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Seizure Disorder

• Also known as convulsions, epileptic seizures, and if recurrent,


epilepsy.
• It is a sudden alterations in normal brain activity that cause distinct
changes in behavior and body function. They are thought to result from
abnormal, recurrent, uncontrolled electric discharges of neurons in the brain.
• Pathophysiology of seizures is poorly understood but seems to be
related to metabolic and electrochemical factors at the cellular level.
• Predisposing factors include head or brain trauma, tumors, cranial
surgery, metabolic disorders (hypocalcemia, hypoglycemia or hyperglycemia,
hyponatremia, anoxia); central nervous system infection; circulating disorders;
drug toxicity; drug withdrawal states (alcohol, barbiturates); and congenital
neurodegenerative disorders.
• Seizures are classified as partial or generalized by the origin of the seizure activity and associated clinical
manifestations.

a. Simple partial seizures – manifest motor, somatosensory, and psychomotor symptoms without impairment of
consciousness.

b. Complex partial seizures – manifest impairment of consciousness with or without simple partial symptoms.

c. Generalized seizures – manifest a loss of consciousness with convulsive or nonconvulsive behaviors and
include tonic-clonic, myoclonic, atonic, and absence seizures.

• Simple partial seizures can progress to complex partial seizures, and complex partial seizures can
secondarily become generalized.
• Seizures affect all ages. Most cases of epilepsy are identified in childhood, and several seizure types are
particular to children.

Assessment:

1. Generalized tonic-clonic (grand mal) seizure

a. May be preceded by an aura such as a peculiar sensation or dizziness; then sudden onset of seizure with loss of
consciousness.

b. Rigid muscle contraction in tonic phase which clenched jaw and hands; eyes open with pupils dilated; lasts 30 to
60 seconds.

c. Rhythmic, jerky contraction and relaxation of all muscles in clonic phase with incontinence and frothing at the
lips; may bite tongue or cheek, lasts several minutes.

d. Sleeping or dazed postictal state for up to several hours.

2. Absence ( petit mal) seizure

a. Loss of contact with environment for 5 to 30 seconds.

b. Appears to be day dreaming or may roll eyes, nod head, move hands, or smack lips.

c. Resumes activity and is not aware of seizure.

3. Myoclonic seizure (infantile spasm)

a. Seen in children or infants, caused by cerebral pathology, often with mental retardation.

b. Infantile spasms usually disappear by age 4, but child may develop other types of seizures.

c. Brief, sudden, forceful contractions of the muscles of the trunk, neck, and extremities.

d. Extensor type – infant extends head, spreads arms out, bend body backward in “spread eagle” position.

e. Mixed flexor and extensor types may occur in clusters or alternate.

f. May cause children to drop or throw something.

g. Infant may cry out, grunt, grimace, laugh, or appear fearful during an attack.

4. Partial (focal) motor seizure

a. Rhythmic twitching of muscle group, usually hand or face.

b. May spread to involve entire limb, other extremities and face on that side, known as jacksonian seizure.
5. Partial (focal) somatosensory seizure

a. Numbness and tingling in a part of the body.

b. May also be visual, taste, auditory, or olfactory sensation.

6. Partial psychomotor (temporal lobe) seizure

a. May be aura of abdominal discomfort or bad odor or taste.

b. Auditory or visual hallucinations, déjà vu feeling, or sense of fear or anxiety.

c. Repetitive purposeless movements (automatisms) may occur, such as picking at clothes, smacking lips, chewing,
and grimacing.

d. Lasts seconds to minutes.

7. Complex partial seizures - begin as partial seizures and progress to impairment of consciousness or impaired
consciousness at onset.

8. Febrile seizure

a. Generalized tonic-clonic seizure with fever over 101.8 degrees Fahrenheit.

b. Occurs in children younger than age 5.

c. Treatment is to decrease temperature, treat source of fever, and control seizure.

d. Long-term treatment to prevent recurrent seizures with fever is controversial.

Diagnostic Evaluation:

1. EEG, with or without video monitoring, locates epileptic focus, spread, intensity, and duration, helps
classify seizure type.
2. CT scanning or MRI identifies lesion that may cause of seizure.
3. Single photon emission CT scanning (SPECT) or positron emission tomography (PET) identifies seizure foci.
4. Neuropsychological studies evaluate for behavioral disturbances.
5. Serum electrolytes, glucose, and toxicity screen determine the cause of first seizure.
6. Lumbar puncture and blood cultures may be necessary if fever is present.

Pharmacologic Interventions:

1. Antiepileptic drugs (AEDs) may be used singly or in combination to increase effectiveness, treat mixed
seizure types, and reduce adverse effects.
2. A wide variety of adverse reactions may occur, including hepatic and renal dysfunction, vision disturbances,
drowsiness, ataxia, anemia, leukopenia, thrombocytopenia, psychotic symptoms, skin rash, stomach upset,
and idiosyncratic reactions.

Surgical Interventions:

1. Surgical treatment of brain tumor or hematoma may relieve seizures caused by these.
2. Temporal lobectomy, extratemporal resection, corpus callosotomy, or hemispherectomy may be necessary
in medically intractable seizure disorders.

Nursing Interventions:

1. Monitor the entire seizure event, including prodromal signs, seizure behavior, and postictal state.
2. Monitor complete blood count, urinalysis, and liver function studies for toxicity caused by medications.
3. Provide safe environment by padding side rails and removing clutter.
4. Place the bed in low position.
5. Do not restrain the patient during seizure.
6. Do not put anything in the patient’s mouth during seizure.
7. Maintain a patent airway until the patient is fully awake after a seizure.
8. Provide oxygen during the seizure if the patient become cyanotic.
9. Place the patient on side during a seizure to prevent aspiration.
10. Protect the patient’s head during the seizure.
11. Teach stress reduction techniques that will fit into the patient’s lifestyle.
12. Tell the patient to avoid alcohol because it interferes with metabolism of AEDs and adds to sedation.
13. Encourage the patient to determine existence of triggering factors for seizures, such as skipped meals, lack
of sleep, and emotional stress.
14. Remind the family the importance of following medication regimen and maintaining regular laboratory
testing, medical check ups, and visual examinations.
15. Encourage patient to follow a moderate lifestyle routine, including exercise, mental activity, and nutritious
diet.
Gastric Cancer

• It is also called malignant tumor of the stomach.


• It is usually an adenocarcinoma.
• It spreads rapidly to the lungs, lymph nodes, and liver.
• Risk factors include chronic atrophic gastritis with intestinal
metaplasia; pernicious anemia or having had gastric resections
(greater than 15 years prior); and adenomatous polyps.
• This cancer is most common in men older than age 40 and in blacks.
• Complications are hemorrhage and dumping syndrome from surgery
or widespread metastasis and death.

Assessment:

1. Most often, the patient presents with the same symptoms as gastric ulcer. Later, evaluation shows the
lesion to be malignant.
2. Gastric fullness (early satiety), dyspepsia lasting more than 4 weeks, progressive loss of appetite are initial
symptoms.
3. Stool samples are positive for occult blood.
4. Vomiting may occur and may have coffee-ground appearance.
5. Later manifestations include pain in black or epigastric area (often induced by eating, relieved by antacids
or vomiting); weight loss; hemorrhage; gastric obstruction.

Diagnostic Evaluation:

1. Upper GI X-ray with contrast media may initially show suspicious ulceration that requires further
evaluation.
2. Endoscopy with biopsy and cytology confirms malignant disease.
3. Imaging studies (bone scan, liver scan, CT scan) helps determining metastasis.
4. Complete blood count (CBC) may indicate anemia from blood loss.

Surgical Interventions:

1. The only successful treatment of gastric cancer is gastric resection, surgical removal of part of the stomach
with involved lymph nodes; postoperative staging is done and further treatment may be necessary.
2. Surgical options include proximal or distal subtotal gastric resection; total gastrectomy (includes adjacent
organs such as tail of pancreas, portion of liver, duodenum); or palliative surgery such as subtotal
gastrectomy with gastroenterostomy to maintain continuity of the GI tract.
3. Surgery may be combined with chemotherapy to provide palliation and prolong life.

Nursing Interventions:

1. Monitor nutritional intake and weigh patient regularly.


2. Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor albumin and prealbumin levels to
determine if protein supplementation is needed.
3. Provide comfort measures and administer analgesics as ordered.
4. Frequently turn the patient and encourage deep breathing to prevent pulmonary complications, to protect
skin, and to promote comfort.
5. Maintain nasogastric suction to remove fluids and gas in the stomach and prevent painful distention.
6. Provide oral care to prevent dryness and ulceration.
7. Keep the patient nothing by mouth as directed to promote gastric wound healing. Administer parenteral
nutrition, if ordered.
8. When nasogastric drainage has decreased and bowel sounds have returned, begin oral fluids and progress
slowly.
9. Avoid giving the patient high-carbohydrate foods and fluids with meals, which may trigger dumping
syndrome because of excessively rapid emptying of gastric contents.
10. Administer protein and vitamin supplements to foster wound repair and tissue building.
11. Eat small, frequent meals rather than three large meals.
12. Reduce fluids with meals, but take them between meals.
13. Stress the importance of long term vitamin B12 injections after gastrectomy to prevent surgically induced
pernicious anemia.
14. Encourage follow-up visits with the health care provider and routine blood studies and other testing to
detect complications or recurrence.

Wilms’ Tumor
• It accounts for 6% of all childhood cancers.
• It generally grows to a large size before it is diagnosed, usually before the child reaches age 5.
• The tumor expands the renal parenchyma, and the capsule of the kidney becomes stretched over the surface of
the tumor.
• Staging if from I (limited to kidney) to IV (matastasis) and stage V, which indicates bilateral involvement (rare).
• The tumor may metastasize to the lymph nodes, lungs, liver, and brain.

Assessment
1. A firm, non-tender mass in the upper quadrant of the abdomen is usually the presenting sign. It may be on
either side.
2. Abdominal pain which is related to rapid growth of the tumor.
3. As the tumor enlarges, pressure may cause constipation, vomiting, abdominal distress, anorexia, weight loss
and dyspnea.
4. Less common manifestation are hypertension, fever, hematuria, and anemia.
5. Associated anomalies includes aniridia (absence of the iris), hemihypertrophy of the vertebrae, and
genitourinary anomalies.

Diagnostic Evaluation
1. Abdominal untrasound detects the tumor and assesses the status of the opposite kidney.
2. Chest X-ray and CT scan may be done to identify matastasis.
3. MRI or CT scan of the abdomen may be done to evaluate local spread to lymph nodes.
4. Urine specimens show hematuria; no increase in vanillylmandelic acid and homovanillic acid levels as occurs
with neuroblastoma.
5. Complete blood count, blood chemistries, especially serum electrolytes, uric acid, renal function tests, and liver
functions tests, are done for baseline measurement and to detect metastasis.

Pharmacologic Interventions
1. Chemotherapy as initiated postoperatively to achieve maximal killing of tumor cells. Drug combinations include
vincristine and doxorubicin or vincristine and actinomycin D, depending on stage.

Surgical Intervention
1. Surgery is the gold standard of therapy. Accurate staging by the type of the tumor and the extent of
invasiveness is performed.

Nursing Interventions
• Observe the surgical incision for erythema, drainage or separation. Report any of theses changes.
• Monitor for elevated temperature or sign of infection post-operatively.
• Monitor I.V. fluid therapy and intake and output carefully, including nasogastric (NG) drainage.
• Encourage the parents to ask questions and to understand fully the risk and benefits of surgery.
• Prepare the child for surgery, explain the procedures at the appropriate developmental level.
• Continue supporting the parents during the postoperative period.
• Insert NG tube as ordered. Many children require gastric suction postoperatively to prevent distention or
vomiting.
• When bowel sounds have returned, begin administering small amounts of clear fluids.
• Administer pain control medications as ordered in the immediate postoperative period.
• Allow the child to participate in the selection of foods.
• As the child recovers, encourage child to eat progressively larger meals.
• If unable to eat because of radiation and chemotherapy provide I.V. fluids, hyperalimentation, or tube feedings as
indicated.
• Prepare child and family for fatigue during recovery from surgery and with radiation treatments. Plan frequently
rest periods between daily activities.
• Prepare the child and parents for loss of hair associated with chemotherapy and encourage use of hat as desired.
Reassure the hair will grow back.

Hodgkin’s Disease

• Is a malignant lymphoma of the reticuloendothelial system that results in an


accumulation of dysfunctional, immature lymphoid-derived cells.
• The disease generally spreads by lymphatic channels, involving lymph nodes, spleen, and ultimately
(through the bloodstream) to extra lymphatic sites, such as gastrointestinal tract, bone marrow, skin,
upper air passages, and other organs.
• It is most common in patient ages 20 to 40 and in those older than age 60.
• It’s cause is unknown.

Assessment:
1. Fatigue, fever, chills, night sweats, painless swelling of lymph nodes (generally unilateral), pruritus, weight
loss.
2. Wide variety of symptoms may occur if there is pulmonary involvement, superior vena cava obstruction,
hepatic or bone involvement, and involvement of other structures.

Diagnostic Evaluation:

1. Lymph node biopsy detects characteristic Reed-sternberg giant cell, helping to confirm diagnosis.
2. Complete blood count and bone marrow aspiration and biopsy determine whether there is bone marrow
involvement.
3. X-rays, CT scan, and MRI detect deep nodal involvement.
4. Lymphangiogram detects size and location of deep nodes involved, including abdominal nodes, which may
not be readily seen by CT scan.
5. Liver function test and liver biopsy determine hepatic involvement.
6. Gallium-67 detects areas of active disease; determines aggressiveness of disease.
7. Surgical staging (laparotomy with splenectomy, liver biopsy, multiple lymph node biopsies) may be done in
selected patients.

Pharmacologic Interventions:

1. Chemotherapy may be used in combination with radiation.

• Initial treatment often begins with a specific four-drug regimen known as MOPP (Mustargen, Oncovin,
procarbazine, and prednisone).
• Three or four drugs may be given in intermittent or cyclical courses, with periods of treatment to allow
recovery from toxicities.

Surgical Interventions:

1. Autologous or allogeneic bone marrows or stem cell transplantation.

Nursing Interventions:

1. To protect the skin receiving radiation, avoid rubbing, powders, deodorants, lotions, or ointments (unless
prescribed) or application of heat or cold.
2. Encourage patient to keep clean and dry, and to bathe the area affected by radiation gently with tepid
water and mild soap.
3. Encourage wearing loose-fitting clothes and to protect skin from exposure to sun, chlorine, and
temperature extremes.
4. To protect oral and gastro-intestinal tract mucous membranes, encourage frequent, small meals, using
bland and soft diet at mild temperatures.
5. Teach the patients to avoid irritants such as alcohol, tobacco, spices, and extremely hot or cold foods.
6. Administer or teach self-administration of pain medication or antiemetic before eating or drinking, if
needed.
7. Encourage mouth care at least twice per day and after meals using a soft toothbrush or toothete and mild
mouth rinse.
8. Assess for ulcers, plaques, or discharge that may be indicative of superimposed infection.
9. For diarrhea [1], switch to low-residue diet and administer anti-diarrheals as ordered.
10. Teach patient about risk of infection. Advice patient to monitor temperature and report any fever or other
sign of infection promptly.
11. Explain to patient that radiation therapy may cause sterility.

Acute Bronchitis

• [1]
Is an infection of the lower respiratory tract
that generally follows an upper respiratory
tract infection. As a result of this viral (most
common) or bacterial infection, the airways
become inflamed and irritated, and mucus
production increases.

Assessment:

1. Fever, tachypnea, mild dyspnea, pleuritic chest


pain (possible).
2. Cough with clear to purulent sputum
production.
3. Diffuse rhonchi and crackles(contrast with
localized crackles usually heard with
pneumonia).

Diagnostic Evaluation:

1. Chest X-ray may rule out pneumonia. In bronchitis, films show no evidence of lung infiltrates or
consolidation.

Therapeutic Intervention:
1. Chest physiotherapy to mobilize secretions, if indicated.
2. Hydration to liquefy secretions.

Pharmacologic Interventions:

1. Inhaled bronchodilators to reduce bronchospasm and promote sputum expectoration.


2. A course of oral antibiotics such as a macrolide may be instituted, but is controversial.
3. Symptom management for fever and cough.

Nursing Interventions:

1. Encourage mobilization of secretion through ambulation, coughing, and deep breathing.


2. Ensure adequate fluid intake to liquefy secretions and prevent dehydration caused by fever and tachypnea.
3. Encourage rest, avoidance of bronchial irritant, and a good diet to facilitate recovery.
4. Instruct the patient to complete the full course of prescribed antibiotics and explain the effect of meals on
drug absorption.
5. Caution the patient on using over-the-counter cough suppressants, antihistamines, and decongestants,
which may cause drying and retention of secretions. However, cough preparations containing the mucolytic
guaifenesin may be appropriate.
6. Advise the patient that a dry cough may persist after bronchitis because of irritation of airways. Suggest
avoiding dry environments and using a humidifier at bedside. Encourage smoking cessation.
7. Teach the patient to recognize and immediately report early signs and symptoms of acute bronchitis

Chronic Bronchitis

• Is an inflammation of the lower airways characterized by


[1]

excessive secretion of mucus, hypertrophy of mucous glands,


and recurring infection, progressing to narrowing and
obstruction of airflow.

Assessment:

1. Signs and symptoms of chronic bronchitis (insidious onset):

• Productive cough lasting at least 3 months during a year for 2


successive years.
• Thick, gelatinous sputum (greater amounts produced during
superimposed infections).
• Dyspnea and wheezing as disease progresses.

Diagnostic Evaluation:

1. Pulmonary function tests, to demonstrate airflow obstruction-reduced forced expiratory volume in 1 second
(FEV1), FEV1 to forced vital capacity ratio; increased residual volume to total lung capacity (TLC) ration,
possibly increased TLC.
2. Chest X-rays to detect hyperinflation, flattened diaphragm, increased retrosternal space, decreased
vascular markings, possible bullae (all in late stages).
3. Arterial blood gases, to detect decreased arterial oxygen pressure (PaO2), pH, and increased arterial
carbon dioxide pressure (Paco2).
4. Sputum smears and cultures to identify pathogens.

Therapeutic and Surgical Interventions:

1. Smoking cessation to stop the progression and preserve lung capacity.


2. Low-flow oxygen to correct severe hypoxemia in a controlled manner and minimize carbon dioxide
retention.
3. Home oxygen therapy, especially at night to prevent turnal oxygen desaturation.
4. Pulmonary rehabilitation to reduce symptoms that limit activity.
5. Chest physical therapy, including postural drainage and breathing retraining.
6. Lung transplant in severe cases of alpha1-antitrypsin deficiency.

Pharmacologic Intervention:

1. Bronchodilators to reduce dyspnea and control bronchospasm delivered by metered-dose inhaler, other
handheld devices, or nebulization.
2. Inhaled corticosteriods may be useful for some with severe airflow limitation and frequent exacerbations.
3. Corticosteroids by mouth or I.V. in acute exacerbations.
4. Antimicrobials to control secondary bacterial infections in the bronchial tree, thus clearing the airways.
5. Alpha1-antitrypsin replacement delivered by I.V. infusion.

Nursing Interventions:

1. Monitor for adverse effects of bronchodilators-tremulousness, tachycardia, cardiac arrhythmias, central


nervous system stimulation, hypertension.
2. Monitor oxygen saturation at rest and with activity.
3. Eliminate all pulmonary irritants, particularly cigarette smoke. Smoking cessation usually reduces
pulmonary irritation, sputum production, and cough. Keep the patient’s room as dust-free as possible.
4. Use postural drainage positions to help clear secretions responsible for airway obstruction.
5. Teach controlled coughing.
6. Encourage high level of fluid intake (8 to 10 glasses; 2 to 2.5 L daily) within level of cardiac reserve.
7. Give inhalations of nebulized saline to humidify bronchial tree and liquefy sputum. Add moisture
(humidifier, vaporizer) to indoor air.
8. Avoid dairy products if these increase sputum production.
9. Encourage the patient to assume comfortable position to decrease dyspnea.
10. Use pursed lip breathing at intervals and during periods of dyspnea to control rate and depth of respiration
and improve respiratory muscle coordination.
11. Discuss and demonstrates relaxation exercises to reduce stress, tension, and anxiety.
12. Encourage frequent small meals if the patient is dyspneic; en a small increase in abdominal contents may
press on diaphragm and impede breathing.
13. Offer liquid nutritional supplements to improve caloric intake and counteract weight loss.
14. Avoid foods producing abdominal discomfort.
15. Encourage use of portable oxygen system for ambulation for patients with hypoxemia and marked
disability.
16. Encourage the patient in energy conservation techniques.

Cystic Fibrosis

• [1]
Is an autosomal recessive disorder affecting the exocrine glands,
in which their secretions become abnormally viscous and liable to
obstruct glandular ducts.
• It primarily affects pulmonary and GI function.
• The average life expectancy for the cystic fibrosis patient is
currently age 30 to 40. Death may occur because of respiratory
infection and failure.
• Other complications include esophageal varices, diabetes, chronic
sinusitis, pancreatitis, rectal polyps, intussusceptions, growth
retardation, and infertility.

Assessment:

1. Usually present before age 6 months but severity varies and may present later.
2. Meconium ileus is found in neonate.
3. Usually present with respiratory symptoms, chronic cough, and wheezing.
4. Parents may report salty taste when skin is kissed.
5. Recurrent pulmonary infections.
6. Failure to gain weight or grow in the presence of a good appetite.
7. Frequent, bulky, and foul smelling stools (steatorrhea), excessive flatus, pancreatitis and obstructive
jaundice may occur.
8. Protuberant abdomen, pot belly, wasted buttocks.
9. Bleeding disorders.
10. Clubbing of fingers in older child.
11. Increased anteroposterior chest diameter (barrel chest).
12. Decreased exertional endurance.
13. Hyperglycemia, glucosuria with polyuria, and weight loss.
14. Sterility in males.

Diagnostic Evaluation:

1. Sweat chloride test measures sodium and chloride level in sweat.


o Chloride level of more than 60 mEq/L is virtually diagnostic.
o Chloride level of 40 to 60 mEq/L is borderline and should be repeated.
2. Duodenal secretions: low trypsin concentration is virtually diagnostic.
3. Stool analysis:
o Reduced trypsin and chymotrypsin levels-used for initial screening for cystic fibrosis.
o Increased stool fat concentration.
o BMC ( Boehringer-Mannheim Corp.) meconium strip test for stool includes lactose and protein
content; used for screening.
4. Chest X-ray may be normal initially; later shows increased areas of infection, overinflation, bronchial
thickening and plugging, atelectasis, and fibrosis.
5. Pulmonary function studies (after age 4) show decreased vital capacity and flow rates and increased
residual volume or increased total lung capacity.
6. Diagnosis is made when a positive sweat test is seen in conjunction with one or more of the following:
o Positive family history of cystic fibrosis.
o Typical chronic obstructive lung disease.
o Documented exocrine pancreatic insufficiency.
7. Genetic screening may be done for affected families.

Pharmacologic Interventions:

1. Antimicrobial therapy as indicated for pulmonary infection.


o Oral or I.V. antibiotics as required.
o Inhaled antibiotics, such as gentamicin or tobramycin, may be used for severe lung disease or
colonization of organisms.
2. Bronchodilators to increase airway size and assist in mucus clearance.
3. Pulmozyme recombinant human DNase (an enzyme) administered via nebulization to decrease viscosity of
secretions.
4. Pancreatic enzyme supplements with each feeding.
o Favored preparation is pancrelipase.
oOccasionally, antacid is helpful to improve tolerance of enzymes.
oFavorable response to enzymes is based on tolerance of fatty foods, decreased stool frequency,
absence of steatorrhea, improved appetite, and lack of abdominal pain.
5. Gene therapy, in which recombinant DNA containing a corrected gene sequence is introduced into the
diseased lung tissue by nebulization, is in clinical trials.

Nursing Interventions:

1. Monitor weight at least weekly to assess effectiveness of nutritional interventions.


2. Monitor respiratory status and sputum production, to evaluate response to respiratory care measures.
3. To promote airway clearance, employ intermittent aerosol therapy three to four times per day when the
child is symptomatic.
4. Perform chest physical therapy three to four times per day after aerosol therapy.
5. Help the child to relax to cough more easily after postural drainage.
6. Suction the infant or young child when necessary, if not able to cough.
7. Teach the child breathing exercises using pursed lips to increase duration of exhalation.
8. Provide good skin care and position changes to prevent skin breakdown in malnourished child.
9. Provide frequent mouth care to reduce chances of infection because mucus is present.
10. Restrict contact with people with respiratory infection.
11. Encourage diet composed of foods high in calories and protein and moderate to high in fat because
absorption of food is incomplete.
12. Administer fat-soluble vitamins, as prescribed, to counteract malabsorption.
13. Increase salt intake during hot weather, fever, or excessive exercise to prevent sodium depletion and
cardiovascular compromise.
14. To prevent vomiting, allow ample time for feeding because of irritability if not feeling well and coughing.
15. Encourage regular exercise and activity to foster sense of accomplishments and independence and improve
pulmonary function.
16. Provide opportunities for parents to learn all aspects of care for the child.
17. Teach the parents about dietary regimen and special need for calories, fat, and vitamins.
18. Discuss need for salt replacement, especially on hot summer days or when fever, vomiting, and diarrhea
occur.

Celiac Disease

• [1]
Also called Gluten-Sensitive Enteropathy.
• Is a disease of the small intestine marked by atrophy of the
villi and microvilli caused by an immune-mediated
inflammatory response to gluten, a protein found in common
grains such as wheat, rye, oats, and barley.
• The cause is unknown, but genetic, environmental, and
immunologic elements maybe involved.
• The disease is triggered by surgery, pregnancy, viral infection,
or severe emotional distress.
• It is most common in young children ages 6 to 24 months but
can occur at any age.
• Symptoms typically diminish or disappear in adolescence and
reappear in early adulthood.
• Complications include impaired growth, inability to fight
infections, electrolyte imbalance, clotting disturbance, and
possible predisposition to malignant lymphoma of the small intestine.

[2]

Assessment:

Ages 3 to 9 months

1. Acutely ill; severe diarrhea and vomiting


2. Irritability
3. Possible failure to thrive

Ages 9 to 18 months

1. Slackening of weight followed by weight loss


2. Abnormal stools
o Pale, soft, bulky
o Offensive odor
o Greasy (steatorrhea)
o May increase in number
3. Abdominal distention
4. [3]Anorexia, discoloration of teeth
5. Muscle wasting: most obvious in buttocks and proximal parts of extremities
6. Hypotonia, seizures
7. Mood changes: ill humor, irritability, temper tantrums, shyness
8. Mild clubbing of fingers
9. Vomiting: usually occurs in the evening
10. Aphthous ulcers, dermatitis

Older Child and Adult

1. Signs and symptoms are commonly related to nutritional or secondary deficiencies resulting from disease.
o Anemia, vitamin deficiency (A, D, E, K)
o Hypoproteinemia with edema
o Hypocalcemia, hypokalemia, hypomagnesemia
o Hypoprothrombinemia from vitamin K deficiency
o Disaccharide (sugar) intolerance
o Osteoporosis due to calcium deficiency
2. Anorexia [4], fatigue, weight loss.
3. May have colicky abdominal pain, distention, flatulence, constipation, and steatorrhea.

Diagnostic Evaluation:

1. Small bowel biopsy, which demonstrates characteristic abnormal mucosa.


2. Hemoglobin, folic acid, and Vitamin K levels may be reduced.
3. Prothrombin time may be prolonged.
4. Elevated immunoglobulin (Ig) A endomysium antibodies and IgA anti-tissue transglutaminase antibodies.
5. Total protein and albumin may be decreased.
6. 72 hour stool collection for fecal fat is increased.
7. D-xylose absorption test – decreased blood and urine levels.
8. Sweat test and pancreatic function studies may be done to rule out cystic fibrosis in child.

Therapeutic Interventions:

1. Dietary modifications includes a lifelong gluten-free diet, avoiding all foods containing wheat, rye, barley,
and possibly, oats.
2. In some cases, fats maybe reduced.
3. Lactose and sucrose may be eliminated from diet for 6 to 8 weeks, based on reduced disaccharidase
activity.

Nursing Interventions:

1. Monitor dietary intake, fluid intake and output, weight, serum electrolytes, and hydration status.
2. Make sure that the diet is free from causative agent, but inclusive of essential nutrients, such as protein,
fats, vitamins, and minerals.
3. Maintain NPO status during initial treatment of celiac crisis or during diagnostic testing.
4. Provide parenteral nutrition as prescribed.
5. Provide meticulous skin care after each loose stool and apply lubricant to prevent skin breakdown.
6. Encourage small frequent meals, but do not force eating if the child has anorexia.
7. Use meticulous hand washing technique and other procedures to prevent transmission of infection.
8. Assess for fever, cough, irritability, or other signs of infection.
9. Teach the parents to develop awareness of the child’s condition and behavior; recognize changes and care
for child accordingly.
10. Explain that the toddler may cling to infantile habits for security. Allow this behavior, it may disappear as
physical condition improves.
11. Stress that the disorder is lifelong; however, changes in the mucosal lining of the intestine and in general
clinical conditions are reversible when dietary gluten is avoided.

Hirschsprung’s Disease

• Also known as Congenital Aganglionic Megacolon.


• It is the congenital absence of or arrested development of parasympathetic ganglion cells in the intestinal
wall, usually in the distal colon.
• Symptoms are related to chronic intestinal obstruction and usually appear shortly after birth but may not
be recognized until later in childhood or (rarely) in adulthood.
• The lack of colorectal innervation inhibits peristalsis, and the affected portion of intestine becomes spastic
and contracted. The internal rectal sphincter fails to relax, which prevents evacuation of fecal material and
gas and causes severe abdominal distention and constipation.
• The most common site affected is the rectosigmoid colon (short segment disease), and the less common is
the upper descending colon and possibly the transverse colon are affected (long segment disease).

Assessment:

1. In the neonate:

• No meconium passed
• Vomiting – bile stained or fecal
• Abdominal distention
• Constipation – occurs in all patients
• Overflow-type diarrhea
• Anorexia, poor feeding
• Temporary relief of symptoms with enema

2. Older child (symptoms not prominent at birth):

• History of constipation at birth


• Distention of the abdomen – progressive enlarging
• Thin abdominal wall with observable peristaltic activity
• Constipation – no fecal soiling, relieved temporarily with enema
• Stool appears ribbon like, fluid like, or in pellet form
• Failure to grow – loss of subcutaneous fat; appears malnourished; perhaps has stunted growth
• Anemia

Diagnostic Evaluation:

1. Rectal examination demonstrate absence of fecal material in the long segment disease; in short segment
disease, rectal impaction may be present and, when the finger is removed, it may cause a rush of stool as
the obstruction is temporary relieved.
2. X-rays shows severe gaseous distention of the bowel, with absence of gas in the rectum.
3. Radiopaque markers, when ingested, measure intestinal transit time. Children with short segment disease
retain the markers in the rectum for long periods.
4. Barium enema [1] shows narrowed intestine proximal to anus and dilated intestine proximal to narrow
segment.
5. Rectal biopsy may be done to demonstrate absent or reduced number of ganglion nerve cells, and confirm
diagnosis.
6. Anorectal manometry may be done to record the reflex response to anal sphincter, requires cooperation of
the child.
7. Ultrasonogram may be done to demonstrate dilated colon.

Therapeutic Interventions:

1. Enema or colonic irrigation with physiologic saline solution.


2. Older child whose symptoms are chronic but not severe may be treated with isotonic enemas, stool
softeners, and a low residue diet.

Surgical Interventions:

1. Initially, a colostomy or ileostomy is performed to decompress intestine, divert fecal stream, and rest the
normal bowel.
2. Definitive surgery is done to remove the non-functioning bowel segment with various pull-through
procedures (abdominoperineal, endorectal, or rectorectal).

Nursing Interventions:

Preoperative

1. Assist in emptying the bowel by giving repeated enemas and colonic irrigations.
2. If abdominal distention is not relieved by enemas, discomfort is significant, and rectal tube insertion fails to
give relief, consult doctor for a nasogastric (NG) tube.
3. Offer pacifier for infant to suck if on parenteral fluids.
4. Encourage parents to hold and rock the infant.
5. Maintain position of comfort with head elevated. Offer soothing stimulation (eg. music, touch, play
therapy).
6. Offer small frequent feedings. Low residue diet will aid in keeping the stool soft.
7. Administer parenteral nutrition if feeding causes additional discomfort because of distention and nausea.
8. For older child, provide demonstration and written and verbal instruction to family for saline enema
administration and use of stool softeners.
Postoperative

1. Change wound dressing using sterile technique.


2. Prevent wound contamination from diaper.
3. Prevent perianal and anal excoriation by thorough cleaning and use of ointments after the infant soils
(postoperative stools can number 7 to 10 per day).
4. Use careful handwashing technique.
5. Report any wound redness, swelling or drainage, evisceration, or dehiscence immediately.
6. Suction oral secretions frequently to prevent infection of the tracheobronchial tree and lungs.
7. In older child, encourage frequent coughing and deep breathing to maintain respiratory status.
8. Allow the infant to cry for a short period to prevent atelectasis.
9. Change position of infant frequently to increase circulation and allow for aeration of all lung areas.
10. Maintain patency of NG tube immediately postoperatively.
11. Maintain NPO status until bowel sounds return and the bowel is ready for feedings as determined by the
physician.
12. Provide frequent oral hygiene while on NPO status.
13. Administer fluids to maintain hydration and replace lost electrolytes. Begin oral feedings as ordered.
14. Support the parents when teaching them to care for their child’s colostomy. Reassure parents that
colostomy will not cause delay in the child’s normal development.
15. Involve the entire family in teaching colostomy care [2] to enhance acceptance of body change of the
child.

Intussusception

• Is the invagination or telescoping of a portion of the intestine into


a adjacent, more distal section of the intestine causing mechanical obstruction.
• The cause may be idiopathic (unknown but following a viral infection); lead point (change in the mucosa
from another condition such as cystic fibrosis, Meckel’s diverticulum, or hematoma); or post operative.
• It occurs in children younger than age 3, most commonly ages 5 to 10 months.
• Without prompt treatment, necrosis of the involved segment leads to shock, perforation, and peritonitis.

Assessment:

1. Paroxysmal abdominal pain; legs drawn up, child is inconsolable; may be comfortable between episodes.
2. Blood in stool, or later “currant jelly” stools containing sloughed mucosa, blood, and mucus.
3. Vomiting.
4. Increasing absence of stools.
5. Abdominal distention, bowel sound diminished, absent or high pitch.
6. Sausage like mass palpable in abdomen (Dance’s sign).
7. Unusual looking anus; may look like rectal prolapse.
8. Dehydration and fever
9. Shock like state with rapid pulse, pallor, and marked sweating.

Diagnostic Evaluation:

1. X-ray of abdomen may show absence of gas or mass in right upper quadrant.
2. Barium enema [1] is done if there is no appearance of peritonitis; shows a concave filling defect (will help
reduce the invagination).
3. Ultrasonogram may be done to locate area of telescoped bowel.
4. Color Doppler sonography determines whether reducible. Absence of blood flow indicates ischemia and,
therefore, enema reduction should be avoided.

Surgical Intervention:

1. Intussusception can be surgically reduced, resection may be necessary if bowel is nonviable.

Nursing Intervention:

1. Monitor I.V. fluids and intake and output to guide in fluid balance.
2. Be alert for respiratory distress due to abdominal distention.
3. Monitor vital signs, urine output, pain, distention, and general behavior preoperatively and postoperatively.
4. Observe infant’s behavior as indicator of pain; may be irritable and very sensitive to handling or lethargic
or unresponsive. Handle the infant gently.
5. Explain cause of pain to parents, and reassure them about purpose of diagnostic tests and treatments.
6. Administer analgesic as prescribed.
7. Maintain NPO status as ordered.
8. Insert nasogastric tube if ordered to decompress stomach.
9. Continually reasses condition because increased pain and bloody stools may indicate perforation.
10. After reduction by hydrostatic enema, monitor vital signs and general condition – especially abdominal
tenderness, bowel sounds, lethargy, and tolerance to fluids – to watch recurrence.
11. Encourage follow up care.
12. Provide anticipatory guidance for developmental age of child.

Crohn’s Disease

• [1]
Also called as Regional Enteritis, Granulomatous Colitis,
Ileitis.
• Is a chronic transmural inflammation of the G.I tract that usually
affects the small and large intestines but it can occur in any part of
the alimentary canal.
• Cause is unknown, but is multifactorial with factors including viral
or bacterial infection, immune disorder, defect in the intestinal
barrier, dysfunctional repair of mucosal injury, genetic
predisposition, dietary and environmental factors (chemical
additives, milk products, heavy metals, low fiber) and cigarette
smoking.
• Complications include stricture and fistulae formation, dehydration,
nutritional deficiencies, hemorrhage, bowel perforation, and
intestinal obstruction.
• Incidence of colorectal cancer is higher in patients with Crohn’s Disease.

Assessment:

1. Signs and symptoms are characterized by exacerbations and remissions; onset may be abrupt or insidious.
2. Crampy intermittent pain.
o Inflammatory pattern result in milder abdominal pain, but with malnutrition due to malabsorption
and weight loss, and possible anemia (hypochromic or macrocytic).
o Fibrostenotic pattern may present with partial small bowel obstructions: Diffuse abdominal pain,
nausea, vomiting, and bloating.
o Perforating pattern is characterized by sudden profuse diarrhea, fever, localized tenderness due to
abscess, and symptoms of fistulae, such as pneumaturia and recurrent urinary tract infection.
3. Abdominal tenderness occurs, especially in right lower quadrant; right lower quadrant fullness or mass is
palpable.
4. Chronic diarrhea caused by irritating discharge; usual consistency is soft or semi-liquid. Bloody stools or
steatorrhea (fatty stools) may occur.
5. Low-grade fever occurs if abscesses are present.
6. Arthralgias may also occur.

Diagnostic Evaluation:

1. Increased white blood cell count and sedimentation rate; decreased hemoglobin; decreased albumin; and
possibly decreased potassium, magnesium, and calcium due to diarrhea.
2. Stool analysis shows leukocytes but no pathogens.
3. Barium enema [2] permits visualization of lesion of large intestine and terminal ileum; needs to be
scheduled before upper G.I. to prevent interference by barium passing through colon.
4. [3]
Upper G.I. barium studies show classic “string sign” at terminal
ileum that suggests constriction of a segment of intestine.
5. Colonoscopy to note cobblestone appearance of ulcerations and
fissures, skip lesions, and rectal sparing; biopsy can be taken for
definitive diagnosis.

Surgical Interventions:

1. Surgery is indicated only for complications. Roughly 70% of Crohn’s


disease patients eventually require one or more operations for
obstructions, fistulae, fissures, abscesses, toxic megacolon, or
perforation.
2. Surgical options include:

• Segmental bowel resection with anastomosis.


• Subtotal colectomy with ileorectal anastomosis (spares rectum).
• Total proctocolectomy with end ileostomy for severe disease in colon and rectum.

Nursing Interventions:

1. Monitor frequency and consistency of stools to evaluate volume losses and effectiveness of therapy.
2. Monitor dietary therapy; weigh the patient daily.
3. Monitor electrolytes, especially potassium. Monitor intake and output. Monitor acid-base balance because
diarrhea can lead to metabolic acidosis.
4. Monitor for distention, increased temperature, hypotension, and rectal bleeding; all signs of obstruction
caused by inflammation.
5. Observe and record changes in pain, especially frequency, location, characteristics, precipitating events,
and duration.
6. Offer understanding, concern, and encouragement because patient is often embarrassed about frequent
and malodorous stools, and often fearful of eating.
7. Have patient participate in meal planning to encourage compliance and increase knowledge.
8. Encourage patient’s usual support persons to be involved in management of the disease.
9. Provide small, frequent feedings to prevent distention of the gastric pouch. Diet is low in residue, fiber, and
fat; high in calories, protein, vitamins, and minerals.
10. Provide fluids as directed to maintain hydration (1,000 mL/24 hours minimum intake to meet body fluid
needs).
11. Clean rectal area and apply ointments as necessary to decrease discomfort from skin breakdown.
12. Facilitate supportive counseling, if appropriate.

Head-To-Toe Assessment (R. Abdomen)

In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a
supine position with the knees slightly flexed to relax abdominal muscles.

Inspection of the abdomen

• Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
• Contour (flat, rounded, scapold)
• Distension
• Respiratory movement.
• Visible peristalsis.
• Pulsations

Normal Findings:

• Skin color is uniform, no lesions.


• Some clients may have striae or scar.
• No venous engorgement.
• Contour may be flat, rounded or scapoid
• Thin clients may have visible peristalsis.
• Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen

• This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by
palpation or percussion.
• The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the
abdominal muscles.
• Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are
relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum.

Peristaltic sounds

These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis
can provide diagnostic clues relevant to the motility of bowel.

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

Divide the abdomen in four quadrants.

Listen over all auscultation sites, starting at the right lower quadrants, following the cross
pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures
that we follow the direction of bowel movement.

Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at
least 5 minutes, especially at the periumbilical area, before concluding that no bowel
sounds are present.

The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5
– 15 seconds. It is suggested that the number of bowel sound may be as low as 3 to as high
as 20 per minute, or roughly, one bowel sound for each breath sound.

Some factors that affect bowel sound:

1. Presence of food in the GI tract.


2. State of digestion.
3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).
4. Bowel surgery
5. Constipation or Diarrhea.
6. Electrolyte imbalances.
7. Bowel obstruction.

Percussion of the abdomen

• Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and
masses, and in assessing solid structures within the abdomen.
• The direction of abdominal percussion follows the auscultation site at each abdominal guardant.
• The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness.
• Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will
percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or at the mid axillary
line on the left side.
• Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver

The palms of the left hand is placed over the region of liver dullness.

1. The area is strucked lightly with a fisted right hand.


2. Normally tenderness should not be elicited by this method.
3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

1. Can be done by either indirect or direct method.


2. Percussion is done over the costovertebral junction.
3. Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

• It is a gentle exploration performed while the client is in supine position. With the examiner’s hands parallel
to the floor.
• The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but
gently palpating with slow circular motion.
• This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.

Tensing of abdominal musculature may occur because of:

1. The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.
2. The client is ticklish or guards involuntarily.
3. Presence of subjacent pathologic condition.

Normal Findings:

1. No tenderness noted.
2. With smooth and consistent tension.
3. No muscles guarding.

Deep Palpation

• It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall.
• The abdominal wall may slide back and forth while the fingers move back and forth over the organ being
examined.
• Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be felt with
this method.
• In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum,
the sigmoid colon, and the aorta.

Liver palpation:

There are two types of bi manual palpation recommended for palpation of the liver. The first one is the
superimposition of the right hand over the left hand.

1. Ask the patient to take 3 normal breaths.


2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation.
3. Press hand deeply over the RUQ

The second methods:

1. The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.
2. Place the examiner’s right hands parallel to the costal margin or the RUQ.
3. An upward pressure is placed beneath the client to push the liver towards the examining right hand, while
the right hand is pressing into the abdominal wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip beneath the examining fingers.

Normal Findings:

• The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise well
individuals, it may be felt a the costal margins.
• When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tender.

Head-To-Toe Assessment P. Thorax (Cardiovascular System)

Inspection of the Heart


The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and
heaves or lifts

Normal Findings:

1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size).
2. There should be no lift or heaves.

Palpation of the Heart


The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex,
moving to the left sternal border, and then to the base of the heart.

Normal Findings:

1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of
cardiac dullness.

Auscultation of the Heart

Anatomic areas for auscultation of the heart:

Aortic valve – Right 2nd ICS sternal border.

Pulmonic Valve – Left 2nd ICS sternal border.

Tricuspid Valve - – Left 5th ICS sternal border.

Mitral Valve - Left 5th ICS midclavicular line

Positioning the client for auscultation:

• If the heart sounds are faint or undetectable, try listening to them with the patient seated and learning
forward, or lying on his left side, which brings the heart closer to the surface of the chest.
• Having the client seated and learning forward s best suited for hearing high-pitched sounds related to
semilunar valves problem.
• The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and
extra heart sounds.

Auscultating the heart

A.
1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound
is best heard over the mitral valve; S2 is best heard over the aortric valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for one full minute.

Normal Findings:

1. S1 & S2 can be heard at all anatomic site.


2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 – 100 bpm.