers Body rapidly absorbs lead – specially in periods of rapid growth – most harmful to children under 6 years Absorbed in GI tract and accumulates in bones, brain, kidneys Low levels in blood can cause behavioral/learning problems, mid-levels anemia-like symptoms and skeletal growth interference, and high levels can be fatal from CNS edema and encephalopathy Diet high in fat, low in iron & calcium can increase lead absorption Intervention=teaching for prevention. If blood level ≥ 45, chelation therapy is

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Salicylate Poisoning  Can be acute or chronic ingestion  S/S = nausea, disorientation, vomiting,

dehydration, hyperpyrexia, oliguria, coma, bleeding tendencies, tinnitus, seizures  Nursing interventions = activated charcoal, sodium bicarbonate for metabolic acidosis, external cooling measures for hyperpyrexia, anticonvulsant and seizure precautions (think patient safety!), vitamin K for bleeding, possible hemo (NOT peritoneal) dialysis

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Acetaminophen Poisoning  Most common drug poisoning in children  Acute ingestion  S/S start as nausea, vomiting, pallor,

sweating » hepatic involvement (jaundice, confusion, coagulation problems, RUQ pain)  Treatment is activated charcoal first, then the antidote N-acetylcysteine (Mucomyst) PO every 4 hours for 17 doses after a loading dose given

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

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Let’s Review Which would be the best approach for gastric emptying in a lethargic 18-month-old who ingested antihistamine tablets an hour ago? A. or B. C. D.

Diluting toxic substance with water milk Administering naloxone (Narcan) Gastric lavage Administering ipecac syrup 59

Physical Assessment of Infant  Assessment is NOT in the head-to-toe       

manner When quiet, auscultate heart, lungs, abdomen Assess heart & respiratory rates before temperature Palpate and percuss same areas Perform traumatic procedures last Elicit reflexes as body part examined Elicit Moro reflex last Encourage caretaker to hold infant during exam Distract with soft voice, offer pacifier, music

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Physical Assessment of Toddler  Inspect body areas through play – “count 

    

fingers and toes” Allow toddler to handle equipment during assessment and distract with toys and bubbles Use minimal physical contact initially Perform traumatic procedures last Introduce equipment slowly Auscultate, percuss, palpate when quiet Give choices whenever possible Photo Source: Del Mar Image Library; Used with permission

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Physical Assessment of Preschooler  If cooperative, proceed with head-to-toe  If uncooperative, proceed as with toddler  Request self undressing and allow to     

wear underpants Allow child to handle equipment used in assessment Don’t forget “magical thinking” Make up “story” about steps of the procedure Give choices when possible Photo Source: Del Mar Image Library; Used with permission If proceed as game, will gain cooperation 62

Physical Assessment of School-Age Child  Proceed in head-to-toe  May examine genitalia last in older

children  Respect need for privacy – remember modesty!  Explain purpose of equipment and significance  Teach about body function and care of body 63

Physical Assessment of the Adolescent  Ask adolescent if he/she would like

parent/caretaker present during interview/assessment  Provide privacy  Head-to-toe assessment appropriate  Incorporate questions/assessment related to genitals/sexuality in middle of exam  Answer questions in a straightforward, noncondescending manner  Include the adolescent in planning their care

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Fever  Causes – Often unknown, may be due to 

  

dehydration, most often viral induced Danger in infants is febrile seizures – most common between 3 months to five years. The seizure is a result of how quickly the temperature rises. Hydration (20mls/kg is formula for bolus) Antipyretics – acetaminophen or ibuprofen Cooling measures – avoid shivering • Tepid bath • Remove excess clothing and blankets • Cooling blankets/mattresses

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Pediatric Differences Fluid & Electrolyte

Percent Body Water compared to Total Body Weight: • Premature infants: 90% water • Infants: 75 - 80% water • Child: 64% water

Higher percentage of water in extracellular fluid in infants Infants and toddlers more vulnerable to fluid and electrolyte disturbances Concentrating abilities of kidneys not fully mature until 2 years Metabolic rate is 2-3 times higher than an adult Greater body surface area per kg body weight than adults; dehydrates more quickly

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Dehydration • Types:  Isotonic – Most common; salt and water lost. Greatest threat – Hypovolemic Shock  Hypotonic – Electrolyte deficit exceeds water deficit- physical signs more severe with smaller fluid losses  Hypertonic – Water loss higher than electrolyte Vomiting leads to metabolic alkalosis Diarrhea leads to metabolic acidosis LAB WATCH: monitor sodium, potassium, chloride, carbon dioxide,

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Assessment of Dehydration • Skin gray, cold, mottled, poor to fair, dry or clammy • Delayed capillary refill • Mucous membranes/lips dry • Eyes and fontanels sunken • No tears present when crying • Pulse and respirations rapid • Irritability to lethargy depending on cause and severity, not responsive to parent and/or environment

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Dehydration: Nursing Interventions

Daily weight, I/O Assess hydration status Assess neurological status Monitor labs (electrolytes) Rehydrate with fluids both PO and IV (20 mls/kg of NS)  Diet progression: Pedialyte⇒ modified Bread-Rice-Apple Juice-Toast (BRAT) ⇒ Diet-for-age (DFA)  Skin care for diaper rash  Stool output (Amount, Color, Consistency, Texture - ACCT)  HANDWASHING!     

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Priorities: fluid replacement & assess

Diarrhea • Often specific etiology unknown, but rotavirus is most common cause of gastroenteritis in infants and kids • Don’t forget contact precautions!! • Leading cause of illness in children younger than 5 • May result in fatality if not treated properly • History very important • Treatment aimed at correcting fluid imbalance and treating underlying cause • Metabolic acidosis = blood pH < 7.35 70

Vomiting • Often result of infections, improper feeding techniques, GI blockage (pyloric stenosis), emotional factors • Management directed toward detection, treatment of cause and prevention of complications • Metabolic alkalosis = blood pH >7.45

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Let’s Review The most appropriate type of IV fluid to infuse in treatment of extra-cellular dehydration in children is: A. B. C. D.

Isotonic solution. Hypotonic solution. Hypertonic solution. Colloid solution. 72

Let’s Review Which laboratory finding would help to identify that a child experiencing metabolic acidosis? A. Serum potassium of 3.8 B. Arterial pH of 7.32 C. Serum carbon dioxide of 24 D. Serum sodium of 136 73

Pain Assessment: Infants Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness Examples: FLACC scale, NIPS scale 74

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

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Pain Assessment: Preschoolers Think pain will magically go away May deny pain to avoid medicine/injections Able to describe location and intensity of pain FACES scale, poker 76 chips and Oucher

Photo Source: Del Mar Image Library; Used with permission

Pain Assessment: Older Children Older children can describe pain with location and intensity Nonverbal cues important, may become quiet or withdrawn Can use scales like Wong’s FACES scale, poker chips, visual analog scales, and numeric rating scales 77

Let’s Review The nurse begins a full assessment on a 10 year-old patient. To ensure full cooperation from this patient it is most important for the nurse to: A. to B. C. at

Approach the assessment as a game play. Provide privacy for the patient. Encourage the friend visiting to stay the bedside to observe. D. Instruct the child to assist the nurse in the 78 assessment.

Let’s Review During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development? A. “Babies progress at different rates. Your infant’s development is within normal limits.” B. “If she is pulling up, you can help her by holding her hand.” C. “She’s a little behind in her physical milestones.” D. “You can strengthen her leg muscles with special

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Let’s Review When assessing a toddler identify the order in which you would complete the assessment: 3. 4. 5. 6.

Ear exam with otoscope Vital signs Lung assessment Abdominal assessment

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Let’s Review When assessing pain in an infant it would be inappropriate to assess for: A. B. C. D.

Facial expressions Localization of pain Crying Extremity movement 81

Genetic Disorders ✗ Principles of Inheritance γ Autosomal Dominant γ Autosomal Recessive γ Sex-linked (X-linked) Inheritance γ Chromosome Alterations ✗Down’s Syndrome ✗Tay-Sachs Disease Nursing intervention is supporting parents and resources 82

Down’s Syndrome • Most common cause of cognitive impairment (moderate to severe)

• 1 in 600 live births • Risk factor- pregnancy in women over 35 yrs old • Cause - extra chromosome 21 (faulty cell division) • Causes change in normal embryogenesis process resulting in: Cardiac defects, GI conditions, Endocrine disorders, Hematologic abnormalities, Dermatologic changes

•

Physical features: small head, flat facial profile, broad flat nose, small mouth, protruding tongue, low set ears, transverse palmar creases, hypotonia

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Tay-Sachs Disease  Occurs predominately in children of Eastern European Jewish ancestry  Fatal Disease - death usually occurs before age 4  Autosomal recessive inheritance  Degenerative brain disease  Caused by absence of hexosainidase A from body tissue  Symptoms: progressive lethargy in previously healthy 2-6 months old

infants, loss of milestones, visual acuity, seizures, hyper-reflexia, posturing, malnutrition, dysphagia  Diagnosis: Classic cherry red spot on macula, enzyme measurement in

serum, amniotic fluid, white cells

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Let’s Review The infant with Down’s Syndrome is closely monitored during the first year of life for which condition? A. B. C. D.

Thyroid complications Orthopedic malformations Cardiac abnormalities Dental malformations 85

Pediatric Differences Neurosensory System

Size and Structure: Rapid head growth in early childhood Bones are not fused until 18-24 months

Function: Autonomic Nervous System is intact neurons are completely myelinized by 1 year Infants behavior initially reflexive, but are replaced with purposeful movement by 1 year Infants demonstrate a dominance of flexor muscles Motor development occurs constantly in head to toe progression

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Pediatric Differences Neurosensory System

Eye and Vision: Changes in development of eye and eye muscles *strabismus normal until 6 months Vision function becomes more organized Papilledema rarely occurs in infants due to expansion of fontanels with increased ICP

Ear and Hearing: Hearing fully developed at birth Abnormal physical structures may indicate genetic problems

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The Neurosensory System Disorders of the Nervous System ✓ Hydrocephalus ✓ Spina Bifida ✓ Reyes Syndrome ✓ Seizures ✓ Cerebral Palsy (CP) ✓ Meningitis 88

Hydrocephalus • Develops as a result of an imbalance of production and absorption of CSF • The increase of CSF causes increased ventricular pressure, leading to dilation of the ventricles, pressing on skull • Signs/Symptoms of Increased ICP: • Poor feeding and vomiting • Bulging fontanel, head enlargement, separation of sutures • Lethargy, irritability, restlessness, not responsive to parents • CHILD - Headache, vomiting, diplopia, ataxia, papilledema • Seizures A child’s head with an open fontanel (under 2 years old) has the ability to expand and better compensate for the increased intracranial pressure.

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Ventriculoperitoneal (VP) Shunts • Relief of hydrocephalus • Prevention/treatment of complications • Management of problems related to psychomotor development • Surgical intervention: ventriculoperitoneal (VP) shunt • One-way pressure valve

releasing CSF into peritoneal cavity where it Photo Source: Del Mar Image Library; Used with is reabsorbed permission 90

General Nursing Interventions • Monitor Neuro Status  Determine baseline  Assess LOC  Assess motosensory  Pupil checks  Vital signs, Head circ

• Provide Patient Safety  Seizure precautions  Fall precautions

• Decrease ICP

 Cluster care/ ⇓ stress  Quiet environment  ⇑ HOB 30-45 degrees  Appropriate position (head midline, no hip flexion, no prone)  Medications(pain meds,corticostero ids, diuretics, stool softeners, anti-infectives, 91 anticonvulsants)

General Nursing Interventions • Maintain Adequate Cerebral Perfusion  Maintain airway  Monitor oxygenation and apply O2 PRN  Monitor temperature and administer antipyretics PRN  Maintain normovolemia  Monitor I/O

• Maintain Nutritional & Fluid Needs  Determine swallow ability prior to PO’s  NGT feedings may be necessary  Dietary consult PRN  Daily weight  Monitor lab results

• Psychosocial

92

Spina Bifida: Occulta and Cystica (meningocele and myelomeningocele)

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• Etilogy is unknown, but genetic & environmental factors considered. – Maternal intake of folic acid – Exposure of fetus to teratogenic drugs • The severity of clinical manifestations depend on the location of the lesion. – T12 - flaccid lower extremities, ⇓ sensation, lack of bowel control and dribbling urine – S 3 and lower - no motor impairment • Other complications may occur. 93 – Hydrocephalus (80-90%)

Spina Bifida Nursing Interventions • • • • • • • •

Sterile dressing pre/post-op Monitor VS, S/S infection Use latex free items Avoid stress on sac - prone position only, especially pre-op; no supine until incision healed Monitor for S/S ⇑ intracranial pressure (ICP) Interventions to ⇓ ICP Encourage touch & talk Social service consult

94

Reye’s Syndrome • A true pediatric emergency - cerebral complications may reach an irreversible state. Vomiting & change in LOC to coma • Acute encephalopathy with fatty degeneration of the liver causing fluid & electrolyte imbalances, metabolic acidosis, hypoglycemia, dehydration, and coagulopathies. • Most frequently seen in children recovering from a viral illness during which salicylates were given. • Therapeutic management is intensive nursing

95

Seizures • Febrile seizures are the most common in children, caused by by a RAPID elevation in temperature, usually above 102°. • Most children do not have a second febrile seizure episode and only about 3% develop epilepsy. • Focus of care is on patient safety, cause of fever and education of parents for home care. • Remember basic CPR during seizures – airway before oxygen • Seizure precautions: Suction, oxygen, padded rails • Infants often have subtle seizures with only occular movements or some extremity

96

Cerebral Palsy (CP) 1.5 - 5 in 1,000 live births Neuromuscular disorder resulting from damage or altered structure of part of the brain Caused by a variety of factors: • Prenatally - genetic, trauma, anoxia • Perinatally - fetal distress, drugs at delivery, precepitate or breech delivery with delay • Postnatally - kernicterus or head trauma 97

Cerebral Palsy

(continued)

Spasticity - exaggerated hyperactive reflexes Athetosis - constant involuntary, purposeless, slow writhing motions Ataxia - disturbances in equilibrium Tremor - repetitive rhythmic involuntary contractions of flexor and extensor muscles Rigidity - resistance to flexion and extension Associated Problems: Mental retardation, hearing loss, speech defect, dental & orthopedic anomalies, GI problems and visual changes 98

Cerebral Palsy: Nursing Interventions • Safety Feed in upright position Seizure precautions Ambulate with assistance if able Medication administration

• Special Needs Nutritional needs include increased calories, assist with feeds, possible GT feeds. Speech, Occupational and Physical therapies 99

Bacterial Meningitis • Infectious process of CNS causing inflammation of meninges and spinal cord. • ISOLATION IS MANDATORY • Signs and symptoms include those of increased ICP plus photophobia, nuchal rigidity, joint pain, malaise, purpura rash, Kernig’s and Brudinski’s signs • Can occur at any age, but often between 1 month-5 years • Most common sequele: hearing and/or visual impairments, seizures, cognitive changes • Diagnostic confirmation is done by lumbar puncture and CSF is cloudy with increased WBCs, increased protein, and low glucose • Nursing Interventions include: appropriate IV antibiotics and meds for increased ICP as well as 100 interventions to decrease ICP

Causes of Blindness Genetic Disorders:

Tay-Sach’s disease Inborn errors of metabolism Perinatal: prematurity, retrolental fibroplasia Postnatal: trauma, childhood infections, Juvenile Arthritis 101

Causes of Deafness Conductive: Interference in transmission from outer ear to middle ear from chronic OM

Sensorineural: Dysfunction of the inner ear Damage to cranial nerve VIII from rubella, meningitis or drugs 102

Let’s Review Which test would confirm a diagnosis of meningitis in children? A. Complete blood count B. Bone marrow biopsy C. Lumbar puncture D. Computerized Tomography (CT) scan 103

Let’s Review In performing a neurological assessment on a patient which data would be most important to obtain? A. B. C. D.

Vital signs. Head circumference. Neurologic “soft signs”. Level of consciousness (LOC). 104

Let’s Review A neonate born with myelomeningocele should be maintained in which position pre-operatively? A. B. C. D.

Prone. Supine. Trendelenberg. Semi-Fowler. 105

Let’s Review The nurse witnesses a pediatric patient experiencing a seizure. The primary nursing intervention would be: A. Careful observation and documentation of the seizure activity. B. Maintain patient safety. C. Minimize the patient’s anxiety. D. Avoid over stimulation and promote rest.

106

Let’s Review Which assessment finding in an infant first day post-op placement of a ventriculoperitoneal (VP) shunt is indicative of surgical complications? A. B. C. D.

Hypoactive bowel sounds. Congestion in upper airways. Increasing lethargy. Incisional pain. 107

Cardiovascular System: Pediatric Variances  Cardiac arrest is related to prolonged

hypoxemia  Heart Rate (HR) higher  Cardiac Output depends on HR until heart muscle is fully developed (around 5 years of age)  Innocuous (benign) murmurs  Sinus arrhythmias normal in infants  Congenital defects present at birth – the greater the defect, the more severe the clinical 108 manifestations (S/S)

FETAL CIRCULATION

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109

Cardiovascular System: Changes from Fetal Circulation Fetal Circulation - Pattern of Altered Blood Flow Normal Circulatory Changes at Birth: Oxygenation takes place in Lungs Structural changes occur: * Ductus venosus constricts by 3-7 days becomes ligamentum venosum * Foramen ovale closes within first weeks 110 * Ductus arteriosus

Cardiovascular System: Changes from Fetal Circulation Abnormal Circulatory Patterns After Birth ♥Abnormal openings between the pulmonary and systemic circulations can disrupt blood flow. ♥Blood will follow the path of least resistance -Left side of heart has greater pressure, so . . . ♥Blood normally shunted from left to right ♥Obstructions to pulmonary blood flow may cause right to left shunting of blood

111

NORMAL HEART ANATOMY BLOOD FLOW

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112

The Cardiovascular System Care of the Child with Congestive Heart Failure Congenital Heart Defects Increased Pulmonary Blood Flow  Decreased Pulmonary Blood Flow Obstruction to Systemic Blood Flow Acquired Heart Disease 

113

Goals of Nursing Care with Congenital Heart Disease Reduce workload-Improve cardiac function Improve respiratory function Maintain nutrition to meet metabolic demands and promote growth Prevent infection and support/instruct parents

114

Congestive Heart Failure Review • COMPENSATORY RESPONSES – – – – – – –

Tachycardia, especially at rest Diaphoresis Fatigue Poor Feeding Failure to Thrive (FTT) Exercise Intolerance Decreased Peripheral Perfusion – Pallor and/or Cyanosis

115

CLINICAL MANIFESTATIONS-CHF • PULMONARY – – – –

Tachypnea Dyspnea Wheezes Crackles Retractions – Nasal Flaring – Cough

• SYSTEMIC – Edema (facial) – Sudden weight gain – Decreased Urine Output – Hepatomegaly – Splenomegaly – Jugular Vein Distention (JVD, children) – Ascites

116

CHF: Focused Review Nursing Interventions Therapeutic Management Improve cardiac function – Digitalization; Infant dose calculated 1000micrograms=1mg, ACE inhibitors Diuretics, fluid restrictions, daily weights, I/O Decrease tissue demands – Promote rest, minimize stress Increase tissue oxygenation – Oxygen Nutrition – Nipple feeds vs. gavage or GT, highercalorie feeds 117

GENERAL NURSING INTERVENTIONS • Improve Cardiac • Decrease Cardiac Function Demands – Medicate – Promote rest • Cardiac – Minimize Stress glycosides – Monitor VS (temp) (Digoxin) • Reduce Respiratory • Promote Fluid Loss Distress – Medicate – HOB elevated • Furosemide – Possible • Spironolactone supplemental oxygen • Clorothiazide – Fluid Restriction • Maintain Nutrition – Nipple vs. – Daily Weight Gavage/GTT – Monitor I/O – Higher-calorie 118 feeds (more than

Increased Pulmonary Blood Flow (Acyanotic) • Atrial Septal Defect (ASD)

• Ventricular Septal Defect (VSD) • Patent Ductus Arteriosus (PDA) • CHF • Feeding intolerance • Activity intolerance • Poor growth, failure to thrive • Frequent Pulmonary Infections due to “boggy lungs”

119

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120

Decreased Pulmonary Blood Flow (Cyanotic) • Pulmonary Stenosis • Tetralogy of Fallot • Transposition of the Great Vessels Assessment findings/Compensatory mechanisms • Oxygen desaturation • Varying degrees of cyanosis • Polycythemia 121

Decreased Pulmonary Blood Flow (Cyanotic)

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122

Obstruction to Systemic Blood flow • Aortic Stenosis • Coarctation of the Aorta • Think perfusion issues -Diminished or unequal pulses -Poor color -Delayed capillary refill time -Exercise intolerance

123

Obstruction to Systemic Blood flow

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124

Rheumatic Fever Acquired Heart Disease Inflammatory disorder involving heart, joints, connective tissue, and the CNS Peaks in school-age children Linked to environmental factors and family history Thought to be an autoimmune disorder: Commonly preceded by a Strep Throat Prognosis depends upon the degree of heart damage Rest important in recovery – priority intervention in acute stage Strep prophylaxis for 5 years or throughout adolescence

125

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

126

The Hematologic System  Disorders of Red Blood Cells  Iron Deficiency Anemia  Sickle Cell Anemia  Disorders of Platelets/Clotting

Factors  Idiopathic Thrombocytopenia

Purpura (ITP)  Hemophilia 127

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

128

IRON DEFICIENCY ANEMIA • Often occurs as a result of increased milk intake • Lab results show low HGB, HCT, MCV, MCH, MCHC, iron, ferritin • Teach parents proper nutrition • Meat, spinach, legumes, sweet

potatoes, egg yolks, seafood • Calcium inhibits iron, Vitamin C enhances iron absorption

129

Sickle Cell Disease

PATHOLOGY

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 Normal RBC has a flexible, round shape  RBC w/HbS has a normal shape until it’s O2

delivered to tissue, then sickle shape occurs  Stiff, non-pliable – can’t flow freely  Trapped in small vessels = causes vasoocclusions, tissue ischemia and infarctions – painful episodes, most common area is joints  Hemolysis of RBC- lifespan down to 20 days  Compensatory mechanism is increased reticulocytes

130

Sickle Cell Disease ACUTE FEBRILE ILLNESS • High mortality rate <5 years old • Splenic dysfunction begins at 6 mo old • Prophylactic PCN – BID at 2-3 mo old • Monitor for Infection – Temp > 101.5 – Respiratory S/S

SPLENIC SEQUESTRATION • Highly vascular • Susceptible to injury/infarction • Occurs 6 mo-3yrs • Pallor, fatigue, abd pain, splenomegaly, CV compromise • Treatment: IV fluids, PRBC’s 131

Sickle Cell Disease: Nursing Interventions GENERAL NURSING CARE • Hydration is Priority! – Fluid Bolus & maintenance + 1/2

• Oxygen - to decrease sickling of of cells • Pain Management – Assess frequently/appropriatel y – IV Morphine q3-4 hr, PCA – Non-pharmacological methods

HOME MANAGEMENT • Pain Control • Fluids • Teaching • Early Identification of infection • Immunizations • Avoid dehydration 132

Idiopathic Thrombocytopenic Purpura (ITP)  Acquired hemorrhagic disorder

characterized by thrombocytopenia and purpura  Cause is unknown, but is to believed to be an auto-immune response to disease-related antigens  Usually follows an URI, measles, rubella, mumps, chickenpox  Greatest frequency is between 2-8 years of age  Platelet count is below 20,000  Therapeutic management is supportive with safety concerns. Activity is usually restricted.  Acute presentation therapy can include 133 prednisone, IV immunoglobulin, or Anti-D

Hemophilia • Group of genetic bleeding disorders of which there is a deficiency of a clotting factor • Most common are Factor VIII (A) & Factor IX (B) • Bleed LONGER not faster • Clinical manifestations: prolonged bleeding, bruising, spontaneous hematuria • Management: replacement of missing clotting factor (recombinant factor VIII concentrate), cryoprecipitate, DDAVP • NSAIDS (aspirin, Indocin) are contraindicated, they inhibit platelet function • Regular non-contact exercise/physical therapy is encouraged 134

Hemophilia COMPLICATIONS • Bleeding into muscle tissue • Hemarthrosis can cause joint pain & destruction • Acute Treatment is

rest, ice, elevation, ROM Photo Source: Del Mar Image Library; Used with permission

135

Let’s Review When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is much greater than that found in the child’s leg. The nurse reacts to these findings in which way? A. Charts the findings and realizes they are normal. D. Suspects the child may have coarctation of the aorta. C. Suspects the child may have Tetralogy of Fallot. D. Notifies the physician and alerts the

136

Let’s Review A 1-month-old infant is being admitted for complications related to a diagnosed ventricular septal defect (VSD). Which physician’s order should be questioned by the nurse? A. Blood pressure every 4 hours. B. Serum digoxin level. C. Diet: Enfamil 20, nipple 6 oz q2H. D. Supplemental oxygen via nasal cannula prn maintain SaO2 >92%. 137

Let’s Review A nursing intervention most pertinent for the child with hemophilia is: A. Sedentary activities to prevent bleeding episodes. B. Meticulous oral care with dental floss to prevent infection. C. Warm compresses to bleeding areas to increase absorption. D. Active range of motion exercises for joint mobility. 138

Let’s Review Which is the most appropriate information to teach a parent of a 14 month-old child with iron deficiency anemia? A. Increase the child’s daily milk intake to a minimum of 24 ounces. B. Administer oral iron supplement for the child to drink in a small cup. C. Increase the amount of dark green, leafy vegetables and eggs in the child’s diet. D. Encourage the parents to let the child choose foods he

139

Let’s Review Which strategy is appropriate when feeding the infant in congestive heart failure? A. Continue the feeding until a sufficient amount of formula is taken B. Bottle feed no longer than 30 minutes C. Feed the infant every 2 hours D. Rock and comfort the infant during feedings

140

Respiratory System Pediatric Variances

 The airway is smaller and more flexible.  The larynx is more flexible and more

susceptible to spasm.  The lower airways are smaller with underdeveloped cartilage.  The tongue is large.  Infants < 6 months old are obligate nose breathers.  Chest muscles are not well developed  The diaphragm is the neonate’s major respiratory muscle.  Irregular breathing pattern and brief periods of apnea (10 15 secs) are common 141  Abdominal muscles are used for inhalation

The Respiratory System Upper Airway Disorders Tonsillitis Croup Epiglottis Foreign Body Aspiration

Lower Airway Disorders Bronchiolitis Asthma Cystic Fibrosis

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Tonsillitis CLINICAL MANIFESTATIONS Sore throat Mouth breathing Sleep Apnea Difficulty swallowing Fever Throat C&S/Rapid Strep

IMPLEMENTATIONS  Ease Respiratory

Efforts  Provide Comfort

Warm saline gargles Pain Medication Throat lozenges

Reduce Fever Promote Hydration Administer Antibiotics Provide Rest Patient Teaching Tonsillectomy may be necessary

143

Tonsillectomy Pre-operative Nursing Care Monitor Labs (CBC, PT, PTT) Age-appropriate Preparation/Teaching Surgical Consent

Post-operative Nursing Care Frequent site assessment - visualize! Monitor for S/S of Complications Pain Management Diet (push fluids-no citrus juices or red, advance diet) Patient Teaching 144

Croup/Epiglottitis • Infection and swelling of larynx, trachea, epiglottis, bronchi • Often preceded by URI traveling downward • Causative agent: Viral • Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress • Most common ages 6 mo-3 yrs • LTB form most common

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Acute Epiglottitis • Bacterial form of croup affecting epiglottis • LIFE-THREATENING EMERGENCY • Wellness to complete obstruction in 2-6 hours • Most common in ages 2-5 years • Do not examine throat! • Have functional emergency equipment at bedside - Priority! • Often the child is intubated • 4 D’s - Drooling, Dysphagia, Dysphonia, Distressed Inspiratory Effort • Lateral Neck X-ray shows “thumb sign” • HIB vaccine has reduced the cases dramatically 146

Croup/Epiglottitis Nursing Interventions Maintain Patent Airway Assess and Monitor Ease Respiratory Efforts Promote Hydration Reduce Fever Calm Environment

Nursing Interventions  Administer Meds  Corticosteroids  (HHN) Nebulizer treatment of Racemic Epinephrine PRN stridor  Antibiotic for epiglottitis 147

Foreign Body Aspiration • Occurs most often in small children • Choking, coughing, wheezing, respiratory difficulty • Often it is round food, such as hot dogs, grapes, nuts, popcorn • Bronchoscopy often needed for removal • Age-appropriate preparation needed for procedure • Prevention and parent education is very important 148

Bronchiolitis/RSV • Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur • Increased amount of mucus and exudates preventing expiration of air and overinflation of lungs • Causative agent in 85% of cases is Respiratory Syncytial Virus (RSV). It is highly contagious - contact isolation must be enforced. • Nasal swab or nasal washing obtained for viral panel, including RSV • CXR shows hyperinflation and consolidation if atelectasis present • Primarily seen in children under 2 years of age • Most common in winter and early spring 149 • Palivizumab (Synagis)

Bronchiolitis/RSV CLINICAL MANIFESTATIONS Nasal Congestion Cough Rhonchi, Crackles, Wheezes Increased RR & SOB Respiratory Distress Fever Poor Feeding

IMPLEMENTATIONS Suction – priority Bronchodilator via HHN CPT Promote fluids Monitor VS , SaO2, lung sounds & respiratory effort Supplemental oxygen Reduce fever Promote rest HANDWASHING! 150

Asthma CLINICAL MANIFESTATIONS Tachypnea SaO2 below 95% on RA Wheezes, crackles Retractions, nasal flaring Non-productive cough Silent chest Restlessness, fatigue Orthopnea Abdominal pain CXR = hyperinflation

INTERVENTIONS Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Ease respiratory efforts Promote hydration Promote rest Monitor labs/x151 rays

Asthma Administer Medications  Bronchodilator via HHN or MDI with spacer (Albuterol) -Peak flows should always be done before and after Tx  Mast cell inhibitor via HHN or MDI (Cromolyn Sodium - Intal)  Corticosteroid IV or PO (Solu-medrol or Decadron)  Antibiotic if precipitated from a respiratory infection

Home Medication Management  Bronchodilator via HHN or MDI with spacer (Albuterol -Proventil, Levalbuterol - Xopenex)  Inhaled steroids (Beclamethasone - Vanceril)  Mast cell inhibitor via HHN or MDI (Cromolyn Sodium - Intal)  Leukotriene modifiers PO for long-term 152 control - Singular

Cystic Fibrosis 1 in 1,500-2,000 live births Dysfunction of the exocrine gland (mucus producing) Multi-system disorder Secretions are thick and cause obstruction and fibrosis of tissue. The clinical manifestations are the result of the obstructive process. Sweat has a characteristic high sodiumSweat Chloride Test Pancreatic involvement in 85% of CF patients Disease is ultimately fatal. Average age at death: 32 years

153

Cystic Fibrosis PULMONARY MANIFESTATIONS

GI MANIFESTATIONS

• Large, loose, frothy • Initial and foul-smelling stools • Wheezing • Dry, non-productive • Increased appetite cough (early) • Eventual & Progressive • Loss of appetite (later) • Repeated lung • Weight loss infections • FTT • Wet & paroxysmal cough • Distended abdomen • Emphysema/Atelectasi • Thin extremities s • Deficiency of A,D, E, • Barrel-chest K - Clubbing • Anemia - Cyanosis

154

Cystic Fibrosis MANAGEMENT/INTERVENTIONS – Airway Clearance - Chest physiotherapy (CPT) Priority – Drug Therapy • • • •

Bronchodilators - via HHN Mucolytic Agent (Dnase-Pulmozyme) - via HHN Antibiotics - via HHN, IV, or PO Digestive enzymes

 Nutrition - needs are at 150% • Increased calories and protein - TPN or GT feedings at night • Additional fat soluble vitamins • Additional salt with vigorous exercise and hot weather  Exercise  Patient Teaching

155

◊ ◊ ◊

Otitis Media Most common childhood illness Inflammation of middle ear Impaired eustachian tube causes decreased ventilation and drainage

◊ Acute otitis media (AOM) ◊ Infectious process by pathogen ◊ Infection can spread leading to meningitis ◊ S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane ◊ Otitis media with effusion (OME)

◊ Inflammation of middle ear with fluid behind tympanic membrane-no infection ◊ Peaks spring and fall (allergies)

◊ Chronic otitis media

◊ Inflammation of middle ear > 3 mo ◊ Can lead to hearing loss/delayed speech Photo Source: Del Mar Image Library; Used with permission

156

Otitis Media RISK FACTORS ◊ Secondary smoke ◊ Formula feeding (positioning) ◊ Day care ◊ Pacifier > 6 mo old TREATMENT ◊ Antibiotics (for AOM) ◊ Myringotomy with Pressure Equalizing (PE) tubes INTERVENTIONS ◊ Teaching ◊ No bottle propping ◊ Feeding techniques ◊ Medication regimen PAIN MANAGEMENT ◊ Fever management ◊ Surgery prep if needed

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Let’s Review The nurse’s first action in responding to a child with tachypnea, grunting, and retractions is to: A. Place the child in an upright, semifowler’s position. B. Apply a pulse oximeter to determine oxygen saturation. C. Assess for further symptoms. D. Call for a stat respiratory nebulizer treatment (HHN). 158

Let’s Review A 3-year-old child is brought to the emergency room with a sore throat, anxiety, and drooling. The priority nursing action is to: A. Inspect the child’s throat for infection. B. Prepare intubation equipment and call the physician. E. Obtain a throat culture for respiratory syncytial virus (RSV). G. Obtain vital signs and auscultate lung sounds.

159

Let’s Review An assessment finding in a child with asthma requiring immediate action by the nurse is: A. B. C. D.

Diminished breath sounds. Wheezing in bronchi. Crackles in lungs. Refusal to take PO fluids. 160

Let’s Review Which sign is indicative of air hunger in an infant? A. Nasal flaring. B. Periods of apnea lasting 15 seconds. C. Irregular respiratory pattern. D. Abdominal breathing. 161

Let’s Review The priority nursing intervention in caring for the infant with Respiratory Syncytial Virus (RSV) induced bronchiolitis is: A. Nasopharyngeal suctioning. B. Coughing and deep breathing exercises. C. Administration of intravenous antibiotic. D. Administration of antipyretics

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Gastrointestinal System • Many GI issues require surgical intervention • Nursing interventions will often include general pre and post-op care • Bilious vomiting is a sign of GI obstruction and requires immediate intervention • Assess stools! • Assess hydration status

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Gastrointestinal System Pediatric Variances • Mechanical functions of digestion are immature at birth • Liver functions are immature throughout infancy • Production of mucosal-lining antibodies is decreased • Infants have decreased saliva • Infant’s stomach lies transversely • Peristalsis is faster in infants • Digestive processes are mature as a toddler • The child’s liver and spleen are large and 164 vascular

The Gastrointestinal System Altered Connections ✓ Esophageal

Atresia/Tracheoesophageal Fistula ✓ Cleft Lip and Palate

Gastrointestinal Disorders ✓

Gastroesophageal Reflux

Stenosis ✓ Hirschsprung’s Disease Imperforate Anus ✓ Intussusception

✓ Pyloric ✓

Acquired Gastrointestinal Disorders 

✓ Celiac Disease ✓ Appendicitis ✓ Parasitic Worms

165

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA

• Congenital defects of esophagus • EA is an incomplete formation of esophagus • TEF is a fistula between the trachea and esophagus • Classic 3 “C’s” Photo Source: Del Mar Image Library; Used with permission coughing,choking,cyanosis

166

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA SIGNS/SYMPTOM • Copious, frothy oral secretions • Abdominal distension from air in stomach • Look for 3 C’s • Confirmed with radiographic studies

TREATMENT • Surgery: either a one- or two-stage repair • Pre-op care focuses on preventing aspiration and hydration • Post-op care focus is a patent airway, prevent incisional 167 trauma

Cleft Lip/Palate  May present as single defect or 



 



combined Non-union of tissue and bone of upper lip and hard/soft palate during fetal development CL-failure of nasal & maxillary processes to fuse at 5-8 weeks gestation CP-failure of palatine planes to fuse 712 weeks gestation Cleft interferes with normal anatomic structure of lips, nose, palate, muscles – depending on severity and placement 168 Open communication between mouth

Cleft Lip/Palate

 Multidisciplinary care

throughout childhood and early adulthood  Nutrition is a challenge in infancy  ESSR method (enlarge,

stimulate, swallow, rest)  Risk for aspiration  Respiratory distress

Photo Source: Del Mar Image Library;

 Altered bonding is aUsed with permission

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CLEFT LIP & CLEFT PALATE: Operative Care  Cleft lip surgery by 4 weeks & again

at 4-5 yrs  Cleft palate surgery at 6-24 months of age, usually done by 1 year so speech will not be affected  Protect suture lines- priority  Monitor for infection  Clean Cleft Lip incision

 Pain Management  Cleft Palate starts feedings 48-hour

post-op:

 Clear and advance to soft diet  No straws, pacifiers, spouted cups  Rinse mouth after feeding

170

GASTROESOPHAGEAL REFLUX  Regurgitation of gastric 

  

contents back into esophagus - 50% healthy term babies affected Related to inappropriate relaxation of Lower Esophageal Sphincter (LES) making the LES pressure less than the intra abdominal pressure GER may predispose patient to aspiration and pneumonia Apnea has been associated with GER ⇓ chance of GER after 12-18 mo old related to growth due to elongation of esophagus and the LES drops below the diaphragm

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GASTROESOPHAGEAL REFLUX SIGNS/SYMPTOMS

DIAGNOSTIC EVAL

• Vomiting/spitting • History of up feedings/PE • Gagging during • Upper GI/Barium feedings swallow to eliminate • Irritability anatomical • Arching/posturing problems • Frequent URI’s/OM • Upper GI • Anemia endoscopy to • Bloody stools visualize esophageal mucosa • pH probe study

172

GASTROESOPHAGEAL REFLUX: Therapeutic Management • Positioning • Prone HOB ⇑ 30° • Right side

• Dietary modifications

• Medications • Prokinetic agents: ⇑ LES pressure & gastric motility • Histamine H-2 antagonists are added if esophagitis : ⇓ acid • Proton Pump Inhibitors if H-2 ineffective:⇓acid • Mucosal Protectants

• Small, frequent feedings, burp often • Possibly thicken formula • Avoid fatty, spicy foods caffeine, & citrus • Surgery: • Teach

fundoplication

173

HIRSHSPRUNG’S • Aganglionic megacolon No ganglion cells at affected area usually at rectum/proximal portion of lower intestine Absence of peristalsis leads to intestinal distension, ischemia & maybe enterocolitis

• Treatment Mild-mod: stool softeners & rectal irrigations Mod-severe: single or 2step surgery Colostomy with later pullthrough

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HIRSHSPRUNG’S SIGNS/SYMPTOMS  Infants  Unable to pass meconium stool within 24 hours of life  Abdominal distention  Bilious vomiting  Refusal to feed  Failure to thrive  Children  Chronic constipation  Pellet or ribbon-like

stools (foul-smelling)  Vomiting/FTT

NURSING INTERVENTIONS • Surgery prep: bowel cleansing, antibiotics, NPO, IVF’s, therapeutic play for surgery preparation • Infection & Skin Integrity: monitor ostomy/anus • Nutrition & Hydration: NGT, NPO then advance to Diet as tolerated, 175 assess bowel

INTUSSUSCEPTION • Prolapse or “telescoping” of one portion of the intestine into another • Abrupt onset • Usually occurs in 3-24 months of age • Sudden abdominal pain • Vomiting • Red, current jelly stool • Abd distention/tender • Lethargy • Can lead to septic shock

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INTUSSUSCEPTION DIAGNOSTIC STUDY • Barium or air enema • Abdominal ultrasound TREATMENT • Hydrostatic reduction: force exerted using watersoluble contrast and air to push the affected intestine apart • Surgical reduction if hydrostatic reduction is unsuccessful

• • •

• •

NURSING INTERVENTIONS Monitor for infection, shock, pain Maintain hydration assess status! Prepare child/parent for hydrostatic reduction - teach, consent, NPO, NGT Monitor stools pre & post procedure If surgery: general pre & post-op care 177

PYLORIC STENOSIS

 Hypertrophy of pyloric sphincter,

causing a narrowing/ obstruction (bands pylorus)  Usually occurs between 2-8 weeks of age  Infant presents with non-bilious projectile vomiting, and is “always hungry” Photo Source: Del Mar Image Library; Used with  Can lead to dehydration and permission hypochloremic metabolic alkalosis  Weight loss

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PYLORIC STENOSIS DIAGNOSTIC EVAL

INTERVENTIONS

• History/PE: “olive” palpated in epigastrum • Upper GI (string sign) • Abdominal Ultrasound

• Pre-op: NPO, NGT to LIS, hydration, I/O, monitor electrolytes • Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule begin w/5cc GW ⇒ half strength formula ⇒ Full strength formula

TREATMENT • Surgical Intervention: Pyloromyotomy

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IMPERFERATE ANUS • Anorectal malformations • No obvious anal opening • Fistula may be present from distal rectum to perineum or GU system • Diagnostic Eval: patency of anus in newborn, passage of meconium; ultrasound is suspected • Therapeutic Management: manual dilatation for anal stenosis, surgical treatment for malformations • Nursing Implementations: pre and post-op care – IV fluids, consent, assessing surgical site for infection and monitoring for complications, possible NGT, diet progression, possible colostomy and teaching; preferred post-op condition is side-180 lying.

Celiac Disease • Malabsorption syndrome characterized by intolerance of gluten (rye, oats, wheat and barley) • Familial disease - more common in Caucasians • Thought to be an inborn error of metabolism or an immunological disorder • Reduced absorptive surfaces in small intestine which causes marked malabsorption of fats (frothy, foul-smelling stools) • Child has diarrhea, abdominal distention, failure to thrive • Treatment is lifelong low-gluten diet; corn and rice are substituted grain foods

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APPENDICITIS • Inflammation and infection of vermiform appendix, usually related to an obstruction • Cause may be bacteria, virus, trauma • Ischemia can result from the obstruction, leading to necrosis causing perforation • S/S: periumbilical pain ⇒RLQ pain (McBurney’s point), fever, vomiting, diarrhea, lethargy, irritability, ⇑ WBC’s

• Surgery is necessary • If ruptured, often child will receive IV antibiotics for 24 hrs prior to OR • Pre-op Care: NPO, pain management, hydration, prep & teaching, consent • Post-op Care: routine post-op care, IVF/antibiotics, NPO⇒DAT, ambulation, positioning, pain 182 management, wound care,

PINWORM (enterobiasis)  Transmission: oral-fecal  Persist in indoors for up to 3 weeks

contaminating anything they contact (toilets, bed linens)  S/S: intense perianal itch, sleeplessness, abd pain, vomiting  Scotch tape test – collects eggs laid by female outside of anus. Must be obtained in am prior to bath or BM.  Treatment: *mebendazole (Vermox) for over 2 years of age. Under 2 years of age treatment may be pyrvinium pamoate (Povan) which stains stool and emesis red 183 *All family members must be treated.

Let’s Review Which intervention would have the highest priority for the nurse assisting in the feeding of a child post cleft palate repair? A. Permiting the child to choose the liquids desired. B. Providing diversional activities during feeding. C. Applying wrist restraints. D. Cleansing the mouth with water after each feeding. 184

Let’s Review Which food choice by a parent of a child with celiac disease indicates a need for further teaching? A. B. C. D.

Oatmeal Rice Cornbread Beef

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Let’s Review Which assessment finding would the nurse find in a child with Hirschsprung’s Disease? C. Current jelly stool D. Diarrhea E. Constipation • Foul-smelling, fatty stool

186

Let’s Review Children with gastroenteritis often receive intravenous fluids to correct dehydration. How would you explain the need for IV fluids to a 3 year-old child? A. “The doctor wants you to get more water, and this is the best way to get it.” B. “Your stomach is sick and won’t let you drink anything. The water going through the tube will help you feel better.” C. “See how much better your roommate is feeling with his IV! You will get better, too.” 187 D. “The water in the IV goes into your veins

Let’s Review The nurse caring for a child with suspected appendicitis would question which physician order? C. NPO status D. Start IV fluids of D5 ½ NS at 50 mls/hour E. Complete Blood Count (CBC) F. Apply heating pad to abdomen for comfort 188

Genitourinary System

Anatomy & Physiology Review • The GU system maintains homeostasis of the body (water & electrolytes) • Responsible for the excretion of waste products • Nephron is the workhorse of the kidney (filter blood at the rate of 125mL/minute)-GFR • Renin helps maintain Na & water balance (and B/P) • Kidneys produce erythropoeitin which stimulates RBC

Photo Source: Del Mar Image Library; Used with permission

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Pediatric Variances

Genitourinary System • Infants & young children excrete urine at a higher rate related to the increased BMR producing more waste • Infant kidneys have ⇓ function if under stress • Infant can’t concentrate urine well until 3-6 mo • In infants, kidney & bladder are abdominal organs • Infant kidneys are less protected because of unossified ribs, less fat 190 padding & large size

The Genitourinary System Minimum urine outputs by age groups: • INFANTS & TODDLERS – 2-3 ml/kg/hr • PRESCHOOLERS & YOUNG SCHOOL-AGE – 1-2 ml/kg/hr • SCHOOL-AGE & ADOLESCENTS – 0.5-1 ml/kg/hr

• TIP: Bladder capacity in ounces: AGE in years + 2 Example: a 2-year-old’s bladder can hold up to 4 ounces or 120 mls 191

The Genitourinary System  Disorders of the Genitourinary

System Enuresis Nephrotic Syndrome Acute Glomerulonephritis  Hemolytic Uremic Syndrome 

(HUS)

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Glomerulonephritis • Group of kidney disorders that show main focus of injury is the glomerulus • It is characterized by inflammation of the glomerular capillaries • Acute disorders occur suddenly and resolve completely • Acute poststreptococcal glomerulonephritis (APSGN) is the most common type • History, presenting symptoms, and lab results establishes the diagnosis of APSGN 193

Glomerulonephritis PATHOPHYSIOLOGY Streptococcal Infection

Producing Antibodies Bacterial Antigens  plus Antibodies form Immune Complexes & trap in Glomerulus

Inflammatory Response Injury to Capillary Walls

Ineffective Filtration Proteins Pass Through Decreased GFR

Kidneys Enlarge

with sodium, water, waste

EDEMA

ACUTE RENAL FAILURE

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

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Glomerulonephritis ASSESSMENT • Hematuria • Proteinuria • Edema: periorbital, ankles ∀ ⇓ Urine Output • Hypertension • Fatigue • Possible fever • Abdominal discomfort • Labs: +ASO, ⇓ Bicarb,⇑K ⇑BUN,⇑ Creat, ⇓ H & H

INTERVENTIONS • Monitor Urine (Dipstick) • Monitor fluid overload • Assess lung sounds/Resp effort • Possible fluid & salt restriction • Monitor I/O, Daily Weights • Monitor VS • Antibiotic, diuretic & antihypertensive medications • Promote & provide rest 195 • Provide comfort

Nephrotic Syndrome • Kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. • There is primary (involving kidney only) and secondary (caused by systemic disease or heavy metal poisoning) NS. Primary is the most common (MCNS). • Cause not fully understood-may have an immunologic component. • Primary age affected is 2-6 years (boys 2:1) • There is no occlusion of glomerular vessels. • Loss of immunoglobulins also occur (IgG) • Hypovolemia and the severe proteinuria put the child in a hypercoagulable state • Treatment is prednisone (2mg/kg/day) for about 4-6 weeks. Remission is obtained when the urine protein is 0-tr for 5-7 days • Albumin followed by furosemide may be given for the edema

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Nephrotic Syndrome PATHOPHYSIOLOGY Alteration in Glomerulus Damage to Basement Membrane of glomerulus (increased permeability)

Proteinuria (Hypoalbuminemia)

Fluid Shift Intravascular to Interstitial HYPOVOLEMIA  Decreased Renal Blood Flow Triggers Renin Production Causing Increased Aldosterone

Reabsorption of Sodium and Water retention Hyperlipidemia

EDEMA

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

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Nephrotic Syndrome ASSESSMENT

• Proteinuria (3-4+), frothy urine • Edema (pitting):periorbital, genitals, lower extremities, abdominal ∀ ⇓ Urine Output (Hypovolemia) • Normotensive or hypotensive • Fatigue • Recent URI, Pneumonia • Abdominal Pain/Anorexia • Labs: ⇓Albumin ⇑ Platelets ⇑H & H ⇑ Cholesterol

INTERVENTIONS

• Monitor Urine (Dipstick) • Monitor edema/dehydration • Assess skin integrity/turn often • Possible fluid & salt restriction • Monitor I/O, Daily Weights • Monitor VS & S/S of infection • Administer medications • Promote & provide rest • Monitor labs • HANDWASHING/monit 198 or visitors

Hemolytic Uremic Syndrome (HUS) • It is the most common cause of acute renal failure (ARF) in children. • HUS is characterized by the triad of anemia, thrombocytopenia, and ARF. • Most children have associated GI symptomsalmost all are caused by e. coli 0157. • Treatment is supportive and based on symptoms. • No antibiotics are given; more damage can be caused. • Serum electrolytes may be outside of normal limits. • Blood transfusions and/or dialysis may be necessary. • More than 90% of the children recover with 199 good renal function.

Hemolytic Uremic Syndrome (HUS) GASTROENTERITIS e. coli #0157 Bacteria Adheres to GI Mucosa Multiplies Releases Toxins  Damages Capillary Walls

Inflammatory Response

Thrombocytopenia

Occlusion of Vessels (Glomerular Vessels)

Collection of Fibrin Lipids Platelet Fragments

Fragmented RBC's Causing Anemia

Decreased GFR Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

Acute Renal Failure

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Hemolytic Uremic Syndrome (HUS) ASSESSMENT • History: emesis, bloody diarrhea, abd pain, ⇓ Urine • Petechiae, bruises, purpura • Edema (possible CHF) • Hepatosplenomegaly • Altered LOC, seizure • Hypertension • Fatigue • Abdominal discomfort • Labs: Lytes may be abnormal ⇑ BUN ⇑ Creatinine ⇓ H&H

INTERVENTIONS • Monitor I/O, Daily Weights • Evaluate for signs of bleeding • Monitor fluid overload/edema • Assess for dehydration • Monitor VS with neuro checks • Seizure Precautions, HOB ⇑ • Diuretic & antihypertensive medications • Provide rest/calm 201 environment

Enuresis • Involuntary passage of urine in children whose chronological or developmental age is at least 5 years of age • Voiding occurs at least twice a week for minimum 3 months • More common in boys • Alteration in neuromuscular bladder function • Often benign and self-limiting • Organic factor could be the cause • Familial tendency • Emotional factor could be considered • Therapeutic techniques include: bladder training, night fluid restriction, drugs (imipramine, oxybutynin, DDAVP) 202

Let’s Review A clinical finding that warrants further intervention for a child with acute post-streptococcal glomerulonephritis is: A. Weight loss to 1 pound of preillness weight. B. Urine output of 1 ml/kg per hour. C. A normal blood pressure. D. Inspiratory crackles.

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Let’s Review A 3 year-old is scheduled for surgery to remove a Wilms tumor from one kidney. The parents ask the nurse what treatments, if any, will be necessary after recovery from surgery. The nurse’s explanation is based on knowledge that: A. No additional treatments are necessary. B. Chemotherapy may be necessary. C. Chemotherapy is indicated. D. Kidney transplant is indicated.

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Let’s Review Fluid balance in the child who has acute glomerulonephritis is best estimated by assessing: A. B. C. D.

Intake and output Abdominal circumference Daily weights Degree of edema 205

Let’s Review In evaluating the effectiveness of nursing actions when caring for a child with nephrotic syndrome, the nurse expects to find: A. B. C. D.

A recurrence of pneumonia. Weight gain. Increased edema. Decreased edema. 206

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

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

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The Musculoskeletal System ✱Disorders of the Musculoskeletal System Developmental Dysplasia of the Hip Talipes (Clubfoot) Osteogenesis Imperfecta Scoliosis Muscular Dystrophy Juvenile Rheumatoid Arthritis

209

Developmental Dysplasia of the Hip (DDH) Variety of hip abnormalities – shallow acetabulum, subluxation or dislocation Often made in newborn period – often appears as hip joint laxity rather than dislocation Ortolani click if < 4 weeks old, older ultrasound needed to diagnose Treatment is Pavlik Harness (abducted position) for newborn to 6 months old – monitor for Avascular Necrosis 6-18 months – traction followed by spica cast Older children – operative reduction Priority nursing interventions are skin care and facilitating normal growth and development 210

Talipes (Clubfoot)  Most common type is when foot is pointed downward and inward  Often associated with other disorders  May be due to decreased movement in utero  Treatment requires surgical intervention  Serial casting is begun shortly after birth and usually lasts for 8-12 weeks  Priority nursing interventions are skin care and facilitating normal growth and development 211

Osteogenesis Imperfecta (OI)  Inherited disorder of connective tissue and excessive fragility of bones  Pathologic fractures occur easily  Incidence of fractures decrease at puberty related to increased hormones making bones stronger  Treatment is supportive: careful handling of extremities, braces, physical therapy, weight control diet, stress on home safety  Surgical techniques for correcting deformities and for intermedullary rodding 212

Scoliosis o Abnormal curvature of the spine (lateral) o Congenital or develops later, most common during the growth spurt of early adolescence (idiopathic) o Diagnosis is made by physical exam and xrays o Treatment for curvatures < 40 degrees is bracing o Surgical intervention is for severe curvatures – internal fixation and instrumentation (Harrington) o Postoperative care includes logrolling, neurologic assessments, pain management, skin care, assessing for 213 paralytic ileus and possible mesenteric

Muscular Dystrophy • Duchenne’s Muscular Dystrophy most common • Gradual degeneration of muscle fibers • S/S begin to show about 3 years of age – difficulties in running and climbing stairs • Changes to having difficulty moving from a sitting/supine position • Profound muscular atrophy continues, wheelchair by 12 yrs • Respiratory and cardiac muscles affected and death is usually respiratory or cardiac in nature • Diagnosis made with physical exam, muscle biopsy, EMG, serum studies: AST (SGOT), aldolase, creatine phosphokinase high first 2 years of life

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Juvenile (Rheumatoid) Arthritis • Inflammatory disease with an unknown cause • Occurs in children < 16 years; lasts > 6 weeks • Clinical manifestations: stiffness, swelling, and loss of motion in affected joints, tender to touch • Therapeutic management includes drug therapy (NSAID’s, SAARD’s, cytoxic drugs, corticosterioids), physical and occupational therapy, exercise (swimming), moist heat for pain and

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General Nursing Interventions for Children with Musculoskeletal Dysfunctions (immobility) • Maintain optimal level of functioning • Promote general good health • Facilitate compliance • Facilitate optimal growth and development • Maintain skin integrity • Safety considerations at home • Pain management • Support child and family

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Let’s Review An infant is being treated nonsurgically for clubfoot. Which describes a major goal of care for this patient? Prevention of: A. B. C. D.

Skin breakdown Calf atrophy Structural ankle deformities Thigh atrophy 217

Let’s Review The nurse is helping parents create a plan of care for their child with osteogenesis imperfecta. A realistic outcome is for this child to: A. Have a decreased number of fractures B. Demonstrate normal growth patterns C. Participate in contact sports D. Have no fractures after infancy

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Let’s Review During acute, painful episodes of juvenile arthritis, a priority intervention is initiating: A. A weight-control diet to decrease stress on the joints. B. Proper positioning of the affected joints to prevent musculo-skeletal complications. C. Complete bedrest to decrease stress to the joints. D. High-resistance exercises to maintain muscular

219

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

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The Endocrine System Disorders of the Endocrine System ✘ Type 1 Diabetes Mellitus ✘ Congenital Hypothyroidism ✘ Growth Hormone Deficiency ✘ Precocious Puberty

221

Type 1 Diabetes Mellitus Pediatric Considerations INSULIN • Most children are well-controlled with BID dosing of fast acting (Lispro) short acting (regular) and intermediate acting (NPH, Lente) insulin. There is also Lantis, an insulin that acts a “basal.” • U-20 insulin is also available for infants • Insulin pump, pen • “Honeymoon” phase • Stress, infection, illness and growth at puberty can increase insulin needs 222

Type 1 Diabetes Mellitus Pediatric Considerations • HYPOGLYCEMIC EPISODES • In small children it is more difficult to determine and may just be a behavior change. • Treatment is the same – simple sugar – assess LOC first!

• NUTRITION • Carb counting – most children’s calories should not be restricted; meal plan might change as child grows. • Some sweets may be incorporated into the diet and may help with compliance. • 3meals with 3 snacks per day

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Type 1 Diabetes Mellitus Pediatric Considerations EXERCISE • Important for normal growth and development • Assists with daily utilization of dietary intake • Enhances insulin absorption, so may decrease amount needed • Add 15-30 grams of carbs for each 4560 minutes of exercise • Watch for hypoglycemia with strenuous exercise 224

Type 1 Diabetes Mellitus Pediatric Considerations DEVELOPMENTAL ISSUES

• Infant/Toddler

• Autonomy & choices, rituals, hypoglycemia identification difficult

• Preschooler • • • •

Magical thinking-let them know they did not cause it Use dolls for teaching Urine testing may be done Can choose finger to use for testing

• School-age

• Very busy with school and activities • Likes tasks and explanations • Can do self blood testing; injections at age 8-10 years

• Adolescents

• Peers and body image preoccupation • High risk for non-compliance • Collaborative health care with parent involvement very important

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Congenital Hypothyroidism • Thyroid is not producing enough thyroid hormone to meet needs of the body (resulting in↓oxygen consumption, BMR and protein synthesis) • Clinical manifestations: cool, mottled skin, bradycardia, large tongue, large fontanel, hypothermic, hypotonia, lethargy, feeding problems - THINK SLOW! • Labs: High TSH, low T4 • Decreased brain development will result with cognitive impairments • Part of newborn screening • Therapeutic management is life-long thyroid hormone replacement (levothyroxine)

226

Growth Hormone (GH) Deficiency • Deficient secretion of growth hormone • Definitive diagnosis is made with GH levels (using stimulation testing) under 10mg/ml and x-rays of hand and wrist for ossification levels • Treatment is replacement of GH (subcutaneous daily injections) until goals met • Nursing care is directed at child and family support • Remember to interact and speak to the 227 child at her appropriate developmental

Precocious Puberty • Manifestations of sexual development in boys younger than 9 years and girls younger that 8 yrs • Causes also an early acceleration of growth with closure of growth plates • Therapeutic management is directed toward the specific cause, if known • The early secretion of sex hormones will be treated with monthly subcutaneous injections of leuteinizing hormonereleasing hormone (LHRH) • Priority interventions are directed at psychological support of child and family – encourage play with same age peers 228

Let’s Review

A child weighing 25 kilograms is being treated with synthetic growth hormone. The recommended dosage range is 0.3 – 0.7 mg/kg/week. The mother informs the nurse that her child receives 1.25 mg subcutaneously at bedtime 6 times per week. The proper response from the nurse would be: C. “That dose is too high, the doctor needs to be notified.” D. “You are doing a great job, that is the correct dose for your child.” E. “The injection should be given intramuscular, not subcutaneous.” F. “That dose is too low based on your

229

Let’s Review The nurse should include which information in teaching the parents of a recently diagnosed toddler with Type 1 diabetes mellitus? A. Allow the toddler to choose which finger to use for blood glucose monitoring B. Allow the toddler to assist with the daily insulin injections C. Test the toddler’s blood glucose every time she 230 goes out to play

Let’s Review Which is the most appropriate teaching intervention for a nurse to give parents of a 6-year-old with precocious puberty? A. Advise the parents to consider birth control for their child B. Inform the parents there is no treatment currently available C. Explain the importance for the child to foster relationships with peers 231 D. Assure the parents there is no

Let’s Review Number in order of priority the following interventions needed while caring for a patient in diabetic ketoacidosis. _____ Hydration _____ Electrolyte replacement _____ Dietary intake _____ IV Insulin _____ Subcutaneous insulin 232

Pediatric Variances Integumentary System Evaporative water loss is greater in infants/small children Skin more susceptible to bacterial infections More prone to toxic erythema More susceptible to sweat retention and maceration

233

The Integumentary System Disorders of the Integumentary System  Impetigo  Roseola  Diaper Rash

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Impetigo • Superficial bacterial skin infection, often secondary from insect bite • Highly contagious • Late summer outbreak • Toddlers & preschoolers • Rash is bullous or honey-colored crusted lesions • Treatment: topical & systemic antibiotics, comfort measures, teaching, preventing comps

Photo Source: Del Mar Image Library; Used with permission

235

Roseola • Transmission: contact with secretions (saliva) • Virus • 6 - 18 months • Fever »flu symptoms » rosepink macular rash • Fades with pressure • Treatment is supportive

Photo Source: Del Mar Image Library; Used with permission

236

Diaper Rash • Cause could be fungal in nature; assess mucous membranes for thrush • Cause could be due to infrequent diaper changes, an allergic reaction to the diaper product or diarrhea • Skin care includes appropriate skin barrier cream/ointment, keeping area dry • Teach parents appropriate skin care 237

Medication Administration • Oral Medication Hold infant with head elevated to prevent aspiration Slowly instill liquid meds by dropper along side of the tongue Crush pills and mix with sweettasting liquid if permitted, but don’t add too much liquid! Allow choices for the child such as which med to take first Flush following gastrostomy or NG 238 tube

Factors to consider when selecting IM sites  Age  Weight  Muscle development  Amount of subcutaneous fat  Type of drug  Drug’s absorption rate

239

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

240

Peds IM Injection Sites  Vastus lateralis for infants  Ventrogluteal and

dorsogluteal Don’t inject into dorsogluteal until age 3 years - muscle not well developed until child walks and sciatic occupies a larger portion of the area.

 Deltoid after 3 years 241

IV Meds  Site may be peripheral or central  Administer IV fluids cautiously  Always use infusion pumps with

infants and small children  Inspect sites frequently (q 1-2 hours) for signs of infiltration  Cool blanched skin, puffiness( infiltration)  Warm and reddened skin (inflammation)

242

Nose Drops  Instill in one nare at a time in infants

because they are obligate nose breathers.  Suction nare with bulb syringe prior to

administration if nasal congestion present

243

Ear Meds Pull the ear down and back to instill eardrops in infants/toddler (↓3 years pull ↓) Pull the ear up and out to instill in older children (↑ 3 years pull ↑) • Have medication at room temperature 244

Rectal Medication  Insert the suppository past the

anal sphincter  Hold buttocks together for a few

seconds after insertion to prevent expulsion of medication It is a very stressful route for children, and the school-age and adolescent have issues with modesty. 245

Inhalers and Spacers  Shake the inhaler for 2-5 seconds.  Position inhaler into spacer (with mask or   



mouthpiece). After normal exhale, place mask on face or mouthpiece in mouth – both with a good seal. Have child inhale slowly after canister is pressed down . Have child take a few breaths with a spacer and without a spacer have them hold breath for few seconds after medication released. Inhalers without spacers aren’t placed in the mouth because spacers require a seal around mouthpiece; masks with spacers can be used for infants.

246

MDI with Spacer MDI with Spacer and Mask

Photo Source: Del Mar Image Library; Used with permission

247

Let’s Review The nurse would prepare which site for an intramuscular injection to a 11 month-old? C. D. E. F.

Dorsogluteal Deltoid Vastus lateralis Ventrogluteal

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Pediatric Oncology Cancer is the leading cause of death from disease in children from 1 - 14 years. Incidence: 6,000 children develop cancer per year 2,500 children die from cancer annually Boys are affected more frequently Etiologic factors: environmental agents, viruses, host factors, familial/genetic factors Leukemia is the most frequent type of

249

Oncology Stressful Events “Treatment is worse than the disease.” 1. Diagnosis 2. Treatment - multimodal 3. Remission 4. Recurrence 5. Death 250

Oncology Interventions ✘ Surgery ✘ Radiation Therapy ✘ Chemotherapy ✘ Bone Marrow Transplant

251

Stages of Cancer Treatment 1.

Induction

2. Consolidation 3.

Maintenance

4. Observation 5. Late Effects of Treatment • Impaired growth & development • CNS damage • Psychological problems 252

Pediatric Oncology Types of Childhood Cancers Leukemia Brain Tumors Wilm’s Tumor Neuroblastoma Osteogenic Sarcoma Ewing’s Sarcoma 253

Leukemias Most common form of childhood cancer Peak incidence is 3 to 5 years of age Proliferation of immature WBCs (blasts) May spread to other sites (CNS, testes) Types of Leukemia:  Acute lymphocytic leukemia (ALL) • 80-85% of childhood leukemia • 95% chance of remission  Acute nonlymphocytic Leukemia (ANLL) • 60-80 % chance of remission

Treatment is chemotherapy: prednisone, allupurinol, selected

254

Leukemias CLINICAL MANIFESTATIONS

• Purpura, Bruising • Pallor • Fever Unknown Origin • Fatigue, Malaise • Weight loss • Bone pain • Hepatosplenomegaly • Lymphadenopathy

LABS & DIAGNOSTIC TESTS ↑ WBC’s (50-100) or Very low WBC’s ↓Hgb, Hct, Platelets Blast cells in differential BONE MARROW ASPIRATION LUMBAR PUNCTURE BONE SCAN possible

255

Brain Tumors

econd most prevalent type of cancer in children

ales affected more often

eak age 3 - 7 years

ypes:

Medulloblastoma Astrocytoma Brain Stem glioma

ook for S/S of increased ICP and area of brain affect 256

Wilm’s Tumor  Also known as Nephroblastoma  Large, encapsulated tumor that

develops in the renal parenchyma (do not palpate abdomen!)  Peak age of occurrence:

1 - 3 years

 Prognosis is good if no metastases-

lungs first  Treatment is surgery, chemotherapy

and sometimes radiation 257

Neuroblastoma Highly malignant tumor – extracranial Often develop in adrenal gland, also found in head, neck, chest, pelvis Incidence: One in 10,000 Males slightly more affected From infancy to age 4 Often diagnosed after metastasis occurs Treatment includes surgery, chemotherapy and radiation 258

Bone Tumors Osteogenic Sarcoma: Occurs most often in boys between 10-20 yrs 10-20% 5 year survival rate Primary bone tumor of mesenchymal cell Treatment:surgery (amputation or salvage) and chemo Ewing’s Sarcoma: Occurs in boys between 5 - 15 years Primary tumor arising from cells in bone 259 marrow

Pediatric Oncology: Nursing Interventions CHEMOTHERAPY SIDE EFFECTS • Leukopenia (Nadir) • Thrombocytopenia • Stomatitis • Nausea/Vomiting • Alopecia • Hepatotoxicity • Nephrotoxicity

NURSING INTERVENTIONS • HANDWASHING! • Monitor visitors • Monitor for infection • Meticulous oral care • Antiemetics ATC • Monitor Labs • Support/Teaching 260

Pediatric Oncology: Nursing Interventions • Supportive care for radiation treatment, focusing on skin care • Surgical interventions are based on location and type of surgery • Basic pre and postoperative care

• Psychosocial care for patient and family – utilize Child Life and Social Services 261

Pediatric Oncology • Teach, teach, teach! • Support the child and family • Provide resources • Be honest • Include the child in the care planning Photo Source: Del Mar Image Library; Used with permission

262

Let’s Review In caring for the child with osteosarcoma, it is important for the nurse to inform the child and family of the treatment plan. Which would be appropriate? A. The affected extremity will have to be amputated. B. The child will only need chemotherapy. E. Both surgery and chemotherapy are indicated. F. Only palliative measures are taken. 263

Let’s Review The nurse assessing a child who is undergoing chemotherapy finds the child to be suffering from mucositis. Which intervention would be the highest priority? A. Meticulous oral care. B. Obtain dietician consult. C. Place the child on a full liquid diet only. D. Medicate for pain around the clock. 264

Let’s Review The priority nursing intervention in caring for a child with acute lymphocytic leukemia (ALL) during the child’s nadir period is: A. B. C. D.

Handwashing. Monitoring lab results. Administering antiemetics. Monitoring visitors.

265

Death & Dying Child’s Response to Death:  Infants & Toddlers:

Do not understand Viewed as a form of separation Can sense sadness in others  Preschooler:

Death is temporary Viewed as sleep or separation Feel guilty and blames self Dying children may regress in behavior

266

Death & Dying School-Age: Have concept of irreversibility of death Fear, pain, mutilation and abandonment Ask many questions Feel death is a punishment May personify death (bogeyman) Will ask directly if they are dying Interested in the death ceremony

Comforted by having parents and loved ones with th

267

Death & Dying

Adolescent: Have an accurate understanding of death Death as inevitable and irreversible May express anger at impending death May find it difficult to talk about death

May wish to leave something behind to remember them May wish to plan own funeral

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Death & Dying Parental responses to death: Major life stress Experience grief at potential loss of child Related to circumstances regarding child’s death (denial, shock, disbelief, guilt) Confronted with major decisions regarding care May have long term disruptive effects on family Bereaved parents experience intense grief of long duration 269

Communicating with the Dying Child and Family •Use child’s own language •Don’t use euphemisms •Don’t expect an immediate response •Communicate through touch •Encourage questions and expressions of feelings •Strengthen positive memories •Listen, touch, cry

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Impending Death Care Guidelines Do not leave child alone

Do not whisper in the room Touching the child is very important Let the child and family talk and cry Let parents participate in care as much as they are emotionally capable of doing Continue to read favorite stories or play the child’s favorite music Be aware of the needs of the siblings 271

Let’s Review Which intervention would be most helpful in supporting a dying child’s family as they cope with the various decisionmaking periods of a lengthy terminal illness? A. Encouraging the parents to take their child home to die. B. Encouraging the parents to go through all of the KublerRoss stages of dying as quickly as possible. C. Referring the child’s family to the hospital clergy service as soon as possible. D. Using active listening to identify specific 272 fears and

Types of Child Abuse Neglect: Intentional or unintentional omission of basic needs and support Physical Abuse: Is non-accidental injury to a child by an adult Sexual Abuse: Forced involvement of children in sexual activities by an adult Emotional Abuse: Withholding of affection, use of

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Child Abuse Reports of violence against children has almost tripled since 1976. Many of the abused children are infants.

“Red Flags” Fractures in infants Spiral fractures Injuries do not match story told

NURSES ARE MANDATED REPORTERS

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Child Abuse Neglect   

Physical or emotional maltreatment Failure to thrive Contributing factors may be ignorance or lack of resources

Physical Abuse    

Minor or major physical injury (bruising, burns, fractures) May cause death Munchausen by Proxy (MSP) Shaken baby syndrome (SBS)

Sexual 

Incest, molestation, child porn, child prostitution

Emotional  

May be suspected, but difficult to substantiate Impairs child’s self-esteem and competence

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Child Abuse Warning Signs     

Incompatibility between history of event and injuries Conflicting stories from various people involved History inconsistent with developmental level of child Repeated visits to emergency rooms Inappropriate response from child and/or caregiver

Nursing Interventions 

 

Assess: Physical assessment and history of event, observe and listen to caregiver’s and child’s verbal and non-verbal communication Documentation: Complete CAR form and contact Child Protective Services, hospital documentation Support family and child: Social services, resources, teaching

THE CHILD’S SAFETY COMES FIRST 276 AND IS THE PRIORITY!

Let’s Review In caring for a 4 year-old with a diagnosis of suspected child abuse, the most appropriate intervention for the nurse is: C. Avoid touching the child. D. Provide the child with play situations that allow for disclosure of event. F. Discourage the child from speaking about the event. G. Give the child realistic choices to feel in control. 277

Let’s Review Which pediatric patient would most necessitate further investigation by the community-based nurse? A. An adolescent who prefers to spend time with friends rather than family. B. A toddler with dark bruises located on both legs. C. An infant with numerous insect bite marks and diaper rash. D. A preschooler with dirty knees and 278 torn pants.

Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery. 279