Exam 3 Study Guide Neurological Dysfunction and Cerebral Injuries 14 Questions Neurological ssessment of t!

e "ediatric "atient First step is to complete a comprehensive history of the childs developmental and neurological status prior to hospitalization Basic Components of the Neurological Assessment - Level of Consciousness (LOC ! "upillary #esponse! $otor Function! and %ital &igns Assess the child in their most a'a(e and alert state possi)le *ey "oints + o ,ave to (no' )aseline in order to determine if changes are occurring o Assess child in most a'a(e and alert state o %erify changes 'ith a colleague + document and report o L-&./N .O "A#/N.& Level of Consciousness (LOC o Assess amount of stimulation re0uired to a'a(en child1 Assess if stimulation is re0uired to (eep a'a(e o 2lasgo' Coma &cale Consists of 3 parts4 /ye Opening #esponse! %er)al #esponse and $otor #esponse 5ocumented as Best /ye Opening #esponses! etc1 Glasgo# Coma Scale Best /ye Opening #esponses + &ame for all ages o 6 - &pontaneous /ye Opening o 3 - /yes Open to &peech o 7 - /yes Open to "ain o 8 - No #esponse Best %er)al #esponse dult$C!ild Infant 9 + Oriented and Appropriate Cooing 6 + 5isoriented Conversation -rrita)le Cry 3 + -nappropriate :ords Cries to "ain 7 + -ncomprehensi)le $oans to "ain 8 + No #esponse No #esponse Best $otor #esponse dult$C!ild Infant ; + O)eys Commands Normal spontaneous 9 + Localizing to "ain :ithdra's to .ouch 6 + :ithdra's from "ain :ithdra's from "ain 3 + 5ecorticate (Fle<or "osturing to "ain (all ages 7 + 5ecere)rate (/<tensor "osturing to "ain (all ages 8 + No #esponse to "ain (all ages

$inimal Attaina)le &core + 3 $a<imal Attaina)le &cored -89 &core of 89 + =naltered LOC &core of > or less + 2enerally accepted as Coma &core of ? 3 + 5eep Coma or 5eath Changes should )e documented and reported to the physician immediately o -ts never enough to assess and document! )e sure to have a colleague verify your assessment! )e sure to alert the physician@ /specially if it a rapid change@@@ o Be familiar 'ith ho' long it ta(es for the rapid response team to get to you1 Childrens for e<ample is 'Ain 89 min for a rapid response1 o -t is up to the nurse to decide 'hether the child can hang on long enough for a rapid response or does a code need to )e called

%e&els of Consciousness '%(C) *ull Consciousness + A'a(e and Alert! Oriented to .ime! "lace and "erson1 Behavior appropriate for age Confusion + -mpaired 5ecision $a(ing Disorientation + Confusion re4 .ime and "lace1 5ecreased LOC %et!argy + Limited spontaneous movement1 &luggish speech! dro'sy! falling asleep 0uic(ly (btundation + Arousa)le 'ith stimulation Stu+or + #emains in deep sleep! responsive only to vigorous and repeated stimulation Coma + No motor or ver)al response to no<ious (painful stimuli "ersistent ,egetati&e State '",S) + "ermanently lost function of the cere)ral corte<1 o /yes follo' o)Bects only 'hen )y refle< or 'hen attracted to the direction )y loud sounds o All 6 e<tremities are spastic )ut can 'ithdra' from painful stimuli o ,ands sho' refle<ive grasping and groping o Face can grimace! some food may )e s'allo'ed and the child may groan or cry )ut utter no 'ords o #efle<ive response! can )e difficult )Ac it can appear that the child is reacting normally )ut in reality there is no cere)ral corte< function

---Nursing lert. %ac/ of res+onse to +ainful stimuli is abnormal and must be re+orted immediately "u+illary 0es+onses Normal &ize 7-; mm /<amine eyes in a dar(ened room 'ith a )right light 5irect #esponse Consensual #esponse o .hat )oth pupils constrict 'hen the light is shined in one eye ConBugate 2aze o Both eyes are trac(ing together! coordinated eye movement Accommodation4 you cant perform on the little guys unless they are old enough to pay attention and follo' instructions1 .hey need to )e a)le to cooperative o Coung children you 'ill not )e documenting "/##LA 1otor *unction "osture and $uscle .one 2rip &trength &ymmetry of $ovements $ade to Commands $ore difficult to e<amine until the child is a)le to )e cooperative ,ital Signs ,eart #ate should )e :NL - 2 to +ain3 fear3 and fe&er

Normal respiratory rate + Normal for neonates to have episodes of periodic )reathing Blood "ressure should )e :NL .emperature should )e :NL

Signs of Deterioration 5ecreasing LOC -nfant Child 2radual loss of eye contact Confusion :ea( irrita)le cry Less responsive Less responsive Lethargy Lethargy Coma Coma o Our assessments are especially important in the child 'ho is una)le to communicate "upillary #esponses o Could )ecome + Larger! &maller! =ne0ual and &luggish o 5isconBugate 2aze o 5ilation and =nresponsiveness to Light o ny sudden a++earance of a fixed and dilated +u+il is a neurosurgical emergency44 $otor Function o :ill diminish as neurological status deteriorates %ital &igns o Change as neurological changes occur + changes in "ulse and Blood "ressure are more important then direction of change o .achycardia then Bradycardia o Could )e D or E o 5idening "ulse "ressure Indicati&e of 2 IC" o Can be !y+er or !y+ot!ermic Extreme !y+ot!ermia is often a sign of acute infection Note + Cushing #efle< + -ncrease in -ntracranial "ressure leads to a4 o .riad of &ymptoms4 Bradycardia -ncrease in B" -rregular Breathing o 6ncommon in c!ildren 7 if it occurs it is a &ery late sign and an ominous sign 8 9 D o Actually means the Brain may )e a)out to ,erniate #espiratory Changes o =sually )est to descri)e 'hat is happening rather then placing a la)el on it o "eriodic Breathing +'hich is an ominous sign 'hich indicates )rainstem (especially medullary dysfunction + usually precedes complete Apnea "eriodic )reathing is not normal for anyone other than the neonate 5eep .endon #efle<es + 5iminished or A)sent o Oculocephalic #efle<es (5olls /yes $ovement of head side to side! 'hen childs )rainstem center for eye movement is normal + conBugate movement of eyes in the direction opposite of the head movement Any tests that re0uire head movement are not attempted until after cervical inBury is ruled out o Oculovesti)ular #efle<es (-ce :ater Calorics + Normal in neurologically intact child &hould never )e done on an a'a(e child or a child 'A a rupture tympanic mem)rane -rrigating e<ternal ear canal 'A 8FmL of ice 'ater 'A ,OB elevated 3F degrees 'ill cause nystagmus of eyes to'ards stimulus in a neurologically intact child Neurological ssessment of t!e Infant ,ead Circumference

o =p until a)out 7 yAo at least 8>mo "alpate Anterior Fontanel o Close typically around 8>mo o 5ecreased fontanel4 dehydration o -ncreased fontanel4 increased intracranial pressure4 meningitis! hematoma! etc "alpate Cranial &utures o Assessing that everything closes smoothly! is there overlapping! are there any crac(les -ncreased Fle<or .one 5ocument #esponse to &timulation o ,o' much does it ta(e to 'a(e the child up 5ocument A)ility to &uc( o Assess &uc(As'allo' coordination Note "upillary #esponse o :hen you sit them up they should refle<ively open their eyes ,ead Control +&hould )e sta)le at 6 months of age Assess Cry o :ea( o Lusty o &hrill o Chromosomal defects4 'ill have an inappropriate cry due to neurological deficits o Appropriate to &timulus #efle<es o *no' 'hen #ooting! &uc(ing! "almar 2rasp! $oro and Ba)ins(i #efle<es Appear and 'hen they should )e gone o 2rading of #efle<es 6G ,yperactive 3G Bris(er than Normal 7G Normal 8G 5iminished O A)sent

Neurological ssessment of t!e (lder C!ild Assess #esponse to Command and Assess &peech Alert Orientation + "erson! "lace! .ime and /vent Note $ood "upillary #esponse A)ility to read! 'rite! dra' or copy shapes o -t is not the chronological age 'e are assessing! )ut developmental stage@ Nursing Im+lications of De&elo+mental Differences Nurses must )e a'are that the assessment of infants and children is limited )y the childs developmental level .he childs neurological status can appear to change rapidly )ecause of the limitations of the assessment1 Also )ecause of open cranial sutures and fontanelHs help to compensate for an increase in -C" Neurological signs may )e evident or they may manifest themselves in more su)tle 'ays! such as lac( of interest in eating or irrita)ility ssessment of Neurological *unction Factors -nfluencing the Assessment o #ate of Change o &everity of the "ro)lem &tatic or "rogressive

Nature and Location of the "ro)lem Focal $ulti-Focal 5iffuse

Diagnostic :ests for Determining Neurological Dysfunction Non--nvasive 5iagnostic .ests o Computerized .omography + C1.1 &can o $agnetic #esonance -maging &can + $1#1-1 o /lectroencephalogram o /vo(ed "otentials o /choencephalogram -nvasive 5iagnostic .ests o Lum)ar "uncture + L1"1 o Cisternal "uncture o &u)dural .ap o $yelogram o Cere)ral Angiography o "neumoencephalogram %umbar "uncture and Cerebral s+inal *luid 'CS*) Examination Normal Findings "ressure ? 7FF cm ,7O Color + Clear and Colorless Blood + None Cells o #BC + F o :BC .otal Neonate F-3F cellsAmL 8-9 years F-7F cellsAmL ;-8> years F-8F cellsAmL Adults F-9 cellsAmL o 5ifferential Neutrophils F-;I Lymphocytes 6F->FI $onocytes 89-69I o "rotein + 89-69 mgAdL (=p to JF mgAdL in children and elderly o 2lucose + 9F-J9 mgAdL or ;F-JF I of Blood 2lucose Level .he stress of the procedure can elevate their )lood glucose! so test prior to L" ge 0elated Differences Brain 2ro'th o 9FI of the )rains gro'th is completed )y 8 year-of-age o J9I )y 3 years-of-age o KFI )y ; years-of-age Cere)ral Blood Flo' (CBF and O<ygen (OL Consumption o Muestion + -s CBF and OL consumption the same! faster or slo'er in childrenN o -t is important to note that the )rain is an OinactiveP organ uses 8F times the OL used )y the rest of the )ody1 Fontanel Closure o $icrocephaly

"rimary vs1 &econdary $acrocephaly "rimary vs1 &econdary Clinical $anifestations of $acrocephaly Accelerated ,ead 2ro'th 5elayed Fontanel Closure $ental and "hysical #etardation &eizures No increase in -C" ,ydrocephalus "rimary4 arrested gro'th in utero + no increase in -C" &econdary4 occurs after inBury + has neurological manifestations

Craniosynostosis ' ; Craniostenosis) "athophysiology + "remature closure at )irth of one or more cranial sutures $ost common form4 "remature closure of the sagittal suture! 'ith resulting elongation of the s(ull in the anteriorposterior direction (similar shape seen in premature infants due to postnatal positioning Clinical $anifestations o -ncreased -C" + :hich may or may not cause mental retardation1 Can result in progressive papilledema! optic atrophy and eventual )lindness .herapeutic $anagement o &urgical e<cision of long )ars of )one along or parallel to the fused suture o :hen should surgery )e performedN Nursing Considerations o Assessment of "remature Closure Neurological &tatus o O)serve post-operatively for hemorrhage and infection

Nursing Care of t!e C!ild #it! Increased Intracranial "ressure 5ynamics of -C" o 5efinition4 "ressure e<erted )y C&F 'ithin ventricles of )rain o Continually fluctuates+ responds to arterial pulsation and respiratory cycle o %alsalva maneuver (cough! sneeze! straining increases -C"! standing up or sitting erect decrease -C" o Normally measures >F-88F mm ,7OA F-89mm ,g - A)ove7Fmm,gA7FFmm,7F is a)normally high "hysiology o &(ull is rigid compartment! filled to capacity (8KFF cc 'ith essentially non-compressi)le contents Brain matter Q >FI -ntravascular )lood Q 8FI C&F Q 8FI o %olume of these 3 remain nearly constant o -f any one component increases in volume! another component must decrease for overall volume to remain constant + other'ise -C" increases Could )e due to hydrocephalus! meningitis! su)dural hematomas! etc1 o -ncreased -C" is significant )ecause it diminishes cere)ral perfusion + leads to )rain ischemia! infarction Q poor prognosis o &ustained increased -C" result in )rainstem compression and herniation of the )rain from one compartment to another + this )ecomes irreversi)le and fatalR herniation forces the cere)ellum and )rainstem do'n'ard through the foramen magnum! compresses )rainstem leading to respiratory arrest Complications of -ncreased -C" o -nade0uate cere)ral perfusion

Cere)ral herniation Fal< cere)ri (thin 'all of dura folded )et'een the corte<! separating the 7 cere)ral hemispheres .enorium cere)elli (rigid fold of dura that separates cere)ral hemispheres from cere)ellum Clinical $anifestations of -ncreased -C" o Anterior Fontanel + Bulging! tense A)sence of normal pulsations o ,ead Circumference + OFC S 7cmsAmonth first 3 months o ,eadaches + 2eneralized or Localized1 "ain increases 'ith valsalva maneuver o Altered $ental &tatus + -rrita)le-Fatigued o %omiting + $ay or may not )e nauseous +may occur after rising in the morning o Altered %ital &igns + 9radycardia 7late sign o Altered %ision + 5iplopia! setting sun sign! restricted fields! papilledema &etting sun sign4 pupils go do'n to'ard the )ottom of the eye into the lo'er conBunctiva! there is increased pressure on the optic nerve forcing the eye do'n'ard o o o o "upillary Changes - normal sluggish fi<ed and dilated (OBlo'nP Can )e unilateral or )ilateral Altered LOC ,igh "itched Cry

Strategies for t!e Nursing Care of t!e C!ild #it! Increased IC" /arly recognition and treatment of increased -C" o /sta)lish a neurological )aseline o $onitor vital signs fre0uently #ecognition of ,ypercapnia and ,ypo<ia o $aintain patent air'ay o $ay need to suction and hyperventilate $aintenance of normothermia or temperature regulation o $aintain temp )et'een 3;19 C and 3> C (KJ1J F-8FFF o -ncreased temp causes OL needs o Fever causes vasodilation 'hich CBF $aintain optimal head and nec( position o "revent nec( fle<ion! e<tension or turning head to the side ris( of Bugular compression o /levate ,OB 89-3FT- "romotes venous drainage and prevents in CBF Nursing Care of t!e C!ild #it! a 9rain :umor Brain tumors + most common solid tumor of childhood o -ncidence 719A8FF!FFF children ? 89 years-of-age o ;FI are infratentorial +cere)ellum and )rainstem -ncreased -C" noted o 6FI are supratentorial -cere)rum Clinical $anifestations o 5irectly related to anatomic location ,eadache! vomiting! neuromuscular changes! )ehavioral changes! cranial nerve neuropathy! %& distur)ances Other signs include seizure! cranial enlargement! tense )ulging fontanel! nuchal rigidity! papilledema o -n infants 'hose sutures are still open! no symptoms may )e detected early + :hen o)struction to C&F occurs then OFC 'ill increase $ost common symptoms o ,eadache4 Brain is insensitive to pain o Compression of 'alls of arteries and veins! and cranial nerves can produce headaches o Often continuous! )ut 'orse in A$ 'ith rising

&training or movement may increase pain1 %omiting4 =sually not preceded )y nausea -ncreased -C" compresses )rainstem 'hich directly stimulates the vomiting center in the medulla 5iagnostic /valuation o $1#1-1 o CA. &can o Cere)ral Angiography o /lectroencephalogram o L1"1 o Biopsy o o .herapeutic $anagement o &urgery &tereotactic + -nvolves use of $#- and CA. &can1 #econstructs the tumor in 3 dimensions1 Lasers are used1 Brain scanning clearly delineates area of )rain to )e avoided o #adiotherapy + =sed to shrin( tumor o Chemotherapy + Controversial + =sed in com)ination 'ith surgery and radiation o :hat are the conse0uences of these treatments on childrenN o #adiation &omnolence &yndrome $ay develop 9-> 'ee(s after CN& irradiation + Last 6-89days $ay indicate long term CN& se0uelae Nursing Considerations o Assess for &igns and &ymptoms + /sta)lish a )aseline Fre0uent %& and pupil chec(s every hour -ncreased temp may occur from surgical interventions in the hypothalamus or )rainstem $ay develop an infection! meningitis or =# Chec( dressings fre0uently + dra' circle around )loody drainage #eport colorless drainage immediately )Ac it is C&F "ositioning + if a large tumor removed + avoid that side Fluid regulation -nfratentorial tumor4 N"O first 76 hours post-op &upratentorial + start fluids slo'ly! if &-A5, occurs + U maintenance fluid rate Anti)iotics and other meds are included in -% rate "ain + narcotics! AL:AC& have Narcan on hand =ltimate goal + cured child 'ith ma<imum functioning o Child and Family "reparation o "revent "ost-Operative Complications Assessment "ositioning Fluid #egulation "ain Control o &upport Family o "romote #eturn to Optimum Functioning

1yelodys+lasia ' ; S+ina 9ifida or Neural :ube Defects 'N:Ds)) .ypes of $yelodysplasia o Anencephaly + A)sence of )rain tissue a)ove rudimentary )rainstem o /ncephalocele + /<ternal mass or sac that may occur at any place a)ove the s(ull1 $ay )e covered 'ith scalp or transparent mem)rane o &pina Bifida Cystica $yelomeningocele + Contains meninges! spinal fluid! and neural tissue1 &pinal nerve roots may end at the sac1 &ensory and motor function 'ill end at this point

$eningocele + Contains meninges and C&F &pina Bifida Occulta $ay )e a tuft of hair! usually not pic(ed up until later

"athophysiology o 5egree of functional impairment depends on the level and the e<tent of the defect1 Neurological findings correlate 'ith the particular muscle groups involved1 5ysfunction can range from incompati)ility 'ith life or total paralysis to minimal involvement Orthopedic "ro)lems associated 'ith N.5s o Clu) Feet (.alipes /0uinovarus o Contractures o 5islocated hips o &coliosis o Are very common in children 'ith a N.5 in the lum)rosacral region o Bo'el and Bladder dysfunction are almost al'ays apparent1 .he nerves that supply these organs are located in the sacral region 1itrofanoff "rocedure o Appendi< is used to provide an alternative route for intermittent catheterization1 .he appendi< is removed from the colon and used to create a contnent conduit )et'een the a)dominal 'all and )ladder o -f the Appendi< 'ont 'or( + A $onti tu)e- part of the intestine! ileum or colon is used to create the conduit o =rinary stasis is dangerous )Ac it leads to infection .herapeutic $anagement o &urgery + Close the &ac Nursing 5iagnoses o #is( for -nfection "rotect the &ac@@ Lay a sterile saline soa(ed 6 < 6 to protect the sac! any tear can lead to immediate infection .he 8st children 'e sa' 'A late< allergies due to the num)er of procedures these children 'ere undergoing o .rauma o -mpaired &(in -ntegrity o -nBury #elated to /<posure to Late< "roducts #elated to neuromuscular -mpairment o Chronic "ro)lems /ncountered )y Children 'ith N.5s *our "rognostic *actors o .he degree of neural involvement o &ize and location of the sac o "resence of other anomalies o Complications that occur

<ydroce+!alus Communicating vs1 Non-Communicating o Communicating + -mpaired a)sorption of C&F 'ithin the &u)arachnoid &pace o Non-Communicating + O)struction to the flo' of C&F through the ventricular system =sually caused )y a developmental malformation 5efect is usually apparent at )irth o Build up of fluid! things arent flo'ing properly &igns and &ymptoms of ,ydrocephalus o ,ead gro's at a)normal rate o Bulging anterior fontanel Build of fluid! things arent flo'ing properly o &etting-&un &ign + /yes rotated do'n'ard 'ith the sclera visi)le a)ove the iris o "oor feeding o -rrita)le 'ith increasing lethargy o Changes in LOC o Opisthotonos (Often /<treme 4 )ac( arching (severe cases can result in Bust the )ac( of head and heels on the )ed o Lo'er /<tremity &pasticity .reatment o "lacement of %entriculoperitoneal (%" &hunt "ressure valves drain C&F 'hen pressure is high enough Once pressure is relieved the valves close .ypically the procedure leaves enough tu)ing so that it allo's for gro'th &ometimes shunts are temporary! most are permanent! often they 'ill need a revision due to clots of infection! sometimes they 'ill have e<ternal shunts o #arely + "lacement of %entriculoatrial (%A &hunt Only have a %A shunt if you cant thread the %" shunt into the peritoneum Complications of &hunt "lacement o $alfunction + &igns and &ymptomsNNN -rrita)ility! headache! fussiness! increased head circumference! )ulging anterior fontanel! pupillary changes! vomiting &ometimes signs can )e more su)tle li(e small amount of s'elling in the face or small changes in attitude o -nfection (especially dangerous 'ith a %A shunt! infection goes straight to the heart $aBor Nursing 5iagnoses for the Child 'ith ,ydrocephalus o ,igh #is( For4 -nBury related to increased -C" -nfection related to presence of mechanical drainage system and surgical procedure -mpaired s(in integrity related to pressure areas! paralysis! rela<ed anal sphincter o Altered Family "rocesses related to situational crisis (child 'ith a physical defect Intracranial Infections. 1eningitis Children - Also seasonal1 $ost often seen in children under the age of 9 years1 "ea( incidence )et'een ;-87 months of age1 $ost common organisms are4 ,aemophilus -nfluenzae .ype B!Neisseria $eningiditis ($eningococcal and &treptococcus pneumoniae ("neumoccocal 1 $enigococcal and "neumococcal o .he most commonly seen versions of the disease seen in children )et'een 7 months and 87 years Neonatal $eningitis + 2roup B &treptococci! /1 Coli! and Listeria $onocytogenes Clinical $anifestations + 5epend on the age of the Child o Neonates + %ery difficult to diagnose in this age group1 &ymptoms may )e vague1 $ay )egin to refuse feedings! have poor suc(ing a)ility! vomiting and diarrhea1 $ay not have )ulging fontanel until late in course of disease

Nec( is usually supple 5isease 'ill progress if untreated and 'ill cause cardiovascular collapse! seizures and apnea o -nfants and Coung Children Classic picture is rarely seen in children )et'een the ages of 3 months and 7 years-of-age Fever! poor feeding vomiting! mar(ed irrita)ility! restlessness! and seizures! Bulging fontanel is the most significant finding Nuchal rigidity and G Brudzins(i and *ernig signs occur late in the young child G Brudzins(i + Fle< head + "ain or involuntary fle<ing of (nees is a)normal G *ernig + Child lies supine + Leg fle<ed at hips + resistance or pain upon e<tension is a)normal o Older Child and Adolescent -llness a)rupt 'ith fever! chills! headache and vomiting that are associated 'ith or follo'ed )y changes in the sensorium1 &eizure Be e<tremely irrita)le and agitated1 ,ave photopho)ia ,ave nuchal rigidity + resistance to fle<ion of the nec( /<hi)it Opisthotonis (/<treme Overe<tension ,ave G Brudzins(i and *ernigs sign ,yperactive refle<es &igns of cardiovascular collapse "etechiae or "urpura if infected 'ith meningococcal organism + 'hyN #esult of throm)osis or e<travasation of #BCs and inflammatory changes around the capillaries in the s(in Complications o O)structive hydrocephalus o &u)dural /ffusions o .hrom)osis in meningeal veins or venous sinuses o Brain a)scesses o 5eafness! Blindness and "aralysis o :aterhouse-Friderichesen &yndrome Over'helming &eptic &hoc( 5-C $assive )ilateral adrenal hemorrhage "urpura o &yndrome of -nappropriate Antidiuretic &yndrome (&-A5, + Occurs in KFI of children 'ith )acterial meningitis + Also have decreased NaG! Cl- and Osmolality Levels o *luids at = or > maintenance +ro+!ylactically so t!at if t!ey are de&elo+ing SI D< t!ey aren?t de&elo+ing IIC" or fluid o&erload :hat complication 'as left outN o &eizures + Caused )y irritation and destructive changes in the cere)ral corte< and hyponatremia as a result of &yndrome of -nappropriate Antidiuretic ,ormone (&-A5, o &eizures - :ithin first 3 days does not interfere 'ith prognosis! after that they 'ill potentially have long term effects 5iagnostic /valuation o L1"1 is the 5efinitive .est o &amples are o)tained for4 Culture and 2ram &tain Blood Cell Count "rotein 2lucose + relationship )et'een &erum glucose and C&F 2lucose is important1 &erum 2lucose is dra'n U hour )efore L1"1 "ressure is measured

o Blood! Nasal and .hroat Cultures may )e ,elpful .herapeutic $anagement o -solation "recautions + #espiratoryA5roplet for first 76 hours o -nitiation of Antimicro)ial .herapy o $aintenance of4 ,ydration + may do fluid restriction to +re&ent or minimi@e effects of &-A5, occurs %entilation o #eduction of -ncreased -C" o $anagement of Bacterial &hoc( o Control of &eizures o Control of /<tremes of .emperature o Correction of Anemia o .reatment of Complication "reventive $easures + "rompt treatment for =#-s! Otitis $edia! etc1 -mmunization 'ith ,i) %accine o $inimize visitors so that you minimize e<posure to anyone else "rophylactic treatment for family and vulnera)le population o Anyone e<posed to an individual 'ith Neisseria $enigitidis ($eningococcal $eningitis should )e given prophyla<is o Anyone ? 6> months 'ho has not )een fully immunized against ,aemophilus -nfluenzae .ype B or is immunocompromised or lives 'ith these children and has )een e<posed! should )e treated prophylactically Nursing 5iagnoses o ,igh ris( for inBury related to presence of infection &eizures or cardiovascular complications o "ain related to inflammatory process Analgesics! i)uprofen (if older than ; months o Altered family processes related to a child 'ith a serious illness

Sei@ures and E+ile+sy A Idio+at!ic &sB cCuired &imple "artial (a(a local or focal + part of the )rain o o o o o No %(C 'only one t!at doesn?t) #arely last longer than 8min $otor symptoms-unilateral movement of e<tremity (arm moves around &ensory symptoms (i1e1 ringing in ear! metallic taste in mouth Autonomic symptoms (i1e1 racing ,#! s(in flushing! sic( to stomach

Comple< "artial + o o o o lteration in Consciousness =sually lasts longer t!an 1 min $otor )ehaviors (no'n as automatisms (i1e1 lip smac(ing! pic(ing at self! patting )ut isnt a'are of it Alterations in memory (dVBW vu

2eneralized + all of )rain X change in LOC including4 o A)sence + %(C characterized )y )rief staring spell only for a fe' sec 'A no motor involvement

o o o

$yoclonic + presents as a sudden e<cessive Ber(ing or stiffening! usually falls to the ground 3 may occur in clusters! %(C Atonic + sudden loss of muscle tone X may fall to ground resulting in inBury! %(C .onic-Clonic (2rand $al + 7 phases4 tonicA stiffeningArigid muscles then clonic -rhythmic Ber(ing of e<tremities Cyanosis (resp may cease /<cessive salivation! tongue or chee( )iting! incontinence! %(C "ostictal phase4 patient lethargic and confused after seizure! often sleeps Full recovery may ta(e hrAdays

Sei@ure :erminology &eizure + &udden! involuntary! time-limited alteration in function1 A)normal discharge of cortical neurons /pilepsy + Chronic condition -ctal &tate + 5uring &eizure "ost-ictal &tate + "eriod follo'ing the seizure &tatus /pilepticus + &eizure that lasts S 3F minutes or series of seizures that do not allo' the child to regain consciousness in )et'een each seizure 5ilantin! Ativan (Lorazipam are typically given o %alium and 5iazepam can )e given also )ut can cause respiratory suppression Infantile S+asms 7 ; infantile 1yoclonus $ost commonly occur 'ithin first ;-> months of life .'ice as common in )oys than girls Numerous seizures during the day 'ithout postictal dro'siness "oor outloo( for normal intelligence Clinical $anifestations o "ossi)le series of sudden! )rief! symmetric! muscular contractions o ,ead fle<ed! arms e<tended! and legs dra'n up o /yes sometimes rolling up'ard or in'ard1 o $ay )e preceded or follo'ed )y a cry or giggling o $ay or may not include loss of consciousness o &ometimes flushing! pallor or cyanosis *ebrile Sei@ures -ncidence + Appro< 3I of all children )et'een ages ; months-3 years1 Boys 748 ratio1 -ncreased incidence in families and children 'ho attend day care &eizures occur during the temperature spi(e .reatment for Fe)rile &eizures o .ylenol and -)uprofen o "rotect Air'ay o "rotect from -nBury o "rophylactic + Antiepileptic Children 'ith focal or prolonged seizure Child 'ith primary relative 'ho has had fe)rile seizures Children ? 8 year+of-age Children 'ith multiple incidents

:ont use "heno)ar) as prophylactic + -neffective and can lo'er -M o Anticonvulsant $edications Alternative $easures of &eizure Control o *etogenic diet + ,igh Fat! Lo' Car)ohydrate and "rotein 5iet + Forces )ody to shift from using glucose to fat as energy source1 .he patient develops a state of (etosis1 .his diet is deficient in vitamins and minerals- so supplements should )e given o %agus Nerve &timulator -mplanta)le device decreases seizures in individuals 'ho have not responded to drug therapy + =sually implanted in individuals 87 years or older1 &ends stimulus to the Left %agus Nerve + Cranial Nerve Y- Caregiver activates stimulator 'ith magnet at the onset of a seizure1 #esearch sho's that only 8A3 of pts have a 9FI or greater reduction in seizures after 8 year of therapy &urgical .reatment for /pilepsy o :hen a hematoma! tumor or other cere)ral lesion causes seizures! surgical removal is the treatment1 o -f a childs seizures are nonresponsive to drug therapy! surgery may )e done to remove the focal area of the seizure activity o ,emispherectomy is used to treat a patient 'ho has severe epilepsy and hemiparesis or nonfunctional hand use Nursing 5iagnoses o #is( of -nBury .ype of &eizure .o hypo<ia and aspiration Nasal cannula or )lo' )y o<ygen -mpaired Consciousness and Automatisms o Altered Family processes related to having a child 'ith a chronic illness

<eadac!es Muestions for /valuating headaches + Bo< 3J-83 pg 89;7 $igraine ,eadaches + $ost common cause of recurrent headaches o Autosomal dominant + Often proceeded )y aura and accompanied )y NA% .ension ,eadaches Current .reatment for ,eadaches o -f trigger identified avoid trigger o Biofeed)ac( and rela<ation techni0ues o .ylenol and N&A-5s + First Line of .reatment o Cyprheptadine + "eriactin (Antihistamine o "ropanolol o AmitriptylineANortriptyline

Cerebral Injury Causes of Cerebral Injury. <ead Injuries3 Com+lications of "rematurity3 Cerebral Infections3 Near Dro#ning /tiology of ,ead -nBuries o -nfants Falls and Child A)use o ? 7 years-of-age Falls o "reschoolA&chool Age Auto Accidents

Older ChildA Adolescent Accidents involving motor vehicles! cycles and sports inBuries $ales outnum)er Females 748

ssessment "hysical /<am + Brief )ut .horough ABCs %ital &igns "upil Chec( Focal Findings 2lasgo' Coma &cale Be sure that )efore any assessment is done that you sta)ilize the head and nec( "at!o+!ysiology "athology is directly related to force of impact "rimary vs1 &econdary o "rimary + Occur at time of trauma &(ull inBuries Contusion -ntracranial hematomas 5iffuse inBuries o &econdary + :hat occurs )ecause of the trauma ,ypo<ic Brain 5amage -ncreased -C" -nfection Cere)ral /dema Concussion Neurological $anifestations o -mpaired consciousness for a varia)le period of time o ,eadache ("ost Concussion &yndrome o %ertigo o 5epressed #efle<es o An<iety o 2eneral $alaise #espiratory $anifestations o 5ecreased #espirations Cardiovascular $anifestations o Bradycardia! ,ypotension "ost Concussion Syndrome &ymptom comple< that may occur 'ithin days of the inBury and can include4 o ,eadaches o 5izziness o Fatigue o -rrita)ility o An<iety o -nsomnia o Loss of Concentration o $emory -mpairment Clinical symptoms of the follo'ing are all closely associated 'ith "ost concussion &yndrome o Loss of Consciousness o "osttraumatic Amnesia

o o o

2C& &core ? 89 5isorientation Other $ental &tatus changes

Contusion and %aceration Neurological $anifestations o "ossi)le loss of consciousness o $ild motor or sensory 'ea(ness o ,eadache o %ertigo o "ost-.raumatic &eizures o Coma o -rrita)ility o #estlessness *ractures Linear 5epressed Compound Basilar 5iastatic

Neurological $anifestations o Altered s(ull contour o ConBuctival ,emorrhage + associated 'ith fracture of the anterior fossa o C&F #hinorrhea o "erior)ital /cchymosis o C&F Otorrhea o "alsies of C8! CJ and C> nerves o "ost-traumatic &eizures + Late &ign o Coma Cardiovascular $anifestations o ,ypovolemia + Associated 'ith fractures over the lateral or sagittal sinus -ntegumentary $anifestations o /cchymosis at the )ase of the nec( + Associated 'ith )asilar s(ull fracture and fractures over the mastoid process

Com+lications of <ead Injuries /pidural ,ematomas &u)dural ,ematomas &u)arachnoid hemorrhage -ntracere)ral ,emorrhage Cere)ral /dema "osttraumatic &yndrome &eizures E+idural <ematoma As the epidural ,ematoma increases the dura is stripped from the s(ull + this leads to forcing the underlying )rain contents do'n'ard and in'ard as it e<pands1 /pidural ,ematomas occur infre0uently in infants and children )ut 'hen they do they are usually caused )y Child A)use (&ha(en Ba)y &yndrome in the infant and child and $otor %ehicle Accidents ($%As in the adolescent =sually arterial in origin 'hich leads to rapid )rain decompression Neurological $anifestations + .he classic picture of an /pidural hematoma is4 o $omentary =nconsciousness + Follo'ed )y a normal period for several hours! then lethargy or coma due to )lood accumulation in the epidural space1 o .he lethargy and coma are due to )lood accumulation in the epidural space and compression of the )rain o Cushing .riad ('idening pulse pressure! hypertension and )radycardia is a late sign of impending )rain herniation and increased -C" #espiratory $anifestations o #espiratory 5epression o Apnea Cardiovascular $anifestations o Bradycardia 2astrointestinal $anifestations o %omiting Subdural <ematoma A &u)dural hematoma is )leeding )et'een the dura and the arachnoid mem)rane $uch more common than epidural hematomas in children 'ith pea( incidence at ; months of age1 Neurological $anifestations + =sually present 'ith diffuse symptoms o ,eadache o Loss of Consciousness o Focal &eizures o =nilateral "upillary 5ilatation o ,emiparesis o Agitation o 5ro'siness 'ith Confusion o "rogressive &lo'ness of .hin(ing Nursing Diagnoses ssociated #it! Cerebral Injury in C!ildren -neffective )reathing pattern ('ith potential for respiratory failure related to 2 IC" ltered "eri+!eral +erfusion 0$: <y+otension Secondary to <y+o&olemic S!oc/ <ig! 0is/ for *luid ,olume Deficit 0$: Nausea and ,omiting Decreased CB(B related to !emorr!age ,igh ris( for inBury #A. to Altered LOC secondary to head inBury or increased -C" or )oth ,igh #is( for inBury secondary to seizures "ain related to head inBury An<iety (Child and "arent related to traumatic head -nBury ,igh ris( for infection #A. -nBury

,igh ris( for impaired s(in integrity #A. physical immo)ility *no'ledge deficit #A. home care

Case Z 8 [1$1 is a 7 month-old infant girl 'ho presented to the /mergency 5epartment (/151 lethargic! hypotonic and )radycardic and 'ith a )ulging anterior fontanel1 ,er 8J-year-old mother stated that [1$1 fell out of her )a)y s'ing onto a carpeted floor 7 days ago1 Four hours after admission! [1$1 )egins to seize continuously (status epilepticus and re0uired endotracheal intu)ation1 A C1A1.1 &can reveals )ilateral su)dural hematomas :hat is the most li(ely etiology of this childs inBuryN o &ha(en )a)y syndrome )Ac the child has )ilateral su)dural hematomas Com+lications of "rematurity "erinatal ,ypo<ic--schemic Brain -nBury o ,ypo<ic--schemic /ncephalopathy is the resultant cellular damage from hypo<ic-ischemic inBury o .he site of the inBury 'ill depend on the neonates gestational age -n the term infant the primary site of inBury is the parasagittal cere)ral inBury cortical necrosis (deeper portion of the )rain -n the premature infant the primary ischemic lesion is in the 'hite matter near the ventricles or periventricular 'ith resultant periventricular leu(oplacia CNS . Intra&entricular 'I,<) A +eri&entricular !emorr!age '",<) $ost common )rain inBury in premature X 9FI of those 'ho die in first fe' days of life have hemorrhage /tiology1 o B" fluctuations! mechanical ventilation! asphy<ia! rapid infusion of volume! Na,CO 3 or hyperosmolar solutions! coagulopathy! pneumothora< &X& o &udden deterioration! Bradycardia! Acidosis! Fall in ,A,! &hoc(! ,yperglycemia! .ense anterior fontanel! $ay )e gradual Late &igns and &ymptoms o .ense! )ulging fontanels! -ncreasing ventilatory support! &eizures! Apnea! Coma .reatment -%, o .reatment + preventive! supportive! 9FI of acute! severe -%, infants die1 o -%, may)e self-resolving o $ay resolve 'ith minimal disa)ility o $ay re0uire placement of an intraventricular shunt 'ith or 'ithout neurodevelopmental disa)ility1 o &eizures + .reated 'ith "heno)ar)ital! Fosphyntoin o -nfection of shunt + meningitis increases ris( for a)normal neurodevelopmental disa)ilities Cerebral Infections /ncephalitis + Occurs as a result of (8 direct invasion of the CN& )y a virus or (7 postinfectious involvement of the CN& after a viral illness o &pecific type of encephalitis may not )e identified o .he maBority of cases in children are associated 'ith measles! mumps! varicella and ru)ella1 Less common causes are enteroviruses! herpes viruses and :est Nile %irus ,erpes /ncephalitis is not common )ut 3FI of the cases reported involve children o Clinical $anifestations Can range from mild (same as 'ith aseptic meningitis to fulminating encephalitis 'ith severe CN& involvement &udden or gradual onset of symptoms &evere Cases ,igh Fever! &tupor! &eizures! 5isorientation! &pasticity! Coma + that may proceed to death! Ocular palsies and paralysis o 5iagnostic /valuation

Clinical findings and identification of the specific virus C1.1 &can may )e normal initially + Later hemorrhagic areas in the frontotemporal region may )e seen .herapeutic $anagement "rimarily &upportive Conscientious Nursing Care Control of Cere)ral $anifestations Ade0uate Nutrition and ,ydration

Submersion Injury $aBor cause of unintentional inBury-related death in children ages 8-86 years1 $ost organ systems 'ill )e affected1 All children 'ho have a su)mersion inBury should )e admitted for o)servation o #espiratory compromise or cere)ral edema may not occur until 76hrs after the accident "ro)lems seen in su)mersion inBuries o ,ypo<ia and asphy<iation '6sually t!e biggest concern) o Aspiration o ,ypothermia o :hich of the follo'ing 'ould have the highest priorityN

Endocrine. D Questions Endocrine System Controls or regulates meta)olic processes in the )ody o /nergy production o 2ro'th o Fluid and electrolyte )alance o #esponse to stress o &e<ual reproduction "rimarily coming from the pituitary gland and the hormones it regulates Diabetes Insi+idus Clinical manifestations o "olyuria o "olydipsia o /nuresis4 night time )ed 'etting o -nfants-irrita)ility relieved 'ith feeding 'ater! 'ill have really heavy diapers 5iagnosis o :ater deprivation test #estrict fluids and chec( specific gravity to determine if urine 'ill concentrate 5one under physician supervision Brain $#- to rule out tumor if positive on 'ater deprivation treatment .reatment o Desmo+ressin cetate (analog of %asopressin is used Oral ta)lets! intranasal spray or su)cutaneous o 5ont have enough vasopressin o Fre0uent chec(s of specific gravity to identify 'hen or if the urine concentrates o Often infants have to get su)cut inBections )Ac the oral ta)lets are not concentrated enough for a high enough dose to )e administered to control the urine output

o &pray may not )e indicative in children 'ho have stuffy noses o &ome children can )e managed 'ith Bust fluids Nursing implications o Closely monitor inta(e and output in patients after head trauma or neurosurgical procedures BAc that area of the )rain could )e damaged and result in dia)etes insipidus o At school! unrestricted use of )athroom! 'ater )ottle at des(! "#N dosing of desmopressin for )rea(through urination Large amount of urine 'here the medicine 'ears off at least once a day &ometimes this occurs at school or at night :hen a )rea(through urination occurs they can then redose the vasopressin Comes in different formulations! ma(e sure to get their home dose 'hen ta(ing the health history

Disorders of :!yroid *unction .hyroid hormone regulates B$# .hyroid secretes t'o types of hormones o .hyroid hormone! 'hich is made up of .hyro<ine (.6 .riiodothyronine (.3 o .hyrocalcitonin $ay have hypo- or hyperthyroidism $ay have distur)ance in secretion of .&, Eu&enile <y+ot!yroidism 'Sc!#eiss) Congenital ,ypothyroidism o Classic symptoms in ne')orns4 Long 2estation S 67 'ee(s Large ,ypoactive infant 5elayed $econium "assage Feeding pro)lems + poor suc( "rolonged physiologic Baundice ,ypothermia #espiratory 5istress and Cyanosis o &ymptoms in /arly -nfancy =sually occur after ; 'ee(s of life .ypical Facial features4 5epressed nasal )ridge! short forehead! puffy eyelids and enlarged tongue Coarse hair Lethargy and sleepiness Flat facial e<pression Constipation Ac0uired o "artial or complete thyroidectomy for CA or thyroto<icosis o Follo'ing radiation for ,odg(in or other malignancy o #arely occurs from dietary insufficiency in =nited &tates Clinical $anifestations of [uvenile ,ypothyroidism o 5ecelerated gro'th o Constipation o &leepiness o $y<edematous s(in changes 5ry s(in &parse hair "erior)ital edema

.herapeutic $anagement o Oral thyroid hormone replacement + &ynthroid is drug of choice o "rompt treatment needed for )rain gro'th in infant o $ay administer in increasing amounts over 6 to > 'ee(s to reach euthyroidism o Compliance 'ith medication regimen is crucial o &erum levels of .3! .6! .&, levels must )e measured on a routine )asis to ensure optimum treatment Nursing Considerations o -dentify children 'ith hypothyroidism o Alert for signs and symptoms o Child needs 0uiet environment! rest periods o ,elp family cope 'ith emotional la)ility associated 'ith disorder o 5ietary re0uirements to meet the childs increased meta)olic rate o $edications\side effects

<y+ot!yroidism ';elly) Congenital hypothyroidism o 5etected on ne')orn screen o "revalent in patients 'ith 5o'ns &yndrome o Clinical $anifestations At )irth! S67 'ee(s gestation! sluggish! delayed meconium passage! feeding pro)lems- poor suc(! prolonged physiologic Baundice! hypothermia &igns in all children4 5ry s(in! coarse hair! constipation! lethargy -f untreated! )rain development affected (cognitive and physical development Ac0uired hypothyroidism o After infection! thyroidectomy for cancer or after radiation .reatment o 5aily thyroid hormone replacement (Levothyro<ine or &ynthroid o #egular )lood dra's to chec( levels (Free t6 and .&, o /ach dose has its o'n color pill 'hich should not change unless the doctor says there is a change /ducate the patient to 0uestions a pill color change Nursing implications o Non adherence to medication 'ill affect physical and )rain development o 5o not administer thyroid replacement 'ith soy or iron o /ducation to parents a)out signs and symptoms of hyper and hypothyroidism o .hey must ta(e the medication everyday )Ac 'hen they are every small 'e 'ill chec( their )lood every month or every 7 months )Ac an alteration in levels can affect their gro'th so 0uic(ly! if you miss a dose parents are instructed to give 7 the ne<t day o /ducate on no soy formula or soy products o /very time a child gro's or is sic( their medication levels may need to )e changed (are they sleeping too much or too little! are they constipated or have diarrhea! in older children are they feeling li(e their heart is racing! etc1 Congenital drenal <y+er+lasia 78 hydro<ylase deficiency o -f untreated- failure to thrive! 'ea(ness! vomiting! dehydration! a)dominal pain! pale Clinical $anifestations o Am)iguous genitalia in females ne')orns Over testosteronized! the la)ia and clitoris appear li(e a penis o -ncreased pigmentation in s(in o /arly se<ual maturation! accelerated linear gro'th o Appear short )Ac they gro' too early

o Not producing enough cortisol hormone 5iagnosis o 5etected on ne')orn screen o =ltrasound of a)domen to visualize se< organs $anagement o Oral glucocorticoids can )e mi<ed in pharmacy for infants o -ncreased dosing in response to stress! fever! trauma! illness! they need to stay on their stress dose until fever is gone for 76 hours :e are no' seeing stress does needed in time physical stress as 'ell! this is a ne' development most often lin(ed 'A all day sports tournaments o -ntramuscular dosing for emergencies %omiting! surgery o -f salt-losing type- re0uires aldosterone (fludrocortisone ta)lets and sometimes salt ta)lets Nursing care o /ducation for parents on deciding se< assignment for child o /ducation for parents on appropriate use of stress dosing /ducate on 'hen dosing needs to )e done! ho' to give an -$ inBection and that if not given the child 'ill )ecome listless! pale and 'ill )e vomiting o 2enetic counseling for future pregnancies! autosomal recessive trait

Current :rends in Diabetic 1edications and Diabetes (&er&ie# :y+e 1 Diabetes 2enetic predisposition4 ,LA gene /nvironmental trigger! -nsulin is necessary! Onset during childhood! pancreas does not ma(e insulin ,oneymoon phase o Occurs 'hen the pancreas has a fe' )eta cells left and starts producing insulin again1 .hey may have lo' enough )lood sugars that they go off the insulin completely! )ut eventually the child 'ill need the insulin again and 'ill have to )e reeducated a)out insulin shots /tiology (Cause of .ype 8 5ia)etes o -n type 8 dia)etes! the immune system attac(s the insulin producing )eta-cells of the pancreas1 .he result is the destruction of the )eta-cells of the -slets of Langerhans of the pancreas1 -n some cases! it is possi)le that the )eta-cells might )e destroyed )y some process other than an autoimmune process1 .his could also produce type 8 dia)etes that 'ould )ehave the same as autoimmune type 8 dia)etes1 o .he result of damage and destruction of the )eta-cells is that the )ody cannot ma(e enough insulin1 .his results in high )lood sugars and dia)etes and can result in the complications o After a)out 8F years of having dia)etes is 'hen youll see complications no matter the age of diagnosis :y+e F Diabetes 2enetic predisposition -nade0uate production andAor inefficient use of insulin /tiology (Cause of .ype 7 5ia)etes o .he cause of type 7 dia)etes is not 'ell understood1 $ost li(ely! it is a com)ination of insulin resistance and an ina)ility to ma(e enough insulin1 -nsulin resistance means that the )ody does not use insulin 'ell1 .here are many causes of insulin resistance! )ut 3 important factors are family history! o)esity or )eing over'eight! and an inherited tendency1 o "eople 'ho have insulin resistance 'ill not necessarily get dia)etes1 .he islet cells or ]-cells of the pancreas may ma(e enough e<tra insulin so that the )lood sugar stays normal1 #emem)er! dia)etes is diagnosed 'hen the )lood sugar is high1 -n some people! ho'ever! the pancreas cannot ma(e enough insulin or may get tired trying1 &ince there is insulin resistance! and the pancreas cannot ma(e enough e<tra insulin! they develop dia)etes1 .his is 'hat type 7 dia)etes is1 o .he high )lood sugars of type 7 dia)etes cause the same (ind of pro)lems and complications as those 'ith type 8 dia)etes1 -n addition! insulin resistance may cause )lood vessel and heart disease even if )lood sugars are not high and the person never gets dia)etes1

.ype 7 5ia)etes -n Couth -s On .he #ise o 5ue to o)esity! poor diet and lac( of e<ercise - a lifestyle disorder1 o Appro<imately 8 in 9 children )et'een the ages of ;-8J are over'eight1 o Num)er of over'eight children and adolescents has dou)led over the last 7 decades1 Changes -n /<ercise And Activity o Overall activity levels of (ids has decreased over the years due to a variety of reasons4 5ecreased time spent in "/Arecess 5ecreased play time at home -ncreased time 'A .%! computer! video games! etc1 Characteristics of Adolescents at 5iagnosis 'ith .ype 7 5ia)etes o O)ese (Average B$- S3F o &edentary lifestyle o 5iet high in calories and fat o $ost are minority children (African American! American -ndians! ,ispanic o $ore girls than )oys o $ean age 83 years o S>FI have a history of dia)etes in a first degree relative o S;FI have physical evidence of insulin resistance (acanthosis nigricans4 dar(ening of s(in folds o Fre0uent co-e<isting medical pro)lem - hypertension! elevated cholesterol and lipids! sleep apnea o .est for the presence of anti)odies present to insulin

:reatment of :y+e 1 Diabetes -nsulin inBections necessary 5iet! /<ercise :arget 9lood Sugar Normal )lood sugar level o ;F-879 2oal for infants o 8FF-7FF 2oal for children o >F-8>F 2oal for teenagers o JF-89F o 2oals for Children 'ith 5ia)etes A normal )lood sugar for someone 'ithout dia)etes is JF-8891 $ost people 'ith dia)etes may find it difficult to (eep their )lood sugars in this range1 -t is much more useful to have a target )lood sugar range that is close to normal )ut that you can realistically achieve1 Cou may already have a goal for your o'n target )lood sugar range1 -f not! 'or( 'ith your health care team to find a realistic target range for you1 .he )est target range may )e different depending on ho' old you are and other factors specific to your dia)etes1 Goals for C!ildren #it! Diabetes .o achieve and maintain )lood sugar control .o gro' and develop normally .o maintain emotional 'ell)eing .o optimize their learning potential and success in school :reatment of :y+e F Diabetes In C!ildren =sually started on insulin $ay )e a)le to s'itch to oral dia)etes pills- important to remem)er that the oral pills are NO. insulin

Oral pills are medicines that ma(e the person more sensitive to their o'n insulin or ma(e the pancreas release e<tra amounts of insulin $ost Common Oral $edication .ried First o 1etformin 'Gluco+!age) Lo'ers )lood sugar $ay help 'ith 'eight loss =sually started on 8 (9FF mg pill once daily! then increased to 8 pill t'ice a day 'ith a ma<imum daily dose of 8FFF mg t'ice a day $ain side effects include4 upset stomach and diarrhea o 1etformin G0Alonger acting form ta/en in t!e morning o 1etformin and Insulin are t!e only a++ro&ed treatment medication for c!ildren #$ :y+e F diabetes o

%ifestyle C!anges 5ietary .reatment is %ery -mportant o Lo'ering calorie! fat and car)ohydrate inta(e is essential o =sually tell them ;Fg of car)s at meals /<ercise is e0ually important o 2oal + at least 3F minutes of moderate e<ercise every day Insulin. :y+es and cti&ity Action .imes for -nsulin -nsulin &tarts "ea(s /nds ,umANovologAApidra 8F-89 minutes ;F-KF minutes 3-6 hr #egular 3F-;F minutes 7-6hr 9-; hr N", 7-3 hr ;-K hr 87-89 hr Lente 7-6 hr >-86hr 8;-76hr ^^Lantus (2largine 8-7 hr 7-7F hr 7F hr ^^Levemir (5etemir 8-7 hr 3-86 hr 8>-7F hr ^^Lantus and 5etemir have little pea(! so lo's are less li(ely unless dose is e<cessive Lo' mostly li(ely at4 7-9 hr 3-J hr 6-8; hr ;-8; hr 9-8F hr >-8; hr

N", is not used often 'A children )Ac of the lifestyle associated 'ith the medication! needing to dose and eat at a particular times Not as common -nsulin #egimens o .'o inBections per day o ,umalogANovolog and N", prior to )rea(fast and supper Advantages of Lantus and Levemir -nsulin o Less varia)ility in a)sorption and activity o #eduction of lo' )lood sugars o Clear insulin - does not need to )e rolled to mi< - no settling and insulin concentrations do not vary from one shot to the ne<t 5isadvantages of Lantus -nsulin o No other insulin can )e mi<ed in the same syringe $ore acidic than other insulin -f mi<ed 'ith another insulin! )oth lose activity o :hen using Lantus! 3 or more shots per day of a short-acting insulin needed o Can )e confused 'ith ,umalog - )oth are clear insulinHs 'ith purple caps on )ottle o -nBections may sting )ecause of lo'er p, 5isadvantages of Levemir insulin o -n type 8 patients! doses are given t'ice a day to get full 76 hour coverage o Cannot )e mi<ed 'ith other insulin- resulting in 9 shots daily o ,o'ever! neutral p, Q less )urning at inBection site "en devices

o Lu<ura ,5- doses in U unit increments! great for smaller children o $emoir- doses in 8 unit increments! has a memory of last 8; inBections o Novopen [#- doses in U unit increments o #efilla)le 'ith 3FF unit cartridges that should )e discarded if not used in 3F days o A ne' needle tip should )e used each time o A priming dose of 7 units should performed )efore /%/#C inBection 'ith a ne' needle %I1I: :I(NS (* INEEC:ED INS6%IN o S3FI daily varia)ility in a)sorption of intermediate and long-acting insulin o #egional differences in a)sorption a)dSarmSthighShip o %ery large insulin doses have unpredicta)le a)sorption (inetics o Once inBected! it cannot )e removed -nsulin pumps o .u)eless vs1 tu)ing o *no' ho' to loo( through the pump to see 'hen last )olus and 'hen site changed (should )e every 3 days o Calorie (ing in pump- "ing and Omnipod =sed for car) counting

<y+erglycemia '<ig! 9lood Sugar) Blood sugar level is greater than 76F mgAdl -ncreases gradually Can usually )e tolerated for a longer period of time Causes of ,yperglycemia o Not enough insulin or missed inBections o /ating too much o -llness or infection o /motionalAphysical stress o Lac( of e<ercise or activity &ymptoms of ,yperglycemia o /<cessive thirst o Fre0uent urination o 5ry! flushed s(in o ,eadacheAstomach ache o Feeling tired or not 'ell o %ision pro)lems /ffects of ,yperglycemia o 5ecreased a)ility to focus G 5ecreased energy level G Fre0uent trips out of the classroom Q 5ecreased school performance

;etones Chemicals that appear in urine 'hen )ody )rea(s do'n fat for energy 5ue to lac( of insulin Build up of *etones can lead to 5ia)etic *etoacidosis (5*A :hen you run hyperglycemic for too long Diabetic ;etoacidosis 'D; ) Lac( of insulin -ncreased )lood sugar Brea(do'n of fat for energy *etones

&tarvation mode and you are losing 'eight! severe headache! vomiting! chest pain! fruity smelling )reath ((etones coming out in their )reath ! limp o =se )icar) levels to test! ?89 is an emergency! ?9 is severeR serum CO7 is a measure of the Bicar) :hen to Chec( for *etones o Blood sugar greater than 3FFmgAdL o Child feels sic( - especially vomiting o Notify parents if moderate or large *etones are present - needs insulin o Can get *etosti< in foil-'rapped strips (that (eep longer o &tudents do not need to )e sent home for high )lood sugars unless moderate to large *etones are present o ,igh )lood sugar 'ithout *etones is not an emergency o -f consistently high at school notify parents or fa< num)ers to office o

<y+oglycemia '%o# 9lood Sugar) Occurs 'hen the )lood sugar is too lo' Occurs 0uic(ly Needs immediate attention Causes of ,ypoglycemia o .oo much insulin o $eals or snac(s are late or missed o /<tra or e<treme e<ercise o /<citement in young children (start and finish of school year! holidays! etc1 o Alcohol e<perimentation (older children &ymptoms of ,ypoglycemia o &ha(iness o "allor o ,unger o -rrita)ility o ,eadacheA stomach ache o BehaviorA personality change o Confusion o &'eatiness o Fatigue o &leepiness .reatment of Lo' Blood &ugar o 3 to 6 glucose ta)lets o 8A7 cup Buice o 8A7 cup regular soda o Carton of mil( o &mall tu)e of glucose gel or ca(e icing o #echec( )lood sugar in 8F-89 minutes1 -f still lo' or if symptoms do not su)side repeat treatment Best treatment is a fast acting sugar! give 89g and rechec( in 89 minutes (repeat until )lood sugars are in the JFs ,ypoglycemia4 Follo' - =p .reatment o 7 - 6 cheese or peanut )utter crac(ers o 8A7 cup mil( and a graham crac(er s0uare -f unconscious! having a seizure or una)le to s'allo'! give glucagon o "lace student on hisAher side in case of vomiting (&/ of glucagon o Call K88 and notify parents Continuous Glucose 1onitors Catheter inserted into the fatty tissue! similar to an insulin pump site .'o )rands availa)le4 .he 2uardian #ealtime made )y $inimed! the 5e<com &even "lus

#e0uire cali)ration )y finger stic( Can recognize trends in Blood 2lucose Blood 2lucose level should )e confirmed )y finger stic( )efore treatment is given (lo' or high $ay help identify highs and lo's at times finger stic(s not normally done (and 'hile sleeping ,elpfulness of C2$s not esta)lished at this time "ro)a)ly re0uire more finger stic(s than standard regimen Coverage )y insurance is not 8FFI! e<pense can )e su)stantial

Nutrition Goals of C!ildren #it! Diabetes *eep )lood sugars in target range "rovide calories and energy for gro'th and development "romote good health Car)ohydrates o Car)ohydrates have the most effect on )lood sugar levels o Car)ohydrate foods include Fruit $il( &tarches - )read! pasta! cereals! starchy vegeta)les o Car)ohydrate Counting One type of meal planning that is most often used 89 grams of car)ohydrate Q 8 car)ohydrate choice A specific amount of car)ohydrate at each meal and snac( is part of the meal plan -dentify individual that 'ill )e responsi)le for ma(ing sure younger child is eating meals and snac(s &ample $eal o Calculate the rapid-acting insulin dose for the follo'ing meal )ased on a dose of 8 unit insulin for 89gm car) plus a correction of 8 unit for every 9F mgAdL B2 is over 89F (&u)tract 8 unit of insulin for B2 ? JF o 8 slice thin crust pizza Q 77gm car) o _ cup tossed salad Q 3gm car) o 7 .B&" #anch dressing Q 7gm car) o U cup peaches (light syrup Q 8>gm car) o >oz 8I mil( Q 87gm car) o :otal gram of carb in sam+le meal8 HI o HI $ 1H 8 3BJ units o 9G8 F3D o Correction K F units :otal dose 8 HBJ units3 round to D units Cancer L Questions Case &tudy Z 8 o $ollys ,g) and ,ct suggest 'hatN Anemia o :hat tests 'ill )e done to confirm the diagnosisN Lum)ar puncture! )one marro' )iopsy! CBC! la) 'or( o $ollys neutrophil count of 78I is indicative ofN A1 Neutro+enia B1 $ego)lastic anemia C1 2ranulocytopenia 51 Leu(ocytosis 5!ite 9lood Cell Count and Differential .otal :BCs < 8FFFAmm`(al Ne')orn4 K-3F

Child ?7 years4 ;17-8J Child S7 yrsAAdult 9-8F 5ifferential I o Neutrophils 99-JF o Lymphocytes 7F-6F o $onocytes 7-> o /osinophil 8-6 o Basophils F19-81F 79-8FF

A)solute (per mm` 79FF->FFF 8FFF-6FFF 8FF-JFF 9F-9FF

Critical ,alues :BCs ?79FF or S 3F!FFFA mm` %eu/ocytosis + :BC b 8F!FFFAmm` + =sually indicates infection! inflammation! tissue necrosis or leu(emic neoplasia %eu/o+enia 7 :BC ? 6!FFFAmm` - occurs in many forms of )one marro' failure bsolute Neutro+!il Count ' NC) 5etermine the total percentage of Neutrophils + O"olysP or O&egsP and OBandsP o :est Question c$ultiply :hite Blood Cell (:BC Countd < cI of Neutrophilsd o /<ample o :BC Q 7FFF o Neutrophils Q 8FI o Non-segmented Neutrophils (Bands Q JI &tep One 8FI G JI Q 8JI &tep .'o F18J < 7FFF Q 36F $ollys4 o :BC Q ;9FF o Neutrophil Count Q 78I o ANC Q F178 < ;9FF Q 83;9 NC M HNN$mmO+atient is at ris/ for. o Over'helming infection (&epsis o 2eneral $alaise o 5ehydration o &eizures + Coung infants and children o -nvasion of organisms producing secondary infections $ollys platelet count of 3F!FFF is responsi)le for 'hich of the follo'ingN o A1 "allor o 9B "etec!iae o CB 9ruises o 51 [oint "ain $ollys serum =ric Acid of ; mg indicates 'hatN o A1 -mmature cells in the urine o B1 A normal level o C1 A)normal renal function o DB Cell 9rea/do#n :hat precautions should )e considered to reduce $ollys suscepti)ility to infectionN o A1 "rotective -solation o 9B %ongAterm +ro+!ylactic antibiotic t!era+y o C1 $aintained $yelosuppression o DB deCuate Nutrition

.he treatment of $ollys disease involves the com)ined use of chemotherapy and irradiation1 :hat side effects can $olly e<perience from these forms of therapyN o B lo+ecia o 9B Diarr!ea o CB Dry S/in o DB 6lceration of 1ucosa :hy is the aim of treatment for $olly directed to'ard preventing a relapseN o Cancer is )ac(! you have to change your treatment approach! usually comes )ac( stronger! less of a chance to get them )ac( into remission 5escri)e the follo'ing components of the treatment regime for ALL o #emission -nduction o -ntensificationAConsolidation o CN& "rophylactic .herapy4 given intrathecally (into the spinal column o $aintenance :hat is complete remission determined )yN o A)sence of clinical signs or symptoms o ? 9I Blast cells in the )one marro' .he follo'ing drugs are most commonly given during the -nduction "hase of the ALL treatment1 *no' these drugs and their most common side effects o %incristine4 may cause neuroto<icity! may see foot drop o Corticosteroids + "rednisone or 5e<amethasone4 tastes )ad! do not che'! foodAsalt cravings o L-asparginase4 typically given -$! 'atch for severe anaphyla<is o 5o<oru)icin may or may not )e used

"ediatric (ncological Emergencies :hat life-threatening condition may develop in $olly prior to the initiation of therapy or right after the initial treatment )eginsN :umor %ysis Syndrome o :hat are the hallmar( meta)olic a)normalities of .umor Lysis &yndromeN ,yperuricemia! ,ypocalcemia! ,yperphosphatmeia! ,yper(alemia and =remia .he crystallization of uric acid in the renal tu)ules can lead to acute renal failure and death o ,ydration! hydration! hydration )Ac of the (idney ris(s associated 'ith the drugs! need to flush them out of the (idneys o .reatment of Acute .umor Lysis &yndrome /arly identification of patients at ris( &erum Chemistries and =rine p, fre0uently &trict - X O Aggressive -% fluids $edications li(e Allopurinol to decrease uric acid production and promote e<cretion of )yproducts of purine meta)olism1 %incristine and "rednisone 'ill )e continued during the maintenance phase of therapy1 .he follo'ing drugs are also given! different medications affect cells at different points of the cell cycle 5aily Oral ;-$ercaptopurine $ethotre<ate Allopurinol Bactrim Care "lan for the Child 'ith Cancer pgs 86JF-86J7 Nursing Diagnoses #is( for -nBury rAt chemotherapy treatment o "rojected (utcome +

Child 'ill e<hi)it no complications of chemotherapy Child 'ill receive prompt! appropriate treatment of complications ,igh #is( for4 o -nfection related to depressed )ody defenses "rojected (utcome Child 'ill not come in contact 'ith infected persons 5oes not e<hi)it signs of infection o -nBury (,emorrhage and ,emorrhagic Cystitis related to interference in cell proliferation "rojected (utcome Child e<hi)its no evidence of )leeding :ill void 'ithout discomfort1 No hematuria 'ill )e present Altered Nutrition4 Less than )ody re0uirements related to loss of appetite o "rojected (utcome + Child 'ill receive ade0uate nutrition -mpaired s(in integrity related to administration of chemotherapeutic agents! radiotherapy and immo)ility o "rojected (utcomes4 &(in remains clean and intact Child and family 'ill comply 'ith suggestions -mpaired physical mo)ility related to neuromuscular impairment (neuropathy o "rojected (utcome + Child am)ulates 'ithout incident or difficulty Body -mage distur)ance related to loss of hair! moon face! de)ilitation o "rojected (utcomes +Child 'ill e<hi)it positive coping s(ills "ain related to diagnosis! treatment! physiological effects of neoplasia o "rojected (utcome + Child 'ill e<perience no pain or reduction of pain to level accepta)le to child Fear related to diagnostic tests! procedures and treatments o "rojected (utcome + Child 'ill have reduced fear rAt diagnostic procedures and treatment -nterrupted family processes related to having a child 'ith a life-threatening disease o "roBected Outcome + Child and family 'ill demonstrate understanding of the disease and treatment

5ilm?s :umor 'Ne+!roblastoma) 5efinition + $alignant neoplasms of the (idney that most often affects young children! often unilateral "ea( age of incidence is 3 U years >18A8 million Caucasian children ? 89 years of age /vidence of genetic inheritance + -s inherita)le in 89-7FI of cases o Autosomal dominant ($ode of inheritance in ? 7I 'ith varia)le penetrance and e<pressivity1 -ncrease incidence )et'een si)lings and identical t'ins Also Associated 'ith other Congenital Anomalies o Aniridia4 a)sence of the iris of the eye o ,emihypertrophy and genitourinary anomalies Clinical $anifestations o "ainless s'elling or mass 'ithin a)domen o ,ematuria o Anemia o <y+ertension 7 5!yP *idney tumor! renin angiotensin system is )eing affected o :eight Loss and Fever o $etastasis to lungs- 5yspnea! Cough! &OB and "ain in the Chest 5iagnostic Assessment o Y-ray + A)dominal =ltrasound o $#- + C. &can o Bone $arro' Aspirate o ,ematological studies

o =rinanalysis .umor ClassificationA&taging o Classification + #efers to )iological characteristics of the tumor o &taging refers to e<tent of disease at time of diagnosis .herapeutic $anagement o &urgery + "re and "ost-op o Chemotherapy o #adiation "reoperative Care for a Child 5iagnosed 'ith a :ilms .umor o "lace Sign o&er bed + N( N(: " %" :E 9D(1EN o Signs and Sym+toms of tumor ru+ture "ain + Acute and localized in a)domen ,emorrhage Cardiac -ncreased ,#! :idening "ulse "ressure! "allor A)domen Acute localization of pain! 5istention! 2uarding .ummy area ,emorrhage Neurological Changes in level of consciousness! -rrita)ility! #estlessness! 5isorientation o .a(e care in )athing and handling of child o O)tain necessary )lood 'or( o $onitor B" =se appropriate sized cuff $onitor =rine Output! 5aily :eight o Assess Child for ,.N Bounding pulses! -ncreasing irrita)ility and headaches! Changes in )ehavior! Flushing "ostoperative Care of the Child after a #esection a :ilms .umor o &ame as any child after a)dominal surgery $aintain -% Accurate -XO "ossi)le N2 + for 'hat purposeN "ain $anagement Fre0uent evaluation of %& especially B" "ulmonary hygiene o "repare for administration of chemotherapy and radiation therapy o Long .erm Child only has one (idney + &hould avoid contact sports "revent =.-s especially in little girls

(steosarcoma ; (steogenic Sarcoma 5efinition + Osseous )one tumor that arises in the mesenchyme1 -s the most common malignant )one tumor seen in childhood o &een primarily in times of )one gro'th spurts and in areas that demonstrate rapid gro'th + $ost common site is metaphysis + 9FI occur in femur o $etastasis most commonly occurs in the lungs )ut often to other )ones1 Lymphatic system and liver may also )e involved -ncidence o "ea( incidence )et'een 8F-79 years-of- age! "ea( ages 89-8K years-of-age o &e<es e0ually affected until pu)erty! then males increase in incidence over females 748 5iagnostic Assessment o ,istory and physical e<am

o Y-ray o Biopsy .herapeutic $anagement o Amputation o Lim) &alvage o Chemotherapy o "hantom Lim) "ain Nursing Care "lan for the Child 'ith a Bone .umor o Anticipatory grieving related to prospect of loss of lim) o -mpaired physical mo)ility related to amputation o 5istur)ed )ody image related to loss of lim) o -nterrupted family processes related to having a child 'ith a lifelong disa)ility and traumatic therapy

Cured &sB :ruly Cured Cured4 Cessation of .herapy! Continuous freedom from clinical and la) evidence of cancer! $inimal or no ris( of relapse .ruly Cured4 Free of disease! 5evelopmentally commiserate 'ith! :ell adBusted despite having had cancer 0enal. H Questions :!e C!ild #it! 0enal Dysfunction Assessment o ,ealth ,istory Neonate + ,< of poor feeding! F..! Fre0uent urination! Crying 'ith urination! 5ehydration! Convulsions! Fever Infant + &ame as neonate and 5iaper #ash! Foul-smelling =rine! &training 'ith =rination (lder C!ildA Anore<ia! %omiting! /<cessive .hirst! /nuresis! -ncontinence! Fre0uent =rination! 5ysuria! Bloody andAor Foul-smelling =rine! Fatigue! Fever! Costoverte)ral Angle (C%A .enderness! Flan( andAor Bac( "ain *amily <istory + #enal disease! ,ypertension

"hysical /<amination .he follo'ing 3 parameters are the most significant on-going assessments in children 'ith #enal Conditions4 5eig!t Accurate -XO Blood pressure A)normal #ate and 5epth of #espirations ,ypertension

Fever F.. &igns of Circulatory congestion A)dominal 5istention /arly signs of =remic /ncephalopathy &igns of Congenital Anomalies

%aboratory Studies and Diagnostic :ests o o o o o o o o o o =rinalysis =rine Culture and &ensitivity Blood =rea Nitrogen and Creatinine =ltrasonography %oiding Cystourethrogram (%C=2 -ntravenous "yelogram (-%" Cystoscopy Clean-catch is preferred =-)ag for collection from child &pecimen o)tained )y catheterization or suprapu)ic needle aspiration has more accurate results $ay )e necessary 'hen clean-catch cannot )e o)tained

6rinalysis o o o o o Color + "ale to Am)er Appearance + Clear to &lightly ,azy &p 2r1 81F89-81F79 (81FF8-81F8> ? 7 yrs p, + 619-> avg 9-; Chemical determinants

Negative for 2lucose! *etones! Blood! Biliru)in! Nitrate for Bacteria! and Leu(ocyte /sterase =ro)ilogen + F18-81F

$icroscopic Negative :BCs and #BCs Casts (Occasionally ,yaline Casts are seen Crystals ,yaline Casts are a mucoprotein secreted )y the renal tu)ule epithelial cells

Fe' /pithelial Cells

6rinary :ract Infections '6:Is) .erminology of -nfections o o o o =rethra + =retheritis Bladder + Cystitis =reters + =reteritis *idneys - "yelonephritis

Four 2oals of .reatment for =.-s o o o o /liminate Current -nfection -dentify Contri)uting Factors "revent &ystemic &pread- =rosepsis "reserve #enal function

"rimary Bacteria are /-coli and other 2ram (- organisms1 Other pathogens have )een (no'n to cause =.-s Contri)uting Factors o o =rinary &tasis =rinary #eflu<

o o o o o o o o o o

"oor "erineal ,ygiene Constipation "regnancy Non-circumcision- 5e)ata)le -nd'elling Catheter "lacement Antimicro)ial agents that alter flora of the uinary tract .ight clothes or diapers Bu))le )aths Local -nflammation + /<4 %aginitis &e<ual -ntercourse

"ea( Ages + 7-; years and se<ually active adolescents1 $uch higher incidence in females o At 'hat age do )oys have a higher incidence of =.-sN Ne')orns

Clinical $anifestations o o Ne')orns + ,yper or ,ypothermia or sepsis -nfants + Fever! :eight Loss! F..! %omiting! 5iarrhea + Characteristically Non-&pecific o A clue might )e persistent diaper rash or s0uirming in the infant and toddler

Older Children Lo'er =.-s + 5ysuria! Fre0uency! =rgency! Daytime Incontinence 'In a +ottyAtrained c!ild)3 foul-smelling urine! A)dominal pain and ,ematuria "yelonephritis + Fever! Chills! Flan( "ain! C%A tenderness

Adolescents + ,ave more specific clinical manifestations &ymptoms of Lo'er .ract -nfections + Fre0uency and painful urination of urine that may )e grossly )loody1 Fever usually not present &ymptom of =pper .ract -nfections + Fever! chills! flan( pain and lo'er tract symptoms that may appear 8-7 days after the =pper .ract &ymptoms

---Nursing lert. ny c!ild #!o ex!ibits t!e follo#ing s!ould be e&aluated for a 6:I. incontinence in a toiletA trained c!ild3 strongAsmelling urine3 freCuency or urgency 5iagnostic Findings o =rinalysis + $ay reveal hematuria! proteinuria! and polyuria1 =rine may )e foul-smelling and is cloudy 'ith possi)le strands of mucus Culture + #eveals gro'th of )acteria

Nursing 5iagnoses and Nursing -nterventions o -nfection and #is( for o "ain o "romote #est and Analgesics and Antipyretics $aintain &terile techni0ue during catheterization Administer medications

Altered "atterns of /limination Note &A& of Fre0uency! =rgency! Burning and C%A .enderness Nursing 5Y + cont11

#is( for Altered Body .emperature Antipyretics and Anti)iotics

o o o

"otential for Altered 2ro'th and 5evelopment "otential for Altered Family "rocesses *no'ledge 5eficit 2ood education on ho' to prevent future =.-s! Avoid -rritants + &uch as NNN &e<ually active adolescents should void right )efore and right after se<ual intercourse

=.- Colla)orative Care 5rug .herapy\Anti)iotics o o Anti)iotic selected on empiric therapy or results of sensitivity testing =ncomplicated cystitis\short-term course of anti)iotics

o o

Complicated =.-s\long-term treatment .rimethoprim-sulfametho<azole (.$"-&$Y or nitrofurantoin &ulfa4 used to treat empiric uncomplicated or initial -ne<pensive

o o o o

Amo<icillin Cephale<in 2entamycin! car)enicillinGG "yridium (O.C "yridium is O.C that provides soothing effect on urinary tract mucosa &tains urine reddish-orange that can )e mista(en for )lood and may stain underclothing /ffective in relieving discomfort

Com)ination agents used to relieve pain

=.- Colla)orative Care 5rug .herapy for #epeated =.-s o "rophylactic or suppressive anti)iotics o &uppressive therapy often effective on short-term )asis Limited )Ac of anti)iotic resistance ultimately leading to )rea(through infections

.$"-&$Y administered every day to prevent recurrence or single dose )efore events li(ely to cause =. .$"-&$Y ta(en )id

,esicoureteral 0eflux ',60) Congenital A)normalities cause "rimary #eflu< + =reters are not inserted normally into the Bladder &econdary #eflu< is caused )y -nfection and =reterovesicular [unction -ncompetency #A. /dema o $ay also )e #A. Neurogenic Bladder

%=# is 2raded according to the degree of #eflu< (--%

Clinical $anifestations o o o o 5ysuria =rinary Fre0uency! =rgency and ,esitancy =rinary #etention Cloudy! 5ar( or Blood .inged urine

5iagnostic Findings o o #BCs or "yuria noted in =rinanalysis -ntravenous "yelogram (-%" ! %oiding Cystourethrogram (%C=2 ! or Cystoscopy may reveal structural a)normalities

Nursing 5iagnoses o o o o o o o Altered urinary elimination =rinary #etention "ain "otential for -nfection "otential for Altered Family "rocesses *no'ledge 5eficit #is( for -nBury at &urgical &ite

.reatment o Non-surgical + 5eflu< -nBection - 2el used in endoscopic inBections + &urgeon inBects the gel around the ureter opening to create a valve function and to ma(e the )ac(flo' of urine into the (idneys more difficult &urgical + detach ureter and reinsert at correct angle1

Ne+!rotic Syndrome

A comple< of symptoms characterized )y "roteinuria! ,ypoal)uminemia! ,yperlipidemia! Altered -mmunity and /dema o "ulling proteins out of the lipids! you 'ill see 3rd spacing due to the changes in the pressure of the vasculature

/tiology is un(no'n in K9I of cases + $inimal Change Nephrotic &yndrome ($CN& accounts for e >FI of cases in children )et'een 7-; years of age o &econdary Nephrotic &yndrome usually occurs after glomerular damage of (no'n etiology4 &ystemic Lupus! 5ia)etes $ellitus or &ic(le Cell 5isease

"athogenesis is unclear1 &omeho' there is an increased permea)ility to protein! there is increased protein! particularly al)umin in the urine1 o o :hat causes the fluid shift from the intravascular space to the interstitial spaceN ,ypoal)uminemia decreases the Colloid Osmotic "ressure (CO" in the Capillaries as a result the ,ydrostatic "ressure e<ceeds the pull of CO" and fluid accumulates in the interstitial spaces and the )ody cavities + particularly the stomach (ascites :hat does this change in intravascular volume stimulateN #enin-angiotensin system and the secretion of antiduretic hormone and aldosterone1 .u)ular rea)sorption of &odium and :ater increases in an attempt to increase intravascular volume1

o o o

Clinical $anifestations-

o o o o o o o o o o o o

"erior)ital! pedal and scrotal edema that progresses to generalized edema :eight increase 5ecreased =rine Output "ossi)le "leural /ffusion "allor Anore<ia Fatigue A)dominal "ain 5iarrhea "erior)ital! gonadal! or L/ edema! 2eneralized /dema (may lead to #espiratory 5istress Blood pressure may )e normal or even slightly decreased $ay have -nfection due to Altered -mmunity

5iagnostic Findings o o =rinanalysis + $ar(ed "roteinuria! ,yaline Casts! Fe' #BCs and -ncreased &p 2r &erum "rotein Level is $ar(edly 5ecreased + /specially the Al)umin Level

Nursing 5Y o o o o o o o o #is( for -nfection Altered Nutrition4 Less that Body #e0uirements #is( for Fluid %olume 5eficit -mpaired .issue -ntegrity Activity -ntolerance Body -mage 5istur)ance Altered Family "rocesses Altered 2ro'th and 5evelopment

*no'ledge 5eficit

.reatment for Nephrotic &yndrome ($CN& 2eneral $easures o o o 5uring /dema "hase + Child limited to 0uiet activities 5uring #emission + Activity is not restricted Acute and recurrent infections are treated 'ith appropriate anti)iotics and efforts are made to minimize the ris( of infection

Corticosteroid .herapy o o o Corticosteroids are started as soon as the diagnosis has )een esta)lished + 7 mgA(g in divided B-5 doses .herapy occurs for 3 months Course of .herapy + =sually not immediate change + usually start to see changes due to decrease in urinary protein and diuresis 'ithin J-78 days

o o

Children 'ith $CN& typically relapse 8-3 timesAyear 0emember to educate +arents t!at steroids al#ays !a&e to be ta+ered 7 NE,E0 abru+tly sto++ed444

5iet o 5!en is salt restriction necessaryP o o o During +eriods of massi&e edema and #!ile on corticosteroid t!era+y

Is #ater restrictedP A Seldom but may be necessary during +eriods of se&ere edema Is a diet !ig! in +rotein beneficialP 7 :!is #ould be logical but is seldom beneficialB Does it alter t!e outcome of t!e diseaseP No it does not alter t!e outcome of t!e disease but +robably s!ould be restricted during +eriods of a@otemia and renal failure

cute Glomerulone+!ritis .ypes of 2lomerulonephritis o $ost are post-infectious + "neumococcal! Stre+tococcal or %iral

o o

$ay )e distinct entity or $ay )e a manifestation of a systemic disorder &L/ - Lupus &ic(le Cell 5isease Others

Clinical $anifestations o o o o o o o o o o o ,ypertension + 5ue to increased /CF "allor -rrita)ility Fatigue Lethargy "erior)ital and 2eneralized /dema :eight 2ain or Loss of appetite /lectrolyte -m)alance Oliguria and ,ematuria + ColaAcolored urine C%A .enderness Anore<ia

5iagnostic Findings o =rinanalysis o #BCs! Casts! :BCs and "rotein -ncreased amount of "rotein Q increase in severity of renal disease

&erum Chemistry /levated B=N! Creatinine! /&# and A&O (Anti-&treptolysin-O .iter 9est #ay to Diagnose is an S(

&erum Complement Level (C3 is decreased initially )ut returns to normal >-8F 'ee(s after onset glomerulonephritis

Nursing 5iagnoses o o o o o o Fluid %olume /<cess #is( for -nfection Altered Nutrition4 Less than Body #e0uirements 5iversion Activity 5eficit Altered Family "rocesses! *no'ledge 5eficit #is( for -mpaired &(in -ntegrity

cute "ostAstre+tococcal Glomerulone+!ritis ' "SG) Noninfectious renal disease (autoimmune Onset 9-87 days after other type of infection Often group A ]-hemolytic streptococci $ost common in children ;-J years of age o o =ncommon in children ? 7 years Can occur at any age

"rognosis o o o K9I rapid improvement to complete recovery 9-89I Chronic 2lomerulonephritis 8 I - -rreversi)le 5amage

Nursing $anagement of A"&2 o $anage /dema 5aily 'eights Accurate :eight 5aily A)dominal 2irth

Nutrition Lo' &odium + $oderate restriction 'ith ,.N or /dema Lo' to $oderate "rotein "otassium containing foods are restricted during the period of oliguria + :hat fruits are higher in potassiumN &tra')erries! (i'i! )ananas! melon

&uscepti)ility to infections Bed #est is not necessary + $ost children 'ill restrict activity due to malaise (they feel crummy

<y+os+adias .he =rethral opening is located )elo' the glans penis or any'here along the ventral surface of the penile shaft -ncidence 849FF )irths1 Can also )e associated 'ith undescended testes and inguinal hernias "athology results from failure of the urethral folds to fuse completely over the ureteral groove Clinical $anifestations o 5efect should )e evident at )irth

Nursing 5iagnoses o o o o Body -mage 5istur)ance Altered =rinary /limination "ain ("ost-operatively #is( for -nfection ("ost-operatively

"ost-op care for ,ypospadius or /pispadius o Care of the ind'elling catheter o o o No )aths until catheter is removed1 -nstruct to gently cleanse around tip of penis and catheter

/ncourage li0uids Analgesia as needed .iming of surgical intervention for hypospadias

o o o o

"rinciple o)Bectives4 -/nhance childs a)ility to void in the standing position --mprove the appearance of the genitalia for psychological reasons -"reserve a se<ually ade0uate organ

1obility. 1F Questions Different *orms of c!ie&ing Immobili@ation Casts .raction &plints /<ternal Fi<ators o Assessing for signs of infection at the pin site! since the pins are a direct access root for developing an infection leading to osteomyelitis Am)ulatory 5evices Neuro&ascular ssessment A H "?s o "ain o "allor o "ulselessness o "arest!esia o "aralysis o Also pay attention to color! temp! sensation! motion! pain! pulse! capillary refill and edema Nursing Care for t!e Immobili@ed C!ild

Alteration -n Comfort

o Administrations of "roper Analgesia! pain relief A.C! dont 'ait for them to as( for it@ o "roper Alignment of .raction o "roper "lacement of "illo's Alteration in &(in -ntegrity o Change position if possi)le o =se /gg crate $attress or &heeps(in on Bed "otential for -nfection o Cast Care4 pedaling the cast 'A tape to smooth out any rough edges around the cast o "in Care o :ound Care "romote Nutrition o Colla)orate 'ith "arents and 5ietician to "lan Nutritious $eals and &nac(s "romote Normal /limination o -ncrease Fluid -nta(e o "rovide ,igh Fi)er 5iet o =se &tool &ofteners Appropriately o "rovide "rivacy 5uring .ime of Bedpan =se "revent $uscle Atrophy and -mpaired $o)iltiy o "revent Contractures o Colla)orate 'ith "hysical .herapy o "repare Child and "arents for 5isuse Atrophy "romote 2ro'th and 5evelopment o =se Age Appropriate /<planations o Normalize the Childs /nvironment as much as possi)le o /ncourage &i)lings and "eers to %isit o "rovide Age Appropriate 2ames o Colla)orate 'ith "arents and &chool to "rovide .utoring Nursing 5iagnoses for the Child 'ho is -mmo)ilized o -mpaired physical mo)ility rAt mechanical restrictions and physical disa)ilty o #is( for impaired s(in integrity rAt to immo)ility andAor therapeutic appliances o #is( for inBury rAt impaired mo)ility o 5iversional activity deficit rAt impaired mo)ility! musculos(eletal impairment! confinement to hospital or home o #is( for altered family processes rAt a child 'ith a disa)ility or illness

*ractures /tiology o ,ave to differentiate )et'een intentional and non-intentional inBury o .rauma + Leading cause of death in children S 8 yr of age Certain developmental characteristics of children at various ages ma(e them more suscepti)le to inBury -nfants + totally dependent on adults for security! head is heavy 'A little control! little capa)ility to )alance .oddlers + no fear! 'al(ing! e<ploring! no such thing as child proof &chool-age and adolescents + )elief that nothing )ad can happen to them Clinical $anifestations o &'elling o "ain o 5iminished =se 5iagnostic /valuation -:hat .ests 'ill )e doneN Y-ray .herapeutic $anagement o -mmo)ilizing! internal fi<ation! depends on degree of inBury

2oals of Fracture $anagement o #eduction + #egain Alignment and Length o -mmo)ilization + #etain Alignment and Length #estore Function "revent Further -nBury Criteria for 5etermining =se of #eduction $ethod for Fractures o Age of Child o 5egree of 5isplacement o Amount of Overriding o 5egree of /dema o Condition of &(in and &oft .issue o &ensation and Circulation 5istal to the Fracture /mergency .reatment of Fractures o Assess 9 "s o 5etermine mechanism of action o $ove inBured part as little as possi)le o Cover open 'ounds 'A sterile or clean dressing o -mmo)ilize lim) and reassess neuro status o /levate! apply cold! call emergency services for transport to hospital #apidity of Bone ,ealing is -nversely #elated to the Childs Age o .rue or False4 False .he older the child the more 0uic(ly their )one 'ill heal .he younger the child! the more 0uic(ly their )one 'ill heal@@@ Cast Care o $ost casts are made out of synthetic material o Advantages 5ries 'ithin minutes Light :eight $ay get 'et 'ith permission of practitioner1 Clean 'ith soap and 'ater1 5ry 'ith )lo' dryer set on C((%3 don?t #ant to burn t!e s/in o :hen handling dont use fingertips + this may cause indentations o Once cast is dry + Ohot spotsP indicate 'hatN o :hat is the chief concern during the first fe' hours after cast applicationN Neuro-circ chec( "ay attention to pain! education a)out the cast and signs of infection! 'hat (ind of follo'-up is needed

.raction 1anual + .raction applied to the )ody part )y the hand placed distally to the fracture1 Nurses typically do this during the Application of a cast S/in :raction + "ull applied to the s(in surfaces and indirectly to the s(eletal surfaces1 "ulling mechanism is applied to the s(in 'ith adhesive material or an elastic )andage1 Not to )e used if there is altered s(in integrity1 Limited 'eight allo'ed1 o .ypes of &(in .raction o Buc( e<tension + lo'er e<tremity o 5unlop + 7 lines pull on arm o #ussell + 7 lines pull on lo'er e<tremity o Bryant + lo'er e<tremities fle<ed at KF degree angle + #arely used S/eletal + "ull directly applied to the s(eletal structure )y a pin! 'ire! tongs into or through the diameter of the )one distal to the fracture1 =sed 'hen significant traction is re0uired1 .he placement of the pin or 'ire puts stress on the )one! not the surrounding tissue o KF degree fle<ion

5unlop traction can )e used as s(eletal

De&elo+mental Dys+lasia of t!e <i+ 'DD<) "athophysiology o Cause is un(no'n1 Certain factors + 6 Fs 2ender (*emale ! Birth order (*irst ! *amily history! -ntrauterine position (*eet first (Breech 5elivery type and postnatal positioning are (no'n to increase the ris( Configuration and relationship of structures

Clinical $anifestations o -nfants =ne0ual s(in folds on the thighs and )uttoc(s Limitation of a)duction on the affected side =ne0ual (nee height or leg length o Older Children Limp and .rendelen)urgs 2ait (pelvis tips for'ard on normal side rather then up'ard 9arlo# 1aneu&er + -f the hip is dislocated! i1e11! the hip can )e popped out of the soc(et + the test is considered positive (rtolani 1aneu&er + "ositive sign is distinctive Oclun(P 'hich can )e heard and felt as the femoral head relocates anteriorly into the aceta)ulum

---Nursing lert. the Barlo' and Ortolani tests should )e performed only )y an e<perience clinician! if performed too vigorously in the first 7 days of life persistent dislocation could occur 5iagnosis of 55, o ? 3 months of age + =ltrasound + ,igh incidence of False "ositives o S 3 months of age + Y-#ay + Ossification of the femoral head occurs )et'een 3-; months of age "avli( ,arness o 5ynamic splinting 'ith the pro<imal femur centered in the aceta)ulum in an attitude of fle<ion o 1a/e sure infant doesn?t #ear !arness #it!out 6nders!irt and Dia+er bet#een s/in and stra+s o =sually used for 3-9 months o f straps every 8-7 'ee(s due to infants rapid gro'th

(steomyelitis /tiology

o Ac0uired from /<ogenous and ,ematogeneous &ources o $ost Common OrganismNN "athophysiology o -nfective em)oli travel from the focus of infection to the small end arteries in the )one metaphysis + 5oes not spread to the epiphysis (,as o'n )lood supply o -nfectious process leads to local )one destruction and a)scess formation o A)scess and necrotic de)ris e<erts pressure 'ithin the rigid )one o -nfection spreads )eneath the periosteum Clinical $anifestations o Fever o Failure to use affected e<tremity o /rythema! heat and s'elling over area of infection o .enderness in affected area o 5ecreased #O$ in the Boints of the affected e<tremity La)oratory Findings o :hat )lood 'or( 'ill )e ordered and 'hat 'ill it sho'N o /levated &ed rate and elevated /&# Nursing $anagement o Aggressive Anti)iotic treatment for at least 6 'ee(s o :hat anti)iotics 'ill )e ordered for &taph AureusN o :hat a)out if it is $ethicillin #esistant &taph Aureus ($#&A N %ancomycin Benadryl or .ylenol given prior to vanc! administered slo'ly to prevent red mans syndrome

Scoliosis /tiology o -n most cases cause is un(no'n + Can )e associated 'ith many different conditions o Comple< &pinal 5eformity in 3 "lanes Lateral Curvature &pinal rotation causing ri) asymmetry .horacic hypo(yphosis Clinical $anifestations o -diopathic &coliosis curvature typically not evident )efore 8F years of age 5iagnostic /valuation o Y-rays of child in standing position and then use Co)) techni0ues for curve magnitude .herapeutic $anagement o Bracing and /<ercise (-n and Out of Brace - Not effective for curvature S 6FT Boston Brace or :ilmington + =sed more often for &coliosis $il'au(ee Brace + =sed more often for *yphosis .horocolum)osacral Orthosis (.L&O .he type of )race and the amount of 'earing time (8;-73 hoursAday is dependent on the nature of the curve! the age of the child and any underlying conditions o &urgical #epair of &coliosis #ealignment and &traightening 'ith -nternal Fi<ation :hat are the (ey areas of nursing focus post-operativelyN "ain! infection! nerve-circ chec(s! respiratory! fluid and electrolytes Cerebral "alsy 'C") /tiology o Any perinatal or neonatal )rain lesion or )rain mal-development! regardless of the cause! may )e lin(ed to as many as >FI of the total cases of C" o "renatalApostnatal -nfection

o "renatalApostnatal hypo<iaA asphy<ia o Often no identifia)le immediate cause o "reterm )irth of /LB: and %LB: is single most important determinant of C" o Ano<ia\most common cause of )rain damage whenever it occurs .ypes of C" o S+astic. most common clinical type "resents as hypotonia most often 'A poor control of posture! )alance! or coordinated movement! primitive refle<es! (G Ba)ins(i! development of contractures eventually .ypes of &pastic C"4 Muadriparesis (tetraparesis o Four e<tremities involvedAsevere disa)ility o &peech and s'allo'ing difficulties o .ongue protrusion (incomplete o La)ile emotions in some patients 5iplegia4 )oth arms or )oth legs $onoplegia4 only one e<tremity .riplegia4 3 e<tremities ,emiplegia4 motor dysfunction on one side of )ody o Dys/inetic4 Athetoid4 chorea (involuntary! Ber(y movement that 'orsens 'A stress ! slo'! 'ormli(e movements of e<tremities! trun(! face! tongue 5ystonic4 slo'! t'isting movements of trun( or e<tremities! a)normal posture -nvolvement of pharyngeal! laryngeal and oral muscles causing drooling! dysarthria (speech pro)lems! esp 'A articulation o taxic. rapid repetitive movementsR 'ide gait! una)le to hold onto o)Bects o 1ixed. com)ination of spastic and athetosis "ossi)le $otor &igns of C" o "oor head control after age 3- 6 months o &tiff or rigid lim)s o Arching )ac(Apushing a'ay o Floppy tone o =na)le to sit 'ithout support at age > months o Clenched fists after age 3 months "ossi)le Behavioral &igns of C" o /<cessive irrita)ility o No smiling )y age 3 months o Feeding difficulties "ersistent tongue thrusting Fre0uent gagging or cho(ing 'ith feeds Cere)ral "alsy and -M o :ide variation o 9FI-;FI of C" patients have normal -M o 5ifficult to assess o #igid! atonic! and 0uadriparesis C" have highest incidence of profound impairment 2oals of .herapy for C" o /sta)lish locomotion! communication! and self-help o 2ain optimum integration of motor functions o Correct associated defects as early and effectively as possi)le o "rovide educational opportunities o "romote socialization e<periences "harmacologic to 5ecrease &pasticity in C" o Botulinum to<in type A (Boto<

Baclofen Oral -mplanted pump for intrathecal administration o 5antrolene sodium (5antrium o 5iazepam (%alium Associated 5isa)ilities and "ro)lems in Children 'ith C" o -ntellectual -mpairment o Attention 5eficitA,yperactivity 5isorder (A5,5 o &eizures o 5rooling o 5ifficulty Feeding + :hich can lead to Aspiration o -mpaired 2as /<change o Orthopedic complications o %isual (Nystagmus and am)lyopia and ,earing Loss o Constipation o 5ental pro)lems + Caries! $alocclusion! 2ingivitis Nursing $anagement of the Child 'ith C" o ,olistic approach o -nterdisciplinary :hat other disciplines 'ould )e involved in this childs careNN o

<y+otonia OFloppy infant syndromeP o $uscles feel atrophied! mar(ed head lag! often have poor suc( 5iagnostic evaluation4 C* level for specific s(eletal muscle! 5NA analysis! Nerve conduction and /$2 studies! muscle )iopsy Nursing $anagement4 identify any &A& that suggest hypotonia Infantile S+inal 1uscular tro+!y 'S1 :y+e 1) Also called :erdnig-,offmann disease Autosomal recessive trait $ost common paralytic form of floppy infant syndrome (congenital hypotonia -nfantile &$A\Characteristics o "rogressive 'ea(ness and 'asting of s(eletal muscles o 5egeneration occurs in spinal cord and )rainstem! resulting in atrophy of s(eletal muscles o Age of onset varia)leR earlier onset has poorest prognosis -ntermediate &$A (.ype 7 o $anifests )et'een 7 and 87 months of age o First! 'ea(ness of arms and legsR later! generalized 'ea(ness o "rominent pectus e<cavatum (concave chest o $ovements a)sent during rela<ationAsleep o Life span J months to J years 1uscular Dystro+!y "seudohypertrophic (5uchene $uscular 5ystrophy (5$5 - the most common + An Y-Lin(ed -nheritance "attern + A)out 8A3 of all cases represent ne' mutations $utation of the gene that encodes dystrophin + "rotein product in s(eletal muscle 5$5 Clinical $anifestations o :hen does muscle 'ea(ness )egin to demonstrate itselfN 3! 6! 9 yAo o "elvic :ea(ness :addling gait + lordosis + fall fre0uently

2o'ers &ign4 using their arms to help 'al( them up to a standing position! late sign@ o $uscle Atrophy + Calf muscle hypertrophies + Fatty infiltrates o Occasional $ental 5eficiency o -ncreasing #espiratory 5istress Nursing $anagements o 2enetic Counseling + "renatal .esting ("olymere Chain #eaction Activity o /ncourage /<ercise + 5elays 'heelchair confinement o -nterdisciplinary Consultation

:ali+es ECuino&arus ; Clubfoot Common foot malformations4 inversion! eversion! plantar fle<ion (toes lo'er than heel or dorsifle<ion (toes are higher than the heel "athophysiology + =n(no'n + .here is a strong familial tendency .herapeutic $anagement + -nvolves 3 &tages o Correction of the 5eformity o $aintenance of the Correction o Follo'-up to avoid reoccurrence &erial Casting )egins shortly after )irth1 o "arent education4 child needs to )e )rought )ac( for fre0uent recasting to correct the clu) foot $ore severe cases 'ill re0uire surgery After correction is achieved the infant may 'ear a splint to prevent reoccurrence1 ,igh occurrence of clu) foot 'ith children 'ho have spina )ifida (steogenesis Im+erfecta '(I) At least 9 different types of O lso /no#n as brittle bone disease3 often can be mista/en for c!ild abuse Clinical *eatures include &arying degrees of. o 9one *ragility3 Deformity and *racture o 9lue Sclerae o <earing %oss o Dentinogenesis Im+erfecta In!eritance "attern o 1ajority of cases 7 autosomal dominant3 alt!oug! t!e most se&ere form demonstrates autosomal recessi&e Classification of O- + 2raded --% .herapeutic $anagement + $ainly supportive

4 General "eds Questions from <ESI 0e&ie# 2ro'th and 5evelopment 81 :hen does the )irth 'eight dou)leN 6 months 71 :hen does the )irth length dou)leN 6 years 31 :hen does a child achieve 9FI of adult heightN 7 years 61 At 'hat age does a child spea( in 7-3 'ord sentencesN 7 years 91 :hen does a child thro' overhandN 8> months

;1 :hen does a child use scissorsN 6 years #emem)er that girls start their gro'th spurts earlier than )oys As early as 8F years of age for girls J1 :hen does a child tie his or her shoesN 9 years #emem)er /ri(sons &tages of 5evelopment -nfant4 trust vs1 mistrust .oddler4 autonomy vs1 dou)t and shame "reschool4 initiative vs1 guilt &chool Age4 industry vs1 inferiority Adolescent4 identity vs1 role confusion Accidents are a maBor cause of death in children and adolescents + /ducate parents on developmentally appropriate safety and accident +prevention techni0ues "ain Assessment and $anagement =ntreated pain may lead to complications (delayed recovery! alterations in sleep and nutrition Assess pain )ased on4 %er)al report )y child O)serve for non-ver)al signs of pain (grimacing! irrita)ility! restlessness -nclude parents in assessment O)serve for %& changes (increased ,#! ##! diaphoresis! decreased O7 sat #evie' different pain scales FAC/&! num)er scale FLACC4 faces! legs! activity! cry! consola)ility $a(e sure scale is developmentally appropriate Consider pharmacological as 'ell as non-pharmacological interventions

Child ,ealth "romotion Assess immunization status at each visit Be a'are of 'hen children should not receive immunizations -mmunocompromised children should not receive live vaccines ,igh fever 'ill prevent children from getting vaccinations Be a'are that $$# ($easles! $umps and #u)ella is a live vaccine and so is %aricella (Chic(en "o< ,ealth "romotion /ducate a)out 'hat symptoms after immunization administration they should report Call the doctor is there is an allergic reaction or really high fever (S 8F7 5.a" causes a hard red )ump! that is normal Be a'are that 2erman measles (#u)ella pose a serious threat to the childs un)orn si)lingN $other cannot receive the vaccine during pregnancy Nutritional Assessment #evie' -ron 5eficiency Anemia Assess for &A&4 pale conBunctiva! pale s(in color! )rittle! ridged or spoon shaped nails! thyroid edema! atrophy of papillae on tongue At 'hat age are solids ()a)y food introducedN 6-; months Child A)use "hysical a)use and neglect /motional a)use and neglect Lead "oisoning *no' a)out the chelation therapy 5o not administer if child is allergic to peanuts #otate sites of inBection if given -$ 5o not administer -ron due to interactions For acute lead poisoning administer cleansing enemas :hat are the clinical manifestations if the child has a high lead level

neuro! seizure! developmental delay! )lindness! convulsions! coma! death #efer to parents to "oison Control &yrup of -pecac no longer recommended

Study Questions

81 .he nurse is caring for a toddler 'ho is not toilet-trained1 .he doctor has ordered inta(e and output measurement1 .he nurse 'ill most accurately measure the urine )y4 A1 B1 /stimating output as small! medium! or large and recording on the childs chart :eighing each 'et diaper and recording the amount as the 'eight of the diaper

CB Subtract t!e amount of a dry dia+er from a #et dia+er and record t!is amount 51 5etermine urine output )y the num)er of diaper changes in each 76-hour period

71 .he nurse is teaching the parents of preschooler information a)out urinary tract infection and means of reducing their recurrence1 :hich statement )y the parents indicates the need for additional teachingN A1 O- should try to get her to drin( a lot of 'ater1P B1 O- 'ill )uy her cotton under'ear a little large1P CB QSoa/ing in a bubble bat! #ill reduce meatal irritationBR 51 O-f - notice her starting to 'et the )ed again! - need to have her chec(ed for another urinary tract infection1P

31A girl 9 U has )een sent to the school nurse for urinary incontinence three times in the last 7 days1 .he nurse should recommend to her parent that the first action is to have the child evaluated for 'hich of the follo'ingN A1 &chool pho)ia B1 2lomerulonephritis CB 6rinary :ract Infection '6:I) 51 A5,5

61.he most useful measure of fluid )alance in a child 'ith acute glomerulonephritis is4

A1 "roteinuria 9B Daily 5eig!t C1 &pecific 2ravity 51 -nta(e and Output

91 A child has )een admitted to the nursing unit 'ith acute glomerulonephritis1 .he test that 'ould confirm this diagnosis is4 B ntistre+tolysinA( ' S() titer B1 =rinalysis C1 Blood Cultures 51 :hite Blood Cell (:BC count

;1.he doctor orders a clean-catch urine specimen on an infant 'ho is not toilet collecting this urine 'ould )e to4 A1 "erform a straight catheterization 9B ++ly a urine collection bag C1 =se diaper analysis 51 "lace an ind'elling foley catheter

trained1 .he )est means of

J1 A teenage child is )eing treated for chronic renal failure 'ith a creatinine clearance of 37mlsAmin1 .he nurse 'ould ensure that the child follo's a4 A1 ,igh-sodium diet 9B "rotein diet S 0D le&els C1 Lo'-sodium diet 51 #estricted potassium diet >1 .he most important nursing activity in managing a young child diagnosed 'ith urinary tract infection (=.- is to4 A1 "rovide ade0uate nutrition to prevent dehydration

9B "re&ent enuresis C1 Administer ordered anti)iotics on schedule 51 #estrict fluids to provide (idney rest

K1 :hen a child is receiving prednisone for treatment of nephrotic syndrome! it is important for the nurse to assess the child for4 B Infection B1 =rinary retention C1 /asy )ruising 51 ,ypoglycemia

8F1 A child has recurrentAchronic nephrotic syndrome1 .he mother reports to the nurse that she is over'helmed 'ith the care of her child1 After the nurse discusses options 'ith the mother! 'hich statement )y the mother indicates continued coping difficultiesN A O- Boined a support group li(e you suggested1 - hope it does some good1P B1 O-m going to as( my mother-in-la' to come on regular )asis to allo' me an afternoon out1P C1 O$y hus)and has agreed to help me manage my sons medication1P DB Q5e?re going to s/i+ !is dietary restrictions one day a #ee/ to allo# us bot! some relaxationBR

881 :hich of the follo'ing la)oratory findings! in conBuction 'ith the presenting symptoms! indicates $CN&N A1 Lo' &pecific gravity B1 5ecreased ,g) C1 Normal "latelet Ct1 DB Decreased Serum lbumin

871 .he nurse is teaching a child e<periencing severe edema associated 'ith $CN& a)out his diet1 .he nurse 'ould discuss 'hich of the follo'ingN A1 #egular 5iet B1 -ncreased "rotein CB *luid 0estrictions 51 5ecreased Calories

831 :hich of the follo'ing is the most common cause of Acute #enal Failure (A#F in childrenN A1 "yelonephritis B1 .u)ular 5estruction CB Se&ere De!ydration 51 =pper tract o)struction

861 A child is admitted in A#F1 .herapeutic management to rapidly provo(e a flo' of urine includes the administration of 'hich of the follo'ingN A1 "ropanolol B1 Calcium 2luconate CB 1annitol and$or *urosemide 51 &odium! Chloride and "otassium

81 A ; year-old has a cast applied for a fractured radius1 .he nurse completes an orthopedic assessment on this child1 :hich of the follo'ing symptoms re0uires immediate attention and should )e reported to the $5N A1 Capillary refill of 6 seconds in the affected foot B1 /dema in the affected hands that improves 'ith elevation CB :!e c!ild describing feeling of t!e affected !and being Qaslee+ and tinglingBR 51 &(in surrounding the cast is 'arm and dry 71 :hich of the follo'ing nursing care measures ta(es highest priority in caring for a child in s(eletal tractionN A1 Assessing )o'els sounds every shift B1 ssessing tem+erature e&ery 4 !ours C1 "roviding ade0uate nutrition 51 "roviding Age-appropriate activities 31 :hich of the follo'ing statements made )uy the caregiver of a child )eing discharged 'ith osteomyelitis re0uires further teaching )y the nurseN

A1 B1 C1 51

QI can sto+ t!e antibiotics #!en I see t!at my c!ild is feeling betterBR O:e 'ill ma(e sure that our child has plenty of calcium and protein1P O - 'ill loo( at the -% site for signs of infection a couple of times a day1P O$y child 'ont ta(e physical education at school until allo'ed )y the doctor1

61 :hich of the follo'ing statements made )y a parent of a child 'ith Osteogenis -mperfecta (O1-1 needs clarification )y the nurseN A1 O$y child may )e a)le to participate in sports1P B1 O.here are no medications availa)le to help this disease process1P C1 O&urgery may )e needed to place rods in the )one for sta)ility1P 51 Q1y c!ild #ill need to be !ome sc!ooled to +rotect !im from injuryBR 91 :hich of the follo'ing interventions is inappropriate to incorporate into the plan of care for a child 'ith 5uchene $uscular 5ystrophy hospitalized for a respiratory infectionN A1 "hysical therapy B1 Aggressive anti)iotic therapy C1 "assive #O$ e<ercises DB Strict 9ed rest ;1 A 86-year-old has )een fitted 'ith a $il'au(ee )race1 :hich of the follo'ing (include all that apply should the nurse include in teaching a)out this )raceN A1 .he )race should only )e 'orn 'hen the adolescent is sleeping or in the recum)ent position B1 .he )race should )e 'orn ne<t to the s(in CB Exercises to increase +el&ic tilt s!ould be done se&eral times +er day #!ile in t!e brace DB :!e adolescent s!ould ex+erience no +ain as a result of #earing t!e braceB J1 An infant is placed in a "avli( ,arness for 5evelopmental 5ysplasia of the ,ip1 :hich of the follo'ing statements (include all that apply made )y a parent indicates incorrect (no'ledge of the care of this infantN A1 O.he straps of the harness should )e 'orn ne<t to the s(in1P B1 O.he harness should )e 'orn for ; hours a day1P C1 O-t 'ill ta(e a long time for my child to 'al( and cra'l1P 51 O- can move my child around on a large s(ate)oard1P All of the A)ove >1 :hich of the follo'ing symptoms is not typical in an adolescent 'ith idiopathic scoliosisN B 9ac/ +ain B1 =ne0ual hip heights C1 =ne0ual shoulder heights 51 =neven 'aist angles K1 "ostoperative care of an adolescent follo'ing a spinal fusion for scoliosis includes4 A1 Oral analgesia for pain 9B %ogrolling #!en re+ositioned CB Nasogastric tube for decom+ression 51 &traight catheterization every 6 hours 8F1 A 3 year-old child is suspected of having 5uchennes muscular dystrophy1 :hich of the follo'ing assessment findings )y the nurse 'ould support this diagnosisN A1 A history of delayed cra'ling B1 -na)ility to am)ulate independently CB Difficulty climbing stairs 51 2o'ers sign (late sign

881 A child is suspected of having osteomyelitis1 :hich of the follo'ing )lood values supports this diagnosisN Choose all that apply A1 5ecreased 'hite )lood cell (:BC count 9B "ositi&e blood cultures C1 -ncreased hematocrit (,ct DB Ele&ated ES0 'Eryt!rocyte sedimentation rate) .he nurse revie's the la)oratory results of a patients )lood glucose level1 .he nurse (no's that 'hich of the follo'ing is a normal levelN o 6F mgAdL o 1NN mg$d% o 8>F mgAdL o 77F mgAdL A hospitalized patient 'ith .ype 8 5ia)etes reports hunger and nervousness and the nurse notes that the patient is diaphoretic1 .he nurse understands that the patient is most li(ely e<periencing o An<iety related to the hospitalization o &igns related to an infection o A hyperglycemic reaction o !y+oglycemic reaction A patient is e<periencing a hypoglycemic reaction1 .he nurse should administer 'hich of the follo'ing items to )est treat the reactionN o :ater o 5iet &oda o 1il/ o One sugar coo(ie .he nurse administers 7 units of #egular -nsulin at FJFF to a patient 'ith .ype 8 5ia)etes mellitus1 .he nurse monitors the patient for a hypoglycemic reaction starting at appro<imately at 'hat timeN o FKFF o 1NNN o 87FF o 86FF :hich of the follo'ing is a common clinical manifestation of Buvenile hypothyroidismN o -nsomnia o 5iarrhea o Dry s/in