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1. Acyanotic diseases
• Pulmonary circulation and systemic circulation are not connected
• If there is a connection, the pressure is higher in the left side than in the
right side
TETRALOGY OF FALLOT
1. VSD
2. Overriding of the aorta
3. Pulmonary valve stenosis
4. Enlarged right ventricular wall
Assessment:
• Primary sign – cyanosis
• Hypoxic spells – usually initiated by crying
• Fainting – due to cerebral hypoxia
• Stunted growth, clubbed fingers and toes
• Squatting position – characteristic position to relieve dyspnea
Implementation
• Decrease hypoxic spells – do not permit child to cry
• Place in knee chest position
• O2 as needed
Assessment:
• cyanotic at birth
• develop polycythemia à risk for emboli and thromboses
• may develop CHF or pulmonary vascular obstructive
Implementation:
• require emergency medical treatment
• cardiac catheterization
• ballool atrial septostomy
TRICUSPID ATRESIA
• condition in which tricuspid valve did not form
• no opening between the right atrium and right ventricle
• 2% of congenital heart defects
• profound cyanosis and dyspnea at birth
• emergency catheterization with balloon atrial septotomy
TRUNCUS ARTERIOSUS
• single vessel arising from the ventricles just above a large VSD
• retarded growth; enlarged liver and heart
• usually infants die within the first year
CARDIOVASCULAR DEFECTS
• Monitor vital signs closely
• Monitor respiratory status
• Auscultate breath sounds for crackles, ronchi or rales
• if respiratory effort is increased, place child in reverse Trendelenburg
position
• administer humidified oxygen
• Monitor for hypercyanotic spells:
1. Place infant in a knee chest position
2. Administer 100% oxygen by mask
3. Administer morphine as ordered
4. IVF as prescribed
CARDIAC SURGERY
Postoperatively:
• monitor for signs of discomfort
• monitor for signs of sepsis (fever, lethargy, diaphoresis, altered LOC)
• Monitor lines, tubes or catheters ; remove promptly
• administer pain medications; note effectiveness
• encourage rest periods
• facilitate parent-child contact as soon as possible
Home Care
• omit activities in which child could fall for 2-4 weeks
• avoid crowds for 2 weeks after discharge
• no added salt diet
• do not put creams, lotions or powders on the incision site
• child may return to school 3rd week after discharge
• no physical education for 2 months
• follow up after 2 weeks
• avoid immunizations, invasive procedure and dental visits for 2 months
• advise parents regarding importance of dental visit every 6 months
• inform dentist of cardiac problem
• instruct parents to call MD if with coughing, tachypnea, cyanosis,
diarrhea
Assessment:
• tachycardia
• tachypnea
• profuse scalp sweating especially in infants
• fatigue and irritability
• sudden weight gain
• respiratory distress
Implementation:
• monitor vital signs closely and for early signs of CHF
• monitor for respiratory distress
• monitor I and O; weigh diapers
• Monitor daily weight to assess for fluid retention; weight gain of 0.5 kg
( 1 lb /day)
• monitor for facial or peripheral edema , auscultate lung sounds
• elevate HOB
• maintain neutral thermal environment to prevent cold stress in infants
• administer cool, humidified oxygen
• organize nursing activities to allow uninterrupted sleep
• maintain adequate nutritional status
• provide rest; decrease environmental stimuli
• feed when hungry and soon after awakening
• infant should be well rested before feeding
• provide small, frequent feedings
• administer sedation
• administer digoxin
• check with physician parameters for witholding digoxin
• Note that infants rarely receive more than 1 mL (50 ug or 0.05 mg) of
digoxin
• Administer diuretics; monitor for hypokalemia
• administer potassium supplements
• monitor serum electrolytes
• restrict fluid in acute stages
• check with physician regarding sodium restriction; infant formulas have
slightly
more sodium than does breast milk
RHEUMATIC FEVER
• an inflammatory autoimmune disease
• affects connective tissue of the heart, joints, subcutaneous tissues and
blood vessels of the CNS
• most serious complication – RHD affecting the cardiac valves
• presents 2-6 weeks following an untreated Group A beta hemolytic strep
• Jones criteria
Asssessment:
• signs of carditis: SOB, edema of the face, abdomen or ankles, precordial
pain
• signs of polyarthritis: edema, inflammation of the large joints, joint pain
• erythema marginatum: macular rash on trunk and extremities
• subcutaneous nodules
• fever
• elevated ASO
• elevated ESR
• elevated CRP
Implementation:
• Assess vital signs
• Control joint pain and inflammation with massage
• Febrile phase – provide bed rest
• limit physical exercise in child with carditis
• Administer antibiotics (penicillin) as prescribed
• administer salicylates and anti-inflammatory agents
• Instruct parents about the importance of follow up and need for
antibiotic prophylaxis for dental work, infection, invasive procedures
• advise child to inform the parents if anyone in school develops a
strep throat infection
KAWASAKI DISEASE
• known as mucocutaneous lymph node syndrome
• acute systemic inflammatory illness
• unknown cause
• cardiac involvement – most serious complication
Assessment:
• fever
• conjunctival injection
• red throat
• Swollen hands, rash, enlargement of the cervical lymph nodes
Implementation:
• monitor temperature frequently
• assess heart sounds and rhythm
• assess extremities for edema, redness, desquamation
• monitor mucus membrane for inflammation
• weigh daily
• administer IV immune globulin
• instruct parents in the administration of prescribed meds
aspirin – need to monitor bleeding
GASTROINTESTINAL SYSTEM
Assessment:
• Presenting problem
a. Vomiting
b. Abnormal bowel habits: diarrhea, constipation, bleeding
c. Weight loss, failure to thrive
d. Pain
• Nutritional history
Physical Examination:
• General appearance:
a. Height and weight
b. Measure mid arm circumference
c. Observe color: jaundice
• Mouth: dentition
• Abdomen
a. Skin integrity
b. Abdominal distension; visible peristaltic waves
c. Inspect for hernias
d. Auscultate bowel sounds ( every 10-30 seconds)
e. Palpate for tenderness
f. Liver span (inferior edge palpated 1-2 cm below RCM)
g. Spleen (felt on inspiration 1-2 cm below left costal margin)
DENTAL CARIES
• erosion of the enamel and dentine of teeth
• results from combination of fermenting sugars and starched
and acid forming organisms
Prevention:
• dental hygiene
• regular dental hygiene
• good nutrition
• fluoridation
• 1 in 1000 births
• multifactorial
• common among children with chromosomal abnormalities
• results from failure of the embryonic structures of the face to unite
• may occur separately or may combine to produce a single unilateral
or bilateral cleft from the lip through the soft palate
• interfere with the child’s capacity to meet oxygenation and
nutritional needs
• may seriously hamper normal bonding process of children with parents
Assessment:
• facial abnormality visible at birth
- cleft lip or palate or both, unilateral or bilateral
• difficulty sucking
• inability to form airtight seal around nipple
• formula/milk escapes through nose in infants with cleft palate
• predispose to infection – communication between mouth and nose
• difficulty swallowing
• abdominal distension – air swallowing
Management:
• team approach
• otolaryngologist, audiologist, pediatrician, dentist, orthodontist, speech
therapist
• Surgical correction:
• early correction – prevent speech defects
Cheiloplasty
• correction of cleft lip
• unite edges to allow lips to be both functional; aesthetic reasons
• performed usually at age 2 months
NURSING INTERVENTION:
Esophageal atresia
• congenital defect; upper segment of the esophagus ends in a blind
pouch
TEF
• defect in which embryonic structures fail to divide into a separate
esophagus and trachea
• opening between the two structures
• usually occur together
Assessment:
• copious oral and nasal secretions –first sign of a defect
• choke or cough
• when suctioning or gavage is attempted – catheter cannot pass
into stomach
Nursing intervention:
• provide nutrition
1. Provide gastrostomy tube feeding until anastomosis site has healed
2. start oral feedings when infant can swallow well
• promote respiratory function
1. position properly
PYLORIC STENOSIS
• narrowing of the outlet of the stomach
• caused by excessive growth of circular muscles that surrounds the
pylorus
• hypertrophy develops over 4-6 weeks of life when symptoms begin to
appear
• more common in Caucasian; first born, full term boys
Assessment:
• olive size bulge under right rib cage
• vomiting – projectile; non bilous
• peristaltic waves during and after feeding
• failure to thrive
• dehydration
• diagnostic tests:
a. UGIS – narrowing of diameter of pylorus
b. Decreased serum Na, K, Cl
c. Increased Hct
d. Metabolic alkalosis
Nursing intervention: Preop
• replace fluids and electrolytes
• prevent vomiting
1. Give thickened feedings
2. High Fowler’s
3. Place on right side after feeding
4. Minimize handling
5. Strict I and O, daily weights, urine sp gravity
INTUSSUSCEPTION
• telescoping of bowel into itself
• ileocecal region
• edema, necrosis of bowel, obstruction
• most common at age 6 months
• more in boys than in girls
• associated with cystic fibrosis
Assessment:
• piercing cry
• severe abdominal pain (pulls leg up)
• vomiting of bile stained fluid
• bloody mucus in stool
• “currant jelly” stool
Management:
1. barium enema
2. surgery
Nursing Intervention:
1. provide routine pre and post op care
2. monitor for peritonitis
HIRSCHSPRUNG’S DISEASE
• absence of autonomic parasympathetic ganglion cells in large intestines
• results in decreased motility in that portion of the colon and signs of
functional obstruction
Assessment:
• failure or delay in passing meconium
• abdominal distension
• failure to pass stool
• temporary relief following rectal exam
• loose stools – only liquid can pass thru
• ribbon like stools
• nausea, anorexia, fecal vomiting
• weight loss, failure to grow
• volvulus – bowel twists upon itself
• diagnostic tests: rectal biopsy – confirms presence of aganglionic cells
•
Nursing intervention:
• enema as ordered
A. Mineral oil or isotonic saline
B. Do not use water or soap suds – water intoxication
C. Use volume appropriate to weight of child
infants – 150-200ml
children – 250-500 ml
• administer TPN as ordered
• Provide low residue diet
• provide client teaching and discharge teaching
• Colostomy care
• Low residue diet
IMPERFORATE ANUS
• during embryonic life – membrane that separates the rectum and anus is
absorbed
• absorption fails to occur -> imperforate anus
• anus appear as a dimple
• fistula may be present – rectovaginal, rectourethral
Assessment:
• inspection of anus, check rectum for patency
• insert rectal thermometer
• absence of stool during 1st 24 hours
• development of a distended abdomen
Intervention:
• surgery
anoplasty – if possible
temporary colostomy
• if with distension – nasogastric suction
Nursing intervention:
• keep operative site clean
• observe infant for signs of hypovolemic shock and infection
• if anoplasty heals – regular dilatation of anus to prevent stricture
• colostomy care
a. Kept clean
b. zinc oxide
• after surgery – side lying or prone with hips elevated
CELIAC DISEASE
• malabsorption syndrome characterized by intolerance of gluten,
found in rye, oats, wheat and barley
• familial disease
• more common in Caucasians
• cause unknown
• flat mucosal surface and atrophy of villi of the intestine
• reduced absorptive surface -> marked malabsorption of fats
Assessment:
• steatorrhea
• chronic diarrhea
• failure to thrive
• distended abdomen
• abdominal pain, irritability, listlessness, vomiting
• symptoms of ADEK deficiency
• diagnostic tests:
• 1. pancreatic enzymes
• 2. jejunal or duodenal biopsies
Management:
• diet therapy
• gluten free diet
• TPN in children
Nursing Intervention:
• gluten free diet (BROW – Barley, Rye, Oatmeal, Wheat)
• supplemental fat soluble vitamins
• client teaching
• 1. gluten free diet
• 2. importance of reading the label
• 3. avoidance of infection
• 4. adhering to diet even if symptoms are controlled
• 5. importance of long term follow up
APPENDICITIS
• inflammation of the appendix
• ischemia, gangrene, rupture, peritonitis – if untreated
• school age children – most common
• due to mechanical obstruction or anatomic defects
Assessment:
• diffuse pain à RLQ
• nausea, vomiting
• guarding of abdomen
• rebound tenderness
• decreased bowel sounds
• fever
• diagnostic tests:
1. CBC
2. elevated acetone in urine
Nursing Intervention:
• antibiotics/ antipyretics as ordered
• no enemas
• no heating pads
• routine preop care
• post op care:
1. semi-Fowler’s position
2. Monitor NGT
3. Monitor penrose drains
PARASITISM
• roundworms, pinworms
Assessment:
• pinworms – anal itching, disturbed sleep
• roundworms – colic , abdominal pain, lack of appetite, weight loss
Nursing intervention:
• obtain stool culture
• observe all excreta for worms
• Scoth tape swab
• instruct parents to change clothing, bed linens, towels and launder in hot
water
• instruct all family members to scrub hands and fingernails prior to eating
and after using toilet
DIABETES MELLITUS
• most common endocrine disease of children
• onset maybe any age
• type 1 IDDM
• risk of complication is high – retinopathy, neuropathy, nephropathy,
skin changes, predisposition to infection
Assessment:
• rapid onset
• polyuria, polydipsia, polyphagia, fatigue
• weight loss
• ketoacidosis
-Dry flushed skin
Management:
• insulin
• diet therapy
• exercise
• prevention of complications
Nursing intervention:
• administer insulin as ordered
• force fluids without sugar
• monitor blood glucose levels daily
• observe for hypoglycemia: behavior changes, sweating
• provide client teaching
a. Daily regimen for home care
b. Urine and blood glucose monitoring
c. Nutrition management
d. Effects of infection and exercise on CHO metabolism
e. Prevention of acute and chronic complications
RESPIRATORY SYSTEM
EPIGLOTTITIS
• inflammation of the epiglottis
• H. influenzae Type b ; Strep pneumoniae
• age 2-5
• abrupt onset; winter
• considered an emergency situation
Assessment:
• fever
• sore, red and inflamed throat
• drooling, difficulty of swallowing
• inspiratory stridor
• muffled voice
• nasal flaring
Implementation
• maintain patent airway
• assess respiratory status and breath sounds
• use of accessory muscles; presence of stridor
• assess temperature
• do not attempt to visualize the posterior pharynx or obtain throat culture
• lateral neck film
• do not force child to lie down
• do not restrain
• administer antibiotics; IV fluids
• cool mist oxygen
• high humidification
• have resuscitation equipment available
• immunization
LARYNGOTRACHEOBRONCHITIS (LTB)
• inflammation of the larynx, trachea, bronchi
• most common type of croup; maybe viral or bacterial
• parainfluenza virus
• gradual onset ; preceded by URI
Assessment:
• fever
• irritability and restlessness
• hoarse voice
• inspiratory stridor and suprasternal retractions
• crackles and wheezing
• cyanosis
Implementation:
• patent airway
• vital signs
• elevate HOB
• humidified oxygen; IVF
• nebulized epinephrine
• resuscitation equipments available
BRONCHITIS
• infection of the major bronchi
• assessment: cough, worse at night; becomes productive in 2-3 days
• Implementation:
1. Monitor for respiratory distress
2. Increased fluid intake
3. Acetaminophen
PNEUMONIA
• inflammation of the alveoli
• inhalation of causative agent à bloodstream
• Primary atypical pneumonia – most common cause of pneumonia
between 5-12 years
Implementation:
• antimicrobial therapy
• oxygen
• cool humidification
• encourage child to lie on the affected side
• isolation procedures as needed
• antipyretics
• IVF; liberal fluid intake
ASTHMA
• chronic inflammatory disease of airways
• commonly caused by physical and chemical irritants common symptoms
– coughing in the absence of respiratory infection,
especially at night
Assessment:
• episodes of wheezing, breathlessness, dyspnea, chest tightness
• SOB, cough, wheezing
• child speaks in short, broken phrases
• retractions
• exercise induced bronchospasm
• severe spasm or obstruction
Implementation
• continuously monitor respiratory status
• administer quick-relief (rescue) medication
• initiate an IV line; prepare to correct dehydration, acidosis or electrolyte
imbalance
Medications
1. Quick relief
• To treat symptoms and exacerbations
• Short acting b2 agonists
• Anticholinergics – for relief of acute bronchospasm (ipratropium bromide)
2. Long term control
• Corticosteroids
• Long acting b2 agonist
• Long acting bronchodilator
3. Nebulizer, MDI
• Used to deliver many medications
• Non-CFC (chlorofluorocarbon) – albuterol
4. Chest physiotherapy
• Includes breathing exercises
OTITIS MEDIA
• Infection of the middle ear occuring as a result of a blocked eustachian
tube, preventing normal drainage
• common complication of ARI
• infants and children more prone – ET shorter, wider, straighter
Assessment:
• fever
• irritability and restlessness
• rolling of head from side to side
• pulling or rubbing the ear
• earache; signs of hearing loss
• purulent ear discharge
• otoscopic exam
Intervention
• Encourage fluids
• upright position when feeding
• avoid chewing – increases pain
• have the child lie with the affected ear down
• instruct on appropriate technique to clean drainage from the ear with
sterile cotton swabs
• administer analgesics and antibiotics (10-14 days)
• screening for hearing loss
• otic medications
1. If younger than age 3 – auditory canal is straightened by pulling the pinna
down and back
2. If older than 3 years – pull pinna up and back
Myringotomy
• Insertion of tympanoplasty tubes into the middle ear to equalize pressure
and keep ear aerated
• Keep ears dry
• Earplugs should be worn during bathing, shampooing, swimming
Preop:
• assess for presence of infection
• assess bleeding and clotting studies
• assess for loose teeth
• prepare the child for a sore throat
Postoperatively:
HEMATOLOGIC SYSTEM
Etiology:
1. Environmental
2. Viruses
3. Familial/genetic
4. Host factors
STAGES OF TREATMENT
1. INDUCTION
• Goal: to remove bulk of tumor
• Methods: surgery, radiotherapy, chemotherapy, BM transplant
• Effects: often the most intensive phase
• Side effects are potentially life threatening
2. CONSOLIDATION
• Goal: to eliminated any remaining malignant cells
• Methods: chemo/radio
• Side effects will still be evident
3. MAINTENANCE
• Goal: to keep the child disease free
• Chemotherapy
• This phase may last several years
4. OBSERVATION
• Goal: to monitor the child at intervals for evidence of recurrent
disease and complications of treatment
• Method: treatment is complete
• Child may continue in this stage indefinitely
4. Nutrition deficits
• Establish baseline
• Provide high calorie, high protein
5. Developmental delay
• Facilitate return to school as soon as possible
• Discuss limit setting, discipline
LEUKEMIA
• most common form of childhood cancer
• peak 3-5 years
• proliferation of abnormal wbc that do not mature beyond the blast phase
• blast cells – infiltrate other organs – liver, spleen, lymph tissue
Types:
1. Acute Lymphocytic leukemia (ALL)
• 80-85%
• Acute
• 75% chance of surviving
Management:
1. diagnosis: blood studies, BMA
2. Treatment stages
a. Induction
b. CNS prophylaxis
c. Maintenance
Nursing Intervention:
1. Provide care for the child receiving chemo and radiotherapy
2. Provide support for the family/child
3. Support child during painful procedures
a. Use distraction, guided imagery
b. Allow the child to retain as much control as possible
c. Administer sedation prior to procedure as ordered
Assessment:
1. Vaso-occlusive crisis
• Most common type of crisis
• Caused by stasis of blood with clumping of the
cells in microcirculation, ischemia and infraction
• Fever, pain and tissue engorgement
2. Splenic sequestration
• Pooling of blood in the spleen
• Profound anemia, hypovolemia, shock
3. Aplastic crisis
• Caused by the diminished production and increased destruction of RBCs,
triggered by viral infection or the depletion of folic acid
• Profound anemia and pallor
Implementation:
• Administer oxygen and blood transfusions
• administer analgesics
• maintain adequate hydration and blood flow with IV normal saline as
prescribed and with oral
fluids
• Assist the child to assume a comfortable position so that the child keeps
the extremities extended
to bed no more than 30 degrees
• avoid putting strain on painful joints
• encourage consumption of a high calorie, high protein diet with folic acid
supplementation
• administer antibiotics as prescribed
• Monitor for signs of increasing anemia and shock (pallor, vital sign
changes)
Assessment:
• pallor
• weakness and fatigue
• irritability
Implementation:
• Increase the oral intake of iron
• Instruct the child and parents in food choices that are high in iron
• Administer iron supplements as prescribed
• Liquid iron prep stains – stains teeth; with straw
• side effects of iron therapy
APLASTIC ANEMIA
• a deficiency of circulating erythrocytes resulting from the arrested
development of RBCs within the bone marrow
• causes: exposure to toxic agents, viruses, infection, autoimmune
disorders, allergic states
• definitive diagnosis: BMA
• Therapeutic management: blood transfusions, splenectomy,
corticosteroids, immunosuppressive therapy, bone marrow transplantation
Assessment
• Pancytopenia
• Petecchiae, purpura, bleeding, pallor, weakness, tachycardia and
fatigue
Implementation:
• Blood transfusion
• corticosteroids and immunosuppresives
• splenectomy
• bone marrow transplant
• Medic Alert bracelet
HEMOPHILIA
• x linked recessive trait
• Hemophilia A – deficiency of Factor VIII
• Hemophilia B – deficiency of factor IX
• Males inherit hemophilia from their mothers and females inherit the
carrier status from their
fathers
Assessment:
• prolonged bleeding after minor injury
1. At birth after cutting cord
2. Following circumcision
3. Following IM immunization
4. Increase bruising as child learns to crawl and walk
• abnormal bleeding in response to trauma
• joint bleeding – pain, tenderness, swelling limited range of motion
• tendency to bruise easily
• prolonged PTT
• normal BT, PT, platelet count
Implementation:
• prepare to administer Factor VIII concentrate /cryoprecipitate
a. Thaw slowly
b. Gently rotate bottle
c. Infuse immediately; deteriorates at room temperature
• monitor for bleeding
• monitor for joint pain; immobilize the affected extremity if joint pain
occurs
• assess neurological status ( child at risk for IC bleed)
• monitor urine for hematuria
• Control bleeding by immobilization, elevation, application of ice; apply
pressure (15 mins)
for superficial bleeding
• instruct parents regarding activities of the child
• avoidance of contact sports
Assessment:
• severe anemia
• pallor
• failure to thrive
• hepatosplenomegaly
• microcytic, hypochromic RBCs
Implementation
• Instruct the administration of folic acid (Vit B9)
• administer blood transfusion as prescribed
• Monitor for iron overload
• iron overload – chelation therapy with deferoxamine
• genetic counseling
Assessment:
• petechiae: spider web appearance of bleeding under the skin due to
small size of platelets
• ecchymosis
• blood in any body secretions, bleeding from mucus membranes,
nosebleeds
• diagnostic test: platelet count decreases, anemia
Management:
• steroids and immunosuppressives
• platelet transfusion
• surgery; splenectomy
Nursing Intervention
• control bleeding
1. Administer platelet transfusion as ordered
2. Apply pressure to bleeding sites as needed
3. Position bleeding part above heart level if possible
• Prevent bruising
• Protect from infection
• Measure normal circumference of extremities for baseline
• Administer meds orally, rectally or IV rather than IM; hold pressure on site
for 5 mins
• Avoid aspirin
• Provide client teaching and discharge planning
1. Pad crib and playpen
2. Provide soft toys
3. Provide protective headgear during toddlerhood
4. Use soft toothbrush
5. Avoid contact sports
INTEGUMENTARY SYSTEM
ECZEMA
• atopic dermatitis - often the first sign of an allergic predisposition in a
child
• usually manifests during infancy
Asssessment:
• erythema, weeping vesicles that rupture and crusts
• severe pruritus; scratching causes thickening and darkening
• dry skin, sometimes urticaria
Intervention:
• topical steroids
• antihistamines
• coal tar preparation
• colloid baths
• diet therapy: elimination of offending food
Nursing Intervention:
• avoid heat and prevent sweating
• check materials in contact with child’s skin (sheets, lotions, soap)
• avoid frequent baths
• avoid use of soap
• provide lubricant immediately after bath
• administer topical steroids as ordered
• use cotton instead of wool
• keep child’s nails short; use elbow or glove restraints if needed
• apply wet saline or Burrow’s solution compresses
DIAPER RASH
• contact dermatitis
• plastic/rubber pants and linings of disposable diapers
exacerbate the condition by prolonging contact with
moist, warm environment
• skin further irritated by acidic urine
Assessment:
• erythema/excoriation in the perineal area
• irritability
Nursing intervention:
• keep area clean and dry; clean with mild soap and water after each stool
and soon as child urinates
• take off diaper and expose area to air during the day
• client teaching:
1. Proper hygiene
2. Avoid use of plastic pants or disposable diapers with a plastic lining
3. Avoid commercially prepared diaper wipes containing alcohols
4. Avoid cornstarch; good medium for bacteria
MUSCULOSKELETAL SYSTEM
Assessment:
• maybe unilateral or bilateral
• limitation of abduction (cannot spread legs to change diaper)
• Ortolani’s click
a. With an infant supine, bend knees and place thumb on bent knees,
fingers at hip joint
b. Bring femur 90degrees to hip, then abduct
c. Palpable click – dislocation
• Barlow’s test
a. With infant on back, bend knees
b. Affected knee will be lower because the head of the femur dislocates
towards the bed of gravity
• additional skin folds with knees bent
• when lying on abdomen, buttocks of affected side will be flatter
• Trendelenburg test – if child can walk
a. Have child stand on affected leg only
b. Pelvis will dip on normal side as child attempts to stay erect
Management:
• Goal : to enlarge and deepen the socket
• Early treatment: positioning the hip in abduction with the head of the
femur in the acetabulum and maintaining it in position for several months
• Traction and casting (hip spica)
• Surgery
Nursing intervention:
• Maintain proper positioning: keep legs abducted
1. Use triple diapering
2. Use Frejka pillow splint (jumperlike suit to keep legs abducted)
3. Place infant on abdomen with legs in “frog” position
4. Use immobilization devices
• Provide adequate nutrition
• Provide sensory stimulation
• Client teaching and discharge planning:
CLUBFOOT (Talipes)
• abnormal rotation of foot at ankle
Varus – inward rotation; bottom of feet face each other
Valgus – outward rotation
Calcaneous – upward rotation; would walk on heels
Equinas – downward rotation; would walk on toes
Most common – talipes equinovarus
Assessment:
• foot cannot be manipulated by passive exercises into correct position
Management:
• exercises
• casting
• Denis Browne splint (bar shoe)
• surgery and casting
Nursing Intervention:
• perform exercises as ordered
• provide cast care
• child who is learning to walk must be prevented from trying to stand;
apply restraints if necessary
• provide diversional activities
• provide skin care
• client teaching
SCOLIOSIS
• lateral curvature of the spine
• most commonly in adolescent girls
• familial pattern; associated with other nueromuscular condition
• idiopathic majority
Assessment:
• failure of curve to straighten when child bends forward with knees
straight and arms hanging down feet
• uneven bra strap marks
• uneven hips
• uneven shoulders
• asymmetry of rib cage
• xray: reveals curvature
Management:
• stretching exercises
• Milwaukee brace – worn 23 hours/day for 3 years
• plaster jacket vest
• spinal fusion
•
Nursing Intervention:
• teach/encourage exercise
• provide care for the child with Milwaukee brace
a. Child wears brace 23 hours/day
b. Monitor pressure points
c. Promote positive body image with brace
• Provide cast care
• Assist with modifying clothing for immobilization devices
• Adjust diet with decreased activity
• Provide client teaching and discharge instructions
a. Exercise
b. Cast care
c. Correct body mechanics
d. Alternative education for long term hospitalization
e. Availability of community agencies
JUVENILE RHEUMATOID ARTHRITIS
• systemic, chronic disorder of connective tissue
• autoimmune reaction
• results from eventual joint destruction
• affected by stress, climate and genetics
Types:
1. Monoarticular JRA
• Fewer than 4 joints involved (usually legs)
• Asymmetric
• Good prognosis
• Mild signs of arthritis
2. Polyarticular JRA
• Multiple joints affected
• Symmetrical
• Involvement of TMJ
• Remissions and exacerbations
• poor prognosis
3. Systemic disease with polyarthritis (Still’s disease)
• Fever, rash, LADP, anorexia, weight loss
• Exacerbations and remissions
Assessment:
• No specific diagnostic tests
• ESR, ASO, RF- not specific
Intervention
• Drugs: ASA, corticosteroids
• NSAIDS
• Physical therapy – strengthening muscles, preventing deformities
• Splints – used for knees, wrists and hands – to reduce pain and prevent
or reduce flexion deformities
Nursing intervention:
GENITOURINARY SYSTEM
Assessment:
• unable to palpate testes in scrotal sac
Management:
• if testes remains in abdomen, damage to testes is possible because of
increased
• chorionic gonadotropin
• orchipexy: surgical procedure to retrieve and secure testes placement;
performed between ages 1-3 yrs
Nursing Management:
• provide treatment options
• support parents if surgery will be done
• post op: avoid disturbing the tension mechanism
• avoid contamination of incision
HYPOSPADIAS
• urethral opening located anywhere along the ventral surface of penis
Assessment:
• urinary meatus misplaced
• inability to make straight stream of urine
Management:
• minimal defects – no intervention
• neonatal circumcision delayed, tissue maybe needed for corrective repair
• surgery at age 3-9 months
Nursing Intervention:
• diaper normally
• provide support for parents
• post op: check pressure pressure dressing
• monitor catheter drainage
PHIMOSIS
• an abnormal narrowing of the foreskin so that it cannot be retracted over
the glans penis
• may be present at birth or may develop as a result of poor hygiene with
accumulation of smegma
Management:
• Prevention – regular pulling the foreskin back and cleaning
• circumcision
Nursing intervention:
• circumcision care:
1. Close observation for bleeding
2. Ice application
3. Administration of analgesics
ENURESIS
• involuntary passage of urine after the age of control is expected (4 years)
• types:
1. Primary – in children who have never achieved control
2. Secondary: in children who have developed complete
control
• May occur anytime but most frequent at night
• More common in boys
• No organic cause
• Etiologic possibilities:
1. Sleep disturbances
2. Delayed neurologic development
3. Immature development of bladder
4. Psychologic problems
Assessment:
• PE normal
• History of repeated voluntary urination management:
• bladder retention exercises
• drug therapy
1. TCA – imipramine
2. Anticholinergics
Nursing Intervention:
• Provide information/counseling to family:
1. Confirm that this not conscious behavior and that the child is not
purposely misbehaving
2. Assure parents that they are not responsible and that this is a relatively
common problem
• Involve child in care; give praises and support with small accomplishments
1. Age 5-6 years – can strip wet beddings
2. Age 10-12 years – can do laundry and change bed
• Avoid scolding and belittling the child
Assessment:
• Associated structural changes
1. Prolapsed rectum
2. Inguinal hernia
3. Widely split symphysis
4. Rotated hips
• Associated anomalies
1. Epispadias
2. Cleft scrotum or clitoris
3. Undescended testes
4. Chordee (downward deflection of the penis)
Management:
• reconstructive surgery
• urinary diversion
• delayed until 3-6 months
Postop:
• Design play activities to foster toddler’s need for autonomy
- child will be immobilized for extended period of time
• Prevent trauma; as child gets older and more mobile,
trauma is more likely
NEPHROTIC SYNDROME
• autoimmune process
• structural alteration of glomerular membrane
• results in increased permeabilityb to plasma proteins
• course: exacerbations and remissions over a period of months to years
• commonly affects preschoolers; boys>girls
Assessment:
1. Proteinuria
2. Hypoproteinemia
3. Hyperlipidemia
4. Dependent edema
• Puffiness around the eyes in morning
• Ascites
• Scrotal edema
• Ankle edema
5. anorexia, vomiting, diarrhea
6. Pallor, lethargy
7. Hepatomegaly
Management:
• drug therapy
1. Corticosteroids
2. Antibiotics
3. Thiazide diuretics
Nursing Intervention:
• Provide bed rest
1. Conserve energy
2. Find activities for quiet play
ACUTE GLOMERULONEPHRITIS
• immune complex disease
• beta hemolytic strep
• More frequently in boys; 6-7 years
• resolves in 14 days
• self limiting
Assessment:
1. History of strep infection (URTI or impetigo)
2. Edema, anorexia, lethargy
3. Hematuria or dark colored urine
4. Fever
5. Hypertension
6. Diagnostic tests:
• Urinalysis – rbc,wbc,protein, cellular casts
• Urine specific gravity increased
• BUN, crea increased
• ESR elevated
• Hgb, Hct decreased
Management:
• antibiotics
• Antihypertensives
• digitalis – if with CHF
• fluid restriction
• peritoneal dialysis – if severe renal complication occurs
Nursing Management:
1. Monitor I and O, BP
2. Weigh daily
3. Provide diversional activity
4. Provide client teaching and discharge planning
• Medication administration
• Prevention of infection
• Signs of renal complications
• Importance of long term follow up
Cranial Defects:
1. Craniosynostosis
• one or more of the sutures close too soon
• ICP increases; interfeeres with normal brain growth à MR
Assessment:
• suture lines of the skull manually palpated
• Radiographs are made to confirm
2. Microcephaly
• The brain fails to grow
• May be due to a chromosomal defect or from drugs, toxins or radiation
• MR
3. Hydrocephalus
• Imbalance of CSF absorption or production
• caused by malformations, tumors, hemorrhage, infection, trauma
Types:
1. Communicating – impaired absorption within arachnoid space
2. Non-communicating – obstruction of CSF flow within the ventricular
system
Assessment:
• Infant – increased HC
• Macewen’s sign – cracked-pot sound on percussion of bones of head
• Anterior fontanel tense, bulging
• Scalp veins dilated
• Frontal bossing, sunsetting eyes
• Child – behavior changes
• Headache, nausea and vomiting
• Ataxia, nystagmus
1. VP Shunt – CSF drains into the peritoneal cavity from the lateral ventricle
2. AV shunt – CSF drains into the right atrium
PostOP Care:
1. Keep child flat as prescribed – to avoid rapid reduction of intracranial fluid
2. Observe increase ICP – if present, elevate HOB 15-30 deg
3. Monitor for infection
4. Measure HC
5. Monitor I and O
6. Provide comfort measures; administer medications (diuretics, antibiotics,
or anticonvulsants)
7. Toddler – headache and anorexia à earliest common signs of shunt
malfunction
SPINA BIFIDA
• CNS defect that occurs as a result of neural tube failure to
close during embryonic development
• defect closure usually done during infancy
Types:
1. Spina bifida occulta
• Posterior vertebral arches fail to close in the lumbosacral area
• Spinal cord intact; not visible
• Meninges not exposed on the skin surfaces
2. Meningocoele
• Protrusion involves meninges and a sac-like cyst
• Lumbosacral area
3. Myelomeningocoele
• Protrusion of meninges, CSF, nerve roots, portion of spinal cord
• Sac covered by a thin membrane à may rupture or leak
• Neuro deficit evidence
Assessment:
• Depends on spinal cord involvement
• Visible spinal defect
• Flaccid paralysis of legs
• Altered bladder and bowel function
Implementation:
• Evaluate sac; measure lesion
• neuro check
• monitor for increase ICP
• measure HC; assess fontanelles
• Protect the sac
1. Cover with sterile, moist (normal saline) non-adherent
dressing
2. Change dressing every 2-4 hours
• Place prone position
• head is turned to one side for feeding
• diapering may be C/I until defect repaired
• Aseptic technique
• Watch for early signs of infection
• Administer antibiotics
• Administer anticholinergics – improve urinary continence
• Administer laxatives , antispasmodics
MENINGITIS
• infectious process of the CNS caused by bacteria and viruses
• acquired as a primary or as a result of complications
• diagnosis – CSF analysis (increase pressure, cloudy CSF, high protein,
low glucose
• bacterial or viral
Assessment:
• signs and symptoms vary depending of age group
• fever, chills
• vomiting, diarrhea
• poor feeding or anorexia
• altered LOC
• bulging anterior fontanel
• nuchal rigidity
Implementation:
• isolation; maintain for at least 24 hours after antibiotics are initiated
• administer antibiotics as prescribed
• monitor VS and neuro status
• Monitor I and O
• assess nutritional status
• determine close contacts of the child with meningitis
SEIZURE DISORDERS
• Sudden transient alterations in brain function resulting from excessive
levels of electrical activity in the brain
Assessment:
• obtain information from parents about the time of onset, precipitating
events and behavior before and after the seizure
• seizure precautions:
1. Raise side rails
2. Pad side rails
3. Place waterproof mattress on bed
4. Instruct child to swim with companion
5. Alert caregivers to the need for special precautions
CEREBRAL PALSY
• disorder characterized by impaired movement and posture resulting from
an abnormality in the extrapyramidal motor system
• spastic type- most common
Assessment:
• extreme irritability and crying
• feeding difficulties
• stiff and rigid arms and legs
• delayed gross development
• abnormal motor performance
• alterations of muscle tone
• abnormal posturing
• persistence of primitive reflexes
Implementattion:
• early recognition
• PT, OT, speech therapy, eduaction and recreation
• assess the child’s developmental level and intelligence
• early intervention
• encourage communication and interaction with the child on a functional
level
• provide safe environment
• position upright after meals
• provide safe, appropriate toys for age and developmental level