Pedia Disordersfinal

SELECTED PEDIATRIC DISEASES

Respiratory Anatomy & Physiology • The respiratory system consists of two main parts- the upper and the lower tracts

Respiratory Anatomy & Physiology The UPPER respiratory system consists of: • 1. nose • 2. sinuses • 3. mouth • 4. pharynx • 5. larynx • 6. epiglottis

UPPER RESPIRATORY TRACT INFECTION

ACUTE NASOPHARYNGITIS (CORYZA) • Most frequent infectious disease in children • Average of 10-12 colds/ year • Incubation period- 2-3 days • The COMMON COLDS

ETIOLOGIC AGENT 1. Rhinovirus-most common cause 2. Parainfluenza virus 3. Respiratory syncytial virus (RSV) 4. Adenovirus 5. Influenza virus 6. Coxsackie virus

SIGNS AND SYMPTOMS 1. nasal congestion 2. watery rhinitis 3. low grade fever 4. mucus membrane is edematous 5. cervical lymph node may be swollen and palpable 6. body malaise

TREATMENT • Common colds is self-limiting • supportive care • relief of nasal obstruction - use of isotonic saline drops and aspiration • antipyretic or analgesic agents • antitussive is sometimes used for persistent cough

Streptococcal Pharyngitis

• Strep throat • Spread by infected nose or throat mucus through coughing or sneezing S/sx: pain on swallowing, fever, headache, swollen lymph nodes, swollen hyperemic tonsils w/ OR w/out pus Dx: throat SWAB and culture & sensitivity

Group A beta-Hemolytic Streptococcal Bacteria – Gram (+) bacteria

TREATMENT & MANAGEMENT PHARYNGITIS 1. antibiotics-

10 day-course of oral (Pen G or Clindamycin) 2. high fluid intake 3. relief of pain

antibiotics

• COMPLICATION: Rheumatic Fever, Rheumatic Heart Disease, Acute Glomerulonephritis

TONSILLITIS term commonly used to refer to infection and inflammation of palatine tonsils palatine tonsils - located on both side of pharynx Adenitis - refers to infection and inflammation of the adenoids ( pharyngeal) tonsils adenoids - located in the nasopharynx Tubal tonsils - located at entrance to the Eustachian tube Lingual tonsils - located at base of tongue

ETIOLOGY • <3 years old - often viral • school age children – often bacterial

Signs and Symptoms 1. 2. 3. 4. 5. 6. 7. 8.

difficulty of swallowing (dysphagia) painful swallowing (odynophagia) fever lethargy mouth breathing difficulty hearing (Eustachian tube) halitosis sleep apnea

TREATMENT 1. antipyretic 2. analgesics 3. Antibiotics ( 10 day course – usually Penicillin but may be Erythromycin if allergic to penicillin) is prescribed for bacterial infections to prevent the complication of rheumatic fever. 4. Surgical – tonsillectomy with adenoidectomy

INDICATIONS FOR TONSILLECTOMY 1. chronic tonsillitis (not done if inflamed because may spread infection) 2. Recurrent tonsillitis (4-6x/year) 3. Peritonsillar Abscess 4. Sleep apnea Nursing diagnosis: Pain related to Surgical Procedure

TONSILLECTOMY Post –op Care: • 1. Observe for, & report unusual bleeding ( frequent swallowing) • 2. Help prevent bleeding by discouraging the child from coughing & clearing the throat. • 3. Position the child on the side or the abdomen (prone) to facilitate drainage from the throat

TONSILLECTOMY • 4. Provide appropriate teaching . Instruct the child & parents to: • a. Observe activity restrictions, especially upon the child’s return to school. • b. Avoid persons with known infections. • c. Avoid acidic & other irritating foods. • d. Monitor the child for bleeding, especially immediately postoperatively & 5 to 10 days post op when tissue sloughing occurs.

EPISTAXIS 1. keep pt in upright position with head tilted slightly forward to minimize the amount of blood pressure in nasal vessels, keep blood moving forward not back to nasopharynx 2. apply pressure to the side of the nose with your fingers, may have ice compress

EPISTAXIS 3. Ask the child to stop crying because crying increases pressure in the blood vessels of the head and prolonged bleeding 4. control of bleeding, can give epinephrine (1:1000) to constrict blood vessels 5. can put nasal packing for continuous pressure on the site of the ruptured blood vessel

Epiglottitis • Inflammation of epiglottis ("cherry-red“) • Hemophilus influenza type B • 2-7 yo Pathophx: upper respiratory infection inflammation of epiglottis

EPIGLOTTITIS S/sx: high fever, sore throat, cough hoarseness, drooling, dysphagia Dx: CBC, elevated c-reactive protein (CRP), culture of epiglottis, neck xray > it is considered an emergency because the

swollen epiglottis is not allowing the airway to open.

- this emergency situation occurs most commonly in children between 3 and 6 years of age.

EPIGLOTTITIS

NURSE ALERT!!! “ Never illicit gag reflex-may cause complete obstruction”

Nsg Dx: Ineffective breathing pattern r/t inflammation Ineffective airway clearance r/t inflammation Parental anxiety r/t respiratory distress in child MANAGEMENT • Emergency treatment (intubation) • Moist air • hydration • O2 • Antibiotics – chloramphenicol, co-amoxiclav • Assurance to avoid agitation

LOWER RESPIRATORY TRACT INFECTION

Respiratory Anatomy & Physiology The LOWER respiratory system consists of: • 1. Trachea • 2. Bronchus • 3. Bronchioles • 4. Respiratory unit

The BRONCHI • RIGHT BRONCHUS

• LEFT BRONCHUS

• Wider • Shorter • More Vertical

• Narrower • Longer • More horizontal

Retraction • Supraclavicular/ Suprasternal retraction suggest upper airway obstruction • intercostal retraction- suggest lower airway obstruction

Bronchitis • Inflammation of bronchi • Starts as URTI S/sx: • initially low grade fever, colds • 3-4 days after, roughening breath sounds, rales, dry, hacking unproductive cough • Cough w/ sputum production - clear to purulent, dyspnea, chest pain

BRONCHITIS Dx: clinical Elevated C-reactive protein (CRP) – bacterial Mgmt: rest CPT Fluids antibiotics

Bronchitis Viral

Bacterial

Etio

Rhinovirus,Influenza, S. pneumoniae, RSV, Parainfluenza S. aureus, adenovirus, paramyxovirus H. Influenzae, M. Catarrhalis

S/sx

Rhinitis, cough, malaise, chills, mild fever, sore throat

higher fever and a more prod cough

Dx

Clinical Xray – normal

Elev c-reactive CHON

Course

Mild & self-limiting

Up to 2 weeks

Rx

supportive

empirical; amoxtetracycline, erythromycin

Bronchiolitis • inflammation & swelling of bronchioles w/ mucous in airways • RSV,parainfluenza, Adenovirus, influenza • 0-2 yo, peak 6 mos old • transmitted via droplets

BRONCHIOLITIS Pathophx: mild upper respiratory infection edema of airway and accumulation of mucus airway narrowing hypoxemia S/sx: wheezing, tachypnea, wet hoarse cough, fever, poor appetite, difficulty sucking, restless sleep, retractions Dx: cxr, pulse oximetry, throat culture

BRONCHIAL ASTHMA • chronic, reversible , obstructive airway disease, characterized by wheezing. It is caused by smooth muscle spasm w/ hypertrophy of the bronchial tubes, or swelling of the bronchial mucosa, after exposure to various stimuli.  Hypersecretion of mucus  Most common chronic disease in childhood. Most children experience their first sx by 5yo • exercise, nocturnal occurrence, seasonal, hx of allergy, stress

Types of Bronchial Asthma A. Extrinsic or Atopic Asthma: r/t external allergens such as: • -contactants: dust, chemicals, soaps, perfumes, lotions, make-up • -inhalants: dust, hay, scents, smoke, sprays • -ingestants: food, milk, chicken, beef, pork, eggs, etc. • -Sudden changes in temperature

Types of Bronchial Asthma B. Intrinsic or Non-Atopic Asthma= not r/t external allergens Stress Fatigue Lack of Sleep Anxiety C. MIXED type of Asthma= both types present

Pathophysiology of Asthma • Heredity + Allergens &/or Stress • Release of IgE from B lymphocytes • IgE + Mast cells of respiratory tract = damage to mast cells

• Release of: Histamine, Bradykinin, Serotonin, Leukotriennes, Prostaglandins, ECF-A, SRS-A from damaged mast cells to respiratory membranes

Bronchial Asthma • =S-ecretions: copious, viscous, sticky, stringy, whitish • =S-pasms: laryngo-tracheo-bronchial spasm • =S-welling: edema of the airway

•

Airway Obstruction

• Dyspnea

Signs & Symptoms of Bronchial Asthma • Successive episodes of coughing: dry, hacking, non-productive cough • Increased respiratory secretions: whitish, stringy • Wheezing on expiration • Prolonged expiration • Dry lips and mucous membranes (mouth) • Dyspnea, Tachypnea, Tachycardia • Apprehension and restlessness

Nursing Interventions Long-term Goal: Patient will achieve an open airway and adequate ventilation as manifested by normal VS and relief of symptoms Short-term Goal: a. b. c. d.

Liquify secretions Easily expectorate and drain secretions Relieve spasms Decrease swelling of airways

Nsg Dx: Impaired Gas Exchange r/t bronchiolar obstruction, atelectasis and hyperinflation Parental anxiety r/t respiratory distress in child Management • nebulization • hydration • O2 • positioning • TSB • Monitor VS esp RR • support

Pneumonia • Inflammation of lung parenchyma Bacterial and atypical pathogens: NB – GBS, Gr (-) bacilli, chlamydia Children – S. pneumoniae, H. Influenzae, M. catarrhalis Adolescents – S and M Pneumoniae, M. catarrhalis Hospital acquired – Pseudomonas, Klebsiella, E. Coli, Enterobacter sp Viral Pneumonia - RSV, Parainfluenza, Adenovirus, Influenza

Pathophx: aspiration/hematogenous/inhalation alveoli inflammation hypoxemia S/sx: fever, chills, cough, irritability, poor feeding, restlessness, headache, GI sx, tachypnea, use of accessory muscles, decreased BS, crackles, dullness on percussion, chest retractions Dx: cxr, blood and sputum c/s

PNEUMONIA

Parameter Bacterial

Viral

Atypical

Age

Any

Any

5-15 yo

Onset

Abrupt

Variable

Insidious

Fever

High

Variable Low-grade

Toxicity

Toxic

Variable

Inc RR

Non-toxic

Common Common Uncommon

Perimeter

Bacterial

Viral

Atypical

Cough

Productive

Non prod

Non prod

Assoc sx

Mild coryza

Mild coryza

Bullous myringitis, pharyngitis

PE

(+) consolidation few crackles

variable

Fine crackles, wheezing

Inc WBC

common

variable

Uncommon

Nsg Dx: • Ineffective breathing pattern r/t physiologic effects of Pneumonia - O2, monitor VS, CPT, encourage coughing and deep breathing • Risk for deficient fluid volume r/t diminished oral intake and increased insensible fluid losses sec to diaphoresis, dyspnea and fever - weigh and monitor daily, sips of fluid, temp control, monitor I and O

PNEUMONIA • Activity Intolerance r/t effects of Pneumonia and Tachypnea - rest periods, O2, small frequent feedings, gradual increase in activity, support and contact with family

Tuberculosis • High incidence in infancy and adolescence • Primary Complex – based on xray; first encounter of a child w/ TB; Ghon’s tubercle w/ lymphangitis and regional (hilar) lymphadenopathy • Primary Pulmonary TB – clinical TB • d/t Mycobacterium Tuberculosis Dx: exposure, s/sx (2 or more), PPD, Chest Xray, sputum AFB test

POSITIVE PPD TEST

Classification of TB Class I Class II Class III

Class IV

TB exposure – (+) exposure TB infection – (+) exposure and PPD TB disease – active TB or 3 or more of criteria Exposure, s/sx, (+) tuberculin test, xray, sputum exam, culture TB inactive – (+/-) hx of prev TB, (+/-) hx of prev hx of chemotherapy, (+)xray evidence of healed lesion and (+) PPD

S/sx: fever, wt loss, cough, anorexia, night sweats, painless lymphadenopathy Tx:

Intensive INH, Rifampicin, PZA x 2 mos Maintenance INH, Rifampicin x 4 mos

Respiratory Distress Syndrome • Preterm, infants of diabetic mothers, C/S, hx of asphyxia S/sx: inc RR, chest retractions, nasal flaring,expiratory grunt, cyanosis, HPN, hypothermia Dx: ABG, Xray Mgmt: surfactant replacement, O2, ventilation, supportive care

Decreased surfactant lungs collapse Inc pulmonary resistance blood shunts through F.O. and D.A. poor lung perfusion and gas exchange further decrease in surfactant

hypoxia acidosis

Cardiovascular Disorders

Fetal Circulation •

placenta provides the exchange of gas and nutrient

•

four shunts in fetal circulation: – Placenta – Ductus venosus – Foramen Ovale – Ductus arteriosus

CONGENITAL HEART DEFECTS • CHD are structural defects of the heart, great vessels, or both that are present at birth. • Children with CHD are more likely to have associated defects such as tracheoesophageal fistula (TEF) • CHD is second only to prematurity as a cause of death in the first year of life.

CONGENITAL HEART DEFECTS 1.Acyanotic Heart Disease L R shunt high pressure to low pressure oxygenated to unoxygenated blood 2. Cyanotic Heart Disease R L shunt low pressure to high pressure 3. Obstructive Defects

ACYANOTIC HEART DISEASE 1. Atrial Septal Defect • Opening between atria • late childhood/early adulthood • S/sx: cyanosis(CHF), dyspnea, fatigue, failure to thrive, split S2 • Mx: Abx, surgery 1-3 yo • Cx: endocarditis, heart failure • Postop: monitor arrhythmia, administer antibiotics

ACYANOTIC HEART DISEASE 2. Ventricular Septal Defect • Opening in ventricular septum • Most common • S/sx: respi infections, failure to thrive, dyspnea, fatigue, pansystolic murmur • Mx: close spontaneously otherwise surgery <2 yo • Cx: pulmonary HPN, endocarditis, heart failure • Postop: monitor arrhythmia, administer antibiotics

ACYANOTIC HEART DISEASE 3. Patent Ductus Arteriosus • • • • • •

Aorta to pulmonary artery Common in prematurity, high altitude, maternal rubella females S/sx:clubbing, dyspnea, “machinery murmur” (2nd-3rd ICS) Cx: heart failure, endocarditis, pulmonary artery stasis/HPN Mx: Indomethacin, surgery

CYANOTIC HEART DISEASE 1. Tetralogy of Fallot (TOF) • S/sx: cyanosis, clubbing, dyspnea, fatigue, squatting, “Tet spells”, failure to thrive, systolic murmur, polycythemia • Cx: thromboembolism, CVA • Mx: O2, knee-chest position, surgery 1-2 yo • Postop: monitor for arrhythmia Blalock Taussig: anastomose SC and pulmo art. - avoid BP and venipuncture in right arm

CLUBBING IN TETRALOGY OF FALLOT

CLUBBING OF THE FINGERS

CYANOTIC HEART DISEASE 2. Transposition of the Great Vessels • Aorta from R ventricle • Pulmonary a. from L ventricle • Males • S/sx:cyanosis, murmurs • Mx: PGE for PDA, Balloon catheter to create ASD, definitive surgery 1 wk-3 mos

CYANOTIC HEART DISEASE 3. Total Anomalous Pulmonary Venous Return • Pulmonary vein drain to SVC or R atrium • PDA or foramen ovale essential • S/sx: cyanosis, fatigue • CX: R heart failure • Mx: PGE, surgery

OBSTRUCTIVE DEFECT Coarctation of the Aorta • Constriction of aorta • S/sx: asymptomatic HPN, irritability, headache, epistaxis, dyspnea, claudication, higher BP in upper extremities, dec femoral and distal pulses,systolic murmur • Cx:chronic HPN • Mx:surgery 2 yo • Postop: monitor abdominal pain, antihypertensives

COARCTATION OF THE AORTA Ndx: Ineffective cardiopulmonary and peripheral tissue perfusion related to impaired cardiac function • Proper positioning to maintain respiration • Conserve energy to promote rest • Quiet activities and stimulation • Anticipate needs • Administer prescribed drugs

COARCTATION OF THE AORTA Activity intolerance r/t effects of congenital heart defect and dyspnea • •

Rest periods Adequate nutrition small frequent feedings iron supplementation

Obstructive Defect 2. PULMONIC STENOSIS Obstruction of blood flow from the right ventricle to the pulmonary artery PULMONIC VALVE Backflow of blood towards the right ventricle Right Ventricle has to PUMP HARDER to push the blood to the pulmonary artery for Oxygenation RIGHT VENTRICULAR ENLARGEMENT RIGHT-SIDED CONGESTIVE HEART FAILURE

Obstructive Defect 3. AORTIC STENOSIS • Involves an obstruction of the ventricular outflow of the blood • S/SX: faint pulse, hypotension, tachycardia, poor feeding, exercise intolerance, chest pains • DX; ECG, Echocardiography reveals left ventricular hypertrophy. • MX: • Surgical aortic valvulotomy or prosthetic valve replacement. • - Balloon Angioplasty to dilate the narrow valve.

Obstructive Defect 3. AORTIC STENOSIS Obstruction of flow to the AORTA • AORTIC VALVE Backflow of blood towards the LEFT VENTRICLE Left Ventricle has to PUMP HARDER to push the blood to the AORTA for distribution of oxygenated blood LEFT VENTRICULAR HYPERTROPHY with Regurgitation of oxygenated blood back to the LUNGS LEFT-SIDED CONGESTIVE HEART FAILURE (Respiratory Signs)

Kawasaki Disease/ Mucocutaneous Lymph Node Syndrome • Before puberty, peaks 4 yo • S/sx:spiking fever x 5 days, bilateral conjunctivitis, reddened pharynx, dry lips, strawberry tongue, cervical lymphadenopathy, peripheral edema, erythema and desquammation, truncal rash, arthritis • Patho: Respi infection immune complex systemic vasculitis aneurysm and MI • Dx: clinical Mx: Salicylates and Immunoglobulins

KAWASAKI DISEASE

KAWASAKI •

Risk for ineffective peripheral tissue perfusion related to inflammation of blood vessels - Observe for chest pain, color changes, vomiting

•

Pain r/t swelling of lymph nodes and inflammation of joints - Comfort measures, administer pain medications

KAWASAKI Other Measures: Protect edematous areas Record intake and output Offer soft food Administer prescribed medication

Rheumatic Fever • • • • •

• •

Autoimmune Grp A Beta hemolytic strep 6-15 yo, peaks 8 yo 1-3 wks after untreated infection Dx: 5 major criteria – polyarthritis, carditis, subcutaneous nodules, erytHema marginatum, sydenham’s chorea minor – fever, polyarthralgia, hx of RF, inc ESR, antecedent strep infection To diagnose, either 2 major or 1 major and 2 minor present Cx:mitral valve insufficiency and myocarditis

J.

N. E. S.

RHEUMATIC FEVER Mgmt: salicylate, penicillin Ndx: Risk for noncompliance r/t knowledge deficit about importance of long term therapy - prevent initial and recurrent attacks Decreased cardiac output r/t disease process - bed rest, comfort and appropriate activities

RHEUMATIC FEVER Nursing Care • Monitor vital signs • Provide adequate nutrition • Promote safety to prevent chorea related injuries

Gastr ointestin al Disor der s

Cleft Lip and Palate •

• • •

failure of fusion of maxillary and median nasal process hereditary unilateral/bilateral Males

Mx: surgery - Cheiloplasty • Rule of 10’s- AGE=10 wks, WT=10 lbs, HgB=10 gm

Cleft Palate • midline opening of palate • usually w/ Cleft lip • Female • surgery 6-18 mos allow anatomic changes <1 yo ie formation of palatine arch and tooth buds

Ndx:

• Risk for imbalanced nutrition, less than body requirements r/t feeding problems • Risk for ineffective airway clearance r/t oral surgery • Risk for infection during post op period

Nursing Care

Preop • Adequate nutrition; sips of fluid btw feeding in upright position; use rubber tipped syringe; Burp • Prevent ear and upper respiratory tract infection • Address body image and speech concerns • Reassurance to parents Postop

• • • • •

monitor respiratory distress d/t edema, hemorrhage Suction mucus and blood gently dropper feeding 1st 3 weeks; regular feeding after Anticipate needs and position to prevent tension on sutures Position side lying in cleft lip; prone in cleft palate

Tracheoesophageal Fistula

• Communication of the esophagus and trachea • maternal hydramnios and prematurity • S/sx:coughing, choking, cyanosis, dyspnea, excessive secretion, abdominal distention • Dx: Ba swallow

TEF Ndx: • Risk for imbalanced nutrition, less than body requirements r/t inability for oral intake • Risk for infection r/t aspiration or seepage of stomach contents into lungs • Risk for impaired skin integrity r/t gastrostomy tube insertion site

Nursing care Preop • Suction regularly • Elevate the head • Gastrostomy feeding • hydration • O2 Postop 1. Observe for respiratory distress 2. Proper positioning –avoid hyperextension of neck 3. Continue suction 4. Prevent wound infection 5. Provide pacifier

Hirschprung’s Disease • Aganglionic megacolon • Absence of innervation to a bowel segment usually rectosigmoid colon • No peristaltic activity in affected area • Familial • males • S/sx:constipation, ribbonlike stools or no meconium, abdominal distention, vomiting • Dx: Ba enema, biopsy • Mx:colostomy, surgery

HIRSHSPRUNG’S DISEASE Ndx: • Constipation r/t reduced bowel function • Imbalanced nutrition, less than body requirements r/t reduced bowel function

Nursing Care Preop 1. Daily enemas w/ 0.9% NaCl *Tap/hypotonic water will cause cardiac congestion or cerebral edema 2. Minimal residue diet w/ vitamin supplementation 3. Position semi fowlers to relieve dyspnea from distended abdomen 4. pacifier Postop 1. Observe for abdominal distention 2. Small frequent feedings after NGT removal 3. Colostomy care 4. Assist parents to cope with children’s feeding problems

Intussusception • 2-6 mos • Invagination of intestine < 1 yo – idiopathic > 1 yo – “Lead point” • S/sx:intense abdl pain, vomiting, blood in stool “currant jelly”, abdominal distention (sausage shaped mass) • NECROSIS: fever, tachycardia, rigid abdomen • Dx:sonogram “coiled spring” • Mx:Ba enema (reduction by hydrostatic pressure), surgery

Ndx: • Pain r/t abnormal abdominal peristalsis • Risk for deficient fluid volume r/t bowel obstruction • Nsg care: 1. NPO 2. Adequate hydration via IV therapy 3. Promote parent-infant bonding 4. Provide comfort measures - pacifier for infants

Pyloric Stenosis • Hypertophy/hyperplasia of pyloric sphincter • Males • S/sx:nonbillous vomiting, s/sx of of dehydration and wt loss, abdominal distention, “olive” sized mass RUQ, visible peristalsis • Dx:xray-”string sign”, USG, endoscopy • Mx: surgery

PYLORIC STENOSIS Ndx: • Risk for deficient fluid volume r/t inability to retain food • Risk for infection at site of surgical incision r/t danger of contamination from feces d/t proximity of incision to diaper area

PYLORIC STENOSIS Postop 1. dropper feeding 4-6 hrs after surgery 45 min- 1 hr

duration; oral rehydration soln then half strength breastmilk/formula at 24 hr interval 2. Side lying position 3. Monitor weight and return of peristalsis 4. Wound care 5. Pacifier for oral needs

Celiac Disease/Gluten sensitive Enteropathy/Celiac Sprue • Malabsorption syndrome that occurs when the mucosa of the proximal small intestine is sensitive to gluten. (wheat, rye, oats, barley) • inability to absorb fat, thus steatorrhea, deficient fat soluble vitamins, malnutrition and distended abdomen • S/Sx appears bet 1-5 yo after introduction of gluten in the diet. • S/sx:diarrhea, wt loss, anorexia, irritability, anemia (Fe deficiency)

Celiac Disease Pathophysiology: • Intolerance for or inability to digest gluten >>>accumulation of the amino acid glutamine>>>toxic to intestinal mucosal cell>>> intestinal villi atrophy >>>reduction of absorptive surface of the small intestine.

Celiac Disease • CELIAC CRISIS (due to ingestion of gluten, infections, prolonged fasting) = acute vomiting and diarrhea & may lead to F & E imbalance & rapid dehydration. • Dx: Biopsy of the jejunum reveals the mucosal surface with hyperplastic villus atrophy. ( Definitive diagnosis of celiac disease). This characteristic lesion return to normal after dietary restriction of gluten which helps confirm the dx. • Mx: hydration, gluten free diet, vitamin & Fe supplementation , avoid cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some chocolates, some ice cream, donuts, pies, hotdogs,

Celiac Disease Foods allowed: • 1. Meats: beef, pork, poultry & fish • 2. Eggs • 3. Milk & dairy products: milk, cheese, cream • 4. Fruits & veg: all • 5. Grains: rice, corn, gluten free wheat flour, corn flakes, corn meal & gluten free pre-cooked cereals

Diaphragmatic Hernia • Herniation of intestinal content into the thoracic cavity • Left side • S/sx:respiratory difficulty, cyanosis, retractions, (-) breath sounds affected side, scaphoid abdomen • Cx: pulmonary HPN • Mx: ’E’ surgery

DIAPHRAGMATIC HERNIA Ndx: Risk for ineffective airway clearance r/t displaced bowel Risk for imbalanced nutrition, less than body requirements, r/t NPO status

Nursing Care Preop • •

Elevate head Low intermittent suction

Postop 1. Semi-fowlers 2. Maintain warm, humidified envt – lung fluid drainage 3. Suction prn 4. Chest pptx 5. NPO – prev pressure on diaphragm

Necrotizing Enterocolitis - Bowel develops necrotic patches, interfere w/ digestion, lead to paralytic ileus, peritonitis and perforation - D/t ischemia sec shock or hypoxia, infection, immature GIT immune protection S/sx: abdomen tense and distended, stool (+) for occult blood, > 2 ml gastric residual, bradycardia, apnea Dx: abdominal xray Mgmt: d/c feeding, IV or TPN, Antibiotic, colostomy, surgery for perforation

Inguinal Hernia • • • • • •

Protrusion of a bowel through the inguinal ring males S/sx: painless lump in the groin Cx: bowel strangulation Mx: surgery <1 yo Post op Nursing care: wound care assess circulation in the leg

Cystic Fibrosis • Autosomal recessive • Dysfunction of exocrine glands; inc viscosity of mucous glands • Affects lungs, pancreas, intestines and sweat glands • S/sx: GI - meconium ileus, rectal prolapse, steatorrhea, malnutrition, failure to thrive Respiratory – recurrent infection,cough, dyspnea, clubbing, cyanosis

Sweat Gland – ”salty taste” Other – males infertile, abnormal glucose tolerance Dx: history, sweat test (NaCl 2-5x the normal), absence of pancreatic enzymes, immunoreactive trypsinogen in blood and pulmonary involvement Mx: chest physiotherapy, antibiotics, pancreatic enzymes, vitamins, lung or pancreas transplant

CYSTIC FIBROSIS Ndx: • Imbalanced nutrition, less than body requirements r/t inability to digest fats • Ineffective airway clearance r/t inability to clear mucus from the respiratory tract

Nursing Care 1. 2. 3. 4. 5.

Hi calorie, Hi CHON, moderate fat diet Nebulization and physiotherapy Frequent Position changes when in bed Oral care Adequate rest and comfort

Neurological Disorders

Brain Tumor • • • •

Second most common form of cancer in children 1-10 yo, peak 5 yo Usual location - brainstem or cerebellum TYPES: Astrocytoma- glial tissue; 5-8 yo Medulloblastoma – cerebellum; 5-10 yo; cause compression of 4th ventricle; most common Brain stem tumor – support tissue of neural cells; paralysis of 5th-7th, 9th-10th CN

BRAIN TUMOR S/sx: headache, vision changes, vomiting, enlarging head circumference, papilledema, lethargy, ataxia, nystagmus, personality changes, seizures, lethargy, coma Dx: skull films, bone scan, CT scan, Lumbar puncture, MRI, angiography Mx: surgery, chemotx

BRAIN TUMOR 1. 2. 3. 4. 5.

Preop Stool softeners Dexamethasone Dilantin Shave head Prepare patient and family psychologically

BRAIN TUMOR SURGERY (CRANIOTOMY) Postop 1. Proper position – low fowler’s 2. Anticipate needs 3. Saline eye drops as needed 4. Monitor VS and NVS 5. Regulate IV 6. Observe head dressings 7. Provide comfort and opportunity for self expression

Benign Febrile Seizure •

• • • • • •

6 mos - 5 years fever >/= 38.5C generalized tonic-clonic rarely persist > 10 minutes Postictal stage 30-40 % recurrence (+) family history

CONVULSION/SEIZURE

NURSING CARE • • • • •

Turn child to side & allow to drool Do not restrain Do not put anything in the mouth Dec temp Refer if: sx persist another sx occurs delirious/difficult to rouse after sx

Erb Duchenne’s Paralysis

• Damage on C5-C6 due to birth trauma • Unilateral • S/sx: shoulder adducted, internally rotated, elbow extended, forearm pronated and the wrist flexed “waiter’s tip”, (-) moro reflex • Mx: PT, surgery • Nsg care: advise exercise and frequent follow up

ERB DUCHENE’S PALSY C5 & C6

Cerebral Palsy

• Damaged motor function d/t anoxic brain injury secondary to infection, perinatal asphyxia, metabolic disorder • Nonprogressive • TYPES: Spastic– most common (65%); hypertonicity Athetoid/dyskinetic – worm-like Ataxic – wide based gait w/ repetitive movement Mixed – spastic and athetoid

• S/sx: spasticity/rigidity, difficulty feeding, delayed speech and motor devt, mood swings, impulsive, short attention span, irritable • Dx: Clinical • Mx: antispastics, antibiotics, surgery, nutrition, prevention of injury, PT NDx: Risk for injury r/t neuromuscular impairment Self care deficit r/t neuromuscular impairment - ensure safety, assist in ADL, ensure adequate nutrition, assist children achieve maximum potential

Hydrocephalus •

Impaired circulation and absorption of CSF 2 TYPES: 1. Obstructive/Noncommunicating – w/n ventricular system 2. Nonobstructive/Communicating – obliteration of SA cisterns or malfunction of arachnoid villi S/sx: head enlargement, ant fontanel wide and bulging, scalp veins dilated, broad forehead, sclera bshows above iris, brisk tendon reflexes, spasticity, irritability, lethargy, poor appetite, cracked pot sound on percussion

HYDROCEPHALUS Ndx: Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure - monitor vs, head circumference, I and O - O2 - position flat or head 30 deg - do not lie on operative site

HYDROCEPHALUS Risk for imbalanced nutrition, less than body requirements, related to increased intracranial pressure - NPO until bowel sounds return - position head w/o flexion - observe for constipation - note how child sucks - IV fluids - obtain daily weight

Spina Bifida • Collective term for all SC disorders Spina Bifida Occulta – posterior laminae fail to fuse - dimpling, abnormal tufts of hair Meningocoele - meninges herniate through unformed vertebrae; protrusion covered by a layer of skin - usually occurs in the lumbar region - protrusion is covered by a skin layer or only the clear dura mater

SPINA BIFIDA Myelomeningocoele – SC and meninges protrude through the vertebrae defect - absent motor and sensory function - flaccidity, lack of sensation in LE - loss of bowel and bladder control - may be accompanied by hydrocephalus Dx: sonography

SPINA BIFIDA • Risk for infection r/t rupture or bacterial invasion of the neural tube sac - position side lying or prone - keep sac moist - place under radiant warmer - post op – prone until site is healed • Risk for ineffective cerebral tissue perfusion r/t increased intracranial pressure - measure head circumference - assess for s/sx of inc ICP

SPINA BIFIDA

• Risk for impaired skin integrity r/t required prone positioning - reposition head every 2 hrs if w/ hydrocephalus - change diapers frequently • Impaired physical mobility r/t neural tube d/o - passive exercises - may use leg braces, crutches - inspect lower extremities and buttocks for irritation or possible infection • Risk for impaired elimination r/t neural tube d/o - intermittent catheterization - surgery

Meningitis • Inflammation of meninges • Bacterial, Tuberculous, viral S/sx: opisthotonus, neck rigidity, irritability, high pitched cry Dx: Lumbar puncture, Bld C/S, Ct scan, MRI NDx: Risk for infection r/t presence of infective organism Tx: Abx

Hematologic Disorders

HEMATOLOGIC DISORDER

Iron Deficiency Anemia Infant’s iron supply 4-6 mos Anemia – 9-24 mos S/sx: pallor, tachycardia, irritability, Hg < 9 g/dl, susceptible to infection Mgmt: iron fortified formula, iron rich diet and vitamins Nsg care: give iron w/ vit c, use w/ dropper at the back of the mouth, expect black stools, provide iron rich food

Hemophilia A • Inherited interference w/ blood coagulation • Factor VIII • Sex linked recessive • S/sx: excessive bleeding NB – apparent Pre-school – accidents/falls School age – bleeding between joints Adolescent – ulcers, hematuria • Mx: factor VIII transfusion

NDx: Acute pain r/t bleeding into joints Nursing Care • • • • •

Promote safety Watch out for bleeding – rest area, ice compress, elevate body part Monitor transfusion reaction Passive ROM Assist in gaining control of situation

Hemophilia B • Christmas Factor • Clotting Factor IX

ACUTE LYMPHOCYTIC LEUKEMIA •

Uncontrolled proliferation of WBC

•

Lymphoblast

•

Most frequent CA in children

•

2-16 yo

•

Males

LEUKEMIA S/sx: pallor, low grade fever, lethargy, petechiae, bleeding, vomiting, anorexia, bone pain, painless lymphadenopathy Dx:WBC variable w/ blasts, low platelet and hematocrit, anemia BMA > 25% blast cells

BONE MARROW ASPIRATION

LEUKEMIA Mx: chemotherapy Cx: CNS s/sx, renal failure NDx: Risk for infection r/t decreased immune function Activity intolerance r/t reduced oxygen carrying capacity of blood

Nursing Care • Prevent infection • monitor bleeding and transfusion reactions • Provide comfort and pain alleviation • Health teaching • Emotional and psychological support

Genitourinary Disorders

• • • •

Urinary Tract Infection

Females E coli Ascending infection S/Sx:infants – mimic GI d/o; dysuria, frequency, hematuria, low grade fever, abdominal pain and bedwetting • Dx: urine culture suprapubic any amount clean catch > 100,000/ml • Mx: antibiotic hydration

Acute Glomerulonephritis • Inflammation of glomeruli or kidney • Follows infection with strep10-14 days • 5-10 yo • Males

S/sx:sudden onset of edema and hematuria, proteinuria, hypertension Dx: urinalysis and 24 hour urine hypoalbuminemia inc ESR, BUN, Crea, antistreptolysin O

Mx: semi fowlers diuretics, antibiotics O2 antihypertensives Nsg Care: quiet play activities diet – normal CHON, mod salt restriction, fluid restriction daily weight and output

Nephrotic Syndrome • Altered glomerular permeability(autoimmune); inc permeability to albumin • 3 yo • Males • Minimal change syndrome • S/sx: proteinuria, edemaperiorbital area, hypoalbuminemia, hyperlipidemia • Dx: urinalysis and 24 hr CHON, inc ESR

Mx:steroids, immunosupressant NDx: Risk for decreased fluid volume r/t CHON and fluid loss Imbalanced nutrition: less than BR r/t CHON and fluid loss Nsg care: Adequate nutrition, proper diet – decrease salt Weigh daily, monitor I and O Protect edematous areas Administer prescribed drugs Health teaching

Wilm’s Tumor • • • • •

Malignant tumor of the kidney Associated with other anomalies 6 mos-5 yo, peaks 3-4 yo Good prognosis S/sx: abdominal mass, hematuria, low grade fever, anemia, wt loss • Dx: CT scan • Mx: Nephrectomy, radiotherapy avoid abdominal palpation

Hypospadia/Epispadia

A. Hypospadia

B. Epispadia

C. Hypospadia w/ chordee

UROGENITAL DEFECTS Hypospadia - common - chordee - fibrous band Mx: surgery Nsg care: Post op – pain relief assist parents in coping

Cryptorchidism (Undescended Testis)

• Failure of one or both testes to descend • Descend up to 6 weeks at birth • May be d/t dec testosterone S/sx: right testis more common Mx: chorionic gonadotrophin hormone Orchiopexy 1 yo

Other Diseases

Sudden Infant Death Syndrome • • • • • •

1 mo-1 year old, peaks 2-4 mos Full term/preterm sudden and silent the victim seems healthy sleeping on prone position Theories of causation: abnormalities in the brain and metabolic disorder

SIDS Maternal risk factors - cigarette smoking during pregnancy, maternal age < 20 yo, poor prenatal care, low weight gain, anemia, use of illegal drugs and alcohol, low socioeconomic status Newborn risk factors – cyanosis, tachycardia, respiratory distress, irritability, hypothermia, poor feeding

SIDS Nsg Dx: Dysfunctional grieving r/t loss of a child Management • assist psychologically - intense grief and guilt for parents

Atopic Dermatitis • 2 mos-3 yo • R/t food allergy S/sx: papular and vesicular skin eruptions w/ erythema, pruritus, dry,flaky scales upon healing Mx: reduce allergen, topical steroids NDx: Impaired skin integrity r/t eczematous lesion Nsg care: Reduce allergen Prevent skin dryness and pruritus

Normal Skin Smooth micro-relief Low roughness Regular desquamation

Dry Skin Tortuous microrelief High roughness Irregular desquamation

ATOPIC DERMATITIS • NURSING MANAGEMENT 1. MEDS: ANTIHISTAMINES, ANTIPRURITICS, STEROIDAL CREAMS 2. Minimize the risk of infection 3. Promote skin integrity 4. Family Health teaching • Cotton fabrics, use mild detergents • Daily baths to hydrate the skin • Use topical moisturizers

Otitis Media • • • •

Inflammation of the middle ear 6-36 mos, 4-6 yo S. Pneumoniae, H. Influenzae, M. Catarrhalis Follows URTI S/sx: pain in affected ear, fever Cx: hearing impairment Mx: antibiotics, analgesics, antipyretics NDx: Acute pain r/t inflammatory process - provide comfort, reinforce completion of antibiotic, offer liquids and finger food (prev pain when chewing)

Diarrhea Viral – Rotavirus, Adenovirus Bacterial – Shigella, Salmonella, Cholera Protozoan – Amoeba TYPES: Mild: fever, irritable, 2-10 episodes/day, dry mucous membranes, tachycardia - 2.5-5% wt loss Mx: oral rehydration

DIARRHEA

Severe: fever, tachycardia, tachypnea, pale and cool skin, apprehensive/lethargic, obvious s/sx of dehydration, UO scanty, several episodes of loose stools - 5-15% wt loss Cx: dehydration Mx: fluid and electrolyte replacement Dx: Stool exam and culture, Electrolyte determination NDx: deficient fluid volume r/t fluid losses in stools - promote hydration and comfort, Record I and O

Protein Energy Malnutrition Marasmus Low calorie, low CHON 0-2 yo (-) edema “all skin and bone” (+) growth retardation Apathetic, quiet Good appetite Infrequent skin/hair changes Anemia uncommon

Kwashiorkor Low CHON 1-3 yo (+) edema Wasting variable Growth retardation variable Irritable, moaning Poor appetite (+) skin and hair changes (+) anemia

Poisoning Usually 2-3 yo Soap, cosmetics, detergents, drugs Males>females – children Females>males – adolescent Mx: 1. Det age wt, type of poison swallowed, ime of ingestion, route of poisoning, amt ingested, present condition of child

POISONING 2.Use syrup of ipecac to induce vomiting except: caustic, corrosive, hydrocarbon, px is comatose 3. Activated charcoal then syrup of ipecac 4. Monitor VS 5. refer to hospital/poison control center

POISONING Acetylsalicilic acid (Aspirin) S/sx: nausea, vomiting, fever, profuse sweating, flushing, hyperthermia, hyperventilation, convulsions, coma Mx: stabilize airway and breathing Fluid and electrolyte replacement Activated charcoal Alkalinization of urine hemodialysis

Down’s Syndrome Trisomy 21 Maternal age >35 yo, paternal age >55 Features: nose is broad and flat, eyelid have an extra fold of tissue at the inner canthus, palpebral fissure slants upwards, white specks in iris, tongue protrudes, back of the head is flat, neck is short, extra fat pad, low set ears, poor muscle tone, short thick fingers, simian crease, cognitively challenged

DOWN’S SYNDROME Poor immune function Congenital heart diseases – Ventricular Septal Defect Cataract ALL occurs 20x more Mx: early education and play opportunities prevention of infection counseling and support

Child Abuse • Non accidental injury inflicted by an adult • Physical, emotional, sexual • Children grow up to be abusers themselves and are violent • Nsg Resp: treat injury, report to DSWD, NGO, Bantay Bata

SIGNS OF CHILD ABUSE

Substance Abuse • • • • • •

Use of chemicals Improve mental state Induce euphoria Peer pressure Feel more confident Adolescent rebellion

TYPES OF ABUSED SUBSTANCES Tobacco - sign of maturity Alcohol - most frequent - no stigma Amphetamines – sense of well being, alertness, self esteem and wt loss Anabolic steroids – improves athletic ability Marijuana – stress reliever bec gives a sense of well being, altered sensory perception

TYPES OF ABUSED SUBSTANCES Hallucinogens – distortions in vision, smell or hearing Opiates – physiologic craving Cocaine – inc VS, dec appetite, cardiovascular arrest, euphoria, excitement, hallucinations

ASSESSMENT OF SUBSTANCE ABUSE • • • • • • •

Failure to complete homework Poor reasoning ability Decreased school attendance Frequent mood swings Deteriorating physical appearance Recent change in peer group Negative perception of parents

Nursing Intervention • Caution against drug abuse • Provide counseling • refer to rehab facilities

Thank you!