PEDIATRIC NURSING

By: Daryl Joel C. Dumdum, RN

 Growth and Development
• Growth
– Increase in size of a structure.
• Development
– Maturation of structures
• Cephalocaudal
– Head to Toe
• Proximo-Distal
– Trunk to Peripheries
• Phylogeny
– Development or evolution of a species or group
• Ontogeny
– Development of an individual within a species
 Rates of Development
• Fast Growth Periods
– INFANCY and ADOLESCENTS
• Slow Growth Periods
– TODDLER THROUGH SCHOOL AGE
• FETAL and INFANCY
– The Head and neurologic tissue grow faster than other
tissues
• TODDLER and PreSCHOOL
– The trunk grows more rapidly than other tissues
• The limbs Grow most during School age periods
• The trunk grows faster than other tissue during
adolescence
 Theorists
Sigmund Freud ( Psychosexual Theory)
0-1 - ORAL STAGE
1-3 - ANAL STAGE
3-6 - PHALLIC STAGE
6-12- LATENCY STAGE
12 and Above - GENITAL SAGE
 ERIK ERIKSON
(PSYCHOSOCIAL)
• 0-1 INFANCY • Trust vs mistrust
• 1-3 TODDLER • Autonomy vs shame
• 3-6 PRESCHOOL • Initiative vs guilt
• 6-12 SCHOOL AGE • Industry vs inferiority
• 12-18 ADOLESCENT • Identity vs role
confusion
• 18-35 Early Adult
• Intimacy vs Isolation
• 35-60 Middle Adult
• Generativity vs
• 60 and above Late stagnation
Adult • Ego Integrity vs Despair
 Jean Piaget
(COGNITIVE)
• 0-2 Sensorimotor
– Reflexes, repetition of acts
• 2-4 Preconceptual
– Egocentrism, use of symbols, magical thinking
• 4-7 intuitive/ preoperational
– Cause and effect
• 7-11 Concrete operations
• 11-15 Formal Operations
– Reality & Abstract thought
 MEASUREMENT TOOLS
• Chronological Age -Assessment of
developmental tasks related to birth date
• Mental age-assessment of cognitive
development
– IQ
• Denver Developmental age
– Generalized assessment tool. Measures gross
motor, fine motor, language, and personal-
social development from newborn to 6 yrs
– Does not measure intelligence
• Growth Parameters
– Bone Age: x-ray of tarsals and carpals
– Growth charts
 Neonate
Birth to 1 month
• Weight increases weekly by 5-7oz (142-
198g)for first 6 months
• Length; grows 1 inch monthly for the first
6months
• Head Growth: equal to or slightly larger than
the chest. Increases by ½ inch monthly for
the first 6moths
• Brain Growth: Increase in size about 2/3
adult size at 1year and 90% adult size at 2
years
 Neonate
Birth to 1 month
• Behavior is reflex controlled
• Flexed extremities
• Can lift head slightly off bed when in prone
• Hearing and touch are well developed at birth
• Sight not fully developed until 6 years
– Differentiate darkness from light at birth
– Rapidly develops clarity of vision within 1 foot
– Fixates on moving objects
 Neonate
Birth to 1 month
• Cries to express displeasure
• Smiles indiscriminately
• Receives gratification through
sucking
• Makes throaty sounds
 1-4 months
• Posterior fontanel closes
• Moro Reflex and Tonic neck reflex begins
to fade
• Gains Head control: Balances head in
sitting position
• Rolls from back to side
• Begins voluntary hand-mouth activity
• Begins to be able to coordinate stimuli
from various sense organs
• Hearing: locates sound by turning and
visually searching
 1-4 months
• Vision: beginning hand eye coordination
• Prefers human face
• Follows objects at 180°
• Accommodation is equal to adult
• Crying becomes differentiated at 1 month
– Decreased during awake periods
– Ceases when parent is in view
• Vocalization distinct from crying at 1 month
– Squeals to show pleasure at 3 moths
– Coos, babbles, laughs, vocalizes when smiling
 SOLITARY PLAY
• BIRTH to 4 months
– Provide variety of brightly colored
objects, different sizes and textures
– Hang mobiles within 8-10 inches of
infant’s face
– Expose to various environmental
sounds; use rattles, musical toys.
 5-6 months
• Birth weight doubles at 6 months
• Eruption of teeth begins
– Lower incisor first
– Causes increased saliva and drooling
– Enzyme released during teething causes diarrhea, facial
skin irritation
– Slight fever
• Intentional rolling over
• Supports weight on arms
• Creeping
• Can grasp and let go voluntarily
• Transfers toys from one hand to another
 5-6 months
• Sits with support
• Hearing: can localize sounds above and
below the ear
• Vision: smiles at own mirror image and
responds to facial expressions of others
• Taste: sucking needs have decreased and
cup weaning can begin; chewing, biting
and taste preference begin to develop
• Vocalization: begins to imitate sounds
• Socialization: recognizes parents, stranger
anxiety begins to develop
 5-6 months
• SOLITARY PLAY
– Provide brightly colored toys to hold and
squeeze
– Allow infant to splash in bath
– Provide crib mirror
• Begins to imitate
• Can find partially hidden objects
 7-9 months
• Teething continues
– 7 months: upper central incisor
– 9 months: upper lateral incisor
• Sits unsupported; goes from prone to sitting
position
• Crawls
• Pulls self to standing position
• Develops finger-thumb opposition (pincer
grasp)
• Preference for dominant hand evident
• Can fixate on small objects
• Beginning to develop depth perception
 7-9 months
• Begins to understand object permanence,
searches for dropped objects
• Reacts to adult anger; cries when scolded
• Imitates simple acts and noises
• Responds to simple commands
• Vocalization: verbalizes all vowels and
most consonants
• Socialization: increased stranger anxiety
and anxiety over separation from parent
• Exhibits aggressiveness by biting at times
• Understands the word “NO”
 10-12 months
• Birth weight triples
• Length: 50% increase over birth length
• Head and chest circumference equal
• Teething
– Lower lateral incisors erupt
– Average of 8 deciduous teeth
• Creeps with abdomen off floor
• Walks with help or cruises
• May attempt stand alone
• Can sit down from upright position
• Weans from bottle to cup
 10-12 months
• Able to discriminate simple geometric forms
• Able to follow rapidly moving objects
• Vocalization: imitates animal sounds, can say 4-5
words but understands many more (ma, da)
• Socialization: begins to explore surroundings
• Play games such as pat-a-cake, peek-a-boo
• Shows emotions such as jealousy, affection,
anger, fear
• Recognizes objects by name
• Looks and follows pictures in book
• Shows more goal-directed actions
 1-3 years
• Slow growth
• Primary dentition (20 teeth) completed by 2 ½
years
• Develops sphincter control necessary for bowel
and bladder control
• Walks alone by 18 months
• Climbs stairs and furniture by 18 months
• Runs fairly well by 2 years
• Jumps from chair or step by 2 ½ years
• Balances on one foot
• Rides tricycle
 3-5 years
• Permanent teeth may appear late in
preschool
– Molars behind last temporary teeth
• Walks upstairs with alternating feet
by 3 yrs
• Walks downstairs using alternate feet
by 4 years
• Stands on 1 foot by 3 years
• Hops on 1 foot by 4 yrs
 3-5 years
• Skips and hops on alternate feet by 5 years
• Balances on 1 foot with eyes closed by 5 years
• Throws and catches ball by 5 years
• Jumps off 1 step by 3 years
• Jumps rope by 5 years
• Hands dominance is established by 5 years
• Builds a tower of blocks by 3 years
• Ties shoes at 5
• Copies a circle by 3 yrs
• Copies squares, traces a diamond by 4 yrs
• Copies a diamond and triangle , print letters and
numbers at 5
• Handles scissors well at 5 years old.
 6-12 years
• Slow growth continues
• Dentition
– Loses first primary teeth at about 6 years
– By 12 years has all permanent teeth except
final molars
• Vision completely mature
• Gross motor skills: children are very
energetic, develops greater strength
• Develops smoothness and speed in fine
motor control
 12 yrs old
– Girls
• Increase in size of breast & genitalia
• Appearance of axillary & pubic hair
• Menarche
– Boys
• Deepening of voice
• Development of muscle
• Increase in size of penis & testes
• Production of viable sperm
 12-18
• Adolescence
– Play - continuation of competitive play
– Fear - of obesity
- of replacement from friends
- of death
- of acne
– Significant Development
• They have distinctive odor
 • Nocturnal emission/ wet dreams are present
• Sperm is viable by the age of 17
• Testes & scrotum increases at age 17
• Breast & female genitalia increases until the
age of 18
– Characteristics
• Idealistic
• Rebellions
• Performance
• Conscious of body image
• Adventure some
• Smoking
• Alcoholism
• Drug addiction
• Premarital sex
 Interventions for the ill or
hospitalized Child
• Speak in quiet, pleasant tones
• Use words appropriate to age
• Do not explain more than necessary
• Always explain what you are going to do and its
purpose
• Be honest; do not lie about whether something will
hurt
• Do not make a promise you know you cant make
• Do not threaten, if necessary, punish the act not
the child
• Never shame the child by using terms like baby or
sissy
 Interventions for the ill or
hospitalized Child
• Involve parents in child care
• Promote independence
• Allow choices where possible, but do not
use yes/no questions unless you can
accept a “no “ answer
• Teach parents to anticipate next stage of
development
• If parents cannot stay with the child,
encourage them to bring in a favorite toy,
pictures of family members, or to make a
tape to be played for the child
 Interventions for the ill or
hospitalized Child
• PLAY
– Is a way to solve problems, becomes
enculturated, express creativity,
decreases stress in the environment,
prepare for different situations, sublimate
sensations, enhance fine and gross motor
development as well as social
development
– Make play appropriate for mental age and
physical disease
– Use multisensory stimulation
 Interventions for the ill or
hospitalized Child
• Provide toys safe for mental age
• Offer play specific to age groups
– Infants and Toddler: enjoys repetition,
solitary play, parallel play
– Preschooler: likes to role play and make
believe play. Associative play
– School age: likes groups, organized
activities (to enhance sharing) cooperative
play, group goals with interaction
 Preparation for procedures
• Allow the child to play with the equipments to be
used but provide safety
• Demonstrate procedure first on a doll
• Teach the child skills that will be needed after the
procedure and provide time for practice
• Desensitize the child
• Describe sensations to be felt by the child post-
procedure
• Parents can often be helpful in preparing the child
for the procedure, but needs to be prepared as well
• Inadequate preparation results in heightened
anxiety that may result in regressive behavior,
uncooperativeness, or acting out
 Failure to Thrive (FTT)
• A condition in which a child fails to gain
weight and is persistently less than the 5th
percentile on growth charts
• When related to inorganic cause it is
usually due to disrupted maternal - child
relationship
• Other pathology especially absorption and
hormonal dysfunctions must be ruled out
first before a diagnosis of FTT can be
obtained
 Failure to Thrive (FTT)
• Growth and development delay usually
improve with appropriate stimulation
• S/S
– Sleep disturbances: voluntary regurgitation
and reswallowing
– History of parental isolation and social
crisis with inadequate support systems
– Delayed growth and development
– Disturbed maternal and- infant interaction
 Failure to Thrive (FTT)
• Nursing Interventions:
– Provide consistent care
– Teach parents positive feeding techniques.
– Maintain face to face posture with the child
– Talk to child encouragingly during feeding
– Involve parents in care
• Provide supportive environment
• Give positive feedback
• Demonstrate and reinforce responding to
child’s cues
 Child Abuse
• Physical, emotional, or sexual abuse of
children; may result from intentional and
nonaccidental actions or may be from
intentional and nonaccidental acts of omission
(neglect)
• In sexual abuse 80% of children know their
abuser
• Adults who abuse are more likely victims of
abuse also
• Only 10 % of abusers have serious
psychologic disturbance, but most have low
self-esteem, little confidence and low
tolerance to frustrations
 Child Abuse
• Abuse is most common among
toddlers as they exercise autonomy
and parents may sense loss of power
• Assessment findings:
– No history to explain injury
– Delay in seeking medical attention
– History changes with repetition
– Injury not consistent with injury
– Skin injuries (bruises, burns, lacerations)
 Child Abuse
– Injury may show outline of instruments
use and may be in varying stages of
healing
– Musculoskeletal injuries, fractures,
sprains, dislocations,
– CNS injuries like subdural hematoma,
retinal hemorrhage
– Abdominal Injuries may include lacerated
liver, ruptured spleen
– Observation of parents and child may
reveal interactional problem
 Child Abuse
• NURSING INTERVENTIONS:
– Attend to physical needs of the child first
– Report suspected child abuse to
appropriate agency
– Encourage parents to express feelings
concerning abuse, hospitalization, and
home situation
– Provide education
– Initiate referrals for long term follow-up
(community agencies, pediatric and
mental heath clinics)
SIDS
(Sudden Infant Death Syndrome)
• Sudden death of any young child that is
unexpected by history and in which
thorough postmortem examination fails to
demonstrate adequate cause of death
• Cannot be predicted, cannot be prevented
• Peak age: 3 months ; 90% by 6 months
• Usually occurs during sleep; there is no
struggle and death is silent
• Diagnosis made at autopsy
SIDS
(Sudden Infant Death Syndrome)
• Although cause is unknown, chronic
hypoxemia and apnea are suggested
factors
• ASSESSMENT:
– Incidence higher in preterm infants,
twins or triplets, low birth weight infants
– Infants with abnormalities in respiration,
feeding, or other neurologic symptoms
at higher risk
 SIDS
(Sudden Infant Death
Syndrome)
• NURSING INTERVENTIONS:
– Nursing care is directed at supporting
parents/family
– Provide a room for the family to be alone
if possible. Stay with them; prepare them
for how infant will look and feel ( baby will
be bruised and blanched due to pooling of
blood until death was discovered; also
cold)
– Let parents say goodbye to the baby
(hold, rock)
SIDS
(Sudden Infant Death Syndrome)
– Reinforce that death was not their fault
– Provide appropriate support referrals;
clergy, significant others
– Explain how parents can receive autopsy
results
– Notify Family physician or pediatrician.
 Death and Dying
• Parental Response
– Major life stress event
– Initially parents experience grief in
response to potential loss of child
– Responses might include shock and
disbelief, denial, guilt, and depression
– May have long term disruptive effects
on family system
• Stress may result to divorce
• Behavioral problems
 Death and Dying
• Child’s Response
– Child concepts to death depends on
mental age
– Infants and toddler
• Live only in present
• Are concerned only with separation from
mother and being alone and abandoned
– Preschooler
• See death as temporary, a type of sleep or
separation
 Death and Dying
– School age
• Have a concept of time, causality, and
irreversibility (but still questions it)
– Adolescents
• Are thinking about the future and knowing that
they can not participate
• May express anger at impending death
• May find it difficult to talk about death
• May wish to plan own funeral
• May wish to write something for friends and
family
 NURSING IMPLICATIONS
• Communicating with dying child
– Use the child's own language
– Do not use euphemisms
– Do not expect an immediate response
– Never give up hope
– Do not leave the child
– Do not whisper in the room
– Touch is therapeutic
– Continue reading favorite stories of the child
– Lat parents participate
 Who ha!
• The nurse has assessed four children
of varying ages; which one requires
further evaluation?
1. a 7-month old who is afraid of strangers
2. A 4 year old who talks to an imaginary
playmate
3. A 9 yr old with enuresis
4. A 16 yr old who had nocturnal emissions
 All right!
• The nurse is caring for a 5 year old child who
has leukemia and is now out of remission and
not expected to survive. The child says to his
mother, “will you take care of me when I am
dead the way you do now?” The childs mother
asks the nurse how to respond. The nurse ‘s
response should be based on which of the
following understanding of the child’s behavior?
1. The child is denying that he has a terminal problem
2. The child may be hallucinating
3. Children of this stage do not understand the finality of
death
4. Most 5 yr old children have a great fear of mutilation
 Grabeh na to!
• When Child abuse is suspected, the
nurse knows that abusive burns will
1. Have a number of scars
2. Have identifiable shapes
3. Display an erratic pattern
4. Be on one side of the body
 Todo na talaga!
• The Nurse is talking with a mother of a one
year-old child in a well baby clinic. Which
statement the mother makes indicates a need
for more instruction in keeping the child safe?
1. I have some syrup of ipecac at home in case my
child ever needs it
2. I put all medicines on the highest shelf in the
kitchen
3. We have moved all the valuable vases and
figurines out of the family room
4. My husbund put the gates up at the top and
bottom of the stairs
 YEYE! BONEL!
• The presence of what condition
would necessitate a change in the
standard immunization schedule for
a child?
1. Allergy to eggs
2. Immunosuppression
3. Congenital defects
4. Mental Retardation
Common Pediatric Disorders
• Autosomal Dominant
– Allele responsible for the disease is
dominant
– Only one parent needs to pass on the gene.
– Examples:
• Huntington’s chorea
• Myotonic muscular dystrophy
• Night blindness
– Genetic Counselling: 50% chance with each
pregnancy that the child will have the
disease or disorder
Common Pediatric Disorders
• Autosomal Recessive
– Allele responsible for disease will not result ihn
expression if the other allele in the pair is
dominant
– Both parents must pass on the genes
– Examples:
• Cystic fibrosis
• PKU
• Sicke cell anemia
• Albinism
• Tay- Sachs
Common Pediatric Disorders
– Genetic Counselling:
• 25% chance with each pregnancy of haing a
child with the disorder
• 50% chance with each pregnancy of having
a child who is a carrier of the disease but
will not manifest the symptoms.
• 25% chance with each pregnancy of having
a child will neither have the disease nor be a
carrier.
• Sex - linked ( X-linked) Inheritance
–Inheritance of characteristics located
on X and Y chromosomes
–Examples:
• Color blindness
• Baldness
• Hemophillia A and B
–Genetic Counselling
• If a woman is a carrier and her partner
does not have the disorder
– 50% chance that her son will have the
disorder
–50% chance her daugther will
become a carrier
–If a man has a sex-linked disorder,
all his daughters will be carriers
but none will manifest the disease.
 Chormosome Disorders
• Down Syndrome
– Caused by an extra chromosome 21
( total of 47)
• Assessment Findings
– Head and Face
• Small head, flat facial profile, broad flat nose
• Small mouth, normal- size protruding tongue
• Low Set ears
– Extremities
• Short Thick Fingers and hands
 Chormosome Disorders
– Simian creases ( Single crease along palms)
– Muscle weakness, lax joints
• Associated anomalies and disorders
– Congenital heart defects
– GI structural defects
– Increase incidence of leukemia
– Increased Incidence of Respiratory infection
– Visual defects
• Mental Retardation
 Chormosome Disorders
• Nursing Interventions
– Provide parent education concerning
• Increased susceptibility to respiratory
infection
• Nutritional Needs
• Medication Administration if necessary
– Promote developmental progress
– Provide genetic counselling
Fluid And Electrolyte, Acid Base
Balance
• Dehydration
– Isotonic Dehydration
• Water and electrolytes loss are
proportionate
– Hypotonic dehydration
• Electrolytes deficit exceeds water loss
– Hypertonic Dehydration
• Water loss exceeds electrolyte loss
 Diarrhea
• A change in consistency and
frequency of stools
• Caused by bacteria and viruses,
parasites, poisons, inflammation,
malabsorption, allergies, etc
• Leads to metabolic acidosis
• Also causes loss of bicarbonate and
potassium
 Diarrhea
• Signs/ Symptoms
– Frequent stools with abdominal cramping
– Decreased urine output, decreased tears
and saliva, dry mucous membranes, dry
skin with poor turgor
– In children less than 18 mos. Depressed
anterior fontanel
– Increased Pulse Rate and decreased BP
– Sunken Eyes
– High pitched cry
 Diarrhea
• Nursing Interventions
– NPO to rest bowel if ordered
– Administer IV Fluids as ordered
– Resume Oral feeding slowly
– Provide skin care
– Monitor lab results
– Isolation if infectious
– Anti - diarrheal drugs
 Vomiting
• Differs from spitting up (dribbling of
undigested formula, often with burping)
• If prolonged may result in metabolic
alkalosis or aspiration
• Nursing Interventions:
– Treat the underlying cause
– Hydration
– Assess amount of vomitus, frequency, and
nature
 Vomiting
– Prevent complications
– Administer anti-emetic Medications
• Trimethobenzamine HCl ( Tigan)
• Promethazine HCl (Phenargan)
Nuerologic
Disorder
 HYDROCEPHALUS
• Increased amount of CSF within the
ventricles of the brain
• May be caused by obstruction of CSF flow
or by overproduction or inadequate
reabsorption of CSF
• Classification
– NONCOMMUNICATING/OBSTRUCTIVE
• obstruction within the ventricles such as congenital
malformation, neoplasm, or hematoma
– COMMUNICATING/CONGENITAL
• inadequate absorption of cerebrospinal fluid (CSF)
resulting from infection, trauma, or obstruction by
thick arachnoid membrane or meninges
Clinical findings
• 1. Increasing head size in the infant because of
open sutures and bulging fontanels
• 2. Prominent scalp veins and taut, shiny skin
• 3. "Sunset" eyes (sclera visible above iris),
bulging eyes, and papilledema of retina
• 4. Head lag, especially important after 4 to 6
months
• 5. Increased intracranial pressure: projectile
vomiting not associated with feeding, irritability,
anorexia, high shrill cry, seizures
• 6. Damage to the brain because increased
pressure decreases blood flow to the cells,
causing necrosis
Therapeutic interventions
• 1. Relief of hydrocephalus
– a. Removal of the obstruction if that is
the cause
– b. Mechanical shunting of fluid to
another area of the body-ventricular
peritoneal shunt: catheter passed
subcutaneously to the peritoneal cavity;
revised as necessary
• 2. Treatment of complications
• 3. Management of problems related
to effect on psychomotor problems
 Nursing Care of Infants and
Children with Hydrocephalus
A. Assessment
• 1. Head circumference/fontanels
• 2. Signs of increased intracranial pressure

B. Analysis/Nursing Diagnoses
• 1. Altered family process related to having
a seriously ill child
• 2. Risk for infection related to shunt
• 3. Risk for injury related to increased
intracranial pressure
• 4. Risk for skin breakdown related to
immobility
Planning/Implementation
• 1. Prevent breakdown of scalp, infection, and
damage to spinal cord
– a. Place the infant in a Fowler's position to
facilitate draining of fluid; infant should be
positioned flat postoperatively with no pressure on
shunted side
– b. When holding the infant, support the neck and
head
– c. Observe shunt site (abdominal site in peritoneal
procedure) for infection
• 2. Monitor for increasing intracranial pressure
– a. Carefully observe neurologic signs
– b. Measure head circumference
– c. Use minimal sedatives or analgesics, which can
mask symptoms
– d. Check the valve frequently for patency
Promote adequate nutrition
– a. Monitor for vomiting, irritability,
lethargy, and anorexia, because these
will decrease the intake of nutrients
– b. Perform all care before feeding to
prevent vomiting; hold infant if possible
– c. Observe for signs of dehydration

4. Keep eyes moist and free of

irritation if eyelids incompletely cover
corneas
5. Postoperative nursing care: similar to that for cardiac
surgery with the addition of:
• a. Place the infant or child on bed rest after surgery, with
minimal handling to prevent damage to shunt
• b. Support parents
– (1) Continued shunt revisions are usually necessary as
growth occurs
– (2) Usually very concerned about developmental delay
• c. Observe for brain damage by recording milestones
during infancy
• d. Teach parents
– (1) Pumping of the shunt, if indicated, to maintain
patency
– (2) Signs of increasing intracranial pressure and
infection
– (3) Evidence of dehydration
 SPINA BIFIDA
1. Failure of posterior vertebral arches to fuse
during embryonic development
2. Causes: idiopathic, sibling with neural tube
defect, radiation, viral, environmental factors
3. 85%= lower thoracic lumber or sacral
area, 15% = upper thoracic & cervical
regions
TYPES
1. SPINA BIFIDA OCCULTA
2. SPINA BIFIDA CYSTICA
2.1. MENINGOCELE
2.2. MYELOMENINGOCELE
 SPINA BIFIDA
• MEDICAL MANAGEMENT
• 1. SURGERY: CLOSURE OF SAC,
SHUNT, ORTHOPEDIC PROCEDURES
• 2. DRUG THERAPY: Antibiotics
• 3. Immobilization
• ASSESSMENT FINDINGS
• 1. Examine the defect for size, level,
tissue covering & CSF leakage
• 2. Motor/sensory involvement
• 3. Bowel & bladder function:
NEUROGENIC BLADDER
 SPINA BIFIDA
DIAGNOSTIC TEST
1. PRENATAL: ALPHAFETOPROTEIN
NURSING INTERVENTIONS
1. Prevent trauma to the sac: covering,
positioning, keeping dryness, antibiotics )
2. Prevent complications ( hydrocephalus,
neurogenic bladder, immobilization )
3. 3. Adequate nutrition
 CEREBRAL PALSY
1.Neuromuscular disorders resulting from
damage to or altered structure of the
part of the brain responsible for motor
function
2. Causes
3. 2.1. PRENATAL: genetic, trauma or
anoxia to mother
2.2. PERINATAL: drugs at delivery,
precipitate delivery, fetal distress, breech
deliveries with delay
2.3. POST NATAL:
kernicterus or head trauma
 CEREBRAL PALSY
MEDICAL MANAGEMENT
1. DRUG therapy: anti-anxiety, skeletal muscle
relaxants, local nerve blocks
2. PT/OT
3. Speech/audiology therapy
4. Surgery
ASSESSMENT FINDINGS
– Spasticity
– Athetosis
– Ataxia
– Tremors
– Rigidity
 CEREBRAL PALSY
ASSOCIATED PROBLEMS
a. Mental retardation e. Orthopedic problems
b. Hearing loss f. Visual disabilities
c. Defective speech g. Disturbances of body image,
touch, perception
d. Dental anomalies h. Feelings of worthlessness

NURSING INTERVENTIONS
1. Obtain a careful pregnancy, birth, and childhood history
2. Limit stimulation
3. Assist in ADL, demonstration of procedure is essential
4. Provide a safe environment ( safety helmet, padded
crib )
5. PT
 Meningitis
• A. Most common CNS infection of
infants and children
• B. Inflammation of the meninges
by viral or bacteria that travel
via the cerebrospinal fluid
Classification: culture of cerebrospinal fluid
used to help identify organism

• 1. Bacterial: caused by pus-forming

bacteria, especially meningococcus,
pneumococcus, and influenza bacillus

• 2. Tuberculous: caused by tubercle bacillus

• 3. Viral or aseptic: caused by a wide

variety of viral agents
Clinical findings
• 1. Opisthotonos: rigidity and
hyperextension of the neck
• 2. Headache
• 3. Irritability and high-pitched cry
• 4. Signs of increased intracranial pressure
• 5. Fever, nausea, and vomiting
• 6. Meningococcal meningitis: petechiae
and purpuric skin rash

Therapeutic intervention - massive doses of

intravenous antibiotics
 Children with Meningitis

A. Assessment
• 1. Fever
• 2. Headache, irritability
• 3. Vomiting
• 4. Seizures
• 5. Nuchal rigidity
B. Analysis/Nursing Diagnoses
• 1. Altered family processes related to
having a child with a serious illness

• 2. Risk for infection related to

presence of infective organisms

• 3. Risk for injury related to presence

of infection
C. Planning/Implementation
• 1. Provide for rest
• 2. Decrease stimuli from the environment (control
light and noise)
• 3. Position on the side with head gently supported
in extension
• 4. Institute respiratory isolation
• 5. Maintain fluid balance because of meningeal
edema
a. Record intake and output carefully
b. Correct any deficits
c. Monitor IV fluid
d. Daily weights
• 6. Provide emotional support for parents, since
child usually becomes ill suddenly
• 7. Administer antibiotic therapy as prescribed
• 8. Observe for complications such as septic shock
and circulatory collapse
D. Evaluation/Outcomes
• 1. Child shows decreasing severity of
illness
• 2. Family verbalizes fears regarding
child's prognosis
CardioVascular
Disorder
 CONGENITAL HEART DEFECTS

• Acyanotic Heart Defects

– Oxygenated blood is shunted from the
systemic to pulmonary circulation ( left
to right shunt) and blood leaving the
aorta is completely oxygenated
• Cyanotic Heart Defects
– Unoxygenated blood is shunted from the
right to the left side of the heart where
it mixes with oxygenated blood
 Acyanotic Heart Defects
• Atrial Septal Defect ( ASD )
– Abnormal opening in the septum between
left and right atria, causing a left to right
shunt
• Ventricular Septal Defect (VSD)
– Opening in the septum between
ventricles, causing a left - to - right shunt
• Patent Ductus Arteriosus (PDA):
Failure to close at birth
 Acyanotic Heart Defects
• Coarctation of the Aorta
– Narrowing of the Aorta usually just
beyond the left subclavian artery
• Pulmonary Stenosis
• Aortic Stenosis
• Endocardial Cushion defects
 ATRIAL SEPTAL DEFECT
• Four types
– Ostium secundum
defect
– Ostium primum
defect
– Sinus venosus
defect
– Coronary sinus
septal defect
 Manifestations
• prominent right ventricular cardiac
impulse
• palpable pulmonary artery pulsations
• Mitral valve prolapse
– In patients with mitral valve prolapse,
an apical holosystolic or late systolic
murmur often is heard radiating to the
axilla.
 Management
• Cardiac catheterization
• surgical closure

NURSING:
Oxygenation
Emotional Support
Education
 Ventricular Septal Defect
• A ventricular septal defect (VSD),
which is a hole between the 2 lower
chambers of the heart, may occur as
a primary anomaly with or without
additional major associated cardiac
defects
• VSD is a developmental defect of the
interventricular septum whereby a
communication exists between the
cavities of the two ventricles.
 Manifestations
• Infants with small defects
– Normal vital signs
– Clear lungs
– Absence of jugular venous distension
(JVD), hepatomegaly, or edema
– Mildly hyperactive precordial impulse
– Second heart sound (S2): S2 may be
obscured entirely by the holosystolic
murmur, which is well localized at the
left sternal border.
 Manifestations
• Infants with large VSDs
– Cyanosis
– Clubbing
– Erythrocytosis
– Prominent RV lift, maximal in xiphoid region, revealed on
palpation
– Very short or no systolic murmur
– S2 - Loud, palpable, single, or closely split
– S3 of right ventricular origin - May be present
– Squatting in 15% of patients
• Hemoptysis: Hemoptysis occurs in 33% of patients
(never in patients <24 y); it occurs in 100% of
patients by age 40 years and contributes to cause of
death.
 Management
– Furosemide in a dosage of 1-3 mg/kg/d in 2 or
3 divided doses is used. Long-term furosemide
treatment results in hypercalcemia and renal
damage and electrolyte disturbances. Increase
the caloric density of the feedings.
– Captopril in a dosage of 0.1-0.3 mg/kg 3 times
daily can be useful to reduce systemic
afterload.
– Digoxin in a dosage of 5-10 mcg/kg/d may be
indicated if diuresis and afterload reduction do
not relieve symptoms adequately
 Patent Ductus Arteriosus
• The ductus arteriosus is normally patent during fetal
life. This patency is promoted by continual production
of prostaglandin E2 (PGE2) by the ductus.
Prostaglandin antagonism, such as maternal use of
nonsteroidal anti-inflammatory medications, can
cause fetal closure of the ductus arteriosus. This can
be associated with severe fetal cardiovascular
compromise.
• Normally, functional closure of the ductus arteriosus
occurs by about 15 hours of life in healthy infants
born at term. This occurs by abrupt contraction of the
muscular wall of the ductus arteriosus, which is
associated with increases in the partial pressure of
oxygen (PO2) coincident with the first breath.
 Manifestations
– The apical impulse is laterally displaced.
A thrill may be present in the
suprasternal notch or in the left
infraclavicular region.
– The first heart sound (S1) is typically
normal. The second heart sound (S2)
often is obscured by the murmur
• MANAGEMENT
– Surgical ligation
 Cyanotic Heart Defects
• Tetralogy of fallot
– Pulmonary stenosis
– Coarctation of the Aorta
– Ventricular Septal Defect
– Right Ventricular Hypertrophy
• Symptoms Depends on the degree of
pulmonary stenosis
 Cyanotic Heart Defects
ASSESSMENT
S/SX= CYANOSIS, Polycythemia, clubbing of
digits, poor growth, squatting, risk for blood
clots, CHF( LEFT SIDE )
A.3. NURSING INTERVENTIONS
a.3.1. Don’t interfere when squatting
a.3.2. Organize care
a.3.3. Administer oxygen
a.3.4. Meet needs quickly
a.3.5. Use soft nipple for feeding
a.3.6. Provide careful skin care
a.3. 7. Antibiotic prophylaxis
 RHD
• Caused by GABHS
• Signs and symptoms
– Fever
– Migratory poly arthritis
– Malnourished
• Treatment:
– Aspirin
– Sumapen
– Supportive
Disorder of the
Hematologic
System
 SICKLE CELL ANEMIA
• A. Autosomal disorder affecting hemoglobin
• B. Defective hemoglobin causes red blood cells
to become sickle shaped and clump together
under reduced oxygen tension; initially fetal
hemoglobin prevents sickling
MEDICAL MANAGEMENT
b.1. Drug therapy: UREA,
ANALGESIC/NARCOTICS( avoid aspirin ), ANTIBIOTICS
b.2. Exchange/blood transfusion
b.3. Hydration
b.4. Bed rest
b.5. Surgery
 SICKLE CELL ANEMIA
ASSESSMENT FINDINGS
1. Abdomen ( first sign: colic )
2. Lower extremities ( hand-foot syndrome,
ulcers)
3. Spleen ( splenomegaly )
4. Bones ( osteoporosis )
5. Nervous system ( CVA )
6. Kidneys ( infarts, enuresis )
7. Heart ( Heart failure = hemosiderosis )
8. Genitals (impotence)
 SICKLE CELL ANEMIA
Vasoocclusive crisis (pain episode): most
common and non–life-threatening
– a. Results from sickled cells obstructing
blood vessels, causing occlusion,
ischemia, and potential necrosis
– b. Symptoms include fever, acute
abdominal pain (visceral hypoxia), hand-
foot syndrome, priapism, and arthralgia
without an exacerbation of anemia
 SICKLE CELL ANEMIA
2. Splenic sequestration crisis
• a. Results from the spleen pooling large
quantities of blood, which causes a
precipitous drop in blood pressure and
ultimately shock
• b. Acute episode occurs most commonly in
children between 8 months and 5 years of
age; can result in death from anemia and
cardiovascular collapse
• c. Chronic manifestation is termed
functional asplenia
 SICKLE CELL ANEMIA
3. Aplastic crisis: diminished red blood cell production
• a. May be triggered by a viral or other infection
• b. Profound anemia results due to rapid destruction
of red blood cells combined with a decreased
production

4. Hyperhemolytic crisis: increased rate of red blood cell

destruction
• a. Characterized by anemia, jaundice, and
reticulcytosis
• b. Rare complication that frequently suggests a
coexisting abnormality such as glucose-6-phosphate
dehydrogenase deficiency
 SICKLE CELL ANEMIA
5. Stroke: sudden and severe complication with
no related illnesses
• a. Sickled cells block the major blood vessels
in the brain
• b. Repeat strokes in 60% of children who
have experienced previous one

6. Chest syndrome: clinically similiar to

pneumonia
7. Overwhelming infection
• a. Streptococcus pneumonia
• b. Haemophilus influenzae type B
 SICKLE CELL ANEMIA
DIAGNOSTIC TEST
d.1. Sickle cell test
d.2. Sickledex
d.3. Hgb electrophoresis

NURSING INTERVENTIONS
1. Hydration & oxygenation
2. Avoid tight clothing
3. Bed rest
4. Correct metabolic acidosis
5. Decrease emotional stress
 SICKLE CELL ANEMIA
Therapeutic interventions
• 1. Prevention of sickling phenomenon
– a. Adequate oxygenation
– b. Adequate hydration
– c. Administration of hydroxyurea to limit
sickling
• 2. Treatment of crisis
– a. Rest
– b. Hydration/electrolyte replacement
– c. Pain management
– d. Antibiotic therapy
– e. Blood products
 SICKLE CELL ANEMIA
Assessment
• 1. Vital signs
• 2. Neurologic signs
• 3. Vision/hearing
• 4. Location and intensity of pain
 SICKLE CELL ANEMIA
. Analysis/Nursing Diagnoses
• 1. Body image disturbance related to:
– a. Retarded growth and maturation
– b. Limited activity tolerance
– c. Chronic illness

• 2. Fear related to:

– a. Unfamiliar environment
– b. Separation from support system

• 3. Pain related to tissue ischemia

• 4. Altered tissue perfusion (cardiovascular) related

to decreased oxygen tension
 SICKLE CELL ANEMIA
Planning/Implementation
• 1. Prevent crisis
– a. Avoid infection, dehydration, and other conditions
causing strain on body, which precipitates a crisis;
prophylactic use of pneumococcal, meningococcal,
and Haemophilus flu vaccines
– b. Avoid hypoxia: treat respiratory tract infections
immediately
– c. Avoid dehydration
• (1) May cause a rapid thrombus formation
• (2) Daily fluid intake should be calculated according to
body weight (130 to 200 ml per kilogram [2 to 3 oz per
pound])
• (3) During crisis, fluid needs to be increased, especially if
the child is febrile
 SICKLE CELL ANEMIA
• 2. During crisis provide for:
– a. Adequate hydration (may need IV
therapy)
– b. Proper positioning, careful handling
– c. Exercise as tolerated (immobility
promotes thrombus formation and
respiratory problems)
– d. Adequate ventilation
– e. Control of pain; use narcotics; schedule
to prevent pain
– f. Blood transfusions for severe anemia
 SICKLE CELL ANEMIA
• 3. Provide for genetic counseling
– a. Disorder mostly of blacks; can be
found in Mediterranean people
– b. Parents need to know the risk of
having other children with trait or disease
– c. If both parents are carriers, each
pregnancy has 25% chance of producing
a child with the disease
– d. Screen young children for the disorder,
since clinical manifestations usually do
not appear before 6 months of age
 SICKLE CELL ANEMIA
. Evaluation/Outcomes
• 1. Child reports minimal pain
• 2. Child verbalizes feelings about
disease process
• 3. Child demonstrates positive body
image
• 4. Child does not exhibit signs of
sickling
 HEMOPHILIA
• TYPES
– b.1. Hemophilia A: Factor VIII
– b.2. Hemophilia B: Christmas
disease/factor IX deficiency
– b.3. Hemophilia C: Factor XI deficiency
– ASSESSMENT FINDINGS
– 1. Prolonged bleeding after minor injury
– 2. Bruising, hematomas, no petechiae
– 3. Hemarthrosis
– 4. Peripheral neuropathies
– 5. Prolonged PTT, anemia
–
 HEMOPHILIA
NURSING INTERVENTIONS
1. Control acute bleeding episode ( I-C-E
)
2. Provide care for hemarthrosis
3. Administer cryoprecipitate
4. Provide client teaching: prevention of
trauma & genetic counselling
 Dengue Hemorrhagic
Fever /Dengue Shock
Syndrome
• Caused by Dengue Virus (I,II,III,IV)
• Vector: Aedes Aegyptii
• MOT: Mosquito bite
• Signs/ Symptoms:
– Petechial rash
– Epistaxis
– Hematemesis
– Melena
– DHN
Disorder of the
Respiratory
System
 CYSTIC FIBROSIS
GENERAL INFORMATION
1. Dysfunction of the exocrine glands ( respiratory, GIT,
sweat, salivary, pancreas )
2. Autosomal recessive inheritance
3. Affected organs: ( 1 ) PANCREAS, ( 2 ) RESPIRATORY,
( 3 ) REPRODUCTIVE, ( 4 ) LIVER
4. Fatal disease: average age at death is 20 years
MEDICAL MANAGEMENT
1. Pancreatic involvement: promote absorption of nutrients
1.a. Diet modification: predigested formula, high
calorie/low fat, high protein
1.b. Pancreatic enzyme supplementation
2. Respiratory involvement: chest physiotherapy, antibiotic
 CYSTIC FIBROSIS
ASSESSMENT FINDINGS
1. PANCREATIC INVOLVEMENT
( 1 ) FTT, steatorrhea, meconium ileus, rectal
prolapse, voracious appetite, protruding
abdomen, vit ADEK deficiencies, anemia
( 2 ) Diagnostic test: DECREASE TRYPSIN,
FECAL FAT increase
2. RESPIRATORY INVOLVEMENT
( 1 ) S/SX of respiratory distress, barrel chest,
productive cough, pseudomonas infection,
clubbing of digits
 CYSTIC FIBROSIS
3. ELECTROLYTE INVOLVEMENT
• ( 1 ) HYPONATREMIA, Salty taste of
sweat
• ( 2 ) PILOCARPINE IONTOPHORESIS
SWEAT TEST = 2-5 x normal amount
NURSING INTERVENTIONS
1. PANCREATIC INVOLVEMENT
1.1. Pancreatic enzymes with meals
1.2. Provide highcalorie, high
carbohydrate & protein, low fat
 CYSTIC FIBROSIS
2. RESPIRATORY INVOLVEMENT
2.1. Administer antibiotics
2.2. Administer expectorants, mucolytic
2.3. Avoid cough suppressants
2.4. Breathing exercises, postural drainage
4 times/day
2.5. Provide aerosol treatments, mist tent
3. ELECTROLYTE IMBALANCE
3.1. High sodium intake
Disorder of the
GIT
 CLEFT LIP AND PALATE
• GENERAL INFORMATION
– Failure of merging between the medial nasal
and maxillary processes at the fifth week of
embryonic development, on one or both sides
• MEDICAL MANAGEMENT
• 1. Speech therapist, dentist/orthodontist,
audiologist,otolaryngologist, pediatrician
• 2. Surgical correction
• 2.1. CHEILOPLASTY( 2 months )
• 2.2. PALATOPLASTY ( 18 months )
•
 CLEFT LIP AND PALATE
• NURSING INTERVENTIONS
• D.1 Pre-operative CHEILOPLASTY
• 1. Proper positioning in feeding
• 2. Burp frequently
• 3. Use a large-holed nipple
• 4. Use a rubber-tipped syringe
• 5. Gavage feeding
• 6. Finish feeding with water
• 7. Provide SFF
• D.2 Post-operative CHEILOPLASTY
• 1. Maintain patent aiway
• 2. Assess color, monitor amount of
swallowing
• 3. DO NOT PLACE IN PRONE
POSITION
• 4. Anticipating child’s needs
• 5. Use elbow restraints
• 6. Keep suture line clean
• 7. Provide pain control relief
• D.3. Pre-operative PALATOPLASTY
• 1. Infant should be weaned to cup
before surgery
• D.4. Post-operative PALATOPLASTY
• 1. POSITION ON SIDE
• 2. Have suction available
• 3. Prevent injury or trauma to suture
line( use CUP,no bottles, straw, utensils )
 PYLORIC STENOSIS
• GENERAL INFORMATION
– also known as infantile hypertrophic pyloric stenosis
(IHPS), is the most common cause of intestinal
obstruction in infancy. It occurs secondary to hypertrophy
and hyperplasia of the muscular layers of the pylorus.
• MEDICAL MANAGEMENT
• b.1. Noninvasive: thickened feedings
• b.2. Surgery: Pyloroplasty

• ASSESSMENT FINDINGS
1. Olive-size bulge under right rib cage
2. FTT
3. Projectile vomiting
4. Dehydration
• 5. DIAGNOSTIC TEST: UGIS, Serum electrolytes, Hematocrit
 PYLORIC STENOSIS
• NURSING INTERVENTIONS
• D.1. PRE-OPERATIVE
• 1. Administer replacement fluids
• 2. Prevent vomiting ( give thickened feeding,
high fowler’s position, place on right side after
feeding )
• 3. Prevent aspiration
• D.2. POST-OPERATIVE
• 1. Advance DAT
• 2. Place on right side after feeding
• 3. Monitor I & O, signs of infection
 INTUSSUSCEPTION
GENERAL INFORMATION
– a segment of intestine invaginates into
the adjoining intestinal lumen, causing a
bowel obstruction.
• A. Telescoping of one portion of the
intestine into another; occurs most
frequently at the ileocecal valve
• B. Males affected two times more
frequently than females
• C. Usually occurs between 3 to 12 months
of age
 INTUSSUSCEPTION

Classification
• 1. Ileocecal: invagination at the
ileocecal valve; most common type
• 2. Ileoileal: one part of ileum
invaginates on another section of the
ileum
• 3. Colocolic: one part of the colon
invaginates on another section of the
colon
Clinical findings
• 1. Healthy, well-nourished infant or child
who wakes up with severe paroxysmal
abdominal pain, evidenced by kicking
and drawing legs up to the abdomen
• 2. One or two normal stools, then bloody
mucus stool ("currant jelly-like“ stool)
• 3. Palpation of sausage-shaped mass
• 4. Other signs of intestinal obstruction
usually present
 MEDICAL MANAGEMENT

• 1. Barium enema to reduce

telescoping
• 2. Surgery ( if with Peritonitis )
– Medical reduction by hydrostatic
pressure (barium enema)
– Surgical reduction; sometimes with
intestinal resection
 Children with Intussusception

Assessment
• 1. Sudden, acute, intermittent
abdominal pain
• 2. Vomiting
• 3. Red "currant jelly-like" stools
• 4. Tender, distended abdomen
 INTUSSUSCEPTION
Planning/Implementation
• 1. Same as for any abdominal
surgery
• 2. Make provisions for frequent
parental visits because the problem
usually occurs when the child is 6 to
8 months of age and separation
anxiety is acute
Evaluation/Outcomes
• 1. Child does not show physiologic
manifestation of pain
• 2. Family can verbalize feelings
about the illness
• 3. Child consumes sufficient
nutrients for growth
• 4. Child does not exhibit signs of
dehydration
Analysis/Nursing Diagnoses
• 1. Pain related to invaginating bowel
• 2. Altered family processes related to
having a child with life-threatening illness
• 3. Altered nutrition: less than body
requirements related to:
– a. Decreased intake
– b. Increased peristalsis
• 4. Risk for fluid volume deficit related to:
– a. Vomiting
– b. Diarrhea
 CELIAC DISEASE
– Absorptive disorder of the GI tract
• MEDICAL MANAGEMENT
• 1. Diet therapy: BROW free/gluten-
free
• 2. TPN
• ASSESSMENT FINDINGS
• 1 Steatorrhea
• 2. Chronic diarrhea
• 3. FTT
•
 CELIAC DISEASE
• 4. Distended abdomen, muscle wasting
• 5. Abdominal pain, listlessness
• 6. Vit A,D,E,K deficiency
• 7. Diagnostic test: ( 1 ) PANCREATIC
ENZYMES & SWEAT CHLORIDE
• TEST ( 2 ) Jejunal &
duodenal biopsy: ATROPHY OF MUCOSA
• NURSING INTERVENTIONS
• 1. Monitor gluten-free diet
• 2. Provide fat-soluble vitamins
 Hirschsprung Disease
• Absence of aganglionic nerve in the
portion of the colon
• Characteristic sign:
– Ribbon-like stool
– Symptoms, same as pyloric stenosis
• Management:
– Resection of the colon
– Colostomy
Disorder of the
Renal System
 NEPHROSIS/NEPHROTIC SYNDROME
• PATHOPHYSIOLOGY
• 1. PROTEINURIA
• 2. HYPOALBUMINEMIA
• 3. EDEMA
• 4. HYPERLIPIDEMIA
• MEDICAL MANAGEMENT
• 1. DRUG THERAPY: Steroids, antibiotics,
diuretics, Antimetabolites ( Cytoxan )
• 2. Bed rest
• 3. Diet: HIGH PROTEIN, LOW
SODIUM
 NEPHROSIS/NEPHROTIC SYNDROME
• ASSESSMENT FINDINGS
• 1. Anorexia, vomiting, diarrhea, malnutrition
• 2. Pallor, lethargy
• 3. Hepatomegaly
• NURSING INTERVENTIONS
• 1. Bed rest 4. I & O and weight
monitoring
• 2. Diet 5. Protect from
known sources of infection
• 3. Maintain skin integrity 6.
Provide scrotal support
•
Pediatric
Oncology
 LEUKEMIA
• GENERAL INFORMATION
• TYPES
• b.1. ACUTE LYMPHOCYTIC LEUKEMIA
( ALL )
• b.2. ACUTE NONLYMPHOCYTIC LEUKEMIA
( ANLL )
• MEDICAL MANAGEMENT
• 1. Diagnosis: blood studies, bone marrow biopsy
• 2. Treatment stages
• a. Induction: intense & potentially life
threatening
• b. CNS prophylaxis
• c. Maintenance: 2 to 3 years
 LEUKEMIA
• ASSESSMENT FINDINGS
• 1. BLOOD: ANEMIA, BLEEDING,
INFECTION
• 2. Enlarged lymph nodes
• 3. Enlarged spleen & liver
• 4. Abdominal pain with weight loss & anorexia
• 5. Bone pain
• NURSING INTERVENTIONS
• 1. Provide care for client receiving
chemotherapy, radiation therapy
• 2. Support for family & child
 WILM’S TUMOR/NEPHROBLASTOMA
• GENERAL INFORMATION
– is the most common type of kidney cancer in children.
About 90% of kidney cancers in children are Wilms
tumors.

• MEDICAL MANAGEMENT
• 1. Nephrectomy( 24-48 hours of diagnosis )
• 2. Radiation therapy
• 3. Chemotherapy: Vincristine, Daunorubicin,
Doxorubicin
• ASSESSMENT FINDINGS
• 1. Mother notices MASS while bathing or dressing child;
nontender, midline near
• liver
• 2. Hypertension, hematuria, anemia
• 3. Diagnostic test: IVP
 WILM’S TUMOR/NEPHROBLASTOMA
• NURSING INTERVENTIONS
• 1. DO NOT PALPATE ABDOMEN
• 2. Handle carefully when bathing
• 3. Provide care for a client post
nephrectomy
• 4. Provide care for a client
receiving chemotherapy, radiation
therapy
 HODGKIN’S LYMPHOMA
• GENERAL INFORMATION
– is a cancer that starts in lymphatic tissue. Lymphatic
tissue includes the lymph nodes and related organs
that are part of the body's immune and blood-forming
systems.
MEDICAL MANAGEMENT
• 1. DIAGNOSIS: Lymphangiogram, biopsy( REED-
STERNBERG CELLS ),
• splenectomy
• 2. RADIATION THERAPY, CHEMOTHERAPY
• ASSESSMENT FINDINGS
• 1. Enlarged nodes in lower cervical region; nodes are
NONTENDER, PAINLESS,
• FIRM & MOVABLE
• 2. Recurrent, intermittent fever
•
 HODGKIN’S LYMPHOMA
• 3. Night sweats
• 4. Weight loss, malaise, lethargy
• 5. Pruritus
• NURSING INTERVENTIONS
• 1. Provide care for child on
chemotherapy, radiation therapy
• 2. Protect from infection if
splenectomy is performed
• 3. Provide support for child/adolescent
parents
POISONING
 Poisoning
• A. Ingestion of a toxic substance or
an excessive amount of a substance
• B. More than 90% of poisonings
occur in the home
• C. Highest incidence occurs in
children under 4
• D. Improper storage is the major
contributing factor to poisonings
 Poisoning
A. Assessment
• 1. Vital signs
• 2. Need for respiratory or cardiac
support
• 3. Treat other symptoms such as
seizures
• 4. See Clinical Findings under type of
poisoning
 Poisoning
Analysis/Nursing Diagnoses
• 1. Altered family processes related to sudden hospitalization
and
emergency aspects of illness

• 2. Fear related to sudden hospitalization and treatment

(multiple
injections for lead poisoning)

• 3. Risk for injury related to sources of toxic substances in the

environment

• 4. Risk for injury related to presence of toxic substance in

the body

• 5. Risk for poisoning related to immature judgment of child

 Poisoning
C. Planning/Implementation
• 1. Terminate the exposure
– a. Empty the mouth of pills, plant parts, or
other material
– b. Thoroughly flush eyes with tap water if they
were involved
– c. Flush skin and wash with soap and soft cloth
– d. Remove clothing, especially if pesticide,
acid, alkali, or hydrocarbon involved
– e. Bring the victim into fresh air if an inhalation
poisoning
– f. Give water to dilute ingested
 Poisoning
• 2. Identify that a poisoning has
occurred
– a. Call the local poison control center,
emergency facility, or physician for
immediate advice regarding treatment
– b. Save all evidence of poison
(container, vomitus, urine, etc.)
– c. Be alert to signs and symptoms of
potential poisoning in absence of other
evidence
 Poisoning
• 3. Do not induce vomiting
– a. If the person is comatose, in severe
shock, or convulsing or has lost the gag
reflex; these conditions can increase the risk
of aspiration
– b. If the poison is a low-viscosity
hydrocarbon; once aspirated,it can cause a
severe chemical pneumonitis
– c. If the poison is a strong corrosive (acid or
alkali), emesis of the corrosive redamages
the mucosa of the esophagus and pharynx
 Poisoning
• 4. Remove the poison
– a. Dilute with water
– b. Induce vomiting except as contraindicated by
administering ipecac syrup (for 6- to 12-month-
olds give 10 ml of ipecac syrup with 8 to 12 oz of
water, for 1- to 2-year-olds give 15 ml of ipecac
syrup with 8 to 16 ounces of water; over 12 years
of age give 30 ml of ipecac syrup with 16 ounces
of water); if vomiting does not occur repeat once
in 20 minutes for those over 12 months of age; for
those under 12 months of age ipecac is not
repeated
 Poisoning
– c. Administer activated charcoal 1 g per kg
30 to 60 minutes after inducing vomiting
– d. Prepare appropriate equipment for
potential medical use, such as gastric lavage
5. Whether vomiting is spontaneous or
induced, prevent aspiration
– a. Keep the child's head lower than the chest
– b. When alert, place the head between the
legs
– c. When unconscious, position on the side
 Poisoning
• 6. Observe for latent symptoms and
complications of poisoning
– a. Monitor vital signs
– b. Treat as appropriate (e.g., institute seizure
precautions, keep warm and position correctly in
case of shock, reduce temperature if hyperpyretic)

• 7. Support the child and parent

– a. Keep calm and quiet
– b. Do not admonish or accuse the child or parent
of wrongdoing
 Poisoning
• 8. Teach prevention of poisoning
– a. Assess possible contributing factors in the occurrence
of an accident, such as discipline, parent-child
relationship, developmental ability, environmental
factors, and behavior problems

– b. Institute anticipatory guidance for possible future

accidents based on the child's age and maturational level

– c. Refer to a visiting nurse agency for evaluation of the

home environment and the need for safety measures

– d. Provide assistance with environmental manipulation

when necessary
 Poisoning
– e. Educate the parents regarding safe storage of all
substances

– f. Teach children the hazards of ingesting nonfood items

without supervision

– g. Caution against keeping large amounts of drugs on hand,

especially children's varieties

– h. Discourage transferring drugs to containers without safety

caps

– i. Discuss problems of discipline and children's noncompliance

 Poisoning
. Evaluation/Outcomes
• 1. Child recognizes and does not ingest harmful substances

• 2. Child is treated without complications

• 3. Child receives medication with minimal distress

• 4. Toxin is eliminated from body

• 5. Child expresses feelings and concerns

• 6. Parents express confidence in care

• 7. Parents and child have knowledge concerning prevention

of future poisoning
 Acetaminophen
Poisoning
• A. One of the most common
drugs taken by children
–1. Toxic dose 150 mg/kg
body weight
–2. Therapeutic use of 150
mg/kg/day for several days
has resulted in toxicity
 Acetaminophen
Poisoning
• Clinical findings - symptoms of overdose
– 1. Profuse diaphoresis
– 2. Nausea and vomiting
– 3. Pallor
– 4. Weakness
– 5. Pain in right upper quadrant
– 6. Slow, weak pulse
– 7. Confusion
– 8. Decreased urine output
– 9. Jaundice
– 10. Coagulation abnormality
– 11. Coma
– 12. Liver failure
 Acetaminophen
Poisoning
• Therapeutic interventions
–1. Induce vomiting with
ipecac syrup, lavage
–2. Administer IV fluid
–3. Administer an antidote
(acetylcysteine)
 Acetaminophen
Poisoning
Specific Nursing Care of Children with
Acetaminophen Poisoning
• A. Identify ingested substance and amount
• B. Monitor the electrocardiograph
• C. Measure intake and output
• D. Measure and record the vital signs
frequently
• E. Obtain blood for hepatic and renal
function tests
• F. Support the child and family
 Salicylate Toxicity and
Poisoning
• Toxic dose: 300 to 500 mg
per kilogram of body weight
or 7 adult aspirins (28 baby
aspirin) for a 9-kg (20-lb)
child
 Salicylate Toxicity and
Poisoning
• Clinical findings
– 1. Mild salicylate toxicity (items i to k are of
little value in small children)
• a. Diaphoresis
• b. Nausea
• c. Vomiting
• d. Dehydration
• e. Delirium
• f. Oliguria
• g. Hyperpnea
• h. Hyperpyrexia
• i. Ringing in the ears
• j. Dizziness
• k. Disturbances of hearing and vision
 Salicylate Toxicity and
Poisoning
– 2. Salicylate poisoning
• a. Hyperventilation: confusion, coma
• b. Metabolic acidosis: anorexia, sweating,
increased temperature
• c. Bleeding, especially if chronic ingestion
• C. Therapeutic interventions
–1. Induce vomiting, gastric
lavage, activated charcoal,
saline cathartics
–2. IV fluids
–3. Vitamin K if bleeding
–4. Peritoneal dialysis in
severe cases
 Lead Poisoning
(Plumbism)
Data Base
• A. A prevalent, significant, preventable health
problem that causes neurologic and intellectual
damage from even low levels of lead

• B. Blood lead concentration should be less than 10

mg per 100 ml of blood

• C. Associated with increased levels of lead in the

environment and pica
– 1. Most common source is lead-based paint
– 2. Soil, dust, or drinking water with lead
– 3. Parental occupations, hobbies
 Lead Poisoning
(Plumbism)
• D. Clinical findings (chronic ingestion)
– 1. Loss of weight, anorexia
– 2. Abdominal pain, vomiting
– 3. Constipation
– 4. Anemia, pallor, listlessness, fatigue
– 5. Lead line on teeth and long bones
– 6. Protein in urine as a result of proximal
tubular damage
– 7. Behavioral changes (impulsiveness,
irritability, hyperactivity, or lethargy)
– 8. Headache, insomnia, joint pains
– 9. Brain damage, convulsions, death
• E. Therapeutic interventions
– 1. Objective: reduce concentration of lead in the blood
and soft tissue by promoting its excretion and
deposition in bones
• a. Calcium disodium edetate (Calcium Disodium
Versenate, calcium EDTA)
– (1) Urine lead content monitored; peak excretion
in 24 to 48 hours
– (2) Adverse effects: acute tubular necrosis,
malaise, fatigue, numbness of extremities, GI
disturbances, fever, pain in muscles and joints
• b. Dimercaprol (BAL)
– (1) Generally used in conjunction with calcium
disodium edetate
– (2) Adverse effects: local pain at the site of
injection; may cause persistent fever in children
receiving therapy; rise in blood pressure
accompanied by tachycardia after injection
 • c. d-penicillamine
– (1) Oral chelating agent
– (2) Increases urinary excretion, but less effective
than calcium EDTA
– (3) Adverse effects: transient decrease in white
blood cells and platelets; rash; enuresis;
abdominal pain
– 2. Prevention of further ingestion
Specific Nursing Care of Children with Lead Poisoning
• A. Determine environmental exposure

• B. Screen children at risk by recognizing clinical findings,

especially behavior changes

• C. Plan preparation of the child and rotation of injection

sites if therapeutic intervention includes IM chelating
agents; warm moist applications may relieve discomfort of
injections

• D. Observe child carefully and closely

• E. Plan discharge and follow-up care of the child

• F. Prevent future lead poisoning by parental and child

education, appropriate environment, and supervision of
child and siblings