Pediatric

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Pediatric Nursing
I. Pediatric Cardiovascular
Congenital Heart Defects
A. General concepts
1. Definition: present at birth - consequences are congestive heart failure
and hpo!e"ia
#. $tiolog: usuall not %no&n - associated &ith "aternal factors:
a. infection
b. alcoholis"
c. age over '( ears
d. diabetes "ellitus) tpe one
e. genetics) chro"oso"al changes
*. +indings of congenital heart defects
a. child s"all for age
b. phsiological failure to thrive
c. e!ercise intolerance
d. dspnea &hile feeding
e. squatting position
f. clubbing of fingers
g. canosis and,or pallor "a be associated &ith poor perfusion
h. unusual pulsations
'. Phsical consequences of congenital heart defects
a. increased &or%load- pul"onar hpertension- decreased sste"ic
output- canotic defects
b. can lead to hpo!e"ia and polcthe"ia
c. concern: for"ation of thro"bus &ith e"bolus
d. blood flo& patterns "a be affected
.. Acanotic defect - infant,child is /pin%/ but child "a develop canosis
1. Patholog: hole in the heart0s internal &all
a. blood flo&s fro" heart0s arterial 1left2 to venous 1right2 side or a
/left to right shunt/) not sste"icall) but onl &ithin heart itself
b. si3e of defect &ill deter"ine severit of condition
#. Co""on tpes:
C. Canotic defect: infant,child is usuall /blue/) but child "a appear pin%
1. Patholog
a. uno!genated blood "i!es &ith o!genated) via a /right to left
shunt/
b. decreases o!genation to the entire sste"
c. results far "ore severe than acanotic
d. thro"bus for"ation is al&as a concern
D. Diagnostics
1. $4G: noninvasive) painless) infants and oung children "a require "ild
sedation
#. Cardiac catheteri3ation
a. presence of diaper rash "a postpone procedure
b. preparation depends on level of gro&th and develop"ent
c. post procedure 5 child "a have difficult co"pling &ith %eeping
insertion point in correct position
$. 6ursing care of the child &ith a congenital heart defect
1. $"otional) phsiological) and pschological interventions
#. Assisting the child and fa"il to ad7ust to special needs
*. Goals of treat"ent
a. child &ill "aintain adequate o!genation and phsiological
stabilit
b. fa"il &ill understand signs and s"pto"s of the condition) and
ho& to "anage each of the"
c. child &ill attain "ilestones of nor"al gro&th and develop"ent
d. &hen child has surger) child and fa"il &ill be prepared) %no&
prognosis) and %no& ho& to give ho"e care after&ard
e. i"prove cardiac function
f. re"ove accu"ulated fluid
g. decrease cardiac de"ands
h. i"prove tissue o!genation
'. 6ursing interventions
a. recogni3e CH+
+I6DI6G8 9+ C96G$8:I;$ H$A<: +AI=><$
b. "onitor height) &eight) vital signs) pulses) pulse o!i"eter) inta%e
and output
c. "edications: digo!in 1=ano!in2) furose"ide 1=asi!2 or
chlorothia3ide 1Diuril2) AC$ inhibitors: Capoten) ;asotec
d. "onitor seru" potassiu" level
e. recogni3e and treat pain appropriatel: phar"acological and
nonphar"acological interventions
f. "aintain a safe environ"ent
g. conserve energ
h. "aintain proper nutrition) &ith s"all) frequent feedings 5 "onitor
sodiu" inta%e) fluid restriction "a be required
i. support and discuss treat"ent &ith parents
7. place in proper position - slanting position &ith head elevated)
older babies in infant seats) occasional %nee-chest
?. :eaching points
a. infor" parents about findings of infection
b. discuss possible behavior changes the child "a e!hibit
c. counsel parents about high-ris% children requiring antibiotic
prophla!is for dental &or%
Acquired Cardiovascular Disorders
occur after birth as a result of infection) autoi""une responses) environ"ental or fa"ilial
tendencies
+. Hperlipide"ia: e!cessive lipids
1. $tiolog: dietar) heredit
#. Pathophsiolog
a. increased lipids and cholesterol
b. causes atherosclerosis) leading to coronar heart disease
*. Diagnosis: lab tests: increased =D=) lipids and cholesterol- decreased
HD=
'. @anage"ent
a. diet: ADA diet in t&o steps:
i. A *( %cal fro" fat- A ten fro" saturated fat- A *(( "g,=
cholesterol
ii. A *( %cal fro" fat) A seven fro" saturated fat- A #(( "g,=
cholesterol
b. "edications: colestipol 1Colestid2) niacin 16icor2) cholestra"ine
1Buestran2
?. 6ursing interventions
a. encourage screening for at ris% children &ith fa"il histor
b. teach dietar guidelines or refer to dietician
G. .acterial endocarditis: infla""ation of the valves of the inner lining of the heart
1. $tiolog: possible causative agents
a. strept
b. staph
c. fungi
#. Pathophsiolog
a. organis"s enter blood strea" 1vascular disse"ination2
b. for" vegetation on endocardiu"
*. Diagnostics
a. $4G changes
b. sedi"entation rate evaluated
c. C.C elevated
d. blood cultures
'. @anage"ent
a. high doses of antibiotics
?. 6ursing interventions
a. "onitor for signs of infection
b. provide rest periods
D. :eaching points
a. need for long-ter" I; therap
b. side effects of antibiotics
c. high-ris% children need prophlactic antibiotic therap before
dental &or% or other invasive procedures
II. Pediatric <espirator
<espirator Infections
A. General concepts
1. $tiolog: bacterial) viral- often influenced b age) season) pree!isting
disorder) living conditions
#. +indings: increased respirator and heart rate) fever) nausea,vo"iting)
nasal discharge and bloc%age) "ucus production) coughing) adventitious
lung sounds
*. 6ursing care goals
a. child &ill not e!hibit findings of respirator distress) &ill be able to
clear secretions) and re"ain co"fortable &ith a patent air&a
b. child &ill not spread infection to others
c. child &ill ingest adequate fluids) and "aintain hdration
'. @anage"ent
a. "edications: antibiotics) antipretics
b. possible: anti-infla""ator) anti-"ucoltics) bronchodilators)
o!gen as needed
?. 6ursing interventions
a. chest phsiotherap
b. provide nutrition and encourage fluids - Eello) soup) puddings
c. pro"ote rest and co"fort
d. prevent spread of infection
e. ease respirator efforts - &ar" "ist
D. :eaching points
a. hand&ashing
b. avoid contact &ith affected children
.. <espirator failure: inabilit to "aintain adequate o!genation
1. Predisposing factors
a. obstructive ano"alies) aspiration
b. infections) tu"ors) anaphla!is
c. restrictive conditions: respirator distress) cstic fibrosis)
pneu"onia) pneu"othora!
d. paraltic conditions
#. +indings
a. restlessness) "ood changes
b. changes in =9C
c. increasing rates of respiration and pulse
d. dspnea
*. @anage"ent
a. frequent observation and phsical e!a"s) &ith pulse o!i"eter
b. correct hpo!e"ia) "aintain ventilation and deliver o!gen
c. "onitor for side effects and e!pected outco"es of therap
C. Air&a obstruction and basic life support
1. Cardiac arrest is usuall due to prolonged hpo!e"ia secondar to
inadequate ventilation) o!gen or circulation
#. Chen follo&ing guidelines for pediatric life support) consider not 7ust the
child0s age) but also si3e. Individual anato" and develop"ent &ill var.
*. Air&a clearance techniques
a. deter"ine conscious versus unconscious child
b. for infants and toddlers: bac% blo&s and chest thrusts
c. for preschool and school-age: "odified Hei"lich "aneuver
1/astride/2
Infant <espirator Disorders
D. <espirator distress sndro"e 1<D82: /haline "e"brane disease/
1. Definition: related to develop"ent dela in lung "aturation
#. $tiolog
a. pre"ature infants: usuall due to surfactant deficienc
b. ne&borns: birth asph!ia) "ultiple gestations) diabetic "other
c. older children: trau"a) dro&ning
*. Pathophsiolog
a. decrease in a"ount and,or qualit of pul"onar surfactant
b. in older children) surfactant "a be &ashed out b dro&ning or
fluid aspiration
c. increased alveolar surface tension
d. i"paired gas e!change
e. increased pul"onar resistance
f. hpoperfusion
4. +indings
a. tachpnea) increased respirator effort
Findings of Respiratory Distress Syndrome
:he transition fro" respirator-related to sste"ic related indicates a
progressive severit of the disease
1. <espirator related
a. rales
b. e!pirator grunting
c. nasal flaring
d. retractions
e. tachpnea
f. apnea
#. 8ste"ic related
a. flaccid bod
b. nonresponsive
c. hpotension
d. shoc%
b. parado!ic /seesa&/ respirations
c. nasal flaring
d. substernal retractions
e. e!pirator grunt) possible apnea
f. canosis
g. hpo!ia
?. Diagnostics
a. phsical e!a") pulse o!i"eter
b. seru": A.G0s) glucose) calciu"
c. chest radiograph confir"ation 5 diffuse pattern over both lung
fields that rese"bles ground glass
D. @anage"ent:
a. o!gen therap 1possible "echanical ventilation2 and chest
phsiotherap to "aintain ventilation and o!genation
b. "edications: possible "edications: surfactant) prophlactic
antibiotics) diuretics) inotropes) "ethl-!anthines
F. 6ursing interventions:
a. frequent respirator assess"ent.
b. "aintain acid base balance and tissue perfusion
c. electrolte status
d. suction as indicated
G. :eaching points:
a. infor" parents about equip"ent
b. positioning of infant
c. need for "eticulous care b nurses due to subtle changes
possible in infantHs o!genation status
$. .ronchopul"onar dsplasia: 1.PD2) chronic obstructive lung disorder
1. $tiolog - at ris%:
a. infants requiring o!gen and,or length "echanical ventilation
b. infants surviving <D8
c. lung i""aturit
#. Pathophsiolog
a. "echanical ventilation presses lung tissue
b. bronchial epitheliu" is da"aged
c. products of infla""ation introduced) alveolar &alls beco"e thic%)
fibrotic
d. continued "echanical ventilation affects the gro&th of ne& cells
and paral3es cilia
e. lungs develop cstic areas 1sacs2 and atelectasis 1collapsed
alveoli2- "ucus "oves less
*. +indings
a. tachcardia and tachpnea
b. increased &or% of breathing
c. pallor
d. canosis &ith activit
e. restlessness
'. @anage"ent
a. o!gen 1possible "echanical ventilation2
b. "edications: diuretics) bronchodilators) anti-infla""ator agents
in graduall decreasing a"ounts
c. diet: increased calorie for"ulas and hdration
d. provide supple"ental o!gen at ho"e as needed
?. 6ursing interventions:
a. provide rest periods
b. observe for fluid overload or pul"onar ede"a
c. provide age appropriate tos
d. frequent respirator assess"ent
+. Apnea: cessation of breathing for over #( seconds
1. $tiologies
a. pre"aturit
b. foreign-bod aspiration) dro&ning) or trau"a
c. incorrect positioning
d. gastroesophageal reflu!
e. infections
f. sei3ure
g. hpoglce"ia
#. Pathophsiolog: dependent on tpe of apnea:
a. central - absence of respirator effort and air "ove"ent
b. obstructive - respirator effort but no air "ove"ent
c. "i!ed - first central) then obstructive
*. +indings
a. depend on tpe 1above2
b. color changes) hpotonia
'. Diagnostics: laborator tests) chest !-ras) $$G) $CG)
pneu"ocardiograph) upper GI series
?. @anage"ent
a. ho"e apnea "onitoring and basic life support 1.=82 training to
fa"il
b. "edications: based on tpe and underling condition
<espirator Conditions
G. >pper respirator tract infections 1><I2
1. $tiolog: often acute viral nasopharngitis) or the /co""on cold/
#. Pathophsiolog
a. organis" invades "ucous "e"branes
b. ede"a) vasodilation and increased "ucus production
c. usuall self-li"iting
*. +indings: nasal congestion) snee3ing) colored nasal discharge) lo& grade
fever) cough) irritabilit
'. @anage"ent:
a. "edications: antipretics) decongestants 1oral or nasal2)
analgesics
b. cool "ist hu"idifier
c. adequate fluids
d. rest
e. assess for presence of earache 1otitis "edia2) te"perature over
*G.* degrees Celsius and refusal to eat - "a indicate
co"plications
H. 8inusitis
1. $tiolog: viral) bacterial) ><I) obstructive defor"ities) cstic fibrosis
#. +indings
a. cold that does not i"prove
b. chronic nasal congestion) purulent nasal discharge
c. headache
d. tenderness over sinus areas
e. halitosis
*. Diagnostics: sinus !-ras) C:
'. @anage"ent
a. "edications
1. antibiotics
#. antipretics
*. analgesics
'. decongestants
?. antihista"ines
?. 6ursing care
a. "onitor respirations
b. &ar" "ist 1possible2
I. Acute pharngitis
1. $tiolog: streptococcus 1bacterial2- or viral 1often acco"panies tonsillitis2
#. +indings
a. bacterial
i. /sic%er/ &ith sudden onset
ii. ver sore throat
iii. high fever
iv. headache
b. viral
i. gradual onset
ii. fever
iii. cough) rhinitis
*. Diagnostics
a. throat culture
b. rapid strep
'. @anage"ent
a. "edications: penicillin for strep) possible antipretics and
analgesics
?. 6ursing interventions
a. "onitor for co"plications such as acute rheu"atic fever and acute
glo"erulonephritis
b. "onitor fluid inta%e
c. "oisture co"press to nec% 5 cold or &ar"
d. cool liquids or ice chips
E. :onsillitis
1. $tiolog: bacterial) viral in association &ith pharngitis
#. Pathophsiolog: infection and infla""ation enlarge tonsils- as air&a
narro&s) it hinders s&allo&ing and breathing
a. palatine tonsils usuall visible during oral e!a"
b. pharngeal tonsils are also %no&n as the adenoids
*. +indings
a. /%issing tonsils/
b. sore throat
c. halitosis
d. "outh breathing- snores at night
e. fever
'. Diagnostics: histor) phsical e!a") throat culture
?. @anage"ent
a. supportive: antibiotics) fluids) rest) antipretics) analgesics
b. surger: tonsillecto" done after * episodes of tonsillitis in one
ear
c. adenoidecto" "a be done &ith tonsillecto") if adenoiditis is
present.
D. 6ursing interventions
a. assess for frequent s&allo&ing 5 bleeding "a be the cause
b. assess an vo"itus
c. place child on side
d. "edicate for pain as needed
e. avoid fluids &ith red or bro&n color
f. soft foods 5 avoid highl seasoned food
F. :eaching points: teach parents
a. child needs quiet activit
b. "onitor for bleeding
c. antipretics and analgesics 5 no A8A
d. soft foods as throat is ver sore
K. Croup sndro"es 1including larngitis) tracheitis) epiglottitis2
8i"ilarities and Differences of Diseases Included in the Croup 8ndro"es
1. Definition: several air&a-bloc%ing infections) co""on in children
a. signs of croup
i. inspirator stridor
ii. harsh,brass cough) bar%ing cough
iii. hoarse voice
iv. respirator distress
b. tpes) b pri"ar area affected:
i. subglottal area: acute spas"odic croup) larngitis)
larngotracheobronchitis 1=:.2) tracheitis
ii. supraglottal area: epiglottitis
#. $tiolog
a. usuall viral
b. occasionall bacterial 1tracheitis) epiglottitis2
c. ounger children &ith /true croup/ 1spas"odic croup2
d. older children &ith tracheitis and epiglottitis
*. Pathophsiolog: "ucosa infla"ed- ede"a narro&s the air&a
'. +indings
a. classic: /bar%/ harsh cough) stridor) hoarseness)fever) purulent
secretions) dspnea if severe
b. bacterial: child loo%s /sic%er/
c. epiglottitis "anifests the four /D0s/
i. drooling
ii. dsphagia 1difficult s&allo&ing2
iii. dsphonia 1hoarse voice2
iv. distressed inspirator efforts
?. @anage"ent
a. viral
i. cool air,"ist- fluids
ii. if inpatient) nebuli3ed race"ic epinephrine and inhaled
steroids
iii. antipretics
b. bacterial: sa"e as above &ith antibiotics) possible intubation
c. epiglottitis is a "edical e"ergenc- tracheoto" "a be
necessar
D. 6ursing interventions
a. teach parent and child signs of i"pending air&a obstruction
b. report increased pulse) respirations) retractions) increased
restlessness
c. never atte"pt to directl visuali3e epiglottis &ith tongue depressor-
it could precipitate larngospas"
=o&er Air&a Disorders
=. .ronchiolitis: acute infection at bronchiolar level
1. $tiolog
a. viral: <8; 1respirator snctial virus2 "ost co""on
b. occasionall bacterial
#. Pathophsiolog
a. virus spreads via direct contact
b. enters bod via nose or ee
c. leads to ede"a) "ucus accu"ulation and cellular debris &hich
obstruct bronchioles
d. can progress to atelectasis
*. +indings - infection is rare in children older than # ears of age
a. usuall "ild ><I
b. snee3ing) productive cough) lo&-grade fever) rhinorrhea 1nasal
discharge2) adventitious lung sounds
c. otitis "edia and con7unctivitis "a also be present
'. Diagnostics: histor) <8;,viral nasal &ashing) chest !-ra
?. @anage"ent depends on severit
a. "ild: fluids) hu"idification) rest
b. severe: hospitali3ation) antiviral) I; fluids) possibl
bronchodilators) steroids and "echanical ventilation. @aintain
contact secretion precautions
c. prophla!is: respirator snctial virus i""une globulin in high
ris% infants
D. 6ursing interventions
a. ad"it each child to single roo" or &ith other <8; infected
children
b. teach hand&ashing and use of contact precautions
c. assess fluid volu"e status
F. :eaching points
a. chec% i""uni3ation schedule. <8; 5 I;IG "a interfere &ith
i""une response. 6o vaccines for I "onths after child receives
these
@. Pneu"onia: infla""ation of lung parench"a
1. $tiolog: usuall classified b anato"ic distribution or pathogen
a. "ost co""onl viral
b. so"eti"es bacterial
c. so"eti"es aspiration of foreign substance
#. Pathophsiolog
a. triggers ter"inal air&as) alveoli infiltrate and cell destruction
b. cellular debris falls into lu"en
c. bacterial agent can reach circulator sste" via pul"onar
l"phatics
d. "a occur as a co"plication of another illness
*. +indings
a. can be abrupt or insidious
b. adventitious lung sounds) fever) "alaise) nonproductive cough)
restless) lethargic
c. progressing to "ore severe &ith retractions) respirator distress)
productive cough
'. Diagnostics
a. increased C.C - chest !-<a reveals consolidation in lungs or
presence of fluid
?. @anage"ent - depends on tpe
a. viral - o!gen) chest phsiotherap) fluids
b. bacterial - antibiotics) o!gen) chest phsiotherap) fluids
c. aspiration - supportive therap) treat"ent of secondar
co"plication ris%
d. ad"inister pneu"ococcal vaccine to at ris% individuals
D. 6ursing interventions
a. frequent assess"ent of respirator status
b. cool "ist tent - change clothing frequentl
c. cluster nursing care
6. Aspiration of foreign bod
1. $tiolog: child aspirates solids) liquids) vegetative "atter into air
passages) "ost co""on in older infants and children up to three ears of
age
#. Pathophsiolog: "ost substances beco"e lodged in bronchi) and
severit is deter"ined b location) substance aspirated and e!tent of
obstruction
*. +indings: sudden coughing) gagging) &hee3ing) canosis) dspnea) and
stridor
'. Diagnostics: chest !-ra) fluoroscop) bronchoscop
?. @anage"ent: direct larngoscop or bronchoscop to re"ove ob7ect)
then supportive therap
D. 6ursing interventions
a. recogni3e signs of +. aspiration
b. ad"inister bac% blo&s or Hei"lich "aneuver as indicated
F. :eaching points
a. parents need to %no& "ost li%el causes to prevent aspiration
1. peanut butter
#. balloons
*. alu"inu" tabs fro" soda cans
'. paper clips
9. =ong-ter" respirator dsfunction: asth"a,reactive air&a disease
1. Definition: chronic infla""ator disorder of the air&as) "anifested b
periods of e!acerbations and re"issions- has an allergic co"ponent
#. $tiolog
a. genetic predisposition
b. triggers are: allergens) infection) stress) e!ercise) "edical
conditions) "edications.
c. tpes: intrinsic) e!trinsic) occupational
*. Pathophsiolog
a. trigger leads to an i""ediate phase reaction 1cell activated) &ith
"ast cell) eosinophils and hista"ine released &ith other "ediators
of infla""ation2
b. resulting in bronchoconstriction &ith additional granulocte
response &ith "ore infla""ator presence
c. later phase reaction 1additional infla""ation and
hperresponsiveness2
d. bronchospas" and obstruction cause "ost s"pto"s
'. +indings
a. classic: hac%ing cough) &hee3e on e!pirations) dspnea
b. cough "a be nonproductive at first) to productive &ith "ucus
c. change in =9C) restlessness
?. Diagnostics
a. phsical e!a") histor
b. pul"onar function tests 1P+:2
c. bronchodilator treat"ents) chest !-ra) s%in testing) C.C &ith
differential
d. allerg testing
D. @anage"ent
a. goals: nor"al gro&th and develop"ent) patent air&a) good
control
b. preventive: allergen control and avoidance
c. use of pea% flo& "eter
d. "edications
1. long ter" control 1preventor2 "edications: to achieve and
"aintain control of infla""ation- also called controllers
1. corticosteroids - anti-infla""ator
#. cro"oln sodiu" - nonsteroidal anti-infla""ator
*. nedocro"il - anti-allergic and anti-infla""ator
'. long acting beta adregenics 1Albuterol2 used for
acute e!acerbations
?. "ethl!anthines 1theophlline2 bronchodilator
D. leu%otriene "odifiers 1Jileuton2 - "ediator of
infla""ation
#. quic% relief 1rescue2 "edications to treat acute s"pto"s
and e!acerbations
1. short acting beta adrenergics
#. anticholinergics
*. sste"ic corticosteroids
F. Acute "anage"ent
a. use of bronchodilators
b. steroids 1inhaled) I; and,or oral2
c. o!gen) I; fluids) possibilit of intubation
G. 6ursing Interventions
a. "onitor child for respirator distress and,or need for nebuli3er
treat"ents.
b. place se"i-high +o&lerHs position
c. sta &ith child if at all possible - have parent sta during acute
phase of illness
d. "onitor fluid volu"e status
I. :eaching points
a. child and fa"il "ust co"pl &ith "edications and treat"ents
b. correct use of "etered-dose inhaler [email protected] &ith a spacer
c. ris%s include overuse of bronchodilators
1(. Co"plications
a. e!ercise-induced bronchospas" 5 acute and reversible) usuall
stop in #(-*( "inutes
b. status asth"aticus 5 e"ergenc situation
P. Cstic fibrosis
1. Definition: inherited autoso"al recessive trait - abnor"al "ucus secretion
and obstruction
#. $tiolog
a. genetic origin
b. basic defect e!ocrine gland dsfunction
*. Pathophsiolog
a. "ucous glands produce a thic% "ucoprotein that accu"ulates
instead of a thin freel flo&ing secretion
b. affects respirator) gastrointestinal and reproductive sste"s
'. +indings
a. gastrointestinal
1. "econiu" ileus
#. steatorrhea
*. prolapse of rectu"
'. failure to gro&
b. respirator
1. thic% tenacious "ucus causes patch atelectasis cough
#. barrel-shaped chest
*. clubbing of fingers and toes
?. Diagnostics
a. s&eat chloride test - iontophoresis - Pilocarpine over D( "$q,= is
diagnostic of C+
b. chest !-ra: patch atelectasis
c. stool analsis
D. @anage"ent
a. CP:
b. "edications: bronchodilators) antibiotics 1Pseudo"onas
aeruginosa - Cepacia) and staph aureus2
c. D-6ase - decreases viscosit of "ucus
d. en3"es ad"inistered &ith "eals and snac%s to replace
pancreatic en3"es
F. 6ursing interventions
a. high protein) high caloric &ell balanced diet) vita"ins AD$4
should be added
b. frequent hospitali3ations to treat respirator infections
c. "onitor I; fluids
III. Pediatric 6eurolog
III. Pediatric 6eurolog
A. General concepts:
1. Assess"ent of cerebral function:
#. Children under # unable to respond to directions
*. Infants pri"aril refle!ive
'. 9bserve spontaneous and elicited refle! responses 5 having parent
present "a be helpful
?. Include fa"il histor and health histor
D. 4no& stage of gro&th and develop"ent and develop"ental "ilestones
.. Increased intracranial pressure 1ICP2
1. $tiolog
a. congenital or acquired 1fro" trau"a) lesion) infection2
b. also see Pediatric 9ncolog 18ee section KI of this lesson2
#. Pathophsiolog: s&elling caused b irritation or bleeding into brain tissue
*. +indings
a. infant: bulging fontanels) &idened cranial sutures) high-pitched
cring) irritable
b. child: headache) nausea) vo"iting) letharg) diplopia) sei3ures
'. Diagnostics:
a. CA: 8can 5 @<I
?. @anage"ent
a. principle of "aintaining cerebral perfusion pressure 1CPP2) &hich
equals "ean arterial blood pressure "inus ICP
b. "edications: os"otic diuretics) antihpertensives) anti-sei3ure)
fentanl) ;ersed and ;ecuroniu" "a be added
c. "aintain patient air&a: "echanical ventilation) o!gen
d. in severe cases) ICP "onitor 5 ventricular tap "a be required to
relieve accu"ulated C8+
e. "ini"i3e e!ternal sti"uli
D. 6ursing interventions:
a. observe,"onitor 5 =9C) pupillar reaction and vital signs,neuro
signs
b. pain "anage"ent should be "onitored
c. nutrition 5 "a require tube feeding if long ter"
d. positioning 5 H9. is elevated 1?-*( degrees head is "aintained
in "idline.
e. cluster care to allo& periods of rest
f. "a not bathe child if ICP is unstable
g. "a need artificial tears
h. support fa"il
C. Hdrocephalus - i"balance in the production and absorption of C8+ in the
ventricles
1. $tiolog: congenital) acquired) or idiopathic
#. Pathophsiolog: depends on tpe
a. co""unicating: i"paired absorption of C8+ &ithin the
subarachoid space
b. nonco""unicating: obstruction of the flo& of C8+ through the
ventricular sste"
*. +indings
a. changes fro" baseline neurological status) and often sa"e as
increased ICP
b. infant 1signs of increased intracranial pressure2
I. bulging fontanels) increased head circu"ference
II. /setting sun/ ees) pupils slo& to constrict to light
III. eats poorl
I;. high-pitched cr
;. variable pulse) changes in respirations
c. older child 1signs of increased intracranial pressure2
I. headaches
II. di33iness
III. vo"iting
I;. diplopia
;. ata!ia
'. Diagnostics:
a. C: 8CA6 5 @<I
I. sedation "a be required
?. @anage"ent
a. surgical place"ent of ventriculoperitoneal 1;P2 shunt in neonates)
infants and older children placed on unoperated side to prevent
pressure on operative site
b. "onitor for increased intracranial pressure
c. "easure head circu"ference
d. no scalp vein I; lines
D. 6ursing interventions:
a. neuro and vital signs
b. assess pain level 5 aceta"inophen &ith or &ithout codeine
c. observe for abdo"inal distention for possible catheter
co"plications
d. 6P9 5 feed after bo&el sounds return
e. "onitor fluid volu"e status
f. "onitor head circu"ference
g. %eep diaper off perineal dressing
F. :eaching points
a. teach fa"il signs of infection
I. elevated te"perature
II. poor feeding
III. irritabilit
I;. altered level of consciousness
b. ho"e care
I. no contact sports
II. child should be as active as possible.
G. Co"plications: shunt infection and "alfunction
D. 8ei3ures
1. Definition: brief "alfunctions of the brain0s electrical sste" that result
fro" cortical neuronal discharge
#. $tiolog: cerebral) bioche"ical) post-trau"atic) febrile) idiopathic) "ost
co""on neurologic dsfunction in children
*. Pathophsiolog
a. trigger electrical discharges affecting nearb nor"al cells
b. spreads throughout brain reaching "idbrain reticular regions
c. possible generali3ed sei3ure &ith neurological s"pto"s
'. +indings
a. deter"ined b site of origin
b. "a include altered levels of consciousness) involuntar
"ove"ents and changes in perception
c. sei3ure "a be a finite event) &ith li"ited "anifestations
d. "a have an aura
e. status epilepticus is continuous sei3ure lasting "ore than *(
"inutes or a series of sei3ures fro" &hich the child does not
regain a pre"orbid level of consciousness
f. febrile sei3ures: occur in association &ith a fever) usuall greater
than *G.G degrees Celsius 11(1.G degrees +ahrenheit2
g. "a be nonrecurrent 1acute2 such as febrile episode or recurrent
1chronic2 such as epileps
?. Diagnostics 5 goal is to ascertain the tpe and cause of sei3ure.
a. detailed and accurate histor
b. phsical e!a" to include neurological assess"ent
c. C.C 5 glucose level
d. s%ull fil"s) C:- @<I 5 $$G
$. $pileps
1. Definition: chronic sei3ure disorder &ith recurrent and unprovo%ed
sei3ures
#. $tiolog: un%no&n. international classification: partial and generali3ed
a. partial: li"ited to a particular local area of the brain
I. "ost co""on
I. si"ple partial &ith "otor signs
II. si"ple partial &ith sensor signs
III. co"ple! partial &ith pscho"otor sei3ures
b. generali3ed: involves both he"ispheres of the brain
I. "ost co""on
I. tonic-clonic 1grand "al2
II. absence 1petit "al2
*. Pathophsiolog: see sei3ures
'. Diagnostics: to!icolog screen) A.GHs) electroltes) anticonvulsant drug
level) possible lu"bar puncture
?. @anage"ent: see sei3ure precautions) sei3ure care) postictal care
a. supportive:
I. air&a suction and o!gen
II. safet 5 loosen clothing) place on floor) clear area) and
re"ove restrictive clothing
b. "edications 5 antiepileptic drugs
D. 6ursing interventions
a. observe sei3ure 5 protect fro" in7ur
I. order of onset
II. "ove"ent
III. face
I;. ees
;. respirations
;I. incontinence of urine or stool
;II. duration
;III. do not restrain
b. assess postictal status
c. sta &ith child until full conscious
F. :eaching points
a. long-ter" care "edication regi"e
b. child can participate in "ost activities for age
c. assess trigger factors -possibl video ga"es &ith flashing lights if
sensitive
+. 6eural tube defects 16:Ds2
1. Anencephal - degeneration of the brain to a spong for" "ass &ith no
bon covering
a. "ost serious
b. both cerebral he"ispheres are absent
c. condition is inco"patible &ith life beond a fe& das
#. 8pina bifida 18.2
a. etiolog: inco"plete closure of vertebrae and neural tube-
un%no&n cause
b. pathophsiolog
I. spina bifida occulta: defect not visible e!ternall
II. spina bifida cstica: visible defect &ith an e!ternal sac%-li%e
protrusion
I. "eningocele: encases "eninges and spinal fluid
but no neural ele"ents- no neurological deficit
II. "eningo"elocele: contains "eninges) spinal fluid)
and nerves- varing neurological deficit
c. findings var &idel to degree of spinal defect - the higher the
location the "ore s"pto"s the infant &ill have.
d. diagnostics:
I. phsical e!a"
II. @<I 5 ultrasound 5 C:- "elograph
III. C.C
e. nursing interventions
I. initial care
I. protect sac fro" rupturing and dring out
II. assess for presence of late! allerg
III. "oist sterile nonadherent dressing 5usuall saline
I;. fluids
;. no diaper
;I. positioning 5 on abdo"en
;II. <[email protected]
;III. earl surgical closure of lesion
IK. avoid rectal te"peratures
II. long ter"
I. protect s%in integrit
II. "aintain bladder and bo&el function
III. support "usculos%eletal integrit
f. teaching points
I. teach parents ho& to "easure head circu"ference after
closure
II. "a require ;P shunt
III. findings of infection
G. Cerebral pals 1CP2
1. $tiolog
a. disorders characteri3ed b earl onset and i"paired "ove"ent
and posture- non-progressive - "issed develop"ental "ilestones
b. cause: abnor"alit in e!trapra"idal or pra"idal "otor sste"
1corte!) basal ganglia) cerebellu"2
c. can occur prenatall) perinatall) or postnatall
d. "a be acco"panied b perceptual proble"s) language deficits
and intellectual involve"ent
e. usuall diagnosed b e!clusion
#. Pathophsiolog
a. classifications: athetoid) spastic) ata!ic) "i!ed
b. associated defects: "ental retardation and cognitive i"pair"ent)
hearing or visual losses) attention deficit disorder 1ADD2
c. high "etabolic rate) leading to increased calorie e!penditure
*. +indings
a. pri"ar disturbances: abnor"al "uscle tone and coordination
b. spastic "ove"ent in one or "ore e!tre"it
c. athetoid "ove"ents
d. pri"itive refle!es persist
e. disturbances in gait) abnor"al posture
f. i"pair"ents in speech and s&allo&ing
'. Diagnostics: phsical e!a") $$G) C:) @<I
?. @anage"ent
a. establish loco"otion) co""unication and self-help
b. gain opti"al appearance and function
c. correct associated proble"s as effectivel as possible
d. pro"ote sociali3ation
D. 6ursing interventions
a. earl recognition- assess children at ris%
b. treat &hat child de"onstrates
c. <[email protected]
d. teach AD=- dressing) feeding) &al%ing
e. incorporate pla into treat"ent plan
F. :eaching points
a. "ulti-disciplinar approach
b. speech training is begun earl
c. long ter" proble" and a financial concern
d. offer support for fa"il resources
H. Do&n sndro"e 1triso" #12
1. $tiolog: e!tra group G chro"oso"e) chro"oso"e #1. Associated &ith
late "aternal age
#. Pathophsiolog: depends on &hich region of chro"oso"e #1 &as
altered
a. distinctive facial features
b. heart defects
c. "ental retardation 1varies fro" severe retardation to lo& average
intelligence2
d. der"atologic changes
Classification of Cerebral Palsy
1. Athetoid
• Characteri3ed b slo& irregular t&isting sna%eli%e "ove"ents occurring in the
upper e!tre"ities
• Involuntar "ove"ent of oral "uscles &hich "a result in drooling and dsarthria
#. 8pasticit
• @a involve either one or both sides
• I"paired fine and gross "otor s%ills
• Individual0s atte"pts at "otion increase the abnor"al posturing and overflo& of
"otion to other parts of bod
• Hpertonic "ove"ents
*. Ata!ic
• <apid repetitive "ove"ents perfor"ed poorl
• Poor integration of "ove"ents &hen individual reaches
'. @i!ed
• Co"bination of athetosis and spaticit
e. inco"plete e"brogenesis
*. +indings
a. facial features
I. brachcephal
II. flat occiput
III. protruding tongue
I;. high-arch palate
;. al"ond shaped ees
;I. lo& slung ears
b. bod features
I. short) broad hands &ith si"ian crease
II. short) broad nec%
III. dr s%in
I;. large space bet&een great toe and second toe
'. Diagnostics
a. phsical e!a"s
b. chro"oso"e analsis
?. @anage"ent
a. supportive: specific to bod sste" affected
b. pro"otion of develop"ental progress
c. cognitive
D. 6ursing interventions
a. treat &hat the child e!hibits
b. assess sight and hearing
c. allo& e!tra ti"e &hen giving instructions
d. support fa"il
F. :eaching points
a. genetic counseling
b. long-ter" disorder
c. financial referrals
Infectious 6eurological Disorders
I. Guillain-.arre sndro"e - infectious de"elinating polneuritis
1. $tiolog: un%no&n - possible sequela to "icrobial infection or
ad"inistration of vaccines
#. Pathophsiolog
a. an un%no&n factor infla"es spinal and cranial nerves
b. infla""ation co"presses and de"elinates nerves
c. nerves conduct i"pulses poorl resulting in paralsis of "uscles
innervated b involved nerves
d. ascending flaccid paralsis
*. +indings
a. preceded b "ild influen3a-li%e illness or sore throat
b. gradual progression of s"pto"s
i. acute - onset of findings
ii. plateau 5 findings re"ain constant
iii. recover 5 begins to i"prove and progress to co"plete
recover) usuall # to * &ee%s after onset.
c. "uscle tenderness) paresthesia usuall ascend fro" feet,legs
up&ard progressing to total paralsis
'. Diagnostics:
a. phsical assess"ent
b. C8+ analsis
c. [email protected] findings 5 acute "uscle denervation
?. @anage"ent
a. short ter": supportive and s"pto"atic
b. based on phsiologic needs and bod sste" affected: possible
tracheosto") ventilator support) I; fluids and plas"apheresis
c. long-ter": integu"entar) "usculos%eletal and respirator
sste"s
d. "edications: I; i""unoglobulin and steroids) possible
i""unosuppressive agents
D. 6ursing interventions:
a. assess for progress of disease especiall s&allo&ing and
breathing
b. neuro and vital signs
c. assess s%in integrit
d. "a require tube feedings
e. "aintain +ole
f. <[email protected]
g. support child and fa"il
F. :eaching points
a. "ulti-disciplinar approach
b. long-ter" process
c. "a have residual disabilit
E. .otulis" - acute flaccid paralsis
1. $tiolog
a. food poisoning fro" anaerobic bacillus: clostridiu" botulisu"
conta"inated food
b. three tpes: infantile) classic) &ound
#. +indings
a. C68 findings usuall appear &ithin 1# to *D hours
b. blurred vision) diplopia) letharg) vo"iting and dsphagia)
&ea%ness) difficult spea%ing) life threatening progressive
respirator paralsis
*. @anage"ent
a. supportive: dependent on bod sste" affected
b. protect ventilation) respiration) and provide nutrition
c. "edications
i. botulis" antito!in
'. 6ursing interventions
a. observe for and report signs of neuro"uscular &ea%ness
b. child &ill tire easil
c. assess for s&allo&ing difficulties
?. :eaching points
a. child "ust rest during recover
b. nor"al bo&el eli"ination "a not return for a &hile- no ene"as or
cathartics
4. <ee0s sndro"e 1to!ic encephalopath2
1. $tiolog: follo&s a co""on viral illness) drugs 1saliclate association2)
to!ins) genetics
#. Pathophsiolog
a. acute noninfla""ator encephalopath and hepatopath
*. +indings
a. related to cerebral ede"a and fatt changes in liver
b. viral upper respirator infection
c. fever
d. severe nausea and vo"iting
e. profoundl i"paired consciousness
f. liver dsfunction
g. co"a
'. Diagnostics: liver biops
a. a""onia levels
b. possible lu"bar puncture
?. @anage"ent
a. supportive: dependent on bod sste" affected
b. avoid aspirin and other saliclates in children &ith viral diseases
such as influen3a or varicella disease
D. 6ursing interventions
a. assess children at ris%
b. continuousl "onitor affected child
c. neuro and vital signs
d. assess I; lines) +ole
e. "a have 6,G tube
f. "onitor fluid volu"e status
F. :eaching points
a. %eep parents infor"ed about status and equip"ent.
:rau"atic 6eurological Conditions
=. Head trau"a
1. $tiolog: force to the scalp) s%ull) "eninges or brain 5 usual causative
agents are falls) "otor vehicle crashes and biccles
#. Pathophsiolog: elastic pliable s%ill of infant and oung child absorbs
"uch of direct energ
a. directl related to force of i"pact and secondar forces
i. acceleration in7ur
ii. deceleration in7ur
b. tpes: pri"ar and secondar
c. cerebral function depends on o!gen) glucose and blood flo& to
brain- cerebral ede"a and hpo!ia can occur quic%l
*. +indings: neurological status depends on ICP
a. "a or "a not be conscious
b. irritable
c. pale
d. vo"iting
e. sleep
f. =9C "a be altered
g. pupils "a be affected
'. Diagnostics: assess for pre-e!isting disorders) ta%e histor of event) CA:
8CA6) @<I) $$G
?. @anage"ent
a. acute
i. control ICP: "edications: sedating agents) steroids) anti-
convulsants) ventilator support) positioning) H9. up *(L
once cervical spine in7ur is ruled out
ii. long-ter" rehabilitation possible
D. Co"plications: he"orrhage) infection) cerebral ede"a and brainste"
herniation through the tentoriu"
F. 6ursing interventions
a. neuro and vital signs
b. "onitor ICP
c. "aintain sei3ure precautions
d. quiet environ"ent
e. assess =9C
f. level of co"fort
g. observe for rhinorrhea) otorrhea and test for glucose if drainage
present
G. :eaching points
a. long-ter" process
b. %eep parents infor"ed and teach about the equip"ent
c. teach parent to tal% to child but donHt as% the" to do things li%e
/squee3e " hand/
@. @eningitis: acute infla""ation of the "eninges and C68
1. $tiolog: can be caused b pneu"ococcal or "eningococcal bacteria
1"ost serious2 or can be caused b a virus.
#. Pathophsiolog: "ost co""on route of infection b vascular
disse"ination fro" an infection else&here
a. organis"s then spread into C8+ and throughout subarachnoid
space
b. infective process
i. infla""ation
ii. e!udate
iii. C.C accu"ulation
iv. tissue da"age
v. brain beco"es hpere"ic and ede"atous
*. +indings
a. fever
b. chills
c. headache
d. vo"iting
e. =9C alterations
f. irritable
g. nuchal rigidit
h. positive 4ernig and .rud3ins%i signs
'. Diagnostics
a. lu"bar puncture: definitive diagnostic tool) C8+ is tested for gra"
stain) blood cell count and presence of glucose and protein
content
b. sedation of child "a be required. ;ersed) De"erol or +entanl
"a be used
?. @anage"ent: treated as bacterial until causative agent is identified
a. bacterial "eningitis is an e"ergenc
b. respirator isolation precautions until causative agent identified
c. "edications: antibiotics
D. 6ursing interventions
a. "onitor fluid status - I; fluids
b. "onitor electroltes
c. neuro and vital signs
d. "aintain quiet environ"ent
e. "onitor for sei3ures
f. assess peripheral vascular collapse if causative agent is
"eningococci
F. :eaching points
a. i""uni3ations are available to prevent several tpes
I;. Pediatric $ndocrinolog
;. :he endocrine sste"
A. :hree tpes of tissues
1. cells that send che"ical "essage via hor"ones
#. target cells in end organ that receive che"ical "essage
*. environ"ent: "ediu" through &hich che"ical "essage travels fro" the
site of snthesis to area of cellular action
.. $ndocrine function
1. endocrine M autono"ic sste"s N neuroendocrine sste"
#. neuroendocrine sste": snthesi3es and releases che"ical substances
that then regulate bodil function: "essages are carried b nerve
i"pulses in the nervous co"ponent and b blood in the endocrine
sste".
*. the t&o sste"s function snergisticall. I"pulses trans"itted via the
nervous sste" sti"ulate the hpothala"us to secrete releasing or
inhibiting factors
.. Hpopituitaris"
1. Definition: di"inished or deficient secretion of pituitar hor"ones)
pri"aril GH 18o"atotropin2
#. $tiolog: tu"ors) hpoplasia) auto-i""une) congenital) acquired)
irradiation) "alnutrition) trau"a
*. Pathophsiolog: leads to gonadotropin deficienc - inhibits so"atic
gro&th in all bod cells
'. +indings
a. usuall dependent on hor"one involved and age of onset
1d&arfis"2
b. absence or regression of secondar se! characteristics
c. e!a"ple: slo& gro&th) short stature) nor"al intelligence- delaed
pubert
?. Diagnostics
a. fa"il histor
b. histor of gro&th patterns of child
c. @<I
d. radioi""unoassa of plas"a GH levels
e. !-ras of hand and &rist for centers of ossification
D. @anage"ent
a. depends on cause
b. hor"one replace"ent therap: gro&th hor"one
F. 6ursing interventions:
a. support child and parents during period of diagnosis
b. plan realistic goals &ith child and fa"il
G. :eaching points
a. sho& parent ho& to ad"inister dail hor"one replace"ent sc
b. educate child and fa"il about long ter" process
C. /Precocious pubert/ - unusuall earl activation of "aturation process that is
considered nor"al later in life
1. Definition: "anifestations of se!ual develop"ent before age nine in bos
or age eight in girls
#. $tiolog: brain lesions) infla""ator disorders) idiopathic) adrenal
disorders
*. Pathophsiolog
a. pre"ature activation of hpothala"ic-pituitar-gonadal a!is
b. earl increased release of =H and +8H
c. earl acceleration of linear gro&th &ith earl closure of gro&th
plates
d. ulti"ate height less than if pubert had been nor"al
'. +indings - occurs "ost often in girls
a. develop"ent of breasts in prepubertal fe"ales
b. earl develop"ent of se!ual hair
c. isolated "enses
d. develop"ent of secondar se! characteristics
?. @anage"ent
a. directed to&ard specific cause
b. hpothala"ic - pituitar origin: luteini3ing hor"one - releasing
hor"one 1=H<H2 in7ections "onthl
D. 6ursing interventions
a. provide support and guidance to parents and child
b. child "a be e"barrassed
c. assign nurse of sa"e se! as child
d. earl identification of affected child
F. :eaching points
a. long-ter" proble"
b. after pubert) child &ill be the sa"e as peers
D. 8IADH: sndro"e of inappropriate antidiuretic hor"one
1. Definition: hpersecretion of antidiuretic hor"one or ADH 1vasopressin2
#. $tiolog: infections) head trau"a) or brain tu"ors
*. Pathophsiolog
a. %idnes reabsorb too "uch free &ater
b. decreased urine output) increased specific gravit 18G2) and
decreased seru" sodiu"
'. +indings
a. urine 8G O 1.(*(
b. anore!ia) nausea) &ea%ness) sto"ach cra"ps
c. increased &eight 1ede"a2
d. decreased seru" sodiu" - under 1#( "$q,= child beco"es
s"pto"atic - lo&er sodiu" levels cause neurological findings
?. @anage"ent
a. restrict fluids to correct hponatre"ia
b. correct underling etiolog
c. "onitor I P 9) electroltes) neuro status
d. observe for signs of fluid overload
D. 6ursing Interventions:
a. assess patients at ris% for earl identification
b. I P 9 5 dail &eights
c. "onitor for signs of fluid overload
d. sei3ure precautions if sodiu" level lo&
$. Hpothroidis"
1. Definition: deficienc of throid hor"one 1:H2- co""on childhood
endocrine disorder
#. $tiolog
a. congenital or acquired deficienc in throid hor"ones
b. throid irradiation
*. Pathophsiolog
a. absent or underdeveloped gland
b. decreased triiodothronine 1:*2 or thro!ine 1:'2
'. +indings: depend on e!tent of dsfunction and age of child at onset
a. letharg) constipation) feeding proble"s
b. hpotonia) large tongue
c. dr s%in) &eight gain) puff ees) sparse hair
d. intolerance to cold
e. slo&ed gro&th) develop"ental dela and,or retardation if :' lo& at
birth and throid replace"ent not started
f. if findings develop after t&o to three ears) &hen brain has gro&n)
no "ental retardation
?. Diagnostics
a. histor and phsical
b. increased :8H
c. decreased seru" :* and :'
d. ane"ia
e. decreased [email protected]< 1basal "etabolic rate2
f. increased cholesterol and triglcerides
g. hpoglce"ia
D. @anage"ent
a. lifelong hor"one replace"ent 1levothro!ine2
b. rest
c. protect client fro" cold
F. 6ursing interventions
a. assess children at ris%.
b. "onitor ad"inistration of replace"ent hor"one 5 canHt be
increased too fast
c. allo& rest periods or cluster care
d. encourage child to e!ercise &hen able
G. :eaching points
a. life-long proble"
b. child needs periodic blood tests to "onitor hor"one levels.
+. Hperthroid: /Graves0 disease/
1. Definition: hpersecretion of throid hor"ones) causing increased [email protected]< or
hperactivit of throid gland
#. $tiolog: auto-i""une response to :8H 1throid-sti"ulating hor"one2
receptors- idiopathic- fa"ilial
*. +indings
a. increases in: [email protected]<) appetite) nervousness) heart rate
b. gradual &eight loss despite voracious appetite
c. lo&ered tolerance to heat
d. e!ophthal"os 1ees bulge2
e. "opath
f. personalit changes) poor school perfor"ance) "ood instabilit
g. linear gro&th and bone age accelerated
h. inso"nia
i. increased blood pressure
'. Diagnostics
a. histor and phsical
b. palpable throid enlarge"ent 1goiter2
c. elevated seru" :* and :' levels
d. elevated radioactive iodine upta%e
e. presence of throid antibodies
f. decreased :8H levels
?. @anage"ent
a. antithroid therap - Proplthiouracil or :apa3ole to decrease
a"ount of circulating throid hor"one
b. surger 1subtotal throidecto"2 5 chec% voice qualit after
surger.
D. 6ursing interventions
a. assess behavior patterns before and after "edication
b. quiet non-sti"ulating environ"ent
c. ad"inister "oisturi3ing ee drops for child &ith e!ophthal"os
d. provide nutrition appropriate for activit level
e. establish a routine &ith child and parents
F. :eaching points
a. side effects of proplthiouracil -sore throat and fever
b. child "a need to reduce activities for a &hile
G. Concern: throto!icosis or Qthroid stor"R fro" sudden release of
hor"one: fro" vigorous palpation or surger
a. can be a life threatening situation
b. findings
1. acute onset of severe irritabilit
#. vo"iting
*. diarrhea
'. hperther"ia
?. hpertension
D. tachcardia
F. prostration
c. treat &ith cooling blan%et
d. propranolol 1Inderal2) potassiu" iodine 1thro-bloc%2
e. antithroid drugs
G. Diabetes "ellitus - tpe 1
1. Definition: deficienc of hor"one insulin - "ost co""on endocrine
disorder of childhood.
#. $tiolog: genetic) auto-i""une response- usuall &ith trigger factors of
virus) bacteriu" or possible che"ical irritant
*. Pathophsiolog
a. trigger directs islet cell antibodies against cell surfaces
b. antibodies destro the insulin-secreting .eta cells
c. less insulin "eans glucose is bloc%ed fro" entering the cells - the
concentration in bloodstrea" increases 1hperglce"ia2
d. &hen glucose level e!ceeds %idne0s threshold 1about 1G( "g,dl2
%idne then /spills/ glucose into urine 1glcosuria2
e. producing os"otic diureses 1poluria2
f. starved for glucose
g. urinar fluid loss causes e!cessive thirst 1poldipsia2
'. +indings
a. hperglce"ia
1. the three /pols/ of diabetes: poldipsia) poluria)
polphagia
#. additional findings: fatigue) hunger) &eight loss) enuresis
?. Diagnostics
a. fasting blood glucose
b. oral glucose tolerance test
c. urine tests for presence of %etones and,or glucose
d. glcoslated he"oglobin 1A1c2 reflects average blood glucose
levels for past # to * "onths
D. @anage"ent
a. "edications: insulin 1rapid-acting-=ispro) short-acting - regular)
inter"ediate-acting-6PH2. Insulin needs are affected b food
inta%e) e!ercise) e"otions) gro&th spurts and illness
b. other: diet) age appropriate activit levels. 6o special foods - need
sufficient calories. @ust eat snac%s - and "eals at the sa"e ti"e
each da.
c. self-blood glucose "onitoring
d. insulin pu"p delivers insulin continuousl
F. Concerns: /hone"oon period/ and insulin regulation) co"pliance) sic%
da "anage"ent) %etones
G. Co"plications
a. D4A 1diabetic %etoacidosis2 or e!tre"e hperglce"ia 1blood
sugar O*?( "g,dl2
1. etiolog: not enough or no insulin - bod chooses alternate
source of energ - fat
#. findings
1. fruit breath) decreased level of consciousness
#. nausea,vo"iting) abdo"inal pain
*. 1( percent dehdration
'. increased urine output
?. 4uss"aul0s respirations
D. "etabolic acidosis
b. "anage"ent
1. place on cardiac "onitor
#. regular insulin 1I; drips and then subcutaneous2
*. frequent "onitoring of blood glucose
'. frequent "onitoring of electroltes- neuro chec%s
I. Hpoglce"ia
a. etiolog: "ost co""on cause of insulin therap and bursts of
phsical activit) &ithout additional food or &ith "issed "eals -
before "eals or &hen insulin is pea%ing
b. findings
1. fatigue
#. nervousness
*. pallor
'. s&eating
?. palpitations
D. hunger
F. loss of coordination
G. sei3ures
I. co"a
c. "anage"ent
1. 1( to 1? "g f si"ple carbohdrate - hone of lo& fat "il%
#. follo&ed b co"ple! carbohdrate such as slice of bread
or crac%ers
*. occasionall glucagons is prescribed - for ho"e treat"ent
- &or%s in about 1( "inutes
1(. 6ursing interventions
a. assess child frequentl neuro and vital signs
b. blood glucose levels
c. ad"inister insulin as ordered
d. support child fa"il
e. arrange "eetings &ith tea" "e"bers - dietar) P:) and social
&or%er
11. :eaching points
a. fa"il "a be over&hel"ed &ith diagnosis
b. use teaching aids to facilitate their success - boo%lets) videos
c. illness "anage"ent
d. insulin should never be o"itted
e. dose "a change
f. fluid balance is a concern
;. Pediatric Gastrointestinal
A. Dehdration
1. Definition: occurs &hen total output of fluid e!ceeds total inta%e
a. D(S of fluid lost fro" e!tracellular fluid 1$C+2
b. '(S of fluid lost fro" intracellular 1IC+2
c. insensible fluid loss 5 lost through s%in) urinar loss) fecal loss)
and respirator tract
#. Differences co"pared to adults
a. are less able to concentrate urine
b. as infants) the have i""ature %idne and i""une regulator
sste"s
c. have a higher "etabolic rate
d. have "ore bod surface in relation to bod "ass
e. because "ore of bod &eight is fluid) children need "ore fluid and
lose "ore urine per %ilogra" of bod &eight
*. :pes of dehdration 1seru" sodiu" deter"ines tpe2
a. isotonic: occurs in conditions in &hich electrolte and &ater
deficits occur in balanced proportions. Pri"ar for" of dehdration
in children.
b. hpotonic: occurs in conditions in &hich electrolte deficit e!ceeds
the &ater deficit
c. hpertonic: occurs in conditions in &hich &ater loss e!ceeds
electrolte loss
'. Pathophsiolog
a. decreased fluids and electroltes fro" $C+
b. leads to eventual loss of fluid fro" IC+
c. cellular dsfunction) shoc%
?. 6ursing interventions
a. fluid losses "ust be replaced
b. "onitor urine output and specific gravit) dail &eight
c. fontanels in infant
d. electrolte losses: "onitor sodiu") potassiu") chloride) calciu"
e. acid-base balance disturbance: "etabolic acidosis
D. +indings of dehdration
F. @anage"ent of pediatric dehdration
a. "onitor the ' first signs and * second signs of dehdration
b. ad"inister fluids 1oral) 6G) I;2
#. ;o"iting
F. Definition: forceful e7ection of gastric contents through the "outh
G. $tiolog: infection) obstruction) allerg) pschological causes) "otion
sic%ness) neurologic lesions) and infla""ator process
I. Pathophsiolog
a. cause sti"ulates e"etic center of brain
b. "echanis" of vo"iting involves autono"ic nervous sste"
1. salivation) s&eating
#. pallor) increased heart rate
*. contraction of sto"ach antru" P duodenu"
c. tpes of vo"iting: regurgitation) forceful) pro7ectile
1(. @anage"ent
a. detect and treat the underling cause
b. prevent dehdration) electrolte loss and acid-base disturbance
c. provide anti-e"etic "edications if needed
11. 6ursing interventions
a. assess vo"itus
b. assess child for dehdration
c. %eep child 6P9
d. position child to avoid aspiration &hen vo"iting
e. "onitor electroltes
f. encourage child to brush teeth or rinse "outh after vo"iting
1#. :eaching points
a. teach parents to start feeding child slo&l &ith clear fluids &hen
tolerated
>pper GI Disorders
C. :racheoesophageal fistula 1:$+2 and esophageal atresia 1$A2
1. Definition: failure of esophagus to develop as a continuous passage and
a failure of the trachea and esophagus to separate into distinct structures
#. $tiolog: congenital) idiopathic) ;A:$< sndro"e 1co"bination of
vertebral) anorectal) and renal abnor"alities in addition to :$+2
*. Pathophsiolog: "ost co""on
a. :$+ 5 pro!i"al esophageal seg"ent ter"inates in a blind pouch
b. distal seg"ent is connected to trachea or pri"ar bronchus
'. +indings
a. coughing
b. canosis &ith feeds
c. increased oral secretions
d. depend on tpe of defect
e. cho%ing
?. Diagnostics: histor) chest and abdo"inal !-ras
D. @anage"ent
a. pre-op: air&a patenc) 6P9) I; therap) place in position least
li%el to cause aspiration
b. prevention of aspiration pneu"onia
c. surgical e"ergenc
F. 6ursing interventions
a. assess each ne&born for the "alfor"ation
b. inter"ittent suctioning
c. position - head of crib elevated *( degrees
d. care of gastrosto" tube
e. tube feedings are begun &hen tolerated
f. observe initial oral feeding 5 sterile &ater
G. :eaching points
a. teach parents the care of the gastrosto" tube and ho& to
ad"inister feedings
b. findings of respirator distress
c. suctioning techniques if appropriate
D. Gastroesophageal reflu! disease: G$<D
1. Definition: transfer of gastric contents in the esophagus
#. $tiolog: phsiological. functional) pathologic 5 ver co""on 5 If G$<D
occurs often and findings persist) treat it 5 hiatal hernia and coughing "a
lead to G$<D
*. Diagnostics: histor) bariu" s&allo&) upper GI series) esophageal pH)
"ano"etr studies) endoscop) scintigraph 5 detects radioactive
"aterial in esophagus after feeding of the "aterial and also assesses
gastric e"pting
'. @anage"ent
a. depends on the severit of findings
b. none if child is thriving &ithout findings
c. diet: thic%en feeds) decrease caffeine inta%e) acid foods and
solutions) give s"all) "ore frequent feeds &ith frequent burping
d. position: prone &ith head of bed elevated or flat prone follo&ing
feeding and at night
e. "edications 5 H#-receptor antagonists 1:aga"et or Pepcid2)
proton pu"p inhibitors 16e!iu" or Protoni!2
f. surger: 6issen fundoplication
?. 6ursing interventions
a. "onitor feeding position and feeding tolerance
b. "onitor nutritional status
c. chec% I P 9
d. "onitor electrolte levels
D. :eaching points
a. teach parents to have child avoid caffeine) chocolate) and spic
foods
b. older children should avoid tobacco and alcohol
c. "edication ad"inistration schedule should be follo&ed to receive
opti"al benefit
$. Ploric stenosis
1. Definition: circu"ferential "uscle of the ploric sphincter beco"es
thic%ened resulting in elongation and narro&ing of the ploric channel
#. $tiolog
a. un%no&n cause
b. hpertroph) hperplasia of circular "uscles of plorus
*. Pathophsiolog
a. trigger irritates "ucoid lining of plorus- ede"a
b. narro&ed plorus resists passing of fluid- ch"e
c. plorus then enlarges and contracts &ith "ore force to atte"pt
gastric e"pting
d. slo&l plorus constricts) and resistance persists until ne!t ccle
'. +indings
a. usuall begins at t&o to four &ee%s of age
b. progressive) pro7ectile) nonbilious vo"iting after eating
c. "etabolic al%alosis
d. "ovable) palpable) fir") olive-shaped "ass in right upper
abdo"inal quadrant
e. irritabilit) cring) hunger
?. Diagnostics: histor) abdo"inal !-ra) upper GI) ultrasound) electroltes
D. @anage"ent
a. pre-op: I; fluids) 6P9) surger 1ploro"oto"2 also called
+redet-<a"stedt Procedure
b. post-op: s"all) frequent feedings initiall) graduall increasing
F. 6ursing interventions
a. pre-op
1. "onitor I; fluids and electrolte replace"ent
#. docu"ent vo"iting episodes and stools
*. access patenc of 6,G tube if present
'. position child flat or head slightl elevated
b. post-op
1. "onitor for vo"iting
#. assess I; sites
*. begin feeding clear liquids &ith glucose and electroltes
'. assess operative site for drainage or infla""ation
G. :eaching points
a. child "a vo"it after surger
b. this disorder "a run in fa"ilies
c. child &ill be discharged &hen able to tolerate feedings
=o&er GI Disorders
+. Constipation
1. Definition: infrequent passage of fir" or hard stools
#. $tiolog
a. triggered b diet) "edication) dehdration) e"otions) or
neurogenic
b. structural disorders 1Hirschsprung0s disease2
c. sste"ic disorders 1hpothroid2
*. +indings
a. abdo"inal pain and cra"ping
b. palpable) "ovable fecal "ass
c. "alaise) anore!ia) nausea
'. Diagnostics: abdo"inal !-ras) rectal e!a") palpation and percussion
?. @anage"ent
a. prevention: higher fiber diet) fluids) e!ercise) regular toileting
habits
b. "edications: stool softeners) ene"as) la!atives
D. 6ursing interventions
a. assess childHs usual pattern of bo&el eli"ination
b. provide dietar "odifications that pro"ote bo&el eli"ination
appropriate for age
c. establish bo&el routine for parents
F. :eaching points
a. dietar "odifications
b. bo&el routine
G. Diarrhea
1. $tiologies: intestinal infections 1bacterial) viral) parasitic2- food intolerance-
overfeeding- "edications- stress- "alabsorption- colon disease
#. Pathophsiolog:
a. causative factor - irritates "ucosal lining
b. da"ages "icrovilli) increases secretion and decreases absorption
c. abnor"al intestinal &ater and electrolte transport
d. increased intestinal &ater per"eabilit and dehdration in ounger
children.
e. possible "etabolic acidosis
f. can be acute or chronic
*. +indings
a. dehdration 1"ild) "oderate) severe2
b. increased stooling
c. increased heart P respirator rate
d. dr hot s%in
e. dr "ucous "e"branes
f. decreased urine) decreased tearing in infants
'. @anage"ent
a. goals: restore fluid and electrolte balance and return bo&el to
nor"al functioning
b. fluids: oral rehdration or parenteral rehdration
c. "edications: antibiotics) antidiarrheals
H. Celiac disease
1. Definition: gluten-sensitive enteropath 1G8$2 N 1celiac sprue2
#. $tiolog: absorption proble" &ith genetic predisposition) possibl i""une
abnor"alit
*. Pathophsiolog
a. inabilit to digest gliadin 1bproduct of gluten2- per"anent
intolerance of gluten
b. increasing levels of gluta"ine in the s"all intestine) to!ic to
"ucosal cells
c. atroph of villi and decreased absorptive surface
d. "alabsorption of fats) carbohdrates) vita"ins and electroltes
e. gluten is found in the grain of &heat) barle) re) and oats
'. +indings 1"ost often appears bet&een ages of one and five ears2
a. diarrhea 1stools: pale and &ater) offensive odor2
b. abdo"inal distention
c. failure to thrive
d. vo"iting
e. "uscle &asting
f. steatorrhea
g. anore!ia
h. abdo"inal pain
?. Diagnostics
a. histor 1s"pto"s occur three to si! "onths after infant begins
eating grains2
b. seru" anti-gliadin antibod 1AGA2
c. 7e7unal biops - reveals "ucosal infla""ation) villous atroph and
crpt hperplasia
d. serologic testing to detect antibodies
D. @anage"ent
a. diet: gluten-free &ith vita"in supple"ents
b. crisis: I; fluids) steroids
F. 6ursing interventions
a. "onitor tolerance of ne& diet 5 &eight gain
b. "onitor episodes of diarrhea
c. assess for steatorrhea
d. provide diet high in calories 5 fruits) vegetables 5 lo& fat
G. :eaching points
a. gluten free diet restrictions
b. reading food labels
I. Intussusception
1. Definition: one of the "ost frequent causes of intestinal obstruction
bet&een ages of three "onths and five ears
#. $tiolog: un%no&n 5 possible hpertrophic response to the virus- is
co""on in children &ith cstic fibrosis
*. Pathophsiolog
a. trigger 5 bo&el 1pro!i"al seg"ent2 QtelescopesR inside itself
causing obstruction
b. pressure on bo&el leads to bleeding
c. possible "esenteric ische"ia
d. ede"a and possible bo&el necrosis) perforation) peritonitis) or
shoc%
e. "ost co""on site: ileocecal valve
'. +indings
a. sudden acute abdo"inal pain
b. bilious vo"iting
c. currant 7ell stools
d. sausage-shaped abdo"inal "ass
e. letharg
?. Diagnostics: bariu" ene"a 5 abdo"inal !-ra) rectal e!a" reveals "ucus
and blood
D. @anage"ent
a. priorit goal: restore bo&el to nor"al position and function quic%l)
and stabili3e fluids
b. non-surgical hdrostatic reduction - bariu") &ater-soluble
contrast) air pressure
c. if not successful) surger
F. 6ursing interventions
a. "onitor fluid status
b. assess pain
c. "onitor for bariu" e!cretion and passage of bro&n stool that
indicates intussusception has resolved
d. usuall post operative care if child has surger
G. :eaching points
a. parents "a feel guilt the didnHt %no& about childHs condition
b. everthing "oves fast
c. child "a need hospitali3ation
E. Hirschsprung0s disease
1. Definition , etiolog: congenital aganglionic "egacolon
#. Pathophsiolog
a. absence of autono"ic 1paras"pathetic2 ganglion cells) usuall at
rectu" and part of large intestine
b. intestine does not propel stool
c. stool builds up- colon dilates) constipation results &ith ris% of
intestinal rupture
*. +indings
a. ne&born: failure to pass stool or "erconiu" in first #' hours of
life) reluctance to ingest fluids) bile-stained vo"itus) distended
abdo"en) /ribbon-li%e/ stools - flat) &ide) and &av
b. later: failure to thrive) distended abdo"en) constipation) signs of
fecal i"paction
'. Diagnostics: histor and phsical e!a") radiographic bariu" ene"a)
rectal biops) anorectal "ano"etr 5 reveals absence of ganglion cells
?. @anage"ent
a. surgical correction: re"ove aganglionic portion
b. te"porar osto" for three to si! "onths) then reanasto"ose
D. 6ursing interventions
a. assess fluid and electrolte status
b. "onitor co"fort level
c. assess colosto"
d. provide nutrition as ordered
e. assess 6,G
f. "a%e referrals for ho"e care assistance
F. :eaching points
a. colosto" care 5 as child &ill be discharged
b. parents should be told that toilet training "a be difficult
4. Appendicitis
1. Definition: infla""ation of ver"ifor" appendi! 1blind sac at end of
cecu"2
#. $tiolog
a. virus) hardened fecal "aterial) parasites) foreign bod
b. "ost co""on in school-aged children
*. Pathophsiolog
a. trigger obstruction increased "ucus accu"ulation
b. distention) capillar occlusion and engorge"ent of capillar &alls
c. eventuall) abscesses and fistula for"
d. possible perforation leading to peritonitis
'. +indings
a. colic% abdo"inal pain
1. generali3ed but usuall locali3es to lo&er right quadrant
#. "ost intense pain at @c.urne0s point
b. nausea) vo"iting
c. possible fever and chills
d. decreased bo&el sounds
e. guarding of abdo"en - stooped posture
f. rebound tenderness
?. Diagnostics: phsical e!a") laborator tests 1C.C &ith C.C2) @<I)
possible also C <eactive Protein 1C<P2
a. "a order HCG seru" hu"an gonadotropin on adolescent
fe"ales to rule out ectopic pregnanc
D. @anage"ent
a. surgical re"oval 1open or laparoscopic2
b. I; fluids
c. antibiotics
d. analgesics
F. 6ursing interventions
a. postoperative
1. "onitor I; fluids 5 co"fort level
#. position in se"i +o&lers
*. chec% drainage tubes if present
'. prevent fluids as bo&el sounds return if ordered
G. :eaching points
a. activit level at ho"e
b. &hen can return to school) if %no&n
c. caution: do not give ene"as or cathartics or use heating pad if
suspected appendicitis
;I. Genitourinar 8ste"
A. Co""on findngs: renal and urinar tract 1>:2 disorders
<enal +indings:
->rination 1poluria) oliguria) urgenc2
-+luids 1increased .P) $de"a2
>: +indings:
-# Clusters G-I 1Anore!ia) 6ausea,vo"iting) :hirst,dehdration) +ailure to thrive2
-=o&er .od 1Abdo"inal P bac% pain) Painful or frequent
urination) Persistent diaper rash2
.. >rinar tract infection
1. Definition
a. bacteria in urine and infla""ator response
b. "a involve an structure in urinar sste": %idne
1pelonephritis2) ureters) bladder 1cstitis2 or urethra
c. findings &ill point to location
d. pea% age: toddler to preschool age
#. $tiolog
a. bacterial 1$. coli. - G(S of cases2) structural defect) phsiological
b. e!trinsic 1e!a"ple: +ole catheter) "edications2
c. i"proper perineal hgiene
*. Pathophsiolog
a. organis" usuall ascends through urethra to bladder
b. &ith a structural defect) urine flo&s bac% fro" ureters into %idne
'. +indings often depend on age
a. under t&o ears: often nonspecific rese"bling GI disturbance
i. failure to thrive) feeding proble"s) nausea,vo"iting
ii. dsuria) persistent diaper rash) abdo"inal distention
b. over t&o ears
i. enuresis) dati"e incontinence in toilet-trained) foul
s"elling urine
ii. frequenc and urgenc) dsuria
iii. possible pelonephritis: si"ilar signs but &ith fever) bac%
pain) and letharg
?. Diagnostics: urine culture and seru" testing) radiographic testing
D. @anage"ent
a. anti"icrobials
b. antipretics
c. analgesics
d. fluids 1I; and oral2
F. 6ursing interventions
a. careful histor
b. chec% diaper ever half-hour
c. provide adequate or increased fluid inta%e
d. "onitor for irritabilit
G. :eaching points
a. hgiene 5 &ipe front to bac% for girls
b. do not dela urination
c. if child is "aintained on dail lo& dose antibiotics 5 giving dose at
bedti"e allo&s "edications to re"ain in bladder overnight
C. $nuresis
1. Definition: inabilit to control bladder functions) often due to "aturation-
nocturnal) or /bed &etting/ ver co""on
#. $tiolog
a. pri"ar: never dr at night) and due to C68 or pschological
reasons
b. secondar: child has been toilet trained and beco"es incontinent
again
i. findings as above
ii. due to infection) "edications) trau"a
*. Diagnostics: histor) urine tests) seru" culture
'. @anage"ent
a. pri"ar
i. have the child participate in activities
ii. li"it fluid at night) void before bedti"e
iii. i"ager) behavioral conditioning - bladder training
iv. "edications
1. tricclic antidepressant- i"ipra"ine 1:ofranil2
#. des"opressin 1DDA;P2
b. secondar: treat underling cause
?. 6ursing interventions
a. help parents understand proble" and treat"ent plan
b. involve child in planning) if age appropriate
D. :eaching points
a. do not punish child if enuresis occurs
>pper >rinar :ract Disorders
D. ;esicourethral reflu! 1;><2
1. Definition: retrograde flo& of bladder urine into the ureters during voiding
#. $tiolog
a. pri"ar 1congenital ano"al2 - abnor"al insertion of ureters into
bladder
b. secondar 1acquired) usuall associated &ith >:I2
*. Pathophsiolog
a. bladder reflu!
b. residual urine fro" ureters re"ains in bladder until ne!t void
c. increases chance for and perpetuates infection
d. vesicoureteral reflu! grading sste": grade 1 to ?
'. +indings: >:I &ith chronic findings and recurrences
?. Diagnostics
a. radiographic studies
b. voiding cstourethrogra"
c. urine culture
D. @anage"ent
a. "edications: for grades 1 to ') lo&-dose antibiotics- "onitor
b. surger: for severe cases) grade ' or grade ?
F. 6ursing interventions
a. adequate or increased fluid inta%e
b. usual post-op care if child has surger
c. "onitor I P 9
G. :eaching points
a. all children in fa"il should be screened for possible reflu!
$. Acute glo"erulonephritis 1AG62
1. Definition: i""une co"ple! disease that occurs after a streptococcal
infection 1A .-he"oltic strep2
#. $tiolog
a. previous acute bacterial infection 1pharngitis) i"petigo2
b. underling sste"ic disorder
*. Pathophsiolog
a. infection 1usuall group a b-he"oltic strep2 provo%es i""une
co"ple! response
b. i""une co"ple!es trapped in glo"erular capillar loop
c. activate infla""ator response) &hich in7ures capillar &alls
d. decrease lu"en functions and G+< 1glo"erular filtration rate2
e. decreased filtration of plas"a results in e!cessive acu""ulation
of &ater and retention of sodiu"
f. onset appears after latent period of about ten das
'. +indings
a. oliguria
b. ede"a 1periorbital and peripheral2
c. he"aturia 1/s"o%/ or /tea-colored/ urine2
d. "ild hpertension
e. letharg
f. "oderate proteinuria
g. loss of appetite
?. Diagnostics: urine testing) seru" 1antibod) co"ple"ent) C<P) $8<)
C.C2) throat culture) histor of antecedent strep infection
D. @anage"ent
a. no specific treat"ents- recover spontanteous and uneventful in
"ost cases
b. supportive &ith careful regulation of fluid balance- I P 9) dail
&eights
c. "edications: antihpertensives) if needed
d. nutrition 1lo& in sodiu") protein) potassiu"2
F. 6ursing interventions
a. "onitor vital signs) fluid balance) and behavior
b. assess childHs appearance 5 presence of ede"a
c. possible institution of sei3ure precautions if indicated
d. possible fluid restriction
e. provide frequent rest periods
G. :eaching points
a. i"portance of finishing "edications as ordered
b. findings of recurrence
+. Chronic nephrosis 1nephrotic sndro"e2
1. Definition: "assive proteinuria) hpoalbu"ine"ia) hperlipe"ia and
ede"a
#. $tiolog: not full understood - possibl renal lesions or other processes
a. tpes
1. pri"ar 1idiopathic nephrosis2: restricted to glo"erular
in7ur
#. secondar: develops as part of sste"ic illness
*. Pathophsiolog: "ainl occurs in children bet&een # and F ears-old
a. glo"erular alteration and increased per"eabilit to
plas"aproteins) especiall albu"in
b. plas"a protein losses- increased presence in urine) decrease
plas"a volu"e) colloidal os"otic pressure in capillaries
decreases
c. hdrostatic pressure is greater than colloidal os"otic pressure
resulting in fluid accu"ulation in interstitial spaces and bod
cavities
d. shift in plas"a fluid leads to hpovole"ia
e. hpovole"ia - triggers %idnes to produce renin) and angiotensin
&hich sti"ulates the release of aldosterone and increases the
reabsorbtion of &ater and sodiu"
f. aldosterone increases
g. decreased blood pressure also causes release of ADH leading to
increase in &ater absorption
'. +indings
a. progressive &eight gain
b. puffiness of face
c. generali3ed ede"a 1insidious2
d. periorbital ede"a
e. loss of appetite
f. oliguria - urine s"o% bro&n 1rese"bles tea or cola2
g. letharg
h. pallor
?. Diagnostics: histor) urine tests &ill sho& "assive proteinuria) .>6 and
creatinine &ill be elevated) and antistreptolsin 91A892 titer
D. @anage"ent 5 "ainl supportive of &hat child de"onstrates
a. diet: no added salt but high in potassiu" and protein
b. "edications: corticosteroids) i""unosuppressants) diuretics
F. 6ursing interventions
a. "onitor vital signs and bod &eight and IP9
b. assess volu"e and character of urine
c. restrict fluid inta%e
d. sei3ure precautions if appropriate
e. activit should increase as protein in the urine decreases
f. place child in se"i-+o&lerHs or +o&lerHs to treat periorbital ede"a
G. :eaching points
a. ho& to test urine at ho"e for presence of protein
b. dietar restrictions
c. findings of infection
G. Cil"Hs tu"or
1. Definition: "ost co""on renal and intraabdo"inal tu"or of childhood
#. $tiolog: probabl arises fro" "alignant undifferentiated cluster of cells 5
favors left %idne
*. Pathophsiolog
a. cells regenerate an abdo"inal structure 5 renal function is
i"paired
'. +indings
a. abdo"inal "ass or s&elling 5 fir") nontender
b. fatigue) "alaise
c. respirator findings if "etastasis
?. Diagnostics
a. chest and abdo"inal !-ras
b. laborator tests 5 C.C
D. @anage"ent
a. surgical re"oval 5 possible che"otherap) actino"cin D and
radiation
F. 6ursing interventions
a. pre-op - post signs on bed /do not palpate abdo"en/
b. post-op - assess .P) urine output and pul"onar status
G. :eaching points
a. support fa"il
b. child should avoid contact sports
c. findings of infection
H. He"oltic ure"ic sndro"e 1H>82
1. Definition: "ost co""on acquired renal failure in children
a. acute disorder sho&s the /triad/
1. he"oltic ane"ia
#. thro"boctopenia
*. acute renal failure
b. occurs "ost often in children under four
#. $tiolog: un%no&n- so"e association &ith genetics) endoto!ins) bacteria
1$. coli.) ric%ettsia) co!sac%ie2) en3"e deficienc) decreased antio!idants
*. Pathophsiolog
a. usuall follo&s an acute GI or upper respirator infection 1><I2
b. pathogen attaches to G> tract
c. G> tract produces to!ins that da"age capillar &alls
d. infla""ation - glo"erular vessels less capable of filtration
e. ane"ia occurs 1due to <.C frag"entation2
f. thro"boctopenia 1due to platelets trapped in s"all vessels2
'. +indings
a. prior ><I
b. rapid onset of pallor
c. acco"paning he"orrhagic "anifestations such as bruising or
rectal bleeding
d. triad
e. hpertension
?. Diagnostics: identif /triad/ fro" histor and lab testing
D. @anage"ent
a. supportive
b. for ane"ia: transfusions 5 fresh fro3en plas"a 1++P2
c. for renal s"pto"s: fluids) possible dialsis or peritoneal dialsis
for the child &ho has been anuric for #' hours
d. treat"ent of hpertension
e. correction of electrolte disorders
F. 6ursing interventions
a. "onitor vital signs
b. "onitor IP9
c. prepare for dialsis
d. "onitor laborator results
e. "onitor transfusion response
G. :eaching points
a. possible renal i"pair"ent
b. %eep parents infor"ed of treat"ent plan as everthing happens
quic%l
I. Acute renal failure
1. Definition: sudden) severe loss of function of %idnes) usuall reversible
#. $tiologies
a. dehdration
b. underling conditions
c. burns 1ther"al in7uries2
d. obstruction
e. infection
*. Pathophsiolog
a. severe reduction in glo"erular rate
b. an elevated .>6
c. decreased tubular reabsorption of sodiu" fro" the pro!i"al
tubule
d. increase in sodiu" in distal tubules sti"ulated renin "echanis"
e. decrease renal blood flo&
f. cortical and tubular necrosis
'. +indings
a. usuall related to i"balances in fluids and electroltes
b. often nonspecific 1ede"a) hpertension) decreased feeding)
anore!ia) letharg) pallor) sei3ures2
c. oliguria
?. Diagnostics
a. histor
b. I P 9
c. laborator testing
d. radiographic 1ultrasound) renal scan2
D. @anage"ent
a. treat"ent directed at
1. correcting underling cause
#. "anaging co"plications
*. supportive therap
b. acute: fluids) electroltes) dialsis 1peritoneal) he"odialsis2)
antihpertensives) diuretics
F. 6ursing interventions
a. "onitor level of dehdration and volu"e restoration to avoid &ater
into!ication and hponatre"ia
b. insert +ole
c. "onitor laborator results
d. assess potassiu" in food and fluid
e. "onitor vital signs especiall blood pressure
f. neuro signs) if appropriate
G. :eaching points
a. nutritional needs and appropriate snac%s
b. include parents &hen for"ulating plan of care
c. possible co"plications: acute and chronic renal da"age) infection
and cardiac failure
E. Chronic renal failure 1C<+2
1. Definition: progressive deterioration of %idnes so that the can no longer
"aintain nor"al che"ical structure of bod fluids under nor"al conditions
#. $tiolog: i""unological in7ur) congenital ano"alies) underling
disease,condition
*. Pathophsiolog: irreversible and per"anent
a. progressive nephron destruction
b. distribution throughout nephron - ure"ia 1urea in blood2
c. final stage: end-stage renal disease 1$8<D2 is irreversible
'. +indings
a. failure to thrive) anore!ia) nausea and vo"iting
b. fluid and electrolte i"balances
c. hpertension) ure"ia) ane"ia) bleeding tendencies
d. increased fatigue on e!ertion
e. s%in: sallo&) "udd appearance
?. Diagnostics: histor) phsical e!a") laborator testing) radiographic
studies
D. @anage"ent
a. dialsis
b. %idne transplant
c. diet: "odified 1decreased sodiu") potassiu") phosphorus)
protein- fluid restriction) high calciu"2
d. "edications: antihpertensives) diuretics) erthropoietin) gro&th
hor"one) i""unosuppressants 1post transplant2
e. "onitor status 1for e!a"ple) laborator reports2
f. give pschological support
F. 6ursing interventions
a. "onitor bod fluid volu"e and electrolte balance
b. "onitor vital signs) especiall blood pressure
c. "onitor A.GHs for "etabolic acidosis
d. "onitor rate of gro&th and develop"ent
e. assess for findings of infection
f. prepare child and parents for possible dialsis and,or
transplantation
G. :eaching points
a. signs of re7ection of ne& %idne
b. need to follo& treat"ent plan and ta%e "edications as ordered
I. Concerns: bone de"inerali3ation) ane"ia) failure to thrive) retention of
&astes- transplant concern
Genitalia Proble"s
4. Crptorchidis"
1. Definition: failure of one or both testes to descend nor"all through
inguinal canal into scrotu"
#. $tiolog,pathophsiolog
a. abnor"al testes) or
b. decrease in the hor"onal sti"ulation necessar for descent
*. @anage"ent: &ait up to one ear for descent) "edications 1HCG2 to
assist in descent 1older child2) or surger 1orchiope!2.
=. Hpospadius
1. Definition: urethral "eatus belo& nor"al place"ent on glans penis or
an&here along ventral 1underside2 surface of penile shaft
#. $tiolog: idiopathic - related to genetics) environ"ent) hor"onal
*. Pathophsiolog: inco"plete develop"ent in utero
'. @anage"ent: surgical correction 1&ith urinar catheter and stents post-
op2) post-op pressure dressing "ust not be re"oved b anone other
than the health care provider) usuall repaired before child goes to school
?. Concerns: stenosis) chordee) bod i"age,self estee"
@. .ladder e!stroph
1. Definition: e!ternali3ation of bladder) splaing at the urethra &ith failure of
tubular for"ation and diastasis of pelvic bone
#. $tiolog: congenital - associated &ith genital abnor"alities
*. Pathophsiolog
a. failure of abdo"inal &all and underling structures) including the
ventral &all of the bladder) to fuse in utero
b. bladder develops outside
c. the earlier in gestation) the "ore severe the defect
d. defect al"ost al&as associated &ith epispadias
'. @anage"ent
a. trea"ent ob7ectives
1. preservation of renal function
#. attain"ent of urinar control
*. adequate reconstructive repair
'. preservation of opti"u" se!ual function
b. pre-op
1. prevent organs fro" dring out) fluids) infection control
#. surger: staged procedure
c. post-op 1antibiotics) co"pression bandage) bed rest2
?. Concerns: urinar incontinence) ;><) infection
6. A"biguous genitalia
1. $tiolog: abnor"alities in chro"oso"al co"ple"ent) e"brogenesis) or
hor"ones
#. Pathophsiolog: interruption in nor"al develop"ent around seven to
eight &ee%s gestation) &hen nor"all "ale begins differentiating fro"
fe"ale
*. Diagnostics: histor) phsical e!a") tests to deter"ine gender
1endoscop) ultrasound) radiographic contract2) genetics lab test)
laparoto") biops
'. Concerns: bod i"age,self estee") fa"il support
;II. Pediatric @usculos%eletal 8ste"
General Concepts:
A. Children0s "usculos%eletal differences
1. .ones are "ore pliable and porous- bend) buc%le) absorb shoc%
#. :endons and liga"ents are "ore fle!ible
*. .ones produce callus that speeds healing
'. :hic%er periosteu") so stronger and "ore active osteogenesis
?. 8%ull is pliable during infanc- anterior fontanel fuses at 1G "onths-
posterior fontanel fuses at t&o "onths
D. 8%eletal "aturation co"pletes &hen epiphsis fuses &ith diaphsis)
&hich is usuall 1G to #1 ears of age
.. I""obili3ation in children
1. Affects "ultiple sste"s
1. "uscular) GI) G>) pul"onar) cardiovascular) integu"entar
#. pschologic) behavioral) econo"ic
#. Affects nor"al gro&th and develop"ent
*. Pathologic changes occur due to
1. decreased "uscle strength and "ass) decreased "etabolis"
#. possible bone de"inerali3ation
*. decreased range of "otion and decreased 7oint "ove"ent
'. Concerns
1. hdration
#. dietar "odification
*. activit as condition per"its
'. self care as condition per"its
?. pla,e!ercise
C. +ractures in children
1. Definition: brea% or disruption in bone continuit
#. $tiolog: usuall due to "obilit and i""ature "otor and cognitive s%ills)
trau"a) osteogenic diseases) birth in7uries) child abuse
*. Pathophsiolog
1. fractures are seldo" co"plete brea%s 1bone is fle!ible2
#.
*. "an tpes: greenstic%) spiral 1"a indicate child abuse2) oblique)
transverse) co""inuted) pathologic
'. classification: si"ple 1closed2 or co"pound 1open2- co"plete or
inco"plete
?. pediatric ris%s
1. e!ternal he"orrhage creates ris% of critical blood loss
#. brea% at epiphseal plate 1gro&th plate bet&een epiphsis
and "etaphsis2 "a affect future li"b gro&th
'. +indings: s&elling) pain) bruising) ede"a) "uscle rigidit) di"inished
functional use of affected part
?. Diagnostics: !-ras) laborator testing
D. @anage"ent: cast or traction to realign) possible surger
F. Concerns: proper bone healing and align"ent) neurovascular status)
pain) bone gro&th) co"part"ent sndro"e
8tructural @usculos%eletal Disorders
D. Clubfoot
1. Definition: congenital "alfor"ation of one or both feet
#. $tiolog: I?S of cases talipes equinovarus - foot is pointed do&n&ard
and in&ard
*. +indings: plantar-fle!ed foot,feet) &ith inverted heel and adducted forefoot
'. @anage"ent: serial "anipulation and casting after birth- possible surger
$. Genu varu" 1bo&leg2 and genus valgu" 1%noc% %nee2
1. $tiolog: congenital
#. +indings
a. bo&legs 1genu varu"2 co""on in infants and toddlers
b. %noc% %nees co""on in preschool age and older
*. @anage"ent: "ost resolve spontaneousl - pathologic for"s "a require
night splints) "anual "anipulation) casting or surger
+. Hip dsplasia
1. Definition: develop"ental dsplasia of the hips 1DDH2) or dislocation
#. $tiolog: congenital) pre- and post-natal positioning
*. Pathophsiolog: head of fe"ur is i"properl seated in acetabulu" in hip
'. +indings
a. li"ited abduction
b. short fe"ur on affected side 1Galea33i0s sign2
c. as""etr of gluteal s%in folds
d. &addling gait 1bilateral dislocations2
e. for children alread &al%ing) increased la!it
?. Diagnostics
a. phsical e!a",screening at birth and "onitor for hip dsplasia
throughout first ear of life
b. chec% for 9rtolani "aneuver and .arlo&0s test fro" birth to # or *
"onths of age
c. radiographic studies
D. @anage"ent: Pavli% harness) spica cast) traction) surger) .rant0s
traction
F. Concerns: co"pliance) s%in integrit) avascular necrosis fro" i"proper
positioning of harness
G. 8coliosis
1. Definition: lateral curvature of the of spine and rotation of vertebral bones
#. $tiolog
a. idiopathic
b. associated &ith neuro"uscular disorders or trau"a 1paraltic2
c. congenital
d. "ost co""onl diagnosed during adolescent gro&th spurt
*. Pathophsiolog
a. dependent on tpe 1idiopathic) congenital) paraltic2
b. curved spine defor"s rib) bod develops co"pensator curve to
"aintain posture and balance
'. +indings
a. visible curve 1either C or 8 shaped curves2
b. /rib hu"p)/ or as""etric rib cage
c. legs are different lengths
d. &aist angles uneven
?. Diagnostics: screening) radiographic studies
D. @anage"ent
a. initiall) e!ercise and bracing to hold curve [email protected]&au%ee brace -
rarel used) Cil"ington and .oston orthoses - plastic shell) or
:=89 - custo"-"olded 7ac%et2
b. if curve progresses) surger - arthrodesis - surger is quite
co"ple!
F. Concerns
a. bod i"age,self estee") pain and disco"fort - long ter"
b. co"pliance &ith e!ercises and bracing- s%in integrit) air&a
clearance
Infectious @usculos%eletal Conditions
H. 9steo"elitis
1. Definition: bacterial bone infection
#. $tiolog: endogenous 1in-bod2 sources) or direct entr via open fracture
or e!ternal fi!ation devices. 8taphlococcus aureus is the "ost co""on
pathogen
*. Pathophsiolog
a. "icrobe affects "etaphsis of long bone- infla""ation
b. pus for"s and spreads along the shaft of the bone
c. ne& bone starts to for") but e!isting corte! loses blood vessels
and necrotic area &ill detach 1sequestru"2
d. /honeco"bed/ areas contain infective "aterial
'. +indings
a. pain) locali3ed tenderness) erthe"a over involved bone
b. decreased range of "otion at affected bone
c. irritabilit) restlessness) fever
?. Diagnostics
a. laborator: blood cultures and bone aspirate cultures
i. erthrocte sedi"entation rate 1$8<2 &ill increase
ii. increased &hite blood cells
iii. blood culture
b. radiographic studies 1often negative for ten to 1' das2- bone scan
D. @anage"ent
a. I; antibiotics- "a require long-ter" I; access 1' to D &ee%s2
b. bed rest
c. possible i""obili3ation &ith splints or cast
d. possible surger
F. 6ursing interventions
a. "onitor antibiotic levels
b. "onitor level of co"fort
c. perfor" range of "otion if possible 5 no &eight bearing
d. "onitor nutrition 5 high calorie liquids
e. provide diversional activities for age
G. :eaching points
a. "a continue I; therap at ho"e
b. phsical therap at ho"e
c. school &or% at ho"e if appropriate
d. pla activities &ithin li"its of phsical abilit
9ther @usculos%eletal Disorders
I. Euvenile rheu"atoid arthritis 1E<A2 - ne& na"e Euvenile Idiopathic Arthritis
1. Definition: infla""ation of 7oints
#. $tiolog: auto-i""une &ith probable genetic predisposition
*. Pathophsiolog
a. trigger infla"es snoviu" - chronic infla""ation
b. effusion of the 7oint and increased fluid
c. erosion and fibrosis of the articular cartilage
d. further deterioration occurs &ith bone erosion
e. decrease in 7oint0s range of "otion and function
'. +indings
a. "a have sudden inabilit to &al% on one leg
b. inter"ittent 7oint pain) stiffness) s&elling
c. decreased range of "otion) "orning stiffness
d. significant disabilit
?. Diagnostics
a. laborator testing - no definitive serologic tests
1. increased $8< and C<P: c-reactive protein 1sign of
rheu"atic fever2
#. ane"ia
*. leu%octosis in earl stages
'. H=A testing 1hu"an leucocte antigen2
b. radiographic testing and !-ras -- &idening of 7oint spaces
follo&ed b gradual fusion and articular destruction &ith soft tissue
s&elling
D. @anage"ent
a. treat"ent ob7ectives
1. preserve 7oint function
#. prevent phsical defor"ities
*. relieve findings
b. "edications: nonsteroidal anti-infla""ator drugs 168AID82 -
napro!en) slo& acting antirheu"atic drugs 18AA<D82)
corticosteroids) i""unosuppressives) ctoto!ic agents -
"ethotre!ate
c. other: P: and 9:) rest,activit) positioning) splinting) ultrasound)
electrical sti"ulation) heat) &hirlpool- surger for 7oint replace"ent
F. 6ursing interventions
a. "onitor for co"pliance &ith therap 5 phsical and occupational
b. prevent contractures
c. "onitor pain,disco"fort 5 possible application of "oist heat
d. provide fa"il and child support services) bod i"age) decreased
"obilit
e. assess for altered patterns of gro&th and develop"ent due to
decreased activit) decreased abilit to perfor" AD=Hs
G. :eaching points
a. "ultidisciplinar approach
b. long-ter" disorder
c. usual develop"ental "ilestones 5 age appropriate tos
d. e!ercise needs
E. =egg-Calve-Perthes disease: osteochondritis
1. Definition: aseptic necrosis of fe"oral head
#. $tiolog: disturbance of circulation to the fe"oral epiphsis
*. Pathophsiolog
a. disturbance in blood suppl
b. ische"ic aseptic necrosis of fe"oral head) usuall self-li"iting
'. +indings
a. insidious onset
b. inter"ittent painful li"p on one side
c. increased pain after e!tended period of activit
d. decreased range of "otion
?. Diagnostics: histor) radiographic studies) bone scan) @<I
D. @anage"ent
a. bed rest
b. non &eight bearing range of "otion
c. corrective devices such as braces) casts) traction 5 conservative
therap "ust be continued for # to ' ears
d. possible surger
F. 6ursing interventions
a. "ostl outpatient activities
G. :eaching points
a. parents "ust learn purpose) function) application) and care of
corrective devices
b. pla and e!ercise activities for a child &ho feels &ell but "ust
re"ain relativel inactive
;III. Pediatric Integu"entar 8ste"
General Concepts
A. Pediatric differences: thinner s%in
1. 6e&born0s s%in thinner) "ore easil hurt b endoto!ins and infection)
shearing and tearing forces
#. Child0s bod absorbs "ore of topical products
*. Harder to regulate bod te"perature
.. +actors in s%in condition
1. Age
#. Hdration and nutrition
*. 8oap) laundr detergents) and topical products
'. @edications
?. Infectious processes 1viral) bacterial) fungal2
D. @echanical forces 1tearing) friction) shearing2 P vascular da"age
F. :ape and adhesive products
G. Allerg
I. I; infiltration
1(. :e"perature
11. .odil secretions: urine) stool) osto" drainage) fistula
C. Counds) &ound healing) "odes of s%in care
1. Assess"ent
a. acute or chronic: etiolog of pressure) shearing) trau"a
b. "easure"ents: depth) si3e) location) /tunneling/) open) closed
c. staging: partial or full thic%ness) co"ple! 1involving "uscle) bone2
#. +actors i"pacting &ound healing
a. perfusion) o!genation
b. nutritional deficiencies
c. infection
d. underling sste"ic condition
e. topical products utili3ed
f. "edications
*. Principles of successful &ound "anage"ent
a. re"ove or eli"inate causative factors
b. provide appropriate sste"ic support: fluids) nutrition
c. appl appropriate topical products: encourage "oist &ound
healing and process of occlusion.
'. $valuation of successful &ound healing
a. tpe: pri"ar) secondar or tertiar &ound closure
b. "easure"ent: decreasing si3e) viable tissue) decreased e!udate)
color
?. @odes of caring for s%in disorders
a. non-surgical: s%in care products) nutrition) health lifestle
b. surgical: debride"ent) s%in grafts and flaps
c.
6oninfectious 8%in Conditions
D. Atopic der"atitis 1ec3e"a2
1. Definition: infla""ation of the s%in
#. $tiolog: genetic tendenc) "ultifactorial &ith fa"il histor of allergies or
asth"a- e!acerbated b stress and certain foods
*. Pathophsiolog: trigger- increased hista"ine release &ith infla""ator
response - itching and findings of e!acerbation
'. +indings
a. dr s%in) itching) erthe"a
b. "acule) papule) pustule and even vesicles possible
c. acute &eeping areas &ith e!coriated red plaques
?. Diagnostics
a. fa"il histor
b. phsical e!a"
c. lab tests 1eosinophils) Ig$2
D. @anage"ent
a. goals: control itching) "oisturi3e) re"ove irritants and allergens)
and prevent secondar proble"s 1infections2
b. products: &et co"presses) occlusive dressings)
crea"s,oint"ents) hdrocortisone crea") "ild detergents
c. "edications: antihista"ines
F. 6ursing interventions
a. re"ove allergens
b. %eep childHs fingernails short
c. clothe lightl to decrease s&eating
d. appl e"ollient preparation i""ediatel after bathing
e. provide rest periods
f. provide hpoallergenic diet if appropriate
G. :eaching points
a. provide fa"il support regarding nutrition and recurrent nature of
this disorder
$. 8eborrheic der"atitis 1in infants: cradle cap2
1. Definition: recurrent infla""ator reaction of s%in that "a also involve
the eelids and e!ternal ear canal
#. $tiolog: probable dsfunction of sebaceous glands
*. +indings: usuall nonpruritic oil scales on scalp) forehead and eebro&s
or behind ears
'. @anage"ent: scalp hgiene &ith "ild bab sha"poos) hdration crea"s)
bab oil
?. :eaching points: teach parents ho& to clean scalp and sha"poo hair
+. Diaper der"atitis 1/diaper rash/2
1. Definition: infla""ator s%in disorder caused directl or indirectl b
&earing of diapers
#. $tiolog
a. a""onia in urine) fecal en3"es) detergents) "oisture) heat
b. can lead to secondar fungal infection 1especiall candida
albicans2
*. Pathophsiolog
a. prolonged and repetitive contact &ith irritant 1especiall urine
a""onia) &hich is for"ed b urea brea%do&n fro" fecal
bacteria2- infla""ation
b. e!coriation) &ith "acules,papules and erosion
c. concern: secondar infection.
'. +indings: red) e!coriated) "acules,papules) "aceration
?. @anage"ent
a. cleaning and frequent diaper changes
b. s%in protectants,"oisture barriers to %eep s%in dr
c. topical antifungals and steroids
d. if diarrhea) treat underling cause
G. Contact der"atitis
1. Definition: infla""ator reaction of the s%in to che"ical substances
natural or snthetic
#. $tiolog: "ultiple factors and irritants foods) solutions) allergens) plants
*. +indings: irritant and allergic tpes
a. irritant: causes dr) infla"ed) pruritic lesions &here irritant touched
b. allergic: blisters after &eeping) pruritic) lesions
'. @anage"ent: topical 1antiinfla""ator) antipruritic2 cold co"presses)
supportive care 5 prevent further e!posure to offending substance if
possible
H. Acne vulgaris
1. Definition: "ost co""on s%in proble" treated b doctors during
adolescence
#. $tiolog: "ultifactorial 1heredit) hor"ones) e"otions2
*. Pathophsiolog
a. pubert 5 increased androgens 5 involves hair follicle and
sebaceous gland co"ple!
b. increased sebaceous glands secrete "ore sebu"
c. pores beco"e plugged and dilated
d. fatt acids are o!idi3ed on s%in and for" blac%heads 9<
e. internal fatt acids for" &hiteheads
f. rupture causes local infla""ation) so"eti"es &ith pustules
'. +indings: &hiteheads 1closed co"edo"es2) blac%heads 1open
co"edo"es2) papules) pustules) nodules) red and e!coriated s%in
?. @anage"ent
a. general: good cleansing of s%in) nutrition) and no squee3ing or
pic%ing at lesions
b. topicals: vita"in A) topical antibiotics) topical ben3ol pero!ide
c. "edications: oral antibiotics and possible estrogen for girls
D. :eaching points
a. possibilit of scarring
b. possible bacterial invasions
c. bod i"age
d. education needed on "ths and realities of causative agents and
treat"ent "odalities
e. stress i"portance of co"pliance to treat"ent progra"
Infectious Disorders
I. I"petigo contagiosa
1. Definition: bacterial infection of s%in
#. $tiolog: staphlococcus aureus) group A beta-he"oltic streptococcus
*. Pathophsiolog: starts in area of bro%en s%in - highl contagious for
seven to ten das
'. +indings
a. pri"ar: "acules-vesicles of bulla that rupture
b. secondar: hone-colored crusts) superficial erosion) easil
bleeds) pruritic
c. tends to heal &ithout scarring unless secondar infection
?. @anage"ent
a. careful re"oval of crusts,debris &ith &ar" soap solution or
.uro&0s solution
b. topical antibiotics for earl s"all lesions
c. treat"ent of choice: sste"ic antibiotics
d. short fingernails
D. Concerns: highl contagious 1good hand &ashing) no sharing to&els or
eating utensils2
E. Cellulitis
1. Definition: infection of der"is and,or subcutaneous tissue
#. $tiolog: strep) 8. aureus) Hae"ophilus influen3a
*. Pathophsiolog
a. starts in area of bro%en s%in
b. highl contagious for das
c. can occur on an part of the bod
'. +indings
a. affected area 1red) ede"a) tender) occasional discoloration2
b. enlarged l"ph nodes) /strea%ing/ frequentl seen) fever) "alaise)
headache
?. Diagnostics: C.C) cultures) possible s%in culture) C:
D. @anage"ent: oral or parenteral antibiotics) &ar" "oist co"presses)
possible incision and drainage) rest of affected area and child
F. Concerns: secondar infection) alteration in s%in integrit
4. Herpes si"ple! tpe one
1. Definition: oral herpes) cold sore) fever blister
#. $tiolog: H8;-1 or H8;-#) cto"egalovirus [email protected];2) $pstein .arr
1infectious "ononucleosis2) ;aricella 3oster
*. Pathophsiolog: virus infects bod fluids) &hich then co"e in contact
&ith brea%s in the s%in or "ucous "e"branes
a. H8;-1 affects areas above the &aist- /cold sore/
b. H8;-#: affects areas belo& the &aist- genital
c. virus dor"ant &ithin nerve cells- then reactivated b fever) stress)
trau"a) sun e!posure) "enstruation
'. +indings
a. often depend on location in bod
b. prodro"al period co""on
c. vesicles) pain) pruritis) paresthesias) increased s%in sensitivit at
site
?. Diagnostics: histor) phsical e!a") s"ears) tissue cultures 1Acclovir -
;altre!2
D. @anage"ent - s"pto"atic: fluids- possible antiviral or antibiotic if
secondar infection- analgesics
F. Concerns: highl contagious) secondar infection) pain) bod i"age-
H8;-# is se!uall trans"itted
+ungal Infections of 8%in
=. @oniliasis candidiasis 1thrush2
1. Definition: oral candidiasis characteri3ed b &hite adherent patches on
the tongue) palate) and inner aspects of the chee%s
#. $tiolog: fungus) candida albicans
*. Pathophsiolog: acquired via birthing process) antibiotics) inhaled
steroids
'. +indings
a. &hite plaques on tongue) gu"s or buccal "ucosa
b. possible ulcerations in oral "ucosa
c. itching
?. @anage"ent
a. oral antifungals 1s&ish and s&allo&2 after feeding - topical
application also
b. education on "outh rinsing after inhaled steroid
D. Concern: "a spread to groin) buttoc%s
@. :inea 1ring&or"2
1. Definition: superficial infection that lives on) not in) the s%in
#. $tiolog: der"atophtes
*. Pathophsiolog
a. trans"itted person to person) ani"al contact) contact &ith
conta"inated fo"ites 1nonliving /host/2
b. associated &ith poor hgiene) friction fro" tight clothing

'. 6ursing interventions
a. co"pliance) good hgiene
b. contagion) teach client never share clothing,hair brushes
c. overuse of 9:C products) especiall for feet
?. :eaching points
a. "aintain "edication schedule as ordered 5 "abe for
several &ee%s or "onths
b. no sharing of to&els) linens or hair brushes
Infestations
6. Pediculosis 1lice2
1. Definition: lice infestation
#. $tiolog: infestation of the scalp - pediculus hu"anus capitis 1parasite2
*. Pathophsiolog:
a. these lice live onl on hu"ans) are trans"itted b direct and
indirect contact
b. tpes include: scalp 1capitis2) bod 1corporis2) pubic area 1pubis2
and eelashes
c. all pierce s%in and suc% blood) &ith fe"ales laing eggs 1nits2 at
the base of hair shaft
'. +indings
a. nits 1tin silver or graish-&hite spec%s2 and pruritis
b. &ith corporis) papular rose-colored der"atitis
?. @anage"ent
a. topical "edicated sha"poos or bod oint"ents - 6i! 1cre"e rinse2
for infants and children
b. teach client to prevent recurrence and spread: &ash clothes in hot
&ater) no sharing of clothes or hair brushes
D. Concerns
a. co"pliance and recurrence
b. lindane 14&ell2 sha"poo is neuroto!ic in children under five
c. lice are highl contagious- in hospital) infested client requires
contact isolation. +or infor"ation on isolation see =esson #: 8afet
and Infection Control
9. 8cabies 1itch "ite2
1. Definition: "ite infestation
#. $tiolog: "ite 1sarcoptes scabiei2
*. Pathophsiolog
a. fe"ale "ite burro&s into epider"is) las eggs
b. "ites) eggs and e!cre"ent all cause intense pruritis 1due to
hista"ine release2
'. +indings
a. pruritis) burro&s 1fine) graish bro&n threadli%e lines2
b. papule li%e ec3e"a in infants
?. @anage"ent
a. scabicide topicals) crea"s - $l"ite is the "edication of choice
b. anti-steroidal agents "a be included
c. &ash clothes and bedding in hot &ater
d. all persons in close contact &ith affected child &ill need treat"ent
IK. :e"perature-<elated Disorders
A. Caused b cold
1. Definition
a. :pes
I. chilblain: s%in 1usuall e!tre"ities2 beco"es red and
s&ollen &hen it is inter"ittentl e!posed to cold
te"peratures
II. frostbite: tissue da"age &hen ice crstals for" in tissue
#. +indings
a. chilblain: redness) ede"a of hands and feet) "a burn or itch
b. frostbite
I. blanching) decreased sensation) "ottled
II. second degree 1cold after re&ar"ing2: blisters and
possible bulla
III. third degree: canosis) "ottling- then red &ith s&elling)
local necrosis) he"orrhagic vesicles
I;. fourth degree: co"plete necrosis) gangrene) loss of bod
part
c. hpother"ia: cooling of the bod0s core te"perature to in7urious
levels 1belo& *? degrees Celsius2
*. @anage"ent
a. cover area i""ediatel but no "assaging
b. re&ar" in 1(( to 1(G degree +ahrenheit &ater - i""erse affected
part
c. give analgesics and sedatives for severe pain during re&ar"ing
d. hpother"ia: heat la"ps) i""ersion in &ater bath
.. 8unburn
1. Definition: overe!posure to the sun
#. $tiolog: overe!posure to ultraviolet light &aves >;A 1"inor burning2 >;.
1tanning) burning) har"ful effects2
*. +actors influencing degree of burn
a. genetic "a%eup and s%in tpe
b. season of ear) altitude) ti"e of da
c. &indo& or glass) light reflected b sno& or &ater
d. "edications) underling conditions) topical products
'. Prevention
a. avoid sun
b. &ear good clothing &ith a tight &eave and ee &ear
c. appl child appropriate topical sunscreens and bloc%s liberall
d. no direct sun bet&een 1( a" to * p"
?. @anage"ent: li%e a first degree burn 1see ne!t page2
C. :her"al in7uries 1burns2
1. Definition: in7uries to s%in resulting fro" e!tre"e heat sources
#. $tiologies: ther"al) che"ical) electrical) secondar to irradiation- ther"al
tpes "ost co""on in children
*. Pathophsiolog
a. severit affected b: location) concurrent inhalation in7ur) trau"a)
underling condition) age of child
I. hot &ater scalds - toddler
II. fla"e related - older children
b. anato" and phsiolog of burns
I. depth
I. a"ount of local tissue destroed or da"aged
II. related to length of e!posure and te"perature
II. tpes: first) second) third) fourth degree
I. partial thic%ness: first and second degree
II. full thic%ness: third and fourth degree
III. fourth degree: involves "uscle) fascia and bone. Cound
appears dull and dr and liga"ents) tendons and bone
"a be e!posed.
I;. severit: classified as "inor 1A1(S :.8A2) "oderate 11(-
#(S :.8A2 or unco"plicated "a7or 1O#(S :.8A2-
deter"ined b the a"ount of sste"ic disruption beond
&hat the bod could nor"all co"pensate.
c. e!tent of burn deter"ines responses: local or sste"ic
'. =ocal response
a. cellular da"age and fluid "ove"ents - ede"a
b. fluid lea%s into interstitial spaces) fluid lost to air
c. fluid is lost to circulating volu"e 1the /oliguric/ phase2
d. burn da"ages tissue
?. @ulti-sste"ic response and potential co"plications
a. cardiovascular: dehdration- /burn shoc%/
b. pul"onar: respirator distress) possible post-inhalation in7ur)
A<D8) aspiration pneu"onia) pul"onar ede"a
c. GI: ische"ia - decreased bo&el sounds) possible ileus) Curling0s
ulcer
d. G>: decreased fluids) increasing .>6 and creatinine
e. "etabolic: increased basal "etabolic rate) vital signs
f. neuroendocrine: increased ADH and aldosterone
g. C68: possible encephalopath) sei3ures) co"a) altered =9C
h. integu"entar: burned) infection) scar tissue for"ation and poor
healing
i. ane"ia: associated &ith "a7or burns
D. .urn in7uries differ in children
a. thinner s%in) so tissue da"age is "ore severe
b. fluid volu"e changes faster than cardiovascular sste" can
respond
c. relativel large surface area increases ris% for losses of fluid and
heat
d. increased ris% for dehdration and acidosis due to: diarrhea)
insensible fluid loss) and because child0s bod requires higher
proportion of &ater than adult0s
e. i""ature i""une sste" increases ris% of infection
f. long ter": scars "ature "ore slo&l and %eloids "ore severe
F. +indings
a. superficial 1first degree2 burn: locali3ed pain) dr surface) blanches
&ith pressure) redness) possible blister
b. partial thic%ness 1second degree2 burn: open &ound) ver painful)
denuded s%in- blistered) "oist
c. full thic%ness 1third degree2 burn
I. tough) leather) dull dr) &ith variable pain 1often severe2.
II. color: bro&n,tan,blac%,red: dependent on severit2
III. "a be life threatening- "a affect "an bod sste"s
d. full thic%ness 1fourth degree2 burn
I. &ound dull and dr
II. liga"ents) tendons) bone "a be e!posed - not painful
G. @anage"ent: priorit is to stop the burning process
[email protected]$<G$6CT :<$A:@$6: 9+ .><68
1. Put out fire
#. If burn is "inor:
a. appl cool &ater to burn
b. re"ove burned clothing,7e&elr
c. do not disturb an blisters that for"
d. do not appl anthing to the burn
*. If burn is serious:
a. assess respirator status and establish air&a
b. resuscitate if necessar
c. cover burn &ith clean cloth
d. arrange for transport to e"ergenc health care facilit
e. superficial: cleanse &ith solutions) debride loose debris or necrotic
tissue) add anti"icrobial oint"ent) and dressing 1fine "esh or
occlusive2) tetanus prophla!is) "ild analgesic
f. care of full thic%ness burn
1. "aintain A.C: air&a) breathing) circulation
#. &eigh client and provide fluids and electroltes. >se
Par%land for"ula for burn shoc%
*. re"ove constrictive clothing or 7e&elr.
'. cover the burn: prevent infection) heat loss) and further
deterioration
?. provide sufficient nutrition and calories to prevent negative
nitrogen balance and "eet bod de"ands
D. provide adequate pain control
F. antibiotic therap
G. tetanus prophla!is
c. care of the child &ith a burn &ound
i. aseptic technique
ii. pre-"edicate for pain before an dressing change
iii. debride"ent: surgical) en3"atic) hdrotherap
iv. cleanse &ounds &ith "ild solutions) then cover &ith
anti"icrobial
v. s%in grafts 1te"porar) per"anent2: allograft and autografts
vi. donor site) usuall covered &ith !erofor" dressing -
1nursing does not change this dressing2
vii. long ter": Eobst pressure stoc%ings and bod &raps)
support surfaces) range-of-"otion activities
I. Concerns in burn cases
a. acute: air&a status) pain) shoc%) infection) fluids
b. long-ter": nutrition) pain control) contractures) &ound healing)
%eloid for"ation) pschological) bod i"age and self estee"
K. Pediatric He"atolog
.lood Co"ponents
A. $rthroctes
1. Carr o!gen to cells and "ove carbon dio!ide bac% to lungs.
#. Average life span: 1#( das
*. He"oglobin: the iron co"ponent of <.Cs
'. .lood tping
a. persons &ith tpe A can receive tpe A or tpe 9 blood
b. persons &ith tpe . can receive tpe . or tpe 9 blood
c. persons &ith tpe 9 can receive onl tpe 9 blood
.. =eu%octes increase &ith infections or infla""ation:
C. Plas"a proteins
1. Include albu"in and globulins
#. @easuring plas"a proteins helps assess nutritional status
D. Platelets
1. 8"all frag"ents of cells
#. =ife span eight to ten das
*. $ssential to blood clotting,coagulation
Disorders of <ed .lood Cells
$. 8ic%le cell ane"ia 18CA2
1. Definition: one of a group of diseases in &hich nor"al adult he"oglobulin
1HbA2 is partl or co"pletel replaced b abnor"al sic%le he"oglobin
1Hb82
#. $tiolog: autoso"al recessive disease- 1 in # African-A"ericans carries
the trait) &hile 1 in *F? is affected &ith sic%le cell disease
*. Pathophsiolog
a. trigger 5 <.CHs shape beco"es sic%led and clu"p
b. generali3ed "icrovascular occlusion 1vaso-occlusive crisis2
'. +indings
a. result fro"
i. obstruction caused b sic%led <.Cs
ii. <.C destruction
b. hpo!ia
c. organ dsfunction 1spleen) liver) %idne2 due to ische"ia and
infarction
d. painful e!acerbations called crises:
i. vaso-occlusive 5 painful distal ische"ic usuall hands and
feet
ii. sequestration crisis 5 pooling of blood in liver and spleen
iii. aplastic crisis 5 di"inished <.C production
iv. hperhe"oltic crisis increased destruction of <.C
?. Diagnostics
a. ne&born screening 1sic%led e!2
b. electrophoreses 1he"oglobin2
D. :herapeutic "anage"ent
a. ai"s of therap
i. to prevent sic%ling pheno"enon
ii. to trust "edical e"ergenc sic%le cell crisis
b. hdration
c. o!gen
d. analgesics
e. antibiotics
f. folic acid
g. prophla!is &ith penicillin reco""ended
h. genetic counseling
F. 6ursing interventions
a. for"ulate teaching plan for patient and fa"il
b. encourage fluids
c. appl to affected areas as ordered
d. accurate I P 9
e. "edicate for disco"fort as ordered
G. :eaching points
a. ho& to ad"inister prophlactic antibiotics
b. findings of infection
c. ho& to increase fluid inta%e especiall in hot &eather
+. .-:halasse"ia
1. Definition: inherited blood disorder characteri3ed b deficiencies in rate of
production of specific globin chains in he"oglobin
#. $tiolog: autoso"al recessive disorder) also %no&n as Coole0s ane"ia
*. Pathophsiolog: abnor"al) chronic production and destruction of <.C0s
resulting in insufficient a"ounts of nor"al circulating he"oglobin
'. +indings
a. severe ane"ia) pallor
b. "icroctic <.Cs
c. i"paired gro&th
d. spleno"egal
?. Diagnostics
a. he"oglobin and he"atocrit
b. he"oglobin electrophoresis
c. !-ras of involved bones
D. @anage"ent
a. chronic transfusion therap to "aintain he"oglobin of ten g",dl
b. referral for chelation counseling
c. genetic counseling
Disorders of $!cess .leeding
8u""ar of bleeding disorders in children:
G. Idiopathic thro"boctopenic purpura 1I:P2
1. Definition: and acquired he"orrhagic disease
#. $tiolog: un%no&n but often occurs one to t&o &ee%s after a febrile viral
illness
*. Pathophsiolog
a. auto-i""une disorder
b. platelets are %illed and fe&er are "ade
c. "a be acute and self-li"iting or chronic
'. +indings: e!cessive bruising) petechiae) internal bleeding
?. Diagnostics: platelet count) bleeding ti"e) and bone "arro& aspiration
D. @anage"ent: steroids) i""unoglobulins 1I;IG2) antibod) splenecto"
for chronic disease
F. 6ursing interventions
a. "onitor for bleeding episodes
b. provide for age appropriate diversional activities
G. :eaching points
a. should not participate in contact sports
b. should not use aspirin to relieve pain use :lenol 1aceta"inophen2
H. ;on Cillebrand0s disease
1. Definition: hereditar bleeding disorder
#. $tiolog: congenital 1autoso"al do"inant2 bleeding disorder- affects both
"ales and fe"ales
*. Pathophsiolog
a. bod "a%es too little von Cillebrand0s factor and factor ;III
b. prolonged bleeding ti"e
'. +indings: e!cessive bleeding of "ucous "e"branes: gu"s) epista!is
1nosebleed2) "enorrhagia
?. Diagnostics: bone "arro& aspiration
D. @anage"ent: replace"ent of "issing clotting factor) and,or
ad"inistration of antidiuretic: des"opressin acetate 1DDA;P2
I. Aplastic ane"ia
1. Definition: bone "arro& failure
#. $tiologies
a. congenital 1e!a"ple: +aconi0s ane"ia2
b. acquired due to e!posure to over&hel"ing infection 1hepatitis)
HP;2
c. causative agents such as antineoplastic agents) che"icals)
chlora"phenicol
*. Pathophsiolog
a. bone "arro& stops "a%ing erthroctes) leu%octes) and platelets
1thro"boctes2
b. result: panctopenia
'. +indings: petechiae) bruising) pallor) fatigue) "elosuppression
?. Diagnostics: bone "arro& aspiration
D. :herapeutic "anage"ent
a. antith"octe globulin 1A:G2) antil"phocte globulin 1A=G2
b. if severe) bone "arro& transplant is treat"ent of choice
E. He"ophilia
1. Definition: group of bleeding disorders in &hich there is a deficienc of
one of the factors necessar for coagulation of blood
#. $tiolog: !-lin%ed recessive disorder
*. Pathophsiolog: "issing or defective factor ;III or factor IK blood
co"ponents necessar for blood coagulation
'. +indings
a. "ild-severe prolonged bleeding- "ost often in "uscles and 7oints
1he"athrosis2
b. longter" loss of range of "otion of affected 7oints
?. Diagnostics: histor of bleeding episodes) P::) assa procedures for
specific factor deficiencies
D. @anage"ent
a. replace"ent of "issing clotting factor) factor ;III concentrate
b. des"opressin acetate) a diuretic 1DDA;P2
c. prophlactic treat"ent &ith clotting factor before surger and
so"e other procedures
d. ice) rest) elevation) i""obili3ation) pressure to bleeding site
F. 6ursing interventions
a. prevent bleeding &hile appropriate e!ercise
b. brushing teeth &ith soft toothbrush
c. recogni3e and control bleeding
d. support fa"il
e. assess school activities
G. :eaching points
a. child should &ear "edical identification
b. genetic counseling for parents
K. Disse"inated intravascular coagulation 1DIC2
1. Definition: disorder of coagulation
#. $tiolog
a. secondar disorder of coagulation that co"plicates other
disorders
b. triggered b endothelial da"age such as trau"a) shoc%)
infections) hpo!ia) liver disease
*. Pathophsiolog
a. the first stage of the coagulation process is abnor"all sti"ulated
b. clotting "echanis" is triggered in circulation) thro"bin is
generated in greater a"ounts than the bod can neutrali3e
c. rapid conversion of fibrinogen to fibrin &ith aggregation and
destruction of platelets
d. local and &idespread fibrin deposition in blood vessels causes
obstruction and necrosis
e. fibrinoltic "echanis" causes e!tensive destruction of clotting
factors
'. +indings
a. bleeding) bruising) petechiae
b. altered seru" levels of clotting-related factors 1increased P:) P::)
::) decreased platelets) degraded fibrinogen2
c. clotting) hpo!e"ia) intracranial he"orrhage) progressive organ
failure
?. Diagnostics: P:) P:: and :: 1:hro"bin ti"e2
D. @anage"ent
a. control of underling etiolog
b. factor replace"ent
c. platelets) fresh fro3en plas"a 1++P2 and <.C transfusions
d. vita"in 4
e. o!gen
F. 6ursing Interventions
a. "onitor I; infusions) blood transfusions
b. ad"inister Heparin as ordered
c. "onitor an severel ill child to recogni3e presence of this
disorder
KI. Pediatric 9ncolog
I. Cardinal findings of cancer in children
I. >nusual "ass
II. Pallor
III. 8udden tendenc to bruise
I;. <apid) une!plained &eight loss
;. Change in vision or ee
;I. <ecurrent fever
;II. Persistent headache) often &ith vo"iting
;III. Change in balance or gait
II. =eu%e"ias - "ost co""on cancer in children
I. Definition: cancer of blood-for"ing tissues
II. Pathophsiolog of acute l"phoid leu%e"ia 1A==2 and acute
"elogenous leu%e"ia [email protected]=2
I. "alignancies of the bone "arro& and l"phatic sste"
II. unrestricted proliferation of i""ature C.Cs
III. leu%e"ia cells de"onstrate the neoplastic properties of solid
cancers
I;. s"pto"s caused b infiltration and replace"ent of an tissue of
the bod &ith non-functional leu%e"ia cells.
;. highl vascular organs such as spleen and liver are "ost severel
affected
III. +indings
I. acute or insidious onset
II. ane"ia) thro"boctopenia) infection) bleeding
III. l"phadenopath) hepatospleno"egal) bone or 7oint pain
I;. "eningeal irritation 5 irritable) lethargic) stiff nec%
I;. Diagnostics: histor) phsical findings) peripheral blood s"ear) and bone
"arro& aspiration
;. @anage"ent
I. co"bination che"otherap to achieve a re"ission
II. radiation if C68 involved or intrathecal ad"inistration of
"ethotre!ate
III. bone "arro& transplant
;I. 6ursing interventions
I. prepare child and fa"il for diagnostic procedures
II. relieve disco"fort
III. "onitor for infection) he"orrhage and ane"ia
I;. "anage proble"s of drug side effects 5 nausea and vo"iting)
anore!ia) "ucosal ulceration) neuropath) alopecia and "oon
face.
;. provide nutritional snac%s
;I. refer for needed services 5 financial or ho"e care
;II. :eaching points
I. long ter" treat"ent plan
II. "ultidisciplinar approach
III. encourage parents to as% questions &hen unsure
I;. school &or% for child &hen appropriate
="pho"as
C. Hodg%in0s disease
1. Definition: "alignanc of the l"ph nodes
#. Pathophsiolog
a. neoplas" of l"phatic sste"
b. characteri3ed b giant) "ultinucleated cells 1<eed-8ternberg cells2
*. +indings
a. characteri3ed b painless enlarge"ent of l"ph nodes)
particularl in supraclavicular area
b. anore!ia) &eight loss) "alaise- painless- night s&eats
c. fever
'. Diagnostics: l"phangiograph) C.C) 8ed <ate) urinalsis) C: 8can)
chest !-ra
?. @anage"ent
a. che"otherap and radiation
b. treat"ent based on staging of disease 1stages I-I;2
D. 6ursing Interventions
a. preparation for diagnostic procedures
b. e!plain side effects of treat"ent
c. provide age appropriate diversional activities
d. refer to appropriate resources if sterilit "a result fro" irradiation
and,or che"otherap
F. :eaching points
a. long ter" treat"ent plan
b. "ultidisciplinar approach
c. encourage to as% questions &hen unsure
d. school &or% for child &hen appropriate
D. 6on-Hodg%in0s l"pho"a
1. Pathophsiolog:
a. proliferation of either .- or :- l"phoctes
b. staging I-I;
#. +indings
a. painless) enlarged l"ph nodes in cervical or a!illar region
b. bone "arro& and,or "ediastinal involve"ent
*. :herapeutic "anage"ent: co"bination of che"otherap and radiation
$. .rain tu"ors: "edulloblasto"a) astrocto"a) epend"o"a) glioblasto"a
1. Pathophsiolog
a. solid tu"ors of the nervous sste"
b. "ost co""on solid tu"or in children
c. location e!tre"el i"portant
#. +indings
a. headache) vo"iting) increased intracranial pressure) ata!ia
b. visual changes) sei3ures) bulging fontanel in infants) behavioral
changes
*. Diagnostics: histor) @<I) C: 8can) $$G) and lu"bar puncture
'. @anage"ent
a. surgical debul%ing
b. radiation
c. che"otherap
?. 6ursing interventions
a. neuro signs
b. vital signs
c. prepare child and fa"il for diagnostic and operative procedures 5
possible shaving of head
d. positioning considerations depend on procedure done
e. "onitor dressing and ICP) if appropriate
f. begin feeding &hen ordered
g. "edicate for disco"fort as indicated
D. :eaching points
a. childHs post operative appearance
b. refer for needed resources
+. 6euroblasto"a
1. Pathophsiolog
a. solid tu"or found onl in children under four ears-old
b. pri"ar sites are adrenal gland or retroperitoneal because it starts
fro" e"bronic neural crest cells of the adrenal gland and
s"pathetic nervous sste".
c. often has "etastasi3ed b the ti"e it is diagnosed
#. +indings
a. fir") nontender "ass in the abdo"en that crosses the "idline
b. distant "etastasis "a cause periorbital ede"a 1s&elling around
ees2
*. :herapeutic "anage"ent
a. treat"ent is dependent on staging criteria
b. surgical debul%ing) che"otherap) radiation
G. 9ther tu"ors
8u""ar overvie& of other tu"ors in children:
H. 9steosarco"a
1. Pathophsiolog
a. originates fro" bone-for"ing "esench"e
b. creating "alignant osteoid tissue
c. "ost co""on in distal fe"ur
d. "etastasis to lung
#. +indings: locali3ed pain) li"p) decrease in phsical activit
*. Diagnostics: histor) phsical assess"ent) chest !-ra) @<I) C: scans)
and radioisotope bone scans
'. :herapeutic "anage"ent: surgical approach
a. li"b salvage &ith prosthetic bone replace"ent- or a"putation
b. plus co"bination che"otherap before and,or after surger
I. $&ing sarco"a
1. Pathophsiolog
a. arises not fro" osteoid tissue but in bone "arro& spaces
b. "ost co""on in shaft of fe"ur) tibia) hu"erus) scapula
c. "ore co""on in "ales
#. +indings: locali3ed pain) decrease in phsical activit
*. :herapeutic "anage"ent
a. intensive radiation therap of the "alignant bone
b. co"bined &ith che"otherap
c. surger not routinel reco""ended
E. <habdo"osarco"a
1. Pathophsiolog
a. soft tissue neoplas"
b. gro&s fro" undifferentiated "esench"al cells of s%eletal "uscle
c. "ost co""on in head and nec%) especiall the orbit
d. staging I-I;
e. highl "alignant- often "etastasi3ed &hen diagnosed
#. +indings
a. non-tender) fir" "ass
b. related to site of tu"or and co"pression of ad7acent organs
c. s"pto"s often vague) si"ilar to otitis "edia or /runn nose/
*. :herapeutic "anage"ent
a. high-dose irradiation of the pri"ar tu"or
b. co"bination che"otherap
c. surgical resection
4. <etinoblasto"a
1. Pathophsiolog: congenital "alignant tu"or of the retina) &ith evidence
of genetic inheritance in certain cases
#. +indings: cat0s ee refle! 1&hitish glo& in pupil2- strabis"us- red) painful
ee
*. Diagnostics: ophthal"oscopic e!a" under general anesthesia)
ultrasound and C: scan
'. @anage"ent
a. radiation therap) enucleation) che"otherap
b. treat"ent depends on stage of tu"or) stages I-;
?. 6ursing interventions
a. assess child for this &hen parents report a strange light in the
childHs ee
b. involve parents in care and teach about diagnostic procedures
D. :eaching points
a. de"onstrate positive aspects of prosthesis 5 sho& pictures of
other affected children after surger
b. genetic counseling for parents
;iral Infections
• ;iruses are parasites that cannot reproduce or "eet o&n "etabolic needs.
• 8%in cells react to virus &ith s&elling) /vesiculation)/ or proliferation) so"eti"es &arts.
• @ost viruses are associated &ith rashes 1characteristic of each disorder) such as
chic%en po!) rubella) roseola2
Pediatric 6eurolog
• Abnor"al posturing is an o"inous sign
• A positive .abins%i is nor"al in children until one ear of age
• @elini3ation continues until adolescence
• Abnor"al C8+ findings include: decreased glucose) positive culture) and cloud
appearance
• Due to phar"aco%inetics and dna"ics) co""on side effect of the "a7orit of anti-
convulsants include dro&siness) ata!ia) letharg) anore!ia) nausea. 8o"eti"es
dscrasias or liver da"age can occur- hence) these children need periodic tests of blood
and of liver en3"es.
• +ebrile sei3ures are generall a one-ti"e event) though there "a be a fa"ilial
predisposition.
• Children are "ore li%el than adults to have neuro"uscular or e!trapra"idal side
effects fro" pschotherapeutic drugs.
• Clinical effectiveness of anticonvulsants varies &ith the drug0s seru" level) "echanis"
of action) phar"aco%inetics and dna"ics. :he effects also "a var fro" child to child.
• A ne&born0s brain is about t&o-thirds the si3e of an adult0s) and reaches G(S adult si3e
in one ear.
• :he sudden appearance of a fi!ed or dilated pupil is an e"ergenc.
• :he progression fro" decorticate posture to decerebrate posturing) and then to flaccid
paralsis) indicates deterioration of neurologic function.
• Do not do an diagnostic tests that require head "ove"ent until cervical spine in7ur has
been ruled out.
• Children &ith congenital neurological disabilities &ill often develop co"plications in other
bod sste"s.
• Cerebral pals is a neuro"uscular disorder. It "a bring &ith it certain proble"s in
perception) language) and,or intellectual function.
• Acute bacterial "eningitis is a "edical e"ergenc) requiring s&ift action and treat"ent.
• :he care of the unconscious child focuses on respirator "anage"ent) neurological
assess"ent) "onitoring inta%e and output) providing appropriate "edications and
evaluating outco"es.
• :he pri"ar indicator of neurological status is =9C 1level of consciousness2.
• 8tatus epilepticus is an e"ergent situation.
• Do not restrain a child e!periencing a tonic-clonic sei3ure) and never place anthing in
the "outh.
• In head trau"a) the pri"ar "echanis" of in7ur is acceleration-deceleration accidents.
• .leeding fro" the nose or ears calls for evaluation.
Pediatric Cardiovascular
• In a cardiac histor) include poor &eight gain) chronic respirator infection) activit
intolerance) and fatigue during eating.
• 9!gen is a drug that requires a prescription and frequent "onitoring.
• Cardiac catheteri3ation serves "an purposes: diagnostic) interventional and
electrophsiologic. It also "onitors cardiac o!gen saturation) pressure changes and
anato"ic defects.
• CH+ signs usuall sho& either left or right sided heart disorders. :hese signs "a
include increased heart rate) adventitious lung sounds) canosis) ede"a)
hepatospleno"egal) and distended nec% veins.
• Acquired cardiac disorders include bacterial endocarditis) acute rheu"atic fever)
hperlipide"ia) 4a&asa%i disease) and cardio"opath.
• $lectrodes for cardiac "onitoring are usuall color coded: &hite 1upper right2) blac%
1upper left2) green 1lo&er right2) and red 1lo&er left2.
• In canotic heart disorders) "a7or concerns are polcthe"ia or increased he"oglobin
and he"atocrit. :hese can lead to thro"bus.
Pediatric <espirator
• :he principal functions of the respirator tract are to allo& air "ove"ent 1ventilation2 and
e!change 1diffusion2 of o!gen and carbon dio!ide.
• Children0s air&as are s"aller) "ore fle!ible and shorter than adult0s and are therefore
"ore prone to obstruction than adults.
• 8tridor usuall indicates an upper air&a concern) &hile &hee3ing indicates a lo&er
air&a disorder.
• Conditions that increase or decrease co"pliance and,or resistance &ill "a%e breathing
harder. 8igns of increased breathing &or% are tachpnea) retractions) abnor"al
positioning) shortness of breath and fatigue.
• <espirator rate is an i"portant indicator of respirator status.
• Central canosis in a ne&born usuall "eans severe hpo!ia and possible cardiac
etiolog.
• Acrocanosis is a co""on finding in a ne&born.
• Asth"a is not a disease but an infla""ator disorder.
• Asth"a is not &hee3 bronchitis.
• :he incidence and severit of respirator tract infections and disorders is related to the
child0s age) si3e) natural defenses) underling disorder and agent involved.
• $piglottitis) acute tracheitis and status asth"aticus are acute "edical e"ergencies.
• :he best &a to stop the spread of <8; is "eticulous hand &ashing. <8; is trans"itted
b direct contact &ith the fo"ite.
Pediatric $ndocrine
• :he bod secretes hor"ones at various ti"es during the da 1influences of diurnal and
circadian rhth"2.
• 6or"al hor"one levels are related to age and stage of pubert.
• :he pituitar gland sti"ulates target organs to produce specific hor"ones- &hen
sufficient) these in return signal pituitar to stop sti"ulation 1negative feedbac% loop2.
• >ntreated infant hpothroidis" &ill lead to "ental retardation.
• Associated ter"s for hpopituitar function include: short stature) constitutional dela)
d&arfis".
• A "a7or concern of precocious pubert is rapid bone gro&th) &hich can result in earl
fusion and short stature.
• Children &ith 8IADH develop an e!panded circulator volu"e but not ede"a.
• 9ral potassiu" tastes ver bitter) "i! it &ith a little strongl flavored fruit 7uice.
• +or a child &ith an endocrine disorder) never discontinue "edication abruptl.
• :he vast "a7orit of children &ith ne&-onset diabetes "ellitus tpe 1 [email protected] &ill
e!perience a /hone"oon/ period &hen their bodies secrete insulin and their need for
e!ogenous insulin decreases.
• .lood glucose "onitoring b finger-stic% reflects glucose currentl and for last several
hours- glcoslated he"oglobin levels indicate long-ter" co"pliance and true diabetic
status.
• 6ever free3e) heat or vigorousl sha%e insulin.
• Chen insulin is absent) the bod cannot properl "etaboli3e fats) proteins and
carbohdrates.
• :he focus of diabetic "anage"ent is the inter-relationship of diet) activit and insulin
ad"inistration.
Pediatric Gastrointestinal
• Infants and children have a "uch s"aller sto"ach capacit than adults.
• Peristaltic &aves "a reverse occasionall during infanc- gastric esophageal reflu! is
ver co""on in infants.
• 8ecretor cells don0t reach adult levels until t&o to three ears of age.
• :he GI tract has both inta%e 1fluid) "inerals) vita"ins) etc.2 and output functions.
• Chenever a ne&born coughs) cho%es and turns blue &ith feeding) suspect
tracheoesophageal fistula. :he * C0s - cough) cho%e) and canosis.
• An ne&born failing to pass "econiu" stool &ithin the first #' hours of life and &ho is
prone to constipation or decreased frequenc of stooling in the first "onth of life) should
be evaluated for Hirschsprung0s disease.
• :he treat"ent of "etabolic acid-base disturbance is oriented to&ard correcting the
underling proble".
• Dehdration can lead to shoc%.
• Dehdrated infants and children face greater "orbidit ris% than adults because children
differ in bod co"position and "etabolic rate) and their fluid-regulation sste"s have not
"atured.
• Potassiu" should onl be added to I; fluids &hen the urine output is sufficient.
• 9ne G" of diaper &eight N one cc of urine.
• Chen assessing diarrhea or constipation) re"e"ber the acron" ACC:: a"ount) color)
consistenc) and ti"e 1duration2.
• .ilious vo"iting indicates source belo& the a"pulla of ;ater.
Pediatric Genitourinar
• :he %idne0s function is to "aintain) in equilibriu") the co"position and volu"e of bod
fluids.
• 4idne function in an infant is nearl that of an adult b 1# "onths of age.
• Children &ith urine output less than one "l,4g,hour should be closel "onitored for
possible renal failure.
• Acute renal failure should be suspected in a child &ith decreased urine output) ede"a
and,or letharg) and &ho is dehdrated) recovering fro" surger or in shoc%.
• In "anaging H>8) the goals are to control he"atologic "anifestations and an renal
co"plications.
• >:I "anage"ent ai"s to eli"inate the underling cause) detect and correct
abnor"alities) and prevent recurrences.
• :he effects of hpo%ale"ia or hper%ale"ia can be devastating.
• >:Is are e!tre"el co""on in oung children) girls "ore than bos.
• In a child &ith a"biguous genitalia) the criterion for choice of gender and rearing is not
genetic se!) but the infant0s anato".
Pediatric @usculos%eletal
• 8ince "an "usculos%eletal disorders begin &ith trau"a) it is i"portant to assess A.C
1air&a) breathing and circulation2 first.
• 9pen fractures increase the ris% of infection.
• I""obili3ation has "ulti-sste" effects.
• +or a child &ith a fracture) it is i"portant to assess the five P0s of ische"ia:
1. Pain and point of tenderness
#. Pulse - distal to the facture
*. Pallor
'. Paresthesia
?. Paralsis
• Children &ith structural defects,disorders require regular follo&-up evaluation until the
reach s%eletal "aturit.
• Children in casts or traction need to be "onitored for alterations in s%in integrit
routinel.
• Children under one ear of age generall do not e!perience fractures.
• Children0s soft tissues are resilient) dislocation and sprains are less co""on.
Pediatric :e"perature-<elated
• :he e!tent of a burn in7ur is e!pressed as percentage of total bod surface area 1:.8A2
• :he larger the percentage of :.8A that is burned) the greater the ris% for burn shoc%.
• In "anaging alterations in s%in integrit) it is necessar to individuali3e the tpe of
treat"ent and "edications to the particular causative agent.
• If ou &ouldn0t put it into an ee) don0t put it into a &ound.
• Counds heal b the process of "oist &ound healing and occlusion.
• Dr &ounds do not heal.
• Cound debride"ent pro"otes healing and prevents infection.
• I""ediate care for a "a7or burn is A.C: air&a establish"ent and patenc) breathing
and absence of respirator distress) and circulation &ith fluid initiation.
• Potassiu" should not be ad"inistered during the initial oliguric phase of a burn in7ur)
but should be added &hen diuresis occurs.
Pediatric He"atolog
• +or a child &ith altered platelet function or bleeding disorder) do not ad"inister
acetlsaliclic acid 1aspirin) A8A2 or ta%e rectal te"peratures. Perfor" invasive
procedures ver cautiousl.
• Children &ith lo& C.C "a not e!hibit co""on findings of infection such as purulent
drainage. In a febrile client &ith granuloctopenia) give antibiotics i""ediatel because
this child ris%s rapid) over&hel"ing sepsis.
• @orphine is the "edication 1or opioid2 of choice for pain in children &ith sic%le cell
disease.
Pediatric 9ncolog
• +indings of pediatric "alignancies var according to the child0s age) location and tpe of
tu"or) and e!tent of disease
• Cure rate is i"proving for "ost tpes of pediatric "alignancies- ho&ever the late effects
of treat"ent are of increasing concern and incidence.
• Children tpicall have longer treat"ent plans than adults due to their increased
"etabolic rate and rate of cell turnover.
• =eu%e"ia affects not onl the blood) but can "etastasi3e to "a7or organ sste"s
1e!tra"edullar disease2) including the central nervous sste".
• 6ursing care includes "onitoring the child for the develop"ent of acute co"plications of
treat"ent including fever) bleeding) and ane"ia.
• Pediatric oncologic e"ergencies include: acute tu"or lsis sndro"e) superior vena
cava sndro"e) septic shoc%.

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