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Pediatric Nursing
I. Pediatric Cardiovascular
Congenital Heart Defects
A. General concepts
1. Definition: present at birth - consequences are congestive heart failure
and hypoxemia
2. Etiology: usually not known - associated with maternal factors:
a. infection
b. alcoholism
c. age over 40 years
d. diabetes mellitus, type one
e. genetics, chromosomal changes
3. Findings of congenital heart defects
a. child small for age
b. physiological failure to thrive
c. exercise intolerance
d. dyspnea while feeding
e. squatting position
f. clubbing of fingers
g. cyanosis and/or pallor may be associated with poor perfusion
h. unusual pulsations
4. Physical consequences of congenital heart defects
a. increased workload; pulmonary hypertension; decreased systemic
output; cyanotic defects
b. can lead to hypoxemia and polycythemia
c. concern: formation of thrombus with embolus
d. blood flow patterns may be affected
B. Acyanotic defect - infant/child is "pink" but child may develop cyanosis
1. Pathology: hole in the heart's internal wall
a. blood flows from heart's arterial (left) to venous (right) side or a
"left to right shunt", not systemically, but only within heart itself
b. size of defect will determine severity of condition
2. Common types:
C. Cyanotic defect: infant/child is usually "blue", but child may appear pink
1. Pathology
a. unoxygenated blood mixes with oxygenated, via a "right to left
shunt"
b. decreases oxygenation to the entire system
c. results far more severe than acyanotic
d. thrombus formation is always a concern
D. Diagnostics
1. EKG: noninvasive, painless, infants and young children may require mild
sedation
2. Cardiac catheterization
a. presence of diaper rash may postpone procedure
b. preparation depends on level of growth and development
c. post procedure – child may have difficulty complying with keeping
insertion point in correct position
E. Nursing care of the child with a congenital heart defect
1. Emotional, physiological, and psychological interventions
2. Assisting the child and family to adjust to special needs
3. Goals of treatment
a. child will maintain adequate oxygenation and physiological
stability
b. family will understand signs and symptoms of the condition, and
how to manage each of them
c. child will attain milestones of normal growth and development
d. when child has surgery, child and family will be prepared, know
prognosis, and know how to give home care afterward
e. improve cardiac function
f. remove accumulated fluid
g. decrease cardiac demands
h. improve tissue oxygenation
4. Nursing interventions
a. recognize CHF
Respiratory Infections
A. General concepts
1. Etiology: bacterial, viral; often influenced by age, season, preexisting
disorder, living conditions
2. Findings: increased respiratory and heart rate, fever, nausea/vomiting,
nasal discharge and blockage, mucus production, coughing, adventitious
lung sounds
3. Nursing care goals
a. child will not exhibit findings of respiratory distress, will be able to
clear secretions, and remain comfortable with a patent airway
b. child will not spread infection to others
c. child will ingest adequate fluids, and maintain hydration
4. Management
a. medications: antibiotics, antipyretics
b. possible: anti-inflammatory, anti-mucolytics, bronchodilators,
oxygen as needed
5. Nursing interventions
a. chest physiotherapy
b. provide nutrition and encourage fluids - Jello, soup, puddings
c. promote rest and comfort
d. prevent spread of infection
e. ease respiratory efforts - warm mist
6. Teaching points
a. handwashing
b. avoid contact with affected children
B. Respiratory failure: inability to maintain adequate oxygenation
1. Predisposing factors
a. obstructive anomalies, aspiration
b. infections, tumors, anaphylaxis
c. restrictive conditions: respiratory distress, cystic fibrosis,
pneumonia, pneumothorax
d. paralytic conditions
2. Findings
a. restlessness, mood changes
b. changes in LOC
c. increasing rates of respiration and pulse
d. dyspnea
3. Management
a. frequent observation and physical exams, with pulse oximeter
b. correct hypoxemia, maintain ventilation and deliver oxygen
c. monitor for side effects and expected outcomes of therapy
C. Airway obstruction and basic life support
1. Cardiac arrest is usually due to prolonged hypoxemia secondary to
inadequate ventilation, oxygen or circulation
2. When following guidelines for pediatric life support, consider not just the
child's age, but also size. Individual anatomy and development will vary.
3. Airway clearance techniques
a. determine conscious versus unconscious child
b. for infants and toddlers: back blows and chest thrusts
c. for preschool and school-age: modified Heimlich maneuver
("astride")
4. Findings
Findings of Respiratory Distress Syndrome
The transition from respiratory-related to systemic related indicates a
progressive severity of the disease
1. Respiratory related
a. rales
b. expiratory grunting
c. nasal flaring
d. retractions
e. tachypnea
f. apnea
2. Systemic related
a. flaccid body
b. nonresponsive
c. hypotension
d. shock
a. tachypnea, increased respiratory effort
b. paradoxic "seesaw" respirations
c. nasal flaring
d. substernal retractions
e. expiratory grunt, possible apnea
f. cyanosis
g. hypoxia
5. Diagnostics
a. physical exam, pulse oximeter
b. serum: ABG's, glucose, calcium
c. chest radiograph confirmation – diffuse pattern over both lung
fields that resembles ground glass
6. Management:
a. oxygen therapy (possible mechanical ventilation) and chest
physiotherapy to maintain ventilation and oxygenation
b. medications: possible medications: surfactant, prophylactic
antibiotics, diuretics, inotropes, methyl-xanthines
7. Nursing interventions:
a. frequent respiratory assessment.
b. maintain acid base balance and tissue perfusion
c. electrolyte status
d. suction as indicated
8. Teaching points:
a. inform parents about equipment
b. positioning of infant
c. need for meticulous care by nurses due to subtle changes
possible in infant’s oxygenation status
E. Bronchopulmonary dysplasia: (BPD), chronic obstructive lung disorder
1. Etiology - at risk:
a. infants requiring oxygen and/or lengthy mechanical ventilation
b. infants surviving RDS
c. lung immaturity
2. Pathophysiology
a. mechanical ventilation presses lung tissue
b. bronchial epithelium is damaged
c. products of inflammation introduced, alveolar walls become thick,
fibrotic
d. continued mechanical ventilation affects the growth of new cells
and paralyzes cilia
e. lungs develop cystic areas (sacs) and atelectasis (collapsed
alveoli); mucus moves less
3. Findings
a. tachycardia and tachypnea
b. increased work of breathing
c. pallor
d. cyanosis with activity
e. restlessness
4. Management
a. oxygen (possible mechanical ventilation)
b. medications: diuretics, bronchodilators, anti-inflammatory agents
in gradually decreasing amounts
c. diet: increased calorie formulas and hydration
d. provide supplemental oxygen at home as needed
5. Nursing interventions:
a. provide rest periods
b. observe for fluid overload or pulmonary edema
c. provide age appropriate toys
d. frequent respiratory assessment
F. Apnea: cessation of breathing for over 20 seconds
1. Etiologies
a. prematurity
b. foreign-body aspiration, drowning, or trauma
c. incorrect positioning
d. gastroesophageal reflux
e. infections
f. seizure
g. hypoglycemia
2. Pathophysiology: dependent on type of apnea:
a. central - absence of respiratory effort and air movement
b. obstructive - respiratory effort but no air movement
c. mixed - first central, then obstructive
3. Findings
a. depend on type (above)
b. color changes, hypotonia
4. Diagnostics: laboratory tests, chest x-rays, EEG, ECG,
pneumocardiography, upper GI series
5. Management
a. home apnea monitoring and basic life support (BLS) training to
family
b. medications: based on type and underlying condition
Respiratory Conditions
a. signs of croup
i. inspiratory stridor
ii. harsh/brassy cough, barking cough
iii. hoarse voice
iv. respiratory distress
b. types, by primary area affected:
i. subglottal area: acute spasmodic croup, laryngitis,
laryngotracheobronchitis (LTB), tracheitis
ii. supraglottal area: epiglottitis
2. Etiology
a. usually viral
b. occasionally bacterial (tracheitis, epiglottitis)
c. younger children with "true croup" (spasmodic croup)
d. older children with tracheitis and epiglottitis
3. Pathophysiology: mucosa inflamed; edema narrows the airway
4. Findings
a. classic: "barky" harsh cough, stridor, hoarseness,fever, purulent
secretions, dyspnea if severe
b. bacterial: child looks "sicker"
c. epiglottitis manifests the four "D's"
i. drooling
ii. dysphagia (difficulty swallowing)
iii. dysphonia (hoarse voice)
iv. distressed inspiratory efforts
5. Management
a. viral
i. cool air/mist; fluids
ii. if inpatient, nebulized racemic epinephrine and inhaled
steroids
iii. antipyretics
b. bacterial: same as above with antibiotics, possible intubation
c. epiglottitis is a medical emergency; tracheotomy may be
necessary
6. Nursing interventions
a. teach parent and child signs of impending airway obstruction
b. report increased pulse, respirations, retractions, increased
restlessness
c. never attempt to directly visualize epiglottis with tongue depressor;
it could precipitate laryngospasm
Lower Airway Disorders
A. General concepts:
1. Assessment of cerebral function:
2. Children under 2 unable to respond to directions
3. Infants primarily reflexive
4. Observe spontaneous and elicited reflex responses – having parent
present may be helpful
5. Include family history and health history
6. Know stage of growth and development and developmental milestones
B. Increased intracranial pressure (ICP)
1. Etiology
a. congenital or acquired (from trauma, lesion, infection)
b. also see Pediatric Oncology (See section XI of this lesson)
2. Pathophysiology: swelling caused by irritation or bleeding into brain tissue
3. Findings
a. infant: bulging fontanels, widened cranial sutures, high-pitched
crying, irritable
1. Athetoid
• Characterized by slow irregular twisting snakelike movements occurring in the
upper extremities
• Involuntary movement of oral muscles which may result in drooling and dysarthria
2. Spasticity
• May involve either one or both sides
• Impaired fine and gross motor skills
• Individual's attempts at motion increase the abnormal posturing and overflow of
motion to other parts of body
• Hypertonic movements
3. Ataxic
• Rapid repetitive movements performed poorly
• Poor integration of movements when individual reaches
4. Mixed
• Combination of athetosis and spaticity
L. Head trauma
1. Etiology: force to the scalp, skull, meninges or brain – usual causative
agents are falls, motor vehicle crashes and bicycles
2. Pathophysiology: elastic pliable skill of infant and young child absorbs
much of direct energy
a. directly related to force of impact and secondary forces
i. acceleration injury
ii. deceleration injury
b. types: primary and secondary
c. cerebral function depends on oxygen, glucose and blood flow to
brain; cerebral edema and hypoxia can occur quickly
3. Findings: neurological status depends on ICP
a. may or may not be conscious
b. irritable
c. pale
d. vomiting
e. sleepy
f. LOC may be altered
g. pupils may be affected
4. Diagnostics: assess for pre-existing disorders, take history of event, CAT
SCAN, MRI, EEG
5. Management
a. acute
a. long-term process
b. keep parents informed and teach about the equipment
c. teach parent to talk to child but don’t ask them to do things like
"squeeze my hand"
M. Meningitis: acute inflammation of the meninges and CNS
1. Etiology: can be caused by pneumococcal or meningococcal bacteria
(most serious) or can be caused by a virus.
2. Pathophysiology: most common route of infection by vascular
dissemination from an infection elsewhere
a. organisms then spread into CSF and throughout subarachnoid
space
b. infective process
i. inflammation
ii. exudate
iii. WBC accumulation
iv. tissue damage
v. brain becomes hyperemic and edematous
3. Findings
a. fever
b. chills
c. headache
d. vomiting
e. LOC alterations
f. irritable
g. nuchal rigidity
h. positive Kernig and Brudzinski signs
4. Diagnostics
a. lumbar puncture: definitive diagnostic tool, CSF is tested for gram
stain, blood cell count and presence of glucose and protein
content
b. sedation of child may be required. Versed, Demerol or Fentanyl
may be used
5. Management: treated as bacterial until causative agent is identified
a. bacterial meningitis is an emergency
b. respiratory isolation precautions until causative agent identified
c. medications: antibiotics
6. Nursing interventions
a. monitor fluid status - IV fluids
b. monitor electrolytes
c. neuro and vital signs
d. maintain quiet environment
e. monitor for seizures
f. assess peripheral vascular collapse if causative agent is
meningococci
7. Teaching points
a. immunizations are available to prevent several types
B. Hypopituitarism
1. Definition: diminished or deficient secretion of pituitary hormones,
primarily GH (Somatotropin)
2. Etiology: tumors, hypoplasia, auto-immune, congenital, acquired,
irradiation, malnutrition, trauma
3. Pathophysiology: leads to gonadotropin deficiency - inhibits somatic
growth in all body cells
4. Findings
a. usually dependent on hormone involved and age of onset
(dwarfism)
b. absence or regression of secondary sex characteristics
c. example: slow growth, short stature, normal intelligence; delayed
puberty
5. Diagnostics
a. family history
b. history of growth patterns of child
c. MRI
d. radioimmunoassay of plasma GH levels
e. x-rays of hand and wrist for centers of ossification
6. Management
a. depends on cause
b. hormone replacement therapy: growth hormone
7. Nursing interventions:
a. support child and parents during period of diagnosis
b. plan realistic goals with child and family
8. Teaching points
a. show parent how to administer daily hormone replacement sc
b. educate child and family about long term process
C. "Precocious puberty" - unusually early activation of maturation process that is
considered normal later in life
1. Definition: manifestations of sexual development before age nine in boys
or age eight in girls
2. Etiology: brain lesions, inflammatory disorders, idiopathic, adrenal
disorders
3. Pathophysiology
a. premature activation of hypothalamic-pituitary-gonadal axis
b. early increased release of LH and FSH
c. early acceleration of linear growth with early closure of growth
plates
d. ultimate height less than if puberty had been normal
4. Findings - occurs most often in girls
a. development of breasts in prepubertal females
b. early development of sexual hair
c. isolated menses
d. development of secondary sex characteristics
5. Management
a. directed toward specific cause
b. hypothalamic - pituitary origin: luteinizing hormone - releasing
hormone (LHRH) injections monthly
6. Nursing interventions
a. provide support and guidance to parents and child
b. child may be embarrassed
c. assign nurse of same sex as child
d. early identification of affected child
7. Teaching points
a. long-term problem
b. after puberty, child will be the same as peers
D. SIADH: syndrome of inappropriate antidiuretic hormone
1. Definition: hypersecretion of antidiuretic hormone or ADH (vasopressin)
2. Etiology: infections, head trauma, or brain tumors
3. Pathophysiology
a. kidneys reabsorb too much free water
b. decreased urine output, increased specific gravity (SG), and
decreased serum sodium
4. Findings
a. urine SG > 1.030
b. anorexia, nausea, weakness, stomach cramps
c. increased weight (edema)
d. decreased serum sodium - under 120 mEq/L child becomes
symptomatic - lower sodium levels cause neurological findings
5. Management
a. restrict fluids to correct hyponatremia
b. correct underlying etiology
c. monitor I & O, electrolytes, neuro status
d. observe for signs of fluid overload
6. Nursing Interventions:
a. assess patients at risk for early identification
b. I & O – daily weights
c. monitor for signs of fluid overload
d. seizure precautions if sodium level low
E. Hypothyroidism
1. Definition: deficiency of thyroid hormone (TH); common childhood
endocrine disorder
2. Etiology
a. congenital or acquired deficiency in thyroid hormones
b. thyroid irradiation
3. Pathophysiology
a. absent or underdeveloped gland
b. decreased triiodothyronine (T3) or thyroxine (T4)
4. Findings: depend on extent of dysfunction and age of child at onset
a. lethargy, constipation, feeding problems
b. hypotonia, large tongue
c. dry skin, weight gain, puffy eyes, sparse hair
d. intolerance to cold
e. slowed growth, developmental delay and/or retardation if T4 low at
birth and thyroid replacement not started
f. if findings develop after two to three years, when brain has grown,
no mental retardation
5. Diagnostics
a. history and physical
b. increased TSH
c. decreased serum T3 and T4
d. anemia
e. decreased BMR (basal metabolic rate)
f. increased cholesterol and triglycerides
g. hypoglycemia
6. Management
a. lifelong hormone replacement (levothyroxine)
b. rest
c. protect client from cold
7. Nursing interventions
a. assess children at risk.
b. monitor administration of replacement hormone – can’t be
increased too fast
c. allow rest periods or cluster care
d. encourage child to exercise when able
8. Teaching points
a. life-long problem
b. child needs periodic blood tests to monitor hormone levels.
F. Hyperthyroid: "Graves' disease"
1. Definition: hypersecretion of thyroid hormones, causing increased BMR or
hyperactivity of thyroid gland
2. Etiology: auto-immune response to TSH (thyroid-stimulating hormone)
receptors; idiopathic; familial
3. Findings
a. increases in: BMR, appetite, nervousness, heart rate
b. gradual weight loss despite voracious appetite
c. lowered tolerance to heat
d. exophthalmos (eyes bulge)
e. myopathy
f. personality changes, poor school performance, mood instability
g. linear growth and bone age accelerated
h. insomnia
i. increased blood pressure
4. Diagnostics
a. history and physical
b. palpable thyroid enlargement (goiter)
c. elevated serum T3 and T4 levels
d. elevated radioactive iodine uptake
e. presence of thyroid antibodies
f. decreased TSH levels
5. Management
a. antithyroid therapy - Propylthiouracil or Tapazole to decrease
amount of circulating thyroid hormone
b. surgery (subtotal thyroidectomy) – check voice quality after
surgery.
6. Nursing interventions
a. assess behavior patterns before and after medication
b. quiet non-stimulating environment
c. administer moisturizing eye drops for child with exophthalmos
d. provide nutrition appropriate for activity level
e. establish a routine with child and parents
7. Teaching points
a. side effects of propylthiouracil -sore throat and fever
b. child may need to reduce activities for a while
8. Concern: thyrotoxicosis or “thyroid storm” from sudden release of
hormone: from vigorous palpation or surgery
a. can be a life threatening situation
b. findings
1. acute onset of severe irritability
2. vomiting
3. diarrhea
4. hyperthermia
5. hypertension
6. tachycardia
7. prostration
c. treat with cooling blanket
d. propranolol (Inderal), potassium iodine (thyro-block)
e. antithyroid drugs
G. Diabetes mellitus - type 1
1. Definition: deficiency of hormone insulin - most common endocrine
disorder of childhood.
2. Etiology: genetic, auto-immune response; usually with trigger factors of
virus, bacterium or possible chemical irritant
3. Pathophysiology
a. trigger directs islet cell antibodies against cell surfaces
b. antibodies destroy the insulin-secreting Beta cells
c. less insulin means glucose is blocked from entering the cells - the
concentration in bloodstream increases (hyperglycemia)
d. when glucose level exceeds kidney's threshold (about 180 mg/dl)
kidney then "spills" glucose into urine (glycosuria)
e. producing osmotic diureses (polyuria)
f. starved for glucose
g. urinary fluid loss causes excessive thirst (polydipsia)
4. Findings
a. hyperglycemia
1. the three "polys" of diabetes: polydipsia, polyuria,
polyphagia
2. additional findings: fatigue, hunger, weight loss, enuresis
5. Diagnostics
a. fasting blood glucose
b. oral glucose tolerance test
c. urine tests for presence of ketones and/or glucose
d. glycosylated hemoglobin (A1c) reflects average blood glucose
levels for past 2 to 3 months
6. Management
a. medications: insulin (rapid-acting-Lispro, short-acting - regular,
intermediate-acting-NPH). Insulin needs are affected by food
intake, exercise, emotions, growth spurts and illness
b. other: diet, age appropriate activity levels. No special foods - need
sufficient calories. Must eat snacks - and meals at the same time
each day.
c. self-blood glucose monitoring
d. insulin pump delivers insulin continuously
7. Concerns: "honeymoon period" and insulin regulation, compliance, sick
day management, ketones
8. Complications
a. DKA (diabetic ketoacidosis) or extreme hyperglycemia (blood
sugar >350 mg/dl)
1. etiology: not enough or no insulin - body chooses alternate
source of energy - fat
2. findings
1. fruity breath, decreased level of consciousness
2. nausea/vomiting, abdominal pain
3. 10 percent dehydration
4. increased urine output
5. Kussmaul's respirations
6. metabolic acidosis
b. management
1. place on cardiac monitor
2. regular insulin (IV drips and then subcutaneous)
3. frequent monitoring of blood glucose
4. frequent monitoring of electrolytes; neuro checks
9. Hypoglycemia
a. etiology: most common cause of insulin therapy and bursts of
physical activity, without additional food or with missed meals -
before meals or when insulin is peaking
b. findings
1. fatigue
2. nervousness
3. pallor
4. sweating
5. palpitations
6. hunger
7. loss of coordination
8. seizures
9. coma
c. management
1. 10 to 15 mg f simple carbohydrate - honey of low fat milk
2. followed by complex carbohydrate such as slice of bread
or crackers
3. occasionally glucagons is prescribed - for home treatment -
works in about 10 minutes
10. Nursing interventions
a. assess child frequently neuro and vital signs
b. blood glucose levels
c. administer insulin as ordered
d. support child family
e. arrange meetings with team members - dietary, PT, and social
worker
11. Teaching points
a. family may be overwhelmed with diagnosis
b. use teaching aids to facilitate their success - booklets, videos
c. illness management
d. insulin should never be omitted
e. dose may change
f. fluid balance is a concern
V. Pediatric Gastrointestinal
A. Dehydration
Lower GI Disorders
F. Constipation
1. Definition: infrequent passage of firm or hard stools
2. Etiology
a. triggered by diet, medication, dehydration, emotions, or
neurogenic
b. structural disorders (Hirschsprung's disease)
Renal Findings:
UT Findings:
Genitalia Problems
K. Cryptorchidism
1. Definition: failure of one or both testes to descend normally through
inguinal canal into scrotum
2. Etiology/pathophysiology
a. abnormal testes, or
b. decrease in the hormonal stimulation necessary for descent
3. Management: wait up to one year for descent, medications (HCG) to
assist in descent (older child), or surgery (orchiopexy).
L. Hypospadius
1. Definition: urethral meatus below normal placement on glans penis or
anywhere along ventral (underside) surface of penile shaft
2. Etiology: idiopathic - related to genetics, environment, hormonal
3. Pathophysiology: incomplete development in utero
4. Management: surgical correction (with urinary catheter and stents post-
op), post-op pressure dressing must not be removed by anyone other
than the health care provider, usually repaired before child goes to school
5. Concerns: stenosis, chordee, body image/self esteem
M. Bladder exstrophy
1. Definition: externalization of bladder, splaying at the urethra with failure of
tubular formation and diastasis of pelvic bone
2. Etiology: congenital - associated with genital abnormalities
3. Pathophysiology
a. failure of abdominal wall and underlying structures, including the
ventral wall of the bladder, to fuse in utero
b. bladder develops outside
c. the earlier in gestation, the more severe the defect
d. defect almost always associated with epispadias
4. Management
a. treament objectives
1. preservation of renal function
2. attainment of urinary control
3. adequate reconstructive repair
4. preservation of optimum sexual function
b. pre-op
1. prevent organs from drying out, fluids, infection control
2. surgery: staged procedure
c. post-op (antibiotics, compression bandage, bed rest)
5. Concerns: urinary incontinence, VUR, infection
N. Ambiguous genitalia
1. Etiology: abnormalities in chromosomal complement, embryogenesis, or
hormones
2. Pathophysiology: interruption in normal development around seven to
eight weeks gestation, when normally male begins differentiating from
female
3. Diagnostics: history, physical exam, tests to determine gender
(endoscopy, ultrasound, radiographic contract), genetics lab test,
laparotomy, biopsy
4. Concerns: body image/self esteem, family support
D. Clubfoot
4. Findings
a. limited abduction
b. short femur on affected side (Galeazzi's sign)
c. asymmetry of gluteal skin folds
d. waddling gait (bilateral dislocations)
e. for children already walking, increased laxity
5. Diagnostics
a. physical exam/screening at birth and monitor for hip dysplasia
throughout first year of life
b. check for Ortolani maneuver and Barlow's test from birth to 2 or 3
months of age
c. radiographic studies
6. Management: Pavlik harness, spica cast, traction, surgery, Bryant's
traction
7. Concerns: compliance, skin integrity, avascular necrosis from improper
positioning of harness
G. Scoliosis
H. Osteomyelitis
1. Definition: bacterial bone infection
2. Etiology: endogenous (in-body) sources, or direct entry via open fracture
or external fixation devices. Staphylococcus aureus is the most common
pathogen
3. Pathophysiology
a. microbe affects metaphysis of long bone; inflammation
b. pus forms and spreads along the shaft of the bone
c. new bone starts to form, but existing cortex loses blood vessels
and necrotic area will detach (sequestrum)
d. "honeycombed" areas contain infective material
4. Findings
a. pain, localized tenderness, erythema over involved bone
b. decreased range of motion at affected bone
c. irritability, restlessness, fever
5. Diagnostics
a. laboratory: blood cultures and bone aspirate cultures
i. erythrocyte sedimentation rate (ESR) will increase
ii. increased white blood cells
iii. blood culture
b. radiographic studies (often negative for ten to 14 days); bone scan
6. Management
a. IV antibiotics; may require long-term IV access (4 to 6 weeks)
b. bed rest
c. possible immobilization with splints or cast
d. possible surgery
7. Nursing interventions
a. monitor antibiotic levels
b. monitor level of comfort
c. perform range of motion if possible – no weight bearing
d. monitor nutrition – high calorie liquids
e. provide diversional activities for age
8. Teaching points
a. may continue IV therapy at home
b. physical therapy at home
c. school work at home if appropriate
d. play activities within limits of physical ability
H. Acne vulgaris
1. Definition: most common skin problem treated by doctors during
adolescence
2. Etiology: multifactorial (heredity, hormones, emotions)
3. Pathophysiology
a. puberty – increased androgens – involves hair follicle and
sebaceous gland complex
b. increased sebaceous glands secrete more sebum
c. pores become plugged and dilated
d. fatty acids are oxidized on skin and form blackheads OR
e. internal fatty acids form whiteheads
f. rupture causes local inflammation, sometimes with pustules
4. Findings: whiteheads (closed comedomes), blackheads (open
comedomes), papules, pustules, nodules, red and excoriated skin
5. Management
a. general: good cleansing of skin, nutrition, and no squeezing or
picking at lesions
b. topicals: vitamin A, topical antibiotics, topical benzoyl peroxide
c. medications: oral antibiotics and possible estrogen for girls
6. Teaching points
a. possibility of scarring
b. possible bacterial invasions
c. body image
d. education needed on myths and realities of causative agents and
treatment modalities
e. stress importance of compliance to treatment program
Infectious Disorders
I. Impetigo contagiosa
1. Definition: bacterial infection of skin
2. Etiology: staphylococcus aureus, group A beta-hemolytic streptococcus
3. Pathophysiology: starts in area of broken skin - highly contagious for
seven to ten days
4. Findings
a. primary: macules-vesicles of bulla that rupture
b. secondary: honey-colored crusts, superficial erosion, easily
bleeds, pruritic
c. tends to heal without scarring unless secondary infection
5. Management
a. careful removal of crusts/debris with warm soapy solution or
Burow's solution
b. topical antibiotics for early small lesions
c. treatment of choice: systemic antibiotics
d. short fingernails
6. Concerns: highly contagious (good hand washing, no sharing towels or
eating utensils)
J. Cellulitis
1. Definition: infection of dermis and/or subcutaneous tissue
2. Etiology: strep, S. aureus, Haemophilus influenza
3. Pathophysiology
a. starts in area of broken skin
b. highly contagious for days
c. can occur on any part of the body
4. Findings
a. affected area (red, edema, tender, occasional discoloration)
b. enlarged lymph nodes, "streaking" frequently seen, fever, malaise,
headache
5. Diagnostics: CBC, cultures, possible skin culture, CT
6. Management: oral or parenteral antibiotics, warm moist compresses,
possible incision and drainage, rest of affected area and child
7. Concerns: secondary infection, alteration in skin integrity
K. Herpes simplex type one
1. Definition: oral herpes, cold sore, fever blister
2. Etiology: HSV-1 or HSV-2, cytomegalovirus (CMV), Epstein Barr
(infectious mononucleosis), Varicella zoster
3. Pathophysiology: virus infects body fluids, which then come in contact
with breaks in the skin or mucous membranes
a. HSV-1 affects areas above the waist; "cold sore"
b. HSV-2: affects areas below the waist; genital
c. virus dormant within nerve cells; then reactivated by fever, stress,
trauma, sun exposure, menstruation
4. Findings
a. often depend on location in body
b. prodromal period common
c. vesicles, pain, pruritis, paresthesias, increased skin sensitivity at
site
5. Diagnostics: history, physical exam, smears, tissue cultures (Acyclovir -
Valtrex)
6. Management - symptomatic: fluids; possible antiviral or antibiotic if
secondary infection; analgesics
7. Concerns: highly contagious, secondary infection, pain, body image;
HSV-2 is sexually transmitted
1. Definition: superficial infection that lives on, not in, the skin
2. Etiology: dermatophytes
3. Pathophysiology
a. transmitted person to person, animal contact, contact with
contaminated fomites (nonliving "host")
b. associated with poor hygiene, friction from tight clothing
4. Nursing interventions
a. compliance, good hygiene
b. contagion, teach client never share clothing/hair brushes
c. overuse of OTC products, especially for feet
5. Teaching points
a. maintain medication schedule as ordered – maybe for
several weeks or months
b. no sharing of towels, linens or hair brushes
Infestations
N. Pediculosis (lice)
Blood Components
A. Erythrocytes
1. Carry oxygen to cells and move carbon dioxide back to lungs.
2. Average life span: 120 days
3. Hemoglobin: the iron component of RBCs
4. Blood typing
a. persons with type A can receive type A or type O blood
b. persons with type B can receive type B or type O blood
c. persons with type O can receive only type O blood
C. Plasma proteins
1. Include albumin and globulins
2. Measuring plasma proteins helps assess nutritional status
D. Platelets
1. Small fragments of cells
2. Life span eight to ten days
3. Essential to blood clotting/coagulation
Lymphomas
C. Hodgkin's disease
1. Definition: malignancy of the lymph nodes
2. Pathophysiology
a. neoplasm of lymphatic system
b. characterized by giant, multinucleated cells (Reed-Sternberg cells)
3. Findings
a. characterized by painless enlargement of lymph nodes,
particularly in supraclavicular area
b. anorexia, weight loss, malaise; painless; night sweats
c. fever
4. Diagnostics: lymphangiography, CBC, Sed Rate, urinalysis, CT Scan,
chest x-ray
5. Management
a. chemotherapy and radiation
b. treatment based on staging of disease (stages I-IV)
6. Nursing Interventions
a. preparation for diagnostic procedures
b. explain side effects of treatment
c. provide age appropriate diversional activities
d. refer to appropriate resources if sterility may result from irradiation
and/or chemotherapy
7. Teaching points
a. long term treatment plan
b. multidisciplinary approach
c. encourage to ask questions when unsure
d. school work for child when appropriate
D. Non-Hodgkin's lymphoma
1. Pathophysiology:
a. proliferation of either B- or T- lymphocytes
b. staging I-IV
2. Findings
a. painless, enlarged lymph nodes in cervical or axillary region
b. bone marrow and/or mediastinal involvement
3. Therapeutic management: combination of chemotherapy and radiation
E. Brain tumors: medulloblastoma, astrocytoma, ependymoma, glioblastoma
1. Pathophysiology
a. solid tumors of the nervous system
b. most common solid tumor in children
c. location extremely important
2. Findings
a. headache, vomiting, increased intracranial pressure, ataxia
b. visual changes, seizures, bulging fontanel in infants, behavioral
changes
3. Diagnostics: history, MRI, CT Scan, EEG, and lumbar puncture
4. Management
a. surgical debulking
b. radiation
c. chemotherapy
5. Nursing interventions
a. neuro signs
b. vital signs
c. prepare child and family for diagnostic and operative procedures –
possible shaving of head
d. positioning considerations depend on procedure done
e. monitor dressing and ICP, if appropriate
f. begin feeding when ordered
g. medicate for discomfort as indicated
6. Teaching points
a. child’s post operative appearance
b. refer for needed resources
F. Neuroblastoma
1. Pathophysiology
a. solid tumor found only in children under four years-old
b. primary sites are adrenal gland or retroperitoneal because it starts
from embryonic neural crest cells of the adrenal gland and
sympathetic nervous system.
c. often has metastasized by the time it is diagnosed
2. Findings
a. firm, nontender mass in the abdomen that crosses the midline
b. distant metastasis may cause periorbital edema (swelling around
eyes)
3. Therapeutic management
a. treatment is dependent on staging criteria
b. surgical debulking, chemotherapy, radiation
G. Other tumors
Summary overview of other tumors in children:
H. Osteosarcoma
1. Pathophysiology
a. originates from bone-forming mesenchyme
b. creating malignant osteoid tissue
c. most common in distal femur
d. metastasis to lung
2. Findings: localized pain, limp, decrease in physical activity
3. Diagnostics: history, physical assessment, chest x-ray, MRI, CT scans,
and radioisotope bone scans
4. Therapeutic management: surgical approach
a. limb salvage with prosthetic bone replacement; or amputation
b. plus combination chemotherapy before and/or after surgery
I. Ewing sarcoma
1. Pathophysiology
a. arises not from osteoid tissue but in bone marrow spaces
b. most common in shaft of femur, tibia, humerus, scapula
c. more common in males
2. Findings: localized pain, decrease in physical activity
3. Therapeutic management
a. intensive radiation therapy of the malignant bone
b. combined with chemotherapy
c. surgery not routinely recommended
J. Rhabdomyosarcoma
1. Pathophysiology
a. soft tissue neoplasm
b. grows from undifferentiated mesenchymal cells of skeletal muscle
c. most common in head and neck, especially the orbit
d. staging I-IV
e. highly malignant; often metastasized when diagnosed
2. Findings
a. non-tender, firm mass
b. related to site of tumor and compression of adjacent organs
c. symptoms often vague, similar to otitis media or "runny nose"
3. Therapeutic management
a. high-dose irradiation of the primary tumor
b. combination chemotherapy
c. surgical resection
K. Retinoblastoma
1. Pathophysiology: congenital malignant tumor of the retina, with evidence
of genetic inheritance in certain cases
2. Findings: cat's eye reflex (whitish glow in pupil); strabismus; red, painful
eye
3. Diagnostics: ophthalmoscopic exam under general anesthesia,
ultrasound and CT scan
4. Management
a. radiation therapy, enucleation, chemotherapy
b. treatment depends on stage of tumor, stages I-V
5. Nursing interventions
a. assess child for this when parents report a strange light in the
child’s eye
b. involve parents in care and teach about diagnostic procedures
6. Teaching points
a. demonstrate positive aspects of prosthesis – show pictures of
other affected children after surgery
b. genetic counseling for parents
Viral Infections
• Viruses are parasites that cannot reproduce or meet own metabolic needs.
• Skin cells react to virus with swelling, "vesiculation," or proliferation, sometimes warts.
• Most viruses are associated with rashes (characteristic of each disorder, such as
chicken pox, rubella, roseola)
Pediatric Neurology
Pediatric Cardiovascular
• In a cardiac history, include poor weight gain, chronic respiratory infection, activity
intolerance, and fatigue during eating.
• Oxygen is a drug that requires a prescription and frequent monitoring.
• Cardiac catheterization serves many purposes: diagnostic, interventional and
electrophysiologic. It also monitors cardiac oxygen saturation, pressure changes and
anatomic defects.
• CHF signs usually show either left or right sided heart disorders. These signs may
include increased heart rate, adventitious lung sounds, cyanosis, edema,
hepatosplenomegaly, and distended neck veins.
• Acquired cardiac disorders include bacterial endocarditis, acute rheumatic fever,
hyperlipidemia, Kawasaki disease, and cardiomyopathy.
• Electrodes for cardiac monitoring are usually color coded: white (upper right), black
(upper left), green (lower right), and red (lower left).
Pediatric Respiratory
• The principal functions of the respiratory tract are to allow air movement (ventilation) and
exchange (diffusion) of oxygen and carbon dioxide.
• Children's airways are smaller, more flexible and shorter than adult's and are therefore
more prone to obstruction than adults.
• Stridor usually indicates an upper airway concern, while wheezing indicates a lower
airway disorder.
• Conditions that increase or decrease compliance and/or resistance will make breathing
harder. Signs of increased breathing work are tachypnea, retractions, abnormal
positioning, shortness of breath and fatigue.
• Respiratory rate is an important indicator of respiratory status.
• Central cyanosis in a newborn usually means severe hypoxia and possible cardiac
etiology.
• Acrocyanosis is a common finding in a newborn.
• Asthma is not a disease but an inflammatory disorder.
• Asthma is not wheezy bronchitis.
• The incidence and severity of respiratory tract infections and disorders is related to the
child's age, size, natural defenses, underlying disorder and agent involved.
• Epiglottitis, acute tracheitis and status asthmaticus are acute medical emergencies.
• The best way to stop the spread of RSV is meticulous hand washing. RSV is transmitted
by direct contact with the fomite.
Pediatric Endocrine
• The body secretes hormones at various times during the day (influences of diurnal and
circadian rhythm).
• Normal hormone levels are related to age and stage of puberty.
• The pituitary gland stimulates target organs to produce specific hormones; when
sufficient, these in return signal pituitary to stop stimulation (negative feedback loop).
• Untreated infant hypothyroidism will lead to mental retardation.
• Associated terms for hypopituitary function include: short stature, constitutional delay,
dwarfism.
• A major concern of precocious puberty is rapid bone growth, which can result in early
fusion and short stature.
• Children with SIADH develop an expanded circulatory volume but not edema.
• Oral potassium tastes very bitter, mix it with a little strongly flavored fruit juice.
• For a child with an endocrine disorder, never discontinue medication abruptly.
• The vast majority of children with new-onset diabetes mellitus type 1 (IDDM) will
experience a "honeymoon" period when their bodies secrete insulin and their need for
exogenous insulin decreases.
• Blood glucose monitoring by finger-stick reflects glucose currently and for last several
hours; glycosylated hemoglobin levels indicate long-term compliance and true diabetic
status.
• Never freeze, heat or vigorously shake insulin.
• When insulin is absent, the body cannot properly metabolize fats, proteins and
carbohydrates.
• The focus of diabetic management is the inter-relationship of diet, activity and insulin
administration.
Pediatric Gastrointestinal
• Infants and children have a much smaller stomach capacity than adults.
• Peristaltic waves may reverse occasionally during infancy; gastric esophageal reflux is
very common in infants.
• Secretory cells don't reach adult levels until two to three years of age.
• The GI tract has both intake (fluid, minerals, vitamins, etc.) and output functions.
• Whenever a newborn coughs, chokes and turns blue with feeding, suspect
tracheoesophageal fistula. The 3 C's - cough, choke, and cyanosis.
• Any newborn failing to pass meconium stool within the first 24 hours of life and who is
prone to constipation or decreased frequency of stooling in the first month of life, should
be evaluated for Hirschsprung's disease.
• The treatment of metabolic acid-base disturbance is oriented toward correcting the
underlying problem.
• Dehydration can lead to shock.
• Dehydrated infants and children face greater morbidity risk than adults because children
differ in body composition and metabolic rate, and their fluid-regulation systems have not
matured.
• Potassium should only be added to IV fluids when the urine output is sufficient.
• One Gm of diaper weight = one cc of urine.
• When assessing diarrhea or constipation, remember the acronym ACCT: amount, color,
consistency, and time (duration).
• Bilious vomiting indicates source below the ampulla of Vater.
Pediatric Genitourinary
• The kidney's function is to maintain, in equilibrium, the composition and volume of body
fluids.
• Kidney function in an infant is nearly that of an adult by 12 months of age.
• Children with urine output less than one ml/Kg/hour should be closely monitored for
possible renal failure.
• Acute renal failure should be suspected in a child with decreased urine output, edema
and/or lethargy, and who is dehydrated, recovering from surgery or in shock.
• In managing HUS, the goals are to control hematologic manifestations and any renal
complications.
• UTI management aims to eliminate the underlying cause, detect and correct
abnormalities, and prevent recurrences.
• The effects of hypokalemia or hyperkalemia can be devastating.
• UTIs are extremely common in young children, girls more than boys.
• In a child with ambiguous genitalia, the criterion for choice of gender and rearing is not
genetic sex, but the infant's anatomy.
Pediatric Musculoskeletal
• Since many musculoskeletal disorders begin with trauma, it is important to assess ABC
(airway, breathing and circulation) first.
• Open fractures increase the risk of infection.
• Immobilization has multi-system effects.
• For a child with a fracture, it is important to assess the five P's of ischemia:
1. Pain and point of tenderness
2. Pulse - distal to the facture
3. Pallor
4. Paresthesia
5. Paralysis
• Children with structural defects/disorders require regular follow-up evaluation until they
reach skeletal maturity.
• Children in casts or traction need to be monitored for alterations in skin integrity
routinely.
• Children under one year of age generally do not experience fractures.
• Children's soft tissues are resilient, dislocation and sprains are less common.
Pediatric Temperature-Related
• The extent of a burn injury is expressed as percentage of total body surface area (TBSA)
• The larger the percentage of TBSA that is burned, the greater the risk for burn shock.
• In managing alterations in skin integrity, it is necessary to individualize the type of
treatment and medications to the particular causative agent.
• If you wouldn't put it into an eye, don't put it into a wound.
• Wounds heal by the process of moist wound healing and occlusion.
• Dry wounds do not heal.
• Wound debridement promotes healing and prevents infection.
• Immediate care for a major burn is ABC: airway establishment and patency, breathing
and absence of respiratory distress, and circulation with fluid initiation.
• Potassium should not be administered during the initial oliguric phase of a burn injury,
but should be added when diuresis occurs.
Pediatric Hematology
• For a child with altered platelet function or bleeding disorder, do not administer
acetylsalicylic acid (aspirin, ASA) or take rectal temperatures. Perform invasive
procedures very cautiously.
• Children with low WBC may not exhibit common findings of infection such as purulent
drainage. In a febrile client with granulocytopenia, give antibiotics immediately because
this child risks rapid, overwhelming sepsis.
• Morphine is the medication (or opioid) of choice for pain in children with sickle cell
disease.
Pediatric Oncology
• Findings of pediatric malignancies vary according to the child's age, location and type of
tumor, and extent of disease
• Cure rate is improving for most types of pediatric malignancies; however the late effects
of treatment are of increasing concern and incidence.
• Children typically have longer treatment plans than adults due to their increased
metabolic rate and rate of cell turnover.
• Leukemia affects not only the blood, but can metastasize to major organ systems
(extramedullary disease), including the central nervous system.
• Nursing care includes monitoring the child for the development of acute complications of
treatment including fever, bleeding, and anemia.
• Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena
cava syndrome, septic shock.