PEDIATRIC NURSING

Fever
Causes Often unknown, may be due to dehydration, most often viral induced Danger in infants is febrile seizures most common between 3 months to five years. The seizure is a result of how quickly the temperature rises. Hydration (20mls/kg is formula for bolus) Antipyretics acetaminophen or ibuprofen Cooling measures avoid shivering Tepid bath Remove excess clothing and blankets Cooling blankets/mattresses Metabolic rate increases 10% for every 1 centimeter increase in temperature 3-5 times during shivering. - Increases Oxygen, fluid and caloric requirements. Especially hazardous if cardiovascular/neuro system already compromised Shivering is the bodys way of maintaining the elevated set point by producing heat-Compensatory shivering greatly increases metabolic requirements above those already caused by the fever.

Pediatric Differences
Fluid & Electrolyte
Percent Body Water compared to Total Body Weight:
Premature infants: 90% water Infants: 75 - 80% water Child: 64% water Higher percentage of water in extracellular fluid in infants Infants and toddlers more vulnerable to fluid and electrolyte disturbances Concentrating abilities of kidneys not fully mature until 2 years Metabolic rate is 2-3 times higher than an adult Greater body surface area per kg body weight than adults; dehydrates more quickly

Dehydration
Types:
 Isotonic Most common; salt and water lost. Greatest threat Hypovolemic Shock  Hypotonic Electrolyte deficit exceeds water deficitphysical signs more severe with smaller fluid losses  Hypertonic Water loss higher than electrolyte Vomiting leads to metabolic alkalosis Diarrhea leads to metabolic acidosis LAB WATCH: monitor sodium, potassium, chloride, carbon dioxide, BUN, and creatinine
4

 ECF constitutes more than body water and thus greater relative content of sodium and chloride- birth to 2 yrs. Infants greater body surface allows larger quantities of fluid loss thru skin. BMR higher to support growth. Kidneys unable to concentrate or dilute urine to conserve or excrete sodium and acidify urine more prone to dehydration with concentrated formulas or overhydrated with excessive fluids. Nursing Tip: 1 g wet diaper = 1 ml urine

Assessment of Dehydration
Skin gray, cold, mottled, poor to fair, dry or clammy Delayed capillary refill Mucous membranes/lips dry Eyes and fontanels sunken No tears present when crying Pulse and respirations rapid Irritability to lethargy depending on cause and severity, not responsive to parent and/or environment

Dehydration: Nursing Interventions

Daily weight, I/O Assess hydration status Assess neurological status Monitor labs (electrolytes) Rehydrate with fluids both PO and IV (20 mls/kg of NS) Diet progression: Pedialyte modified Bread-RiceApple Juice-Toast (BRAT) Diet-for-age (DFA) Skin care for diaper rash Stool output (Amount, Color, Consistency, Texture ACCT) HANDWASHING! Priorities: fluid replacement & assess for S/S of shock
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Diarrhea
Often specific etiology unknown, but rotavirus is most common cause of gastroenteritis in infants and kids Dont forget contact precautions!! Leading cause of illness in children younger than 5 May result in fatality if not treated properly History very important Treatment aimed at correcting fluid imbalance and treating underlying cause Metabolic acidosis = blood pH < 7.35

 NPO to see if diarrhea limits itself; ORT treatment of choice avoid sweetened beverages, carbonated soft drinks and chicken or beef broth initially. If this doesnt work and diarrhea continues, IV fluids and NPO. Oral Rehydration Sols (ORS) Approx 10ml/kg or -1 cup ORS for each diarrhea stool

Vomiting
Often result of infections, improper feeding techniques, GI blockage (pyloric stenosis), emotional factors Management directed toward detection, treatment of cause and prevention of complications Metabolic alkalosis = blood pH >7.45

10

 Teaching for proper positioning during and after feeding; blockage NPO or special feeding techniques; maintain hydration-prevent dehydration; proper treatment of infection; administer antiemetics

11

Lets Review
The most appropriate type of IV fluid to infuse in treatment of extra-cellular dehydration in children is:
A. B. C. D. Isotonic solution. Hypotonic solution. Hypertonic solution. Colloid solution.

12

Lets Review
Which laboratory finding would help to identify that a child experiencing metabolic acidosis?
A. B. C. D. Serum potassium of 3.8 Arterial pH of 7.32 Serum carbon dioxide of 24 Serum sodium of 136

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Pain Assessment: Infants

Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness Examples: FLACC scale, NIPS scale

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Pain Assessment: Toddlers

Toddlers may have a word that is used for pain (owie, booboo, ouch or no); be sure to use term that toddler is familiar with when assessing. Can also use FLACC scale, or Oucher scale (for older toddlers)

15

Pain Assessment: Preschoolers

Think pain will magically go away May deny pain to avoid medicine/injections Able to describe location and intensity of pain FACES scale, poker chips and Oucher scale may be used
Photo Source: Del Mar Image Library; Used with permission

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Pain Assessment: Older Children

Older children can describe pain with location and intensity Nonverbal cues important, may become quiet or withdrawn Can use scales like Wongs FACES scale, poker chips, visual analog scales, and numeric rating scales

17

Lets Review
The nurse begins a full assessment on a 10 yearold patient. To ensure full cooperation from this patient it is most important for the nurse to:
A. Approach the assessment as a game to play. B. Provide privacy for the patient. C. Encourage the friend visiting to stay at the bedside to observe. D. Instruct the child to assist the nurse in the assessment.

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Lets Review
During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development?
A. Babies progress at different rates. Your infants development is within normal limits. B. If she is pulling up, you can help her by holding her hand. C. Shes a little behind in her physical milestones. D. You can strengthen her leg muscles with special exercises to make her stronger.

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Lets Review
When assessing a toddler identify the order in which you would complete the assessment:
1. 2. 3. 4. Ear exam with otoscope Vital signs Lung assessment Abdominal assessment

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Lets Review
When assessing pain in an infant it would be inappropriate to assess for:
A. B. C. D. Facial expressions Localization of pain Crying Extremity movement

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Genetic Disorders
Principles of Inheritance KAutosomal Dominant KAutosomal Recessive KSex-linked (X-linked) Inheritance KChromosome Alterations Downs Syndrome Tay-Sachs Disease Nursing intervention is supporting parents and resources

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Downs Syndrome
Most common cause of cognitive impairment (moderate to severe) 1 in 600 live births Risk factor- pregnancy in women over 35 yrs old Cause - extra chromosome 21 (faulty cell division) Causes change in normal embryogenesis process resulting in:
Cardiac defects, GI conditions, Endocrine disorders, Hematologic abnormalities, Dermatologic changes

Physical features: small head, flat facial profile, broad flat nose,
small mouth, protruding tongue, low set ears, transverse palmar creases, hypotonia

* Feeding is often a problem in infancy *

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Lets Review
The infant with Downs Syndrome is closely monitored during the first year of life for which condition?
A. B. C. D. Thyroid complications Orthopedic malformations Cardiac abnormalities Dental malformations

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Pediatric Differences
Neurosensory System
Size and Structure:
Rapid head growth in early childhood Bones are not fused until 18-24 months

Function:
Autonomic Nervous System is intact - neurons are completely myelinized by 1 year Infants behavior initially reflexive, but are replaced with purposeful movement by 1 year Infants demonstrate a dominance of flexor muscles Motor development occurs constantly in head to toe progression
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Pediatric Differences
Neurosensory System
Eye and Vision:
Changes in development of eye and eye muscles *strabismus normal until 6 months Vision function becomes more organized Papilledema rarely occurs in infants due to expansion of fontanels with increased ICP

Ear and Hearing:

Hearing fully developed at birth Abnormal physical structures may indicate genetic problems

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The Neurosensory System

Disorders of the Nervous System Hydrocephalus Spina Bifida Reyes Syndrome Seizures Cerebral Palsy (CP) Meningitis
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Hydrocephalus
Develops as a result of an imbalance of production and absorption of CSF The increase of CSF causes increased ventricular pressure, leading to dilation of the ventricles, pressing on skull Signs/Symptoms of Increased ICP: Poor feeding and vomiting Bulging fontanel, head enlargement, separation of sutures Lethargy, irritability, restlessness, not responsive to parents CHILD - Headache, vomiting, diplopia, ataxia, papilledema Seizures
A childs head with an open fontanel (under 2 years old) has the ability to expand and better compensate for the increased intracranial pressure.

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Ventriculoperitoneal (VP) Shunts

Relief of hydrocephalus Prevention/treatment of complications Management of problems related to psychomotor development Surgical intervention: ventriculoperitoneal (VP) shunt
One-way pressure valve releasing

CSF into peritoneal cavity where it is reabsorbed

Photo Source: Del Mar Image Library; Used with permission

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General Nursing Interventions

Monitor Neuro Status
         Determine baseline Assess LOC Assess motosensory Pupil checks Vital signs, Head circ Seizure precautions Fall precautions Possible restraints Determine LOC ac

Decrease ICP
Cluster care/ stress Quiet environment HOB 30-45 degrees Appropriate position (head midline, no hip flexion, no prone)  Medications(pain meds,corticosteroids, diuretics, stool softeners, antiinfectives, anticonvulsants)    

Provide Patient Safety

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General Nursing Interventions

Maintain Adequate Cerebral Perfusion
 Maintain airway  Monitor oxygenation and apply O2 PRN  Monitor temperature and administer antipyretics PRN  Maintain normovolemia  Monitor I/O  Assess perfusion

Maintain Nutritional & Fluid Needs

 Determine swallow ability prior to POs  NGT feedings may be necessary  Dietary consult PRN  Daily weight  Monitor lab results

Psychosocial Support
 Child Life consult  Teaching
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Spina Bifida:
Occulta and Cystica
(meningocele and myelomeningocele) Etilogy is unknown, but genetic & environmental factors considered. Maternal intake of folic acid Exposure of fetus to teratogenic drugs The severity of clinical manifestations depend on the location of the lesion. T12 - flaccid lower extremities, sensation, lack of bowel control and dribbling urine S 3 and lower - no motor impairment Other complications may occur. Hydrocephalus (80-90%) Orthopedic issues such as scoliosis, kyphosis, club foot Urinary retention Skin breakdown/Trauma

Photo Source: Del Mar Image Library; Used with permission

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Spina Bifida
Nursing Interventions
Sterile dressing pre/post-op Monitor VS, S/S infection Use latex free items Avoid stress on sac - prone position only, especially pre-op; no supine until incision healed Monitor for S/S intracranial pressure (ICP) Interventions to ICP Encourage touch & talk Social service consult
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Seizures
Febrile seizures are the most common in children, caused by by a RAPID elevation in temperature, usually above 102. Most children do not have a second febrile seizure episode and only about 3% develop epilepsy. Focus of care is on patient safety, cause of fever and education of parents for home care. Remember basic CPR during seizures airway before oxygen Seizure precautions: Suction, oxygen, padded rails Infants often have subtle seizures with only occular movements or some extremity movements.

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Cerebral Palsy (CP)

1.5 - 5 in 1,000 live births Neuromuscular disorder resulting from damage or altered structure of part of the brain Caused by a variety of factors: Prenatally - genetic, trauma, anoxia Perinatally - fetal distress, drugs at delivery, precepitate
or breech delivery with delay Postnatally - kernicterus or head trauma

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Cerebral Palsy

(continued)

Spasticity - exaggerated hyperactive reflexes Athetosis - constant involuntary, purposeless, slow writhing motions Ataxia - disturbances in equilibrium Tremor - repetitive rhythmic involuntary contractions of flexor and extensor muscles Rigidity - resistance to flexion and extension
Associated Problems: Mental retardation, hearing loss, speech defect, dental & orthopedic anomalies, GI problems and visual changes

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Cerebral Palsy: Nursing Interventions

Safety
Feed in upright position Seizure precautions Ambulate with assistance if able Medication administration

Special Needs
Nutritional needs include increased calories, assist with feeds, possible GT feeds. Speech, Occupational and Physical therapies

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Bacterial Meningitis
Infectious process of CNS causing inflammation of meninges and spinal cord. ISOLATION IS MANDATORY Signs and symptoms include those of increased ICP plus photophobia, nuchal rigidity, joint pain, malaise, purpura rash, Kernigs and Brudinskis signs Can occur at any age, but often between 1 month-5 years Most common sequele: hearing and/or visual impairments, seizures, cognitive changes Diagnostic confirmation is done by lumbar puncture and CSF is cloudy with increased WBCs, increased protein, and low glucose Nursing Interventions include: appropriate IV antibiotics and meds for increased ICP as well as interventions to decrease ICP

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Causes of Blindness
Genetic Disorders:
Tay-Sachs disease Inborn errors of metabolism Perinatal: prematurity, retrolental fibroplasia Postnatal: trauma, childhood infections, Juvenile Arthritis

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Causes of Deafness
Conductive:
Interference in transmission from outer ear to middle ear from chronic OM

Sensorineural:
Dysfunction of the inner ear Damage to cranial nerve VIII from rubella, meningitis or drugs

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Lets Review
Which test would confirm a diagnosis of meningitis in children?
A. B. C. D. Complete blood count Bone marrow biopsy Lumbar puncture Computerized Tomography (CT) scan

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Lets Review
In performing a neurological assessment on a patient which data would be most important to obtain?
A. B. C. D. Vital signs. Head circumference. Neurologic soft signs. Level of consciousness (LOC).

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Lets Review
A neonate born with myelomeningocele should be maintained in which position pre-operatively? A. B. C. D. Prone. Supine. Trendelenberg. Semi-Fowler.
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Lets Review
The nurse witnesses a pediatric patient experiencing a seizure. The primary nursing intervention would be:
A. Careful observation and documentation of the seizure activity. B. Maintain patient safety. C. Minimize the patients anxiety. D. Avoid over stimulation and promote rest.

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Lets Review
Which assessment finding in an infant first day post-op placement of a ventriculoperitoneal (VP) shunt is indicative of surgical complications?
A. B. C. D. Hypoactive bowel sounds. Congestion in upper airways. Increasing lethargy. Incisional pain.

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Rheumatic Fever
Acquired Heart Disease Inflammatory disorder involving heart, joints, connective tissue, and the CNS Peaks in school-age children Linked to environmental factors and family history Thought to be an autoimmune disorder: Commonly preceded by a Strep Throat Prognosis depends upon the degree of heart damage Rest important in recovery priority intervention in acute stage Strep prophylaxis for 5 years or throughout adolescence

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Hematologic System: Pediatric Variances

All bone marrow in a young child is involved in the formation of blood cells. By puberty, only the sternum, ribs, pelvis, vertebrae, skill, and proximal epiphyses of femur and humerus are involved in blood cell formation. During the first 6 months of life, fetal hemoglobin is gradually replaced by adult hemoglobin.

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The Hematologic System

Disorders of Red Blood Cells
 Iron Deficiency Anemia  Sickle Cell Anemia

Disorders of Platelets/Clotting Factors

 Idiopathic Thrombocytopenia Purpura (ITP)  Hemophilia

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IRON DEFICIENCY ANEMIA

Most common nutritional anemia in childhood Severe depletion of iron stores resulting in a low HGB level Decreased O2 to tissues = fatigue, headache, pallor, increased heart rate Occurs after depletion of iron stores in body (6-9 mo of age) Most likely to occur during rapid physical growth and low iron intake
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IRON DEFICIENCY ANEMIA

Often occurs as a result of increased milk intake Lab results show low HGB, HCT, MCV, MCH, MCHC, iron, ferritin Teach parents proper nutrition
Meat, spinach, legumes, sweet potatoes,

egg yolks, seafood Calcium inhibits iron, Vitamin C enhances iron absorption

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Sickle Cell Disease

PATHOLOGY

Photo Source: Del Mar Image Library; Used with permission

Normal RBC has a flexible, round shape RBC w/HbS has a normal shape until its O2 delivered to tissue, then sickle shape occurs  Stiff, non-pliable cant flow freely  Trapped in small vessels = causes vaso-occlusions, tissue ischemia and infarctions painful episodes, most common area is joints  Hemolysis of RBC- lifespan down to 20 days  Compensatory mechanism is increased reticulocytes

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Sickle Cell Disease

ACUTE FEBRILE ILLNESS High mortality rate <5 years old Splenic dysfunction begins at 6 mo old Prophylactic PCN BID at 2-3 mo old Monitor for Infection Temp > 101.5 Respiratory S/S SPLENIC SEQUESTRATION Highly vascular Susceptible to injury/infarction Occurs 6 mo-3yrs Pallor, fatigue, abd pain, splenomegaly, CV compromise Treatment: IV fluids, PRBCs
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Sickle Cell Disease: Nursing Interventions

GENERAL NURSING CARE Hydration is Priority!
Fluid Bolus & maintenance + 1/2

Oxygen - to decrease sickling of of cells Pain Management

Assess frequently/appropriately IV Morphine q3-4 hr, PCA Non-pharmacological methods

HOME MANAGEMENT Pain Control Fluids Teaching Early Identification of infection Immunizations Avoid dehydration

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Hemophilia
Group of genetic bleeding disorders of which there is a deficiency of a clotting factor Most common are Factor VIII (A) & Factor IX (B) Bleed LONGER not faster Clinical manifestations: prolonged bleeding, bruising, spontaneous hematuria Management: replacement of missing clotting factor (recombinant factor VIII concentrate), cryoprecipitate, DDAVP NSAIDS (aspirin, Indocin) are contraindicated, they inhibit platelet function Regular non-contact exercise/physical therapy is encouraged

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Hemophilia
COMPLICATIONS Bleeding into muscle tissue Hemarthrosis can cause joint pain & destruction
Acute Treatment is rest, ice,

elevation, ROM

Photo Source: Del Mar Image Library; Used with permission

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Lets Review
When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is much greater than that found in the childs leg. The nurse reacts to these findings in which way?
A. B. C. D. Charts the findings and realizes they are normal. Suspects the child may have coarctation of the aorta. Suspects the child may have Tetralogy of Fallot. Notifies the physician and alerts the surgery team.

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Lets Review
A 1-month-old infant is being admitted for complications related to a diagnosed ventricular septal defect (VSD). Which physicians order should be questioned by the nurse?
A. Blood pressure every 4 hours. B. Serum digoxin level. C. Diet: Enfamil 20, nipple 6 oz q2H. D. Supplemental oxygen via nasal cannula prn maintain SaO2 >92%.

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Lets Review
A nursing intervention most pertinent for the child with hemophilia is:
A. Sedentary activities to prevent bleeding episodes. B. Meticulous oral care with dental floss to prevent infection. C. Warm compresses to bleeding areas to increase absorption. D. Active range of motion exercises for joint mobility.

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Lets Review
Which is the most appropriate information to teach a parent of a 14 month-old child with iron deficiency anemia?
A. Increase the childs daily milk intake to a minimum of 24 ounces. B. Administer oral iron supplement for the child to drink in a small cup. C. Increase the amount of dark green, leafy vegetables and eggs in the childs diet. D. Encourage the parents to let the child choose foods he prefers.

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Lets Review
Which strategy is appropriate when feeding the infant in congestive heart failure?
A. Continue the feeding until a sufficient amount of formula is taken B. Bottle feed no longer than 30 minutes C. Feed the infant every 2 hours D. Rock and comfort the infant during feedings

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Respiratory System Pediatric Variances

The airway is smaller and more flexible. The larynx is more flexible and more susceptible to spasm. The lower airways are smaller with underdeveloped cartilage. The tongue is large. Infants < 6 months old are obligate nose breathers. Chest muscles are not well developed The diaphragm is the neonates major respiratory muscle. Irregular breathing pattern and brief periods of apnea (10 15 secs) are common Abdominal muscles are used for inhalation until age 5-6 yrs. Respiratory rate is higher Increased BMR raises oxygen needs
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The Respiratory System

Upper Airway Disorders
Tonsillitis Croup Epiglottis Foreign Body Aspiration

Lower Airway Disorders

Bronchiolitis Asthma Cystic Fibrosis
Photo Source: Del Mar Image Library; Used with permission

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Tonsillitis
CLINICAL MANIFESTATIONS Sore throat Mouth breathing Sleep Apnea Difficulty swallowing Fever Throat C&S/Rapid Strep IMPLEMENTATIONS Ease Respiratory Efforts Provide Comfort
Warm saline gargles Pain Medication Throat lozenges

Reduce Fever Promote Hydration Administer Antibiotics Provide Rest Patient Teaching Tonsillectomy may be necessary
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Tonsillectomy
Pre-operative Nursing Care
Monitor Labs (CBC, PT, PTT) Age-appropriate Preparation/Teaching Surgical Consent

Post-operative Nursing Care

Frequent site assessment - visualize! Monitor for S/S of Complications Pain Management Diet (push fluids-no citrus juices or red, advance diet) Patient Teaching
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Croup/Epiglottitis
Infection and swelling of larynx, trachea, epiglottis, bronchi Often preceded by URI traveling downward Causative agent: Viral Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress Most common ages 6 mo-3 yrs LTB form most common

Photo Source: Del Mar Image Library; Used with permission

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Acute Epiglottitis
Bacterial form of croup affecting epiglottis LIFE-THREATENING EMERGENCY Wellness to complete obstruction in 2-6 hours Most common in ages 2-5 years Do not examine throat! Have functional emergency equipment at bedside - Priority! Often the child is intubated 4 Ds - Drooling, Dysphagia, Dysphonia, Distressed Inspiratory Effort Lateral Neck X-ray shows thumb sign HIB vaccine has reduced the cases dramatically

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Croup/Epiglottitis
Nursing Interventions
Maintain Patent Airway Assess and Monitor Ease Respiratory Efforts Promote Hydration Reduce Fever Calm Environment Promote Rest

Nursing Interventions
Administer Meds
 Corticosteroids  (HHN) Nebulizer

treatment of Racemic Epinephrine PRN stridor  Antibiotic for epiglottitis

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Foreign Body Aspiration

Occurs most often in small children Choking, coughing, wheezing, respiratory difficulty Often it is round food, such as hot dogs, grapes, nuts, popcorn Bronchoscopy often needed for removal Age-appropriate preparation needed for procedure Prevention and parent education is very important

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Bronchiolitis/RSV
Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur Increased amount of mucus and exudates preventing expiration of air and overinflation of lungs Causative agent in 85% of cases is Respiratory Syncytial Virus (RSV). It is highly contagious - contact isolation must be enforced. Nasal swab or nasal washing obtained for viral panel, including RSV CXR shows hyperinflation and consolidation if atelectasis present Primarily seen in children under 2 years of age Most common in winter and early spring Palivizumab (Synagis)
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Bronchiolitis/RSV
CLINICAL MANIFESTATIONS IMPLEMENTATIONS Suction priority Nasal Congestion Bronchodilator via HHN Cough CPT Rhonchi, Crackles, Wheezes Promote fluids Monitor VS , SaO2, lung Increased RR & SOB sounds & respiratory effort Respiratory Distress Supplemental oxygen Fever Reduce fever Poor Feeding Promote rest HANDWASHING!

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Asthma
CLINICAL MANIFESTATIONS Tachypnea SaO2 below 95% on RA Wheezes, crackles Retractions, nasal flaring Non-productive cough Silent chest Restlessness, fatigue Orthopnea Abdominal pain CXR = hyperinflation INTERVENTIONS Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Ease respiratory efforts Promote hydration Promote rest Monitor labs/x-rays Patient teaching
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Asthma
Administer Medications
 Bronchodilator via HHN or MDI with spacer (Albuterol) Peak flows should always be done before and after Tx  Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal)  Corticosteroid IV or PO (Solu-medrol or Decadron)  Antibiotic if precipitated from a respiratory infection

Home Medication Management

 Bronchodilator via HHN or MDI with spacer (Albuterol Proventil, Levalbuterol - Xopenex)  Inhaled steroids (Beclamethasone - Vanceril)  Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal)  Leukotriene modifiers PO for long-term control - Singular

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Cystic Fibrosis
1 in 1,500-2,000 live births Dysfunction of the exocrine gland (mucus producing) Multi-system disorder Secretions are thick and cause obstruction and fibrosis of tissue. The clinical manifestations are the result of the obstructive process. Sweat has a characteristic high sodium- Sweat Chloride Test Pancreatic involvement in 85% of CF patients Disease is ultimately fatal. Average age at death: 32 years

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Cystic Fibrosis
PULMONARY MANIFESTATIONS GI MANIFESTATIONS

Initial
Wheezing Dry, non-productive cough

Eventual & Progressive

Repeated lung infections Wet & paroxysmal cough Emphysema/Atelectasis Barrel-chest - Clubbing - Cyanosis

Large, loose, frothy and foul-smelling stools Increased appetite (early) Loss of appetite (later) Weight loss FTT Distended abdomen Thin extremities Deficiency of A,D, E, K Anemia

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Cystic Fibrosis
MANAGEMENT/INTERVENTIONS Airway Clearance - Chest physiotherapy (CPT) Priority Drug Therapy
Bronchodilators - via HHN Mucolytic Agent (Dnase-Pulmozyme) - via HHN Antibiotics - via HHN, IV, or PO Digestive enzymes

Nutrition - needs are at 150%

Increased calories and protein - TPN or GT feedings at night Additional fat soluble vitamins Additional salt with vigorous exercise and hot weather

Exercise Patient Teaching

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Otitis Media
Most common childhood illness Inflammation of middle ear Impaired eustachian tube causes decreased ventilation and drainage

Acute otitis media (AOM) Infectious process by pathogen Infection can spread leading to meningitis S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane Otitis media with effusion (OME)
Inflammation of middle ear with fluid behind tympanic membrane-no infection Peaks spring and fall (allergies)

Chronic otitis media

Inflammation of middle ear > 3 mo Can lead to hearing loss/delayed speech
Photo Source: Del Mar Image Library; Used with permission

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Otitis Media
RISK FACTORS Secondary smoke Formula feeding (positioning) Day care Pacifier > 6 mo old TREATMENT Antibiotics (for AOM) Myringotomy with Pressure Equalizing (PE) tubes INTERVENTIONS Teaching No bottle propping Feeding techniques Medication regimen PAIN MANAGEMENT Fever management Surgery prep if needed

Photo Source: Del Mar Image Library; Used with permission

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Lets Review
The nurses first action in responding to a child with tachypnea, grunting, and retractions is to:
A. Place the child in an upright, semi-fowlers position. B. Apply a pulse oximeter to determine oxygen saturation. C. Assess for further symptoms. D. Call for a stat respiratory nebulizer treatment (HHN).

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Lets Review
A 3-year-old child is brought to the emergency room with a sore throat, anxiety, and drooling. The priority nursing action is to:
A. Inspect the childs throat for infection. B. Prepare intubation equipment and call the physician. C. Obtain a throat culture for respiratory syncytial virus (RSV). C. Obtain vital signs and auscultate lung sounds.

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Lets Review
An assessment finding in a child with asthma requiring immediate action by the nurse is:
A. B. C. D. Diminished breath sounds. Wheezing in bronchi. Crackles in lungs. Refusal to take PO fluids.

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Lets Review
Which sign is indicative of air hunger in an infant?
A. Nasal flaring. B. Periods of apnea lasting 15 seconds. C. Irregular respiratory pattern. D. Abdominal breathing.

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Lets Review
The priority nursing intervention in caring for the infant with Respiratory Syncytial Virus (RSV) induced bronchiolitis is:
A. Nasopharyngeal suctioning. B. Coughing and deep breathing exercises. C. Administration of intravenous antibiotic. D. Administration of antipyretics for fever.

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Gastrointestinal System
Many GI issues require surgical intervention Nursing interventions will often include general pre and post-op care Bilious vomiting is a sign of GI obstruction and requires immediate intervention Assess stools! Assess hydration status
Photo Source: Del Mar Image Library; Used with permission

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Gastrointestinal System Pediatric Variances

Mechanical functions of digestion are immature at birth Liver functions are immature throughout infancy Production of mucosal-lining antibodies is decreased Infants have decreased saliva Infants stomach lies transversely Peristalsis is faster in infants Digestive processes are mature as a toddler The childs liver and spleen are large and vascular Infants and children who vomit bile-colored emesis require immediate attention Gastric acidity is low at birth
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The Gastrointestinal System

Altered Connections
Esophageal Atresia/Tracheoesophageal Fistula Cleft Lip and Palate

Gastrointestinal Disorders
Gastroesophageal Reflux Hirschsprungs Disease Intussusception Celiac Disease Appendicitis Parasitic Worms
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Pyloric Stenosis Imperforate Anus

Acquired Gastrointestinal Disorders

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA

Congenital defects of esophagus EA is an incomplete formation of esophagus TEF is a fistula between the trachea and esophagus Classic 3 Cs - coughing,choking,cyanosis
Photo Source: Del Mar Image Library; Used with permission

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ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA

SIGNS/SYMPTOM
Copious, frothy oral secretions Abdominal distension from air in stomach Look for 3 Cs Confirmed with radiographic studies

TREATMENT
Surgery: either a one- or two-stage repair Pre-op care focuses on preventing aspiration and hydration Post-op care focus is a patent airway, prevent incisional trauma

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Cleft Lip/Palate
May present as single defect or combined Non-union of tissue and bone of upper lip and hard/soft palate during fetal development CL-failure of nasal & maxillary processes to fuse at 5-8 weeks gestation CP-failure of palatine planes to fuse 7-12 weeks gestation Cleft interferes with normal anatomic structure of lips, nose, palate, muscles depending on severity and placement Open communication between mouth and nose with cleft palate
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Cleft Lip/Palate

Multidisciplinary care throughout childhood and early adulthood Nutrition is a challenge in infancy
 ESSR method (enlarge, stimulate,

swallow, rest)  Risk for aspiration  Respiratory distress

Altered bonding is a possibility

Photo Source: Del Mar Image Library; Used with permission

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CLEFT LIP & CLEFT PALATE: Operative Care

Cleft lip surgery by 4 weeks & again at 4-5 yrs Cleft palate surgery at 6-24 months of age, usually done by 1 year so speech will not be affected Protect suture lines- priority Monitor for infection
 Clean Cleft Lip incision

Pain Management Cleft Palate starts feedings 48-hour post-op:

 Clear and advance to soft diet  No straws, pacifiers, spouted cups  Rinse mouth after feeding
90

GASTROESOPHAGEAL REFLUX Regurgitation of gastric contents back

into esophagus - 50% healthy term babies affected Related to inappropriate relaxation of Lower Esophageal Sphincter (LES) making the LES pressure less than the intra abdominal pressure GER may predispose patient to aspiration and pneumonia Apnea has been associated with GER chance of GER after 12-18 mo old related to growth due to elongation of esophagus and the LES drops below the diaphragm
Photo Source: Del Mar Image Library; Used with permission

91

GASTROESOPHAGEAL REFLUX
SIGNS/SYMPTOMS
Vomiting/spitting up Gagging during feedings Irritability Arching/posturing Frequent URIs/OM Anemia Bloody stools

DIAGNOSTIC EVAL
History of feedings/PE Upper GI/Barium swallow to eliminate anatomical problems Upper GI endoscopy to visualize esophageal mucosa pH probe study

92

GASTROESOPHAGEAL REFLUX: Therapeutic Management

Positioning
Prone HOB 30 Right side

Medications
Prokinetic agents: LES pressure & gastric motility Histamine H-2 antagonists are added if esophagitis : acid Proton Pump Inhibitors if H-2 ineffective:acid Mucosal Protectants

Dietary modifications

Small, frequent feedings, burp often Possibly thicken formula Avoid fatty, spicy foods caffeine, & citrus Surgery: fundoplication Teach

93

HIRSHSPRUNGS
Aganglionic megacolon
No ganglion cells at affected area usually at rectum/proximal portion of lower intestine Absence of peristalsis leads to intestinal distension, ischemia & maybe enterocolitis

Treatment
Mild-mod: stool softeners & rectal irrigations Mod-severe: single or 2-step surgery Colostomy with later pull-through
Photo Source: Del Mar Image Library; Used with permission

94

HIRSHSPRUNGS
    

SIGNS/SYMPTOMS Infants Unable to pass meconium stool within 24 hours of life Abdominal distention Bilious vomiting Refusal to feed Failure to thrive Children

 Chronic constipation  Pellet or ribbon-like stools (foul-

smelling)  Vomiting/FTT

NURSING INTERVENTIONS Surgery prep: bowel cleansing, antibiotics, NPO, IVFs, therapeutic play for surgery preparation Infection & Skin Integrity: monitor ostomy/anus Nutrition & Hydration: NGT, NPO then advance to Diet as tolerated, assess bowel function and abdominal status
95

INTUSSUSCEPTION
Prolapse or telescoping of one portion of the intestine into another Abrupt onset Usually occurs in 3-24 months of age Sudden abdominal pain Vomiting Red, current jelly stool Abd distention/tender Lethargy Can lead to septic shock
Photo Source: Del Mar Image Library; Used with permission

96

INTUSSUSCEPTION
DIAGNOSTIC STUDY Barium or air enema Abdominal ultrasound TREATMENT Hydrostatic reduction: force exerted using water-soluble contrast and air to push the affected intestine apart Surgical reduction if hydrostatic reduction is unsuccessful

NURSING INTERVENTIONS Monitor for infection, shock, pain Maintain hydration - assess status! Prepare child/parent for hydrostatic reduction teach, consent, NPO, NGT Monitor stools pre & post procedure If surgery: general pre & post-op care

97

PYLORIC STENOSIS

Hypertrophy of pyloric sphincter, causing a narrowing/ obstruction (bands pylorus) Usually occurs between 2-8 weeks of age Infant presents with non-bilious projectile vomiting, and is always hungry Can lead to dehydration and hypochloremic metabolic alkalosis Weight loss

Photo Source: Del Mar Image Library; Used with permission

98

PYLORIC STENOSIS
DIAGNOSTIC EVAL
History/PE: olive palpated in epigastrum Upper GI (string sign) Abdominal Ultrasound

INTERVENTIONS
Pre-op: NPO, NGT to LIS, hydration, I/O, monitor electrolytes Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule begin w/5cc GW half strength formula Full strength formula

TREATMENT
Surgical Intervention: Pyloromyotomy

99

IMPERFERATE ANUS
Anorectal malformations No obvious anal opening Fistula may be present from distal rectum to perineum or GU system Diagnostic Eval: patency of anus in newborn, passage of meconium; ultrasound is suspected Therapeutic Management: manual dilatation for anal stenosis, surgical treatment for malformations Nursing Implementations: pre and post-op care IV fluids, consent, assessing surgical site for infection and monitoring for complications, possible NGT, diet progression, possible colostomy and teaching; preferred post-op condition is sidelying.

100

Celiac Disease
Malabsorption syndrome characterized by intolerance of gluten (rye, oats, wheat and barley) Familial disease - more common in Caucasians Thought to be an inborn error of metabolism or an immunological disorder Reduced absorptive surfaces in small intestine which causes marked malabsorption of fats (frothy, foul-smelling stools) Child has diarrhea, abdominal distention, failure to thrive Treatment is lifelong low-gluten diet; corn and rice are substituted grain foods

101

APPENDICITIS
Inflammation and infection of vermiform appendix, usually related to an obstruction Cause may be bacteria, virus, trauma Ischemia can result from the obstruction, leading to necrosis causing perforation S/S: periumbilical painRLQ pain (McBurneys point), fever, vomiting, diarrhea, lethargy, irritability, WBCs Surgery is necessary If ruptured, often child will receive IV antibiotics for 24 hrs prior to OR Pre-op Care: NPO, pain management, hydration, prep & teaching, consent Post-op Care: routine post-op care, IVF/antibiotics, NPODAT, ambulation, positioning, pain management, wound care, possible drains.

102

PINWORM (enterobiasis)
Transmission: oral-fecal Persist in indoors for up to 3 weeks contaminating anything they contact (toilets, bed linens) S/S: intense perianal itch, sleeplessness, abd pain, vomiting Scotch tape test collects eggs laid by female outside of anus. Must be obtained in am prior to bath or BM. Treatment: *mebendazole (Vermox) for over 2 years of age. Under 2 years of age treatment may be pyrvinium pamoate (Povan) which stains stool and emesis red *All family members must be treated.

103

Lets Review
Which intervention would have the highest priority for the nurse assisting in the feeding of a child post cleft palate repair?
A. Permiting the child to choose the liquids desired. B. Providing diversional activities during feeding. C. Applying wrist restraints. D. Cleansing the mouth with water after each feeding.

104

Lets Review
Which food choice by a parent of a child with celiac disease indicates a need for further teaching? A. B. C. D. Oatmeal Rice Cornbread Beef

105

Lets Review
Which assessment finding would the nurse find in a child with Hirschsprungs Disease?
A. Current jelly stool B. Diarrhea C. Constipation D. Foul-smelling, fatty stool

106

Lets Review
Children with gastroenteritis often receive intravenous fluids to correct dehydration. How would you explain the need for IV fluids to a 3 year-old child?
A. The doctor wants you to get more water, and this is the best way to get it. B. Your stomach is sick and wont let you drink anything. The water going through the tube will help you feel better. C. See how much better your roommate is feeling with his IV! You will get better, too. D. The water in the IV goes into your veins and replaces the water you have lost from vomiting and diarrhea.
107

Lets Review
The nurse caring for a child with suspected appendicitis would question which physician order?
A. NPO status B. Start IV fluids of D5 NS at 50 mls/hour C. Complete Blood Count (CBC) D. Apply heating pad to abdomen for comfort

108

Genitourinary System
Anatomy & Physiology Review
The GU system maintains homeostasis of the body (water & electrolytes) Responsible for the excretion of waste products Nephron is the workhorse of the kidney (filter blood at the rate of 125mL/minute)-GFR Renin helps maintain Na & water balance (and B/P) Kidneys produce erythropoeitin which stimulates RBC production in marrow
Photo Source: Del Mar Image Library; Used with permission

109

Pediatric Variances
Genitourinary System
Infants & young children excrete urine at a higher rate related to the increased BMR producing more waste Infant kidneys have function if under stress Infant cant concentrate urine well until 3-6 mo In infants, kidney & bladder are abdominal organs Infant kidneys are less protected because of unossified ribs, less fat padding & large size Young children have shorter urethras Nephrons continue to develop after birth
110

The Genitourinary System

Minimum urine outputs by age groups:
INFANTS & TODDLERS 2-3 ml/kg/hr PRESCHOOLERS & YOUNG SCHOOL-AGE 1-2 ml/kg/hr SCHOOL-AGE & ADOLESCENTS 0.5-1 ml/kg/hr

TIP: Bladder capacity in ounces: AGE in years + 2

Example: a 2-year-olds bladder can hold up to 4 ounces or 120 mls

111

The Genitourinary System

G Disorders of the Genitourinary System  Enuresis Nephrotic Syndrome Acute Glomerulonephritis  Hemolytic Uremic Syndrome (HUS)

112

Glomerulonephritis
Group of kidney disorders that show main focus of injury is the glomerulus It is characterized by inflammation of the glomerular capillaries Acute disorders occur suddenly and resolve completely Acute poststreptococcal glomerulonephritis (APSGN) is the most common type History, presenting symptoms, and lab results establishes the diagnosis of APSGN

113

Glomerulonephritis
PATHOPHYSIOLOGY
Streptococcal Infection
Producing Antibodies Bacterial Antigens plus Antibodies form Immune Complexes & trap in Glomerulus

Inflammatory Response
Injury to Capillary Walls

Ineffective Filtration
Proteins Pass Through Decreased GFR

Kidneys Enlarge
with sodium, water, waste

EDEMA

ACUTE RENAL FAILURE

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

114

Glomerulonephritis
ASSESSMENT Hematuria Proteinuria Edema: periorbital, ankles Urine Output Hypertension Fatigue Possible fever Abdominal discomfort Labs: +ASO, Bicarb,K BUN, Creat, H & H INTERVENTIONS Monitor Urine (Dipstick) Monitor fluid overload Assess lung sounds/Resp effort Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS Antibiotic, diuretic & antihypertensive medications Promote & provide rest Provide comfort measures Monitor labs
115

Nephrotic Syndrome
Kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. There is primary (involving kidney only) and secondary (caused by systemic disease or heavy metal poisoning) NS. Primary is the most common (MCNS). Cause not fully understood-may have an immunologic component. Primary age affected is 2-6 years (boys 2:1) There is no occlusion of glomerular vessels. Loss of immunoglobulins also occur (IgG) Hypovolemia and the severe proteinuria put the child in a hypercoagulable state Treatment is prednisone (2mg/kg/day) for about 4-6 weeks. Remission is obtained when the urine protein is 0-tr for 5-7 days Albumin followed by furosemide may be given for the edema

116

Nephrotic Syndrome
PATHOPHYSIOLOGY
Alteration in Glomerulus Damage to Basement Membrane of glomerulus (increased permeability)

Proteinuria (Hypoalbuminemia)

Fluid Shift Intravascular to Interstitial HYPOVOLEMIA Decreased Renal Blood Flow Triggers Renin Production Causing Increased Aldosterone Reabsorption of Sodium and Water retention Hyperlipidemia

EDEMA

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

117

Nephrotic Syndrome
ASSESSMENT
Proteinuria (3-4+), frothy urine Edema (pitting):periorbital, genitals, lower extremities, abdominal Urine Output (Hypovolemia) Normotensive or hypotensive Fatigue Recent URI, Pneumonia Abdominal Pain/Anorexia Labs:
Albumin Platelets H & H Cholesterol Triglycerides

INTERVENTIONS
Monitor Urine (Dipstick) Monitor edema/dehydration Assess skin integrity/turn often Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS & S/S of infection Administer medications Promote & provide rest Monitor labs HANDWASHING/monitor visitors

118

Enuresis
Involuntary passage of urine in children whose chronological or developmental age is at least 5 years of age Voiding occurs at least twice a week for minimum 3 months More common in boys Alteration in neuromuscular bladder function Often benign and self-limiting Organic factor could be the cause Familial tendency Emotional factor could be considered Therapeutic techniques include: bladder training, night fluid restriction, drugs (imipramine, oxybutynin, DDAVP)

119

Lets Review
A clinical finding that warrants further intervention for a child with acute poststreptococcal glomerulonephritis is:
A. B. C. D. Weight loss to 1 pound of pre-illness weight. Urine output of 1 ml/kg per hour. A normal blood pressure. Inspiratory crackles.

120

Lets Review
A 3 year-old is scheduled for surgery to remove a Wilms tumor from one kidney. The parents ask the nurse what treatments, if any, will be necessary after recovery from surgery. The nurses explanation is based on knowledge that:
A. B. C. D. No additional treatments are necessary. Chemotherapy may be necessary. Chemotherapy is indicated. Kidney transplant is indicated.

121

Lets Review
Fluid balance in the child who has acute glomerulonephritis is best estimated by assessing:
A. B. C. D. Intake and output Abdominal circumference Daily weights Degree of edema

122

Lets Review
In evaluating the effectiveness of nursing actions when caring for a child with nephrotic syndrome, the nurse expects to find:
A. B. C. D. A recurrence of pneumonia. Weight gain. Increased edema. Decreased edema.
123

Pediatric Variances Musculoskeletal System

Bone Growth:
Linear growth results from skeletal development Bone circumference growth occurs as new bone tissue is formed beneath the periosteum Skeletal maturity is reached by age 17 in boys and 2 years after menarche in girls (14 yrs) Bone growth affected by Wolffs Law - bone grows in the direction in which stress is placed on it Certain characteristics of bone affect injury and healing Childrens bones are softer and are easily fractured

124

Pediatric Variances Musculoskeletal System

Muscle Growth:
Responsible for a large part of increased body weight The number of muscle fibers is constant throughout life Results from increase in size of fibers and increased number of nuclei per fiber Most apparent in adolescent period

125

The Musculoskeletal System

Disorders of the Musculoskeletal System
PDevelopmental Dysplasia of the Hip PTalipes (Clubfoot) POsteogenesis Imperfecta PScoliosis PMuscular Dystrophy PJuvenile Rheumatoid Arthritis

126

Developmental Dysplasia of the Hip (DDH)

Variety of hip abnormalities shallow acetabulum, subluxation or dislocation Often made in newborn period often appears as hip joint laxity rather than dislocation Ortolani click if < 4 weeks old, older ultrasound needed to diagnose Treatment is Pavlik Harness (abducted position) for newborn to 6 months old monitor for Avascular Necrosis 6-18 months traction followed by spica cast Older children operative reduction Priority nursing interventions are skin care and facilitating normal growth and development
127

Talipes (Clubfoot)
 Most common type is when foot is pointed downward and inward  Often associated with other disorders  May be due to decreased movement in utero  Treatment requires surgical intervention  Serial casting is begun shortly after birth and usually lasts for 8-12 weeks  Priority nursing interventions are skin care and facilitating normal growth and development

128

Osteogenesis Imperfecta (OI)

 Inherited disorder of connective tissue and excessive fragility of bones  Pathologic fractures occur easily  Incidence of fractures decrease at puberty related to increased hormones making bones stronger  Treatment is supportive: careful handling of extremities, braces, physical therapy, weight control diet, stress on home safety  Surgical techniques for correcting deformities and for intermedullary rodding

129

Scoliosis
o Abnormal curvature of the spine (lateral) o Congenital or develops later, most common during the growth spurt of early adolescence (idiopathic) o Diagnosis is made by physical exam and x-rays o Treatment for curvatures < 40 degrees is bracing o Surgical intervention is for severe curvatures internal fixation and instrumentation (Harrington) o Postoperative care includes logrolling, neurologic assessments, pain management, skin care, assessing for paralytic ileus and possible mesenteric artery syndrome o Dont forget the developmental needs of the adolescent

130

Muscular Dystrophy
Duchennes Muscular Dystrophy most common Gradual degeneration of muscle fibers S/S begin to show about 3 years of age difficulties in running and climbing stairs Changes to having difficulty moving from a sitting/supine position Profound muscular atrophy continues, wheelchair by 12 yrs Respiratory and cardiac muscles affected and death is usually respiratory or cardiac in nature Diagnosis made with physical exam, muscle biopsy, EMG, serum studies: AST (SGOT), aldolase, creatine phosphokinase high first 2 years of life Nursing care is to maintain optimal level of functioning and to help the child and family cope with the progression and limitations of the disease

131

Juvenile (Rheumatoid) Arthritis

Inflammatory disease with an unknown cause Occurs in children < 16 years; lasts > 6 weeks Clinical manifestations: stiffness, swelling, and loss of motion in affected joints, tender to touch Therapeutic management includes drug therapy (NSAIDs, SAARDs, cytoxic drugs, corticosterioids), physical and occupational therapy, exercise (swimming), moist heat for pain and stiffness, general comfort measures

132

General Nursing Interventions for Children with Musculoskeletal Dysfunctions (immobility)

Maintain optimal level of functioning Promote general good health Facilitate compliance Facilitate optimal growth and development Maintain skin integrity Safety considerations at home Pain management Support child and family

133

Lets Review
An infant is being treated non-surgically for clubfoot. Which describes a major goal of care for this patient? Prevention of:
A. B. C. D. Skin breakdown Calf atrophy Structural ankle deformities Thigh atrophy

134

Lets Review
The nurse is helping parents create a plan of care for their child with osteogenesis imperfecta. A realistic outcome is for this child to:
A. Have a decreased number of fractures B. Demonstrate normal growth patterns C. Participate in contact sports D. Have no fractures after infancy
135

Lets Review
During acute, painful episodes of juvenile arthritis, a priority intervention is initiating:
A. A weight-control diet to decrease stress on the joints. B. Proper positioning of the affected joints to prevent musculo-skeletal complications. C. Complete bedrest to decrease stress to the joints. D. High-resistance exercises to maintain muscular tone in the affected joints.

136

Pediatric Variances Endocrine System

Growth Hormone: Does not effect prenatal growth Main effect on linear growth Maintains rate of body protein synthesis Thyroid-stimulating hormone (TSH): Important for growth of bones, teeth, brain Secretion decreases throughout childhood and increases at puberty Adrenocorticotrophic Hormone (ACTH): Activated in adolescent Stimulates adrenals to secrete sex hormones Influences production of gonadotropic hormone

137

The Endocrine System

Disorders of the Endocrine System
Type 1 Diabetes Mellitus Congenital Hypothyroidism Growth Hormone Deficiency Precocious Puberty

 

138

Type 1 Diabetes Mellitus Pediatric Considerations

INSULIN
Most children are well-controlled with BID dosing of fast acting (Lispro) short acting (regular) and intermediate acting (NPH, Lente) insulin. There is also Lantis, an insulin that acts a basal. U-20 insulin is also available for infants Insulin pump, pen Honeymoon phase Stress, infection, illness and growth at puberty can increase insulin needs
139

Type 1 Diabetes Mellitus Pediatric Considerations

HYPOGLYCEMIC EPISODES
In small children it is more difficult to determine and may just be a behavior change. Treatment is the same simple sugar assess LOC first!

NUTRITION
Carb counting most childrens calories should not be restricted; meal plan might change as child grows. Some sweets may be incorporated into the diet and may help with compliance. 3meals with 3 snacks per day

140

Type 1 Diabetes Mellitus Pediatric Considerations

EXERCISE
Important for normal growth and development Assists with daily utilization of dietary intake Enhances insulin absorption, so may decrease amount needed Add 15-30 grams of carbs for each 45-60 minutes of exercise Watch for hypoglycemia with strenuous exercise

141

Type 1 Diabetes Mellitus Pediatric Considerations

DEVELOPMENTAL ISSUES
Infant/Toddler
Autonomy & choices, rituals, hypoglycemia identification difficult

Preschooler
Magical thinking-let them know they did not cause it Use dolls for teaching Urine testing may be done Can choose finger to use for testing

School-age
Very busy with school and activities Likes tasks and explanations Can do self blood testing; injections at age 8-10 years

Adolescents
Peers and body image preoccupation High risk for non-compliance Collaborative health care with parent involvement very important

142

Congenital Hypothyroidism
Thyroid is not producing enough thyroid hormone to meet needs of the body (resulting in oxygen consumption, BMR and protein synthesis) Clinical manifestations: cool, mottled skin, bradycardia, large tongue, large fontanel, hypothermic, hypotonia, lethargy, feeding problems - THINK SLOW! Labs: High TSH, low T4 Decreased brain development will result with cognitive impairments Part of newborn screening Therapeutic management is life-long thyroid hormone replacement (levothyroxine)
143

 Ideal time for newborn screening would be 3-6 days, but most often done much earlier. Results may be falsely interpreted due to an increase in TSH immediately after birth, which is part of the normal newborn transition.

144

Growth Hormone (GH) Deficiency

Deficient secretion of growth hormone Definitive diagnosis is made with GH levels (using stimulation testing) under 10mg/ml and x-rays of hand and wrist for ossification levels Treatment is replacement of GH (subcutaneous daily injections) until goals met Nursing care is directed at child and family support Remember to interact and speak to the child at her appropriate developmental level!
145

Precocious Puberty
Manifestations of sexual development in boys younger than 9 years and girls younger that 8 yrs Causes also an early acceleration of growth with closure of growth plates Therapeutic management is directed toward the specific cause, if known The early secretion of sex hormones will be treated with monthly subcutaneous injections of leuteinizing hormone-releasing hormone (LHRH) Priority interventions are directed at psychological support of child and family encourage play with same age peers

146

Lets Review
A child weighing 25 kilograms is being treated with synthetic growth hormone. The recommended dosage range is 0.3 0.7 mg/kg/week. The mother informs the nurse that her child receives 1.25 mg subcutaneously at bedtime 6 times per week. The proper response from the nurse would be:
A. That dose is too high, the doctor needs to be notified. B. You are doing a great job, that is the correct dose for your child. C. The injection should be given intramuscular, not subcutaneous. D. That dose is too low based on your childs new weight.

147

Lets Review
The nurse should include which information in teaching the parents of a recently diagnosed toddler with Type 1 diabetes mellitus?
A. Allow the toddler to choose which finger to use for blood glucose monitoring B. Allow the toddler to assist with the daily insulin injections C. Test the toddlers blood glucose every time she goes out to play D. Let the toddler determine meal times

148

Lets Review
Which is the most appropriate teaching intervention for a nurse to give parents of a 6year-old with precocious puberty?
A. Advise the parents to consider birth control for their child B. Inform the parents there is no treatment currently available C. Explain the importance for the child to foster relationships with peers D. Assure the parents there is no increased risk for sexual abuse.
149

Lets Review
Number in order of priority the following interventions needed while caring for a patient in diabetic ketoacidosis.
_____ Hydration _____ Electrolyte replacement _____ Dietary intake _____ IV Insulin _____ Subcutaneous insulin

150

Medication Administration
Oral Medication Hold infant with head elevated to prevent aspiration Slowly instill liquid meds by dropper along side of the tongue Crush pills and mix with sweet-tasting liquid if permitted, but dont add too much liquid! Allow choices for the child such as which med to take first Flush following gastrostomy or NG tube

151

Factors to consider when selecting IM sites

Age Weight Muscle development Amount of subcutaneous fat Type of drug Drugs absorption rate

152

IM and SQ Meds
Select needle length according to muscle size for IM Infant - should use 1 inch needle Preemies can use 5/8 inch needle Use Z-track for iron and tissue-toxic meds Apply EMLA or other topical anesthetic 45-60 minutes prior to injection May mix medication with lidocaine Some medications may be need to be separated into 2 injections depending on amount

153

Peds IM Injection Sites

Vastus lateralis for infants Ventrogluteal and dorsogluteal
Dont inject into dorsogluteal until age 3 years - muscle not well developed until child walks and sciatic occupies a larger portion of the area.

Deltoid after 3 years

154

IV Meds
Site may be peripheral or central Administer IV fluids cautiously Always use infusion pumps with infants and small children Inspect sites frequently (q 1-2 hours) for signs of infiltration Cool blanched skin, puffiness( infiltration) Warm and reddened skin (inflammation)

155

Nose Drops
Instill in one nare at a time in infants because they are obligate nose breathers. Suction nare with bulb syringe prior to administration if nasal congestion present

156

Ear Meds
Pull the ear down and back to instill eardrops in infants/toddler ( 3 years pull ) Pull the ear up and out to instill in older children ( 3 years pull ) Have medication at room temperature

157

Rectal Medication
Insert the suppository past the anal sphincter Hold buttocks together for a few seconds after insertion to prevent expulsion of medication
It is a very stressful route for children, and the school-age and adolescent have issues with modesty.

158

Inhalers and Spacers

Shake the inhaler for 2-5 seconds. Position inhaler into spacer (with mask or mouthpiece). After normal exhale, place mask on face or mouthpiece in mouth both with a good seal. Have child inhale slowly after canister is pressed down . Have child take a few breaths with a spacer and without a spacer have them hold breath for few seconds after medication released. Inhalers without spacers arent placed in the mouth because spacers require a seal around mouthpiece; masks with spacers can be used for infants.

159

MDI with Spacer MDI with Spacer and Mask

Photo Source: Del Mar Image Library; Used with permission

160

Lets Review
The nurse would prepare which site for an intramuscular injection to a 11 month-old?
A. B. C. D. Dorsogluteal Deltoid Vastus lateralis Ventrogluteal

161

Pediatric Oncology
Cancer is the leading cause of death from disease in children from 1 - 14 years. Incidence: 6,000 children develop cancer per year 2,500 children die from cancer annually Boys are affected more frequently Etiologic factors: environmental agents, viruses, host factors, familial/genetic factors Leukemia is the most frequent type of childhood cancer followed by tumors of the CNS system.

162

Oncology Stressful Events

Treatment is worse than the disease.
1. Diagnosis 2. Treatment - multimodal 3. Remission 4. Recurrence 5. Death

163

Oncology Interventions
Surgery Radiation Therapy Chemotherapy Bone Marrow Transplant

164

Stages of Cancer Treatment

1. 3. Induction Maintenance 2. Consolidation 4. Observation 5. Late Effects of Treatment
Impaired growth & development CNS damage Psychological problems
165

Pediatric Oncology
Types of Childhood Cancers
Leukemia Brain Tumors Wilms Tumor Neuroblastoma Osteogenic Sarcoma Ewings Sarcoma

166

Leukemias
Most common form of childhood cancer Peak incidence is 3 to 5 years of age Proliferation of immature WBCs (blasts) May spread to other sites (CNS, testes) Types of Leukemia:
 Acute lymphocytic leukemia (ALL) 80-85% of childhood leukemia 95% chance of remission  Acute nonlymphocytic Leukemia (ANLL) 60-80 % chance of remission

Treatment is chemotherapy: prednisone, allupurinol, selected chemotherapeutic agents

167

Leukemias
CLINICAL MANIFESTATIONS
Purpura, Bruising Pallor Fever Unknown Origin Fatigue, Malaise Weight loss Bone pain Hepatosplenomegaly Lymphadenopathy

LABS & DIAGNOSTIC TESTS

WBCs (50-100) or Very low WBCs Hgb, Hct, Platelets Blast cells in differential BONE MARROW ASPIRATION LUMBAR PUNCTURE BONE SCAN possible

168

Brain Tumors
Second most prevalent type of cancer in children Males affected more often Peak age 3 - 7 years Types: Medulloblastoma Astrocytoma Brain Stem glioma Look for S/S of increased ICP and area of brain affected

169

Wilms Tumor
Also known as Nephroblastoma Large, encapsulated tumor that develops in the renal parenchyma (do not palpate abdomen!) Peak age of occurrence: 1 - 3 years Prognosis is good if no metastases- lungs first Treatment is surgery, chemotherapy and sometimes radiation

170

Neuroblastoma
Highly malignant tumor extracranial Often develop in adrenal gland, also found in head, neck, chest, pelvis Incidence: One in 10,000 Males slightly more affected From infancy to age 4 Often diagnosed after metastasis occurs Treatment includes surgery, chemotherapy and radiation
171

Bone Tumors
Osteogenic Sarcoma: Occurs most often in boys between 10-20 yrs 10-20% 5 year survival rate Primary bone tumor of mesenchymal cell Treatment:surgery (amputation or salvage) and chemo Ewings Sarcoma: Occurs in boys between 5 - 15 years Primary tumor arising from cells in bone marrow Treatment is radiation and chemotherapy
172

Pediatric Oncology: Nursing Interventions

CHEMOTHERAPY SIDE EFFECTS Leukopenia (Nadir) Thrombocytopenia Stomatitis Nausea/Vomiting Alopecia Hepatotoxicity Nephrotoxicity NURSING INTERVENTIONS HANDWASHING! Monitor visitors Monitor for infection Meticulous oral care Antiemetics ATC Monitor Labs Support/Teaching

173

Pediatric Oncology: Nursing Interventions

Supportive care for radiation treatment, focusing on skin care Surgical interventions are based on location and type of surgery
Basic pre and postoperative care

Psychosocial care for patient and family utilize Child Life and Social Services

174

Pediatric Oncology
Teach, teach, teach! Support the child and family Provide resources Be honest Include the child in the care planning
Photo Source: Del Mar Image Library; Used with permission

175

Lets Review
In caring for the child with osteosarcoma, it is important for the nurse to inform the child and family of the treatment plan. Which would be appropriate?
A. B. C. D. The affected extremity will have to be amputated. The child will only need chemotherapy. Both surgery and chemotherapy are indicated. Only palliative measures are taken.

176

Lets Review
The nurse assessing a child who is undergoing chemotherapy finds the child to be suffering from mucositis. Which intervention would be the highest priority?
A. Meticulous oral care. B. Obtain dietician consult. C. Place the child on a full liquid diet only. D. Medicate for pain around the clock.

177

Lets Review
The priority nursing intervention in caring for a child with acute lymphocytic leukemia (ALL) during the childs nadir period is:
A. B. C. D. Handwashing. Monitoring lab results. Administering antiemetics. Monitoring visitors.

178

Death & Dying

Childs Response to Death: Infants & Toddlers:
Do not understand Viewed as a form of separation Can sense sadness in others

Preschooler:
Death is temporary Viewed as sleep or separation Feel guilty and blames self Dying children may regress in behavior
179

Death & Dying

School-Age:
Have concept of irreversibility of death Fear, pain, mutilation and abandonment Ask many questions Feel death is a punishment May personify death (bogeyman) Will ask directly if they are dying Interested in the death ceremony Comforted by having parents and loved ones with them

180

Death & Dying

Adolescent:
Have an accurate understanding of death Death as inevitable and irreversible May express anger at impending death May find it difficult to talk about death May wish to leave something behind to remember them by May wish to plan own funeral

181

Death & Dying

Parental responses to death:
Major life stress Experience grief at potential loss of child Related to circumstances regarding childs death (denial, shock, disbelief, guilt) Confronted with major decisions regarding care May have long term disruptive effects on family Bereaved parents experience intense grief of long duration

182

Communicating with the Dying Child and Family

Use childs own language Dont use euphemisms Dont expect an immediate response Communicate through touch Encourage questions and expressions of feelings Strengthen positive memories Listen, touch, cry
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Impending Death Care Guidelines

Do not leave child alone Do not whisper in the room Touching the child is very important Let the child and family talk and cry Let parents participate in care as much as they are emotionally capable of doing Continue to read favorite stories or play the childs favorite music Be aware of the needs of the siblings
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Lets Review
Which intervention would be most helpful in supporting a dying childs family as they cope with the various decision-making periods of a lengthy terminal illness? A. Encouraging the parents to take their child home to die. B. Encouraging the parents to go through all of the KublerRoss stages of dying as quickly as possible. C. Referring the childs family to the hospital clergy service as soon as possible. D. Using active listening to identify specific fears and concerns of the childs family members.

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Types of Child Abuse

Neglect: Intentional or unintentional omission of basic needs and support Physical Abuse: Is non-accidental injury to a child by an adult Sexual Abuse: Forced involvement of children in sexual activities by an adult Emotional Abuse: Withholding of affection, use of cruel and degrading language towards a child by an adult
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Child Abuse
Reports of violence against children has almost tripled since 1976. Many of the abused children are infants.

Red Flags
Fractures in infants Spiral fractures Injuries do not match story told

NURSES ARE MANDATED REPORTERS

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Child Abuse
Neglect
Physical or emotional maltreatment Failure to thrive Contributing factors may be ignorance or lack of resources

Physical Abuse
Minor or major physical injury (bruising, burns, fractures) May cause death Munchausen by Proxy (MSP) Shaken baby syndrome (SBS)

Sexual
Incest, molestation, child porn, child prostitution

Emotional
May be suspected, but difficult to substantiate Impairs childs self-esteem and competence
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Child Abuse
Warning Signs
Incompatibility between history of event and injuries Conflicting stories from various people involved History inconsistent with developmental level of child Repeated visits to emergency rooms Inappropriate response from child and/or caregiver

Nursing Interventions
Assess: Physical assessment and history of event, observe and listen to caregivers and childs verbal and non-verbal communication Documentation: Complete CAR form and contact Child Protective Services, hospital documentation Support family and child: Social services, resources, teaching

THE CHILDS SAFETY COMES FIRST AND IS THE PRIORITY!

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Lets Review
In caring for a 4 year-old with a diagnosis of suspected child abuse, the most appropriate intervention for the nurse is:
A. Avoid touching the child. B. Provide the child with play situations that allow for disclosure of event. C. Discourage the child from speaking about the event. D. Give the child realistic choices to feel in control.

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Lets Review
Which pediatric patient would most necessitate further investigation by the community-based nurse?
A. An adolescent who prefers to spend time with friends rather than family. B. A toddler with dark bruises located on both legs. C. An infant with numerous insect bite marks and diaper rash. D. A preschooler with dirty knees and torn pants.

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