Pediatric Nursing - Continuation From N.U.R. Online Review

8/4/2019 Pediatric Nursing - Continuation From N.U.R. Online Review

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CARDIOPULMONARY RESUSCITATION

CPCR = cardiopulmonary and cerebral resuscitation

5 minutes of 02 deprivation will cause irreversible brain damage

Priority: Airway, Breathing, Circulation

AIRWAY

Clear the airway Shake the baby

If no response, call help

Immediately do 1 minute CPR before calling for help

Flat on bed, put a board if the bed is soft

Head tilt chin lift maneuver

No head tilt for suspect of cervical damage

Overextension may cause occlusion

BREATHING

Ventilating the lungs

Check breathlessness

If breathless = give 2 breaths

If newborn = mouth and nose If child = mouth and pinch the nose

Force = puff only

Use one way mask to prevent contact with the secretion

CIRCULATION

By cardiac compression

Check if pulseless

Use brachial pulse = children

No breath + No pulse = CPR

Infant = 1 finger breadth below nipple line, 2 finger

1 year old = heal of the palm


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RESPIRATION

Normal Values = 30 60 bpm irregular

Either abdominal or diaphragmatic breathing with short period of apnea without cyanosis

Normal apnea in newborn is 15 seconds or less

Age Rate

Newborn 40 901 year old 20 40

2 3 years old 20 30

5 years old 20 25

10 years old 18 22

15 and above 12 20

Breath Sounds Heard on AuscultationVesicularNormal

Soft, low pitched, heard over periphery oflungs, aspiration is longer than expiration

BronshovesicularNormal

Soft, medium pitched heard over majorbronchi, inspiration equals expiration

Bronchial

Normal

Loud, high pitched, heard over the trachea,

expiration is longer than inspirationRonchiNormal

Snoring sound made by air moving throughmucus in bronchi

RalesAbnormal

Crackles (like Cellophane) made by air movingthrough fluid in alveoli

Denotes pneumonia, fluid in the lungs orpulmonary edema

WheezingAbnormal Whistling on expiration made by air beingpushed through narrowed bronchi

Denotes children with asthma or foreign bodyairway obstruction

Stridor Crowing or roster like sound made by air being

pulled through a constricted larynx Indicative of Respiratory Obstruction

Resonance Loud, low tone, percussion sound over normallung tissue

HyperResonance

Louder, lower sound than resonance,percussion sound over hyperinflated lung tissue


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1. RESPIRATORY DISTRESS SYNDROME Lack of surfactant within 24 hours of life

Aka Hyaline Membrane Disease

Common in preterm babies

The alveoli cannot expand properly

Signs and symptoms

o

Present within 4 hours of lifeo Using the Silverman Anderson Scoring to determine RDSo Increased RR with retraction (1st sign of RDS)o Expiratory Grunting (major sign)o Xiphoid retractiono Flaring nasal flareso Cyanosiso Respiratory acidosis

Managemento Head elevatedo Proper suctioningo O2 administration with increased humidityo Client placed on

o

CPAP Continuous Positive Airway Pressureo PEEP Positive End Expiratory Pressureo Purpose id to maintain the alveoli partially open and prevent alveolar

collapseo Monitor for acidosiso Surfactant replacement

2. LARYNGOTRACHEO BRONCHITIS (LTB) Most common form of croup

Viral infection of the larynx, trachea and bronchi

Signs and symptomso BARKING or CROUPY COUGH = outstanding signo Inspiratory Stridor

o

Respiratory acidosiso Cyanosiso Death

Diagnostic Examso Throat swab for c & so ABGo Chest and x-ray to rule out epiglottitis

Managemento Racemic Epinephrine bronchodilatoro Humidified Oxygen

3. BRONCHIOLITIS Inflammation of the bronchioles characterized by production of tenacious mucus

FLU LIKE SYMPTOMS outstanding sign Increased RR

Causative Agent: Respiratory Syncitial Virus

Drug: Antiviral Ribavirin

LTB and Bronchiolitis ends with Epiglottitis

4. EPIGLOTITIS Inflammation of the epiglottitis


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Sudden onset

The child always assume the tripod position

Less than 18 months cannot cough must be placed on mist tent or Croup tie makesure that the edges are tucked in

o Provide washable plastic toys or materialso Avoid toys that crate frictiono

Avoid toys that are hairy or furry


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Blood Pressure

Newborn 80 46 mmHg

After 10 days 100/ 50 mmHg

BP taking begins by 3 years old

SKIN If cyanotic after the first cry suspect Transposition of the Great Arteries

1. Acrocyanosis body is pink, extremities are blue2. Generalized Mottling due to the immaturity of the circulatory system3. Birthmarks

a. Mongolian Spots Slate gray or bluish discoloration/ patches commonly seen across the sacrum or

buttock

Related to increased melanocyte which is common in Asian newborn

Usually disappear by 1 5 years old (preschool)b. Milia

Plugged or unopened sebaceous glands usually seen as a white pinpoint patches

at the nose, chin and cheeks and will disappear by 2 4 weeksc. Lanugo

Fine downy hair which is common in pretermd. Desquamation

Peeling of the newborns skin within 24 hours characterized by extreme drynessthat begin in the sole and palm, common in post term babies

e. Stork Bites (Talengeiclasis Nevi) Pink patches at the nape, never disappears

f. Erythema Toxicum (Flea Bite Rash) First self limiting rash to appear sporadically and unpredictably as to time and

placeg. Harlequin Sign

Dependent part is pink, independent part is blue because of the immaturity of

circulation, the RBC settles downh. Cutis Memorata

Transitory mottling of the neonates skin when exposed to coldi. Hemangiomas

Vascular tumors of the skin

Types:o Nevus Flammeus/ Port Wine Stain

Macular purple or dark red lesions usually seen on the faceor thigh, disappears and be removed surgically

o Nevus Vasculosus/ Strawberry Hemangioma Dilated capillary in the entire dermal or subdermal area

continuing to enlarge but disappear after 10 years oldo Cavenous Hemangiomas

Consist of communicating network of venules in thesubcutaneous tissue that never disappear with age

j. Vernix Caseosa White cream cheese like substance that serves as skin lubricant


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SKIN COLOR AND THEIR SIGNIFICANCE

1. Blue = cyanosis , hypoxia2. White = edema3. Gray = infection4. Yellow = jaundice or carotinemia

5.

Pale = anemia

BURN MANAGEMENT

First Aido Put out the flames by rolling the child on a blanketo Immerse the burned part on cold watero Removed burned clothing (sterile material)o Cover burned part with sterile dressing

Maintenance of patent airwayo Suction PRNo O2 administration with increased humidityo Endotracheal Intubationo

Tracheostomy Prevention of shock and fluid and electrolyte imbalances

o Colloids to expand blood volumeo Isotonic saline to replace electrolyteo Dextrose in water to provide calories

Booster dose of Tetanus Toxoid

Relief pain such as IV analgesic (morphine sulfate)

Prevention of wound infectiono Cleaning and debriding the woundo Open or close method of wound careo Whirl pool therapy

Skin graftingo 3rd degree burn

o

get skin from buttocks or pig skin (xenograft) or from frozen cadaver Diet = increase CHON and calories


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BLEEDING DISORDERS/ BLOOD DYSCARIAS

Hemophilia

Sex linked (X) Recessive disorders

The mother is the carrier

The son is affected

The father transmits to daughter Deficiency in clotting factor

o Hemophilia A factor 8 classic hemophiliao Hemophilia B Factor 9 Christmas diseaseo Hemophilia C Factor 11

OMPHALAGIA earliest signo >300 cc loss of blood during cutting of the cord

the maternal clotting factor is present in the new born that is why there is a delayed diagnosisof hemophilia

in toddlers sudden bruising

HEMARTHROSIS major sign repeated bleeding, bleeding of the synovial membrane

Diagnostic exam: PTT

Nursing Diagnosis: High Risk for Injury

Goal: Prevention of injury Health Teaching

o Avoid contact sportso Determine the case before doing any invasive procedure

In immunization change the needle into a smaller oneo In case of fracture/ injury

Immobilize and elevateo Cold compresso Gentle pressureo Blood transfusion of cryoprecipitate

Leukemia

Group of malignant disease characterized by rapid proliferation of immature RBC

Ratio is 500 RBC : 1 WBC The client is immunocompromised

Classification of Leukemiao Lympho affects the lymphatic systemo Myelo affects the bone marrowo Acute/ Blastic affects the immature cellso Chronic/ cystic affects the mature cells

Acute Lymphocytic Leukemia

Most common in children

Increase immature WBC

Signs and Symptomsa.Infection

i.

Feverii. Poor wound healing

b.Bone weakness and causes fracturesc.Signs of bleeding

i. Blood in the urineii. Emesisiii. Petechiaeiv. Epistaxis

d.Signs of anemia


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i.Pallorii. Body malaiseiii. constipation

e.Invasion of the organsi. Hepatomegaly abdominal painii. Spleenomegaly

2.Diagnostic examinationsa.Peripheral Blood Smear reveals immature WBCb.CBC reveals anemia and thrombocytopenia; neutropeniac.Lumbar Puncture

i. To determine CNS involvementii. Fetal position without flexion of the neck because it will cause airway

obstructioniii. C position or shrimp position

d.Bone Marrow Aspirationi. Determines the presence of blast cellsii. Site of bone marrow aspiration iliac Crest post op : prevent hemorrhageiii. Lie on affected site

e.Bone Scan determines the degree of bone involvementf. CT Scan determine the degree of organ involvement

3.Management Triada.Surgeryb.Irradiationc.Chemotherapyd.Bone marrow transplant

4.4 Levels of Chemotherapya.Induction

i. To achieve remissionii. Drugs

IV VincristineL AsparagineOral Prednisone

b.Sanctuaryi.

To treat the leukemic cells that has invaded the testes and CNS

ii. Drugs intrathecal methotrexate via spinecytocinearabinase steroids irradiation

c.Maintenancei. To continue remissionii. Drugs

oral methotrexateoral 6-mecaptopurinecytarabine

d.Reinductioni. Give anti-gout agent Toii. To treat leukemic cells after relapse occursiii. Treat hyperurecemic neuropathy

Alopurinol or zylorene5.Nursing Management

a.Assess for common side effects of chemotherapy nausea and vomitingb.Assess for stomatitis ulceration and abscess of oral mucosa

i. Oral care


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ii. Alcohol free mouthwashiii. Cotton pledglets

c.Diet give food according to childs preferenced.Alopecia temporary side effect of chemotherapy

HEMOLYTIC DISORDERS

Rh Incompatibility

Rh = monkey foreign body

Mother (-) no antigen; no protein factor

Fetus (+), Father (+) has antigen and protein factor

4th baby is severely affected

Erythroblastocis Fetaliso hemolysis/ destruction of RBC leading to O2 carrying capacity leading to IUGR with

pathologic jaundice w/in 24 hours

ALERT! Baby is small and yellowish

Managemento RHOGAM

Vaccine given to Rh(-) mothers within the first 24 hours or within 72 hours Given once If pregnancy was aborted and the mother undergo D & C, RHOGAM must be given

w/in 24 hours, if not given within 24 hours, mother will produce antibody Action: destroys RBC preventing antibody formation

Diagnostic TestCoombs Test

ABO Incompatibility

Mother Type O; Fetus Type A most common

Mother Type O; Fetus Type B most severe

Hydrops Fetaliso Common in abo incompatibilityo Newborn is edematous, on lethal state, accompanied by pathologic jaundice w/in 24

hours Difference from Rh Incompatibility

o First pregnancy is affectedo NB is yellow and edematous

Managemento Initiation of breastfeeding, then temporary suspension of breastfeeding after 4 days (

breastfeeding releases prenanediole causing kernicterus)o Pregnanediole delays actions of Glucoonyl transferase ( liver enzyme that converts

indirect bilirubin into direct bilirubin) Indirect bilirubin

Fat soluble

Cant be excreted by kidneysCauses hyperbilirubinemia causing jaundice

Direct Bilirubin Water soluble Can be excreted by the kidneys

o Use phototherapyo Exchange transfusion for Rh and ABO affectations that tend to cause a continuous

decrease in hemoglobin during the first 6 months because the bone marrow fails toproduce erythrocytes in response to the continuous hemolysis

Hyperbilirubenemia

More than 12mg of indirect bilirubin among full terms


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Normal Indirect Bilirubin Level: 0 3 mg/dl

Kernicterus/ Bilirubin Encephalopathy

Irreversible brain damage

> 20 mg/dl of indirect bilirubin among full terms

> 12 mg/ dl of indirect bilirubin among preterm because of immaturity

Physiologic Jaundice Pathologic Jaundice Breastfeeding JaundiceNormalWithin 48 72 hoursMx:Expose to early morningsunlight

Within 24 hoursYellow upon birth

Possible Rh/ ABOincompatibility

Within 6t 7t dayDue to glucoronyl transferase

Assessment of Jaundice

blanching of forehead, nose and sternum

yellow skin, sclera

light stool

dark urine

Management

Phototherapy/ Photooxygenationo Nursing Responsibilities

Cover the eyes prevents retinal damage Height of light from baby 18 20 inches Increase Fluid intake Cover genitalia prevent priapism ( painful continuous erection Change position Avoid lotion and oils Monitor I&O best way is to weigh the baby Monitor VS

Bronze Baby Syndrome Transient bronze discoloration of the skin

Minor side effect of phototherapy


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HEAD

of its length

Structureso sutureso fontanels

anterior/ bregma 3 x 4 12 18 mos

posterior/ lambda - 1 x 1 2 3 mos Noticeable structures of the Head

o Craniotabes Localized softening of the cranial bone common to first bone child due to early

lightening If present in older children, sign of rickets or Vit. D deficiency

o Seborrheic dermatitis/ Cradle Cap Scaling, greasing, appearing salmon colored patches Usually seen at the scalp, behind ears and umbilicus Usually caused by improper hygiene Management

Application of baby oil the night before shampooing the childo Caput Succedaneum

Edema of the scalp due to prolonged pressure at birth Present at birth

Crosses the suture line Disappears 2 3 days Disappears without treatment

o Cephalhematoma Collection of blood due to rupture of capillaries of poriosteal capillaries Present after 24 hours Does not cross the suture line Disappears after 4 6 weeks Disappears without treatment

o Hydrocephalus Excessive accumulation of CSF Types

Communicating/ extraventricular hydrocephalus

No-communication/ intraventricular hydrocephalus/ obstructivehydrocephalus caused by tumor

Signs and symptoms

Signs of increased ICPo Diplopia eye deviation @ 6th mos and aboveo Management

Low semi fowlers (30 degrees) best position

Frontal bossing 9 prominent forehead)

Sunset eyes

Prominent scalp vein Therapeutic management

Osmotic Diuretico Mannitolo Diamox / acetazolamide

Seizure precautions

Surgery Shuntingo AV Shunt - atrioventricularo VP shunt ventriculoperitonial most common

Best time to shave the head just before the surgery prevent infection Post VP Shunt management


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Position sidelying on non-operated side ( applicable to all eyes andhead surgeries)

Sign of good shunting sunken fontanel

Sign of blocked shunting bulging fontanel

Catheter is changed as the child is growing

Child with BP shunt is prone to infection

SENSES

Sense of Sight

Sclerao Normal light blueo Later Color dirty white

Pupilso Normal round and adult size

o Coloboma key hole pupils part of the iris is missingo Congenital N Cataract whiteness/ opacity of the lens

Corneao Normal round and adult size

o

Congenital Glaucoma larger than normal

Test for BlindnessAge Common Test

NewbornCan see @ a distance

of 10 12 inches withvisual acuity of 20/200to 20/ 800

General appearanceCheck ability to follow object pass midlineDOLLS EYE TEST done at approximately 10th dayGLADELLAR TEST test for blink reflex, not blinking is a sign ofblindness

Infant and children ALLENS CARD test for visual acuity- familiar pictures are flashed 20 ft away from the child

ISHIARA PLATE test for color blindness

3 years old School age Cover testing test for strabismus

School age adult Snellens test

RETINOBLASTOMA

malignant tumor of the eye

signs and symptomso cats eye reflex (whitish glow of pupil)o red, painful eye usually accompanied by glaucoma

Managemento Surgery innucleation - removal of the eyeballo Irradiationo Therapy

SENSE OF SMELL

Normal nasal membrane - pinkish

Check for sense of smell

Check for nasal flaring

Sign of Cocaine User

Ulceration and abscess of nasal mucosa

Absence of hair


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Epistaxis

Nose bleeding

Managemento Position, upright, sitting, head tilted, slightly forwardo Gentle pressureo

Cold compresso Epinephrine last resort

SENSE OF HEARING

Normal should be aligned with the outer canthus of the eye

Low Set Ears is a sign ofo Kidney malformation

Renal agenesis

Absence of kidneyo Chromosomal Abnormalities

Due to advance maternal age - >35y/o

Typeso Nondisjunction (uneven division)

Trisomy 21

Down Syndrome

Most common type

Extra chromosome 21

47xx + 21/ 47xy + 21

can be related to advance paternal age

signs and symptomso broad noseo protruding tongueo low- set ears

o

puppys necko hypotonia prone to URTIo simian crease single traverse line in palmo mental retardation ranging from educable to

institutionalization

Trisomy 18

Has 3 numbers of 18 chromosomes

Severely cognitively impaired SGA

Low set ears, small jaw, CHD, index finger crosses over the otherfingers, rounded soles of feet

Trisomy 13

Pataus syndrome

Extra chromosome 13

Severely cognitively impaired

Signs and symptomso Microcephalyo Micropthalmiao Cleft-lip and palateo Low-set earso VSDo Do not survive

Turners


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Gonadal Dysgenesia

One functional x chromosome

Short in stature

Neck appear to be webbed and short

COA and kidney problems

Only 1 streak (nonfunctional) gonads

Secondary sex characteristic does not develop except for pubic hair Lack ovarian function sterility

Cognitively challenged but mostly normal intelligence

Klinefelters syndrome

Males with a XXY chromosome pattern

@ puberty child has poorly developed secondary characteristics andsmall testes that produces ineffective sperm

boys tend to develop Gynecomastiao Deletion Abnormalities

Cri du chat Syndrome

Result of a short arm on chromosome 5

Cats cry

Small head, wide set eyes, downward slant to the palbepral fissure of

the eyes

Severe cognitive impairment

Fragile X Syndrome

X linked pattern

One arm of x chromosome is weakened

Most common cause of cognitive impairment in boys

Before puberty, boys typically have maladaptive behavior likehyperactivity and autism

Large head, long face with high forehead, prominent lower jaw, largeprotruding ears

o Translocation abnormalities

Balance translocation Carrier

Unbalanced Translocation Syndromeo Others

Mosaicism

A situation wherein the nondisjunction of chromosome occurs duringmitotic cell division after fertilization resulting to different cellscontains different numbers of chromosome

Isochromosomes

A situation wherein the chromosome instead of dividing vertically itdivides horizontally resulting to chromosomal mismatch

Otitis Media

Inflammation of the middle ear

Common to children due to wider and shorter Eustachian tube

Predisposing factorso Bottle proppingo Cleft lip/ palate

Signs and symptomso During otoscopic exam, reveals bulging tympanic membraneo Observe for passage of purulent, foul smelling odor discharge

Managemento Positioning sidelying on the affected sideo Supportive care


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Medical managemento Massive dosage of antibioticso Mucolyticso Ear drops

< 3 y/o down and back >3 y/o up and back

o Surgery Myringectomy slight incision of tympanic membrane to prevent hearing loss

Side effect bacterial meningitis

MOUTH AND TONGUE

Check for symmetry

Bells palsy/ Facial Nerve Paralysis

7th CN injury

usually related to forceps delivery

risk for URTI

Signs and symptomso

Continuous drooling of salivao Inability to open one eye and close the other

Managemento Artificial tearo Self limitingo Refer to PT for rehabilitation

TEF/ TEA

No connection between esophagus and stomach

There is a blind pouch

Hydramnios earliest sign intrauterine

Signs and symptoms

o

Coughingo Chockingo Cyanosiso Continuous drooling

Managemento Emergency surgery

Epstein Pearls

White glistening cyst

Usually seen on palate, gum

Related to hypercalcemia

Natal Tooth

Tooth at the moment of birth Related to hypervitaminosis

Managemento Manual extraction if rootless

Neonatal Tooth

Appearance of tooth within 28 days of life

Oral Thrush


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White cheese-like, curd like patches

Usually seen in mouth and on tongue

Causative agent C. Albicans fungi

Managemento Do not remove can cause woundo Wash with cold, bottled water

o

Medical Mycostatin/ Nystatin

Kawasaki Disease

Discovered in Korea

Strawberry tongue

Common in Asian countries

Criteria for diagnosiso Fever lasting for more than 5 dayso Bilateral conjunctivitiso Changes in lips and oral cavity

Dry red fissure lips Strawberry tongue Diffuse erythema of mucus membrane

o

Changes in the peripheral extremities Erythema on the palms and soles Erythema on the hands and feet Membranous desquamation from fingertips

o Polymorphous rash (primarily at trunk)o Acute non purulent swelling of the cervical lymph nodes to > 1.5 cm in diameter

Drug of Choice : ASPIRIN

Cleft Lip

Failure of the median maxillary nasal process to fuse

Common to boys

Surgery cheiloplasty

o

Done w/in 1 3 monthso To save sucking reflex

Signs and symptomso Evident at birtho Milk from nostrils spillso Cold is commono Frequent URTI and otitis media

Post cheilo sidelying

Nutrition use rubber tip syringe

Cleft Palate

Failure of the palate to fuse

Common to girls

Surgery Uranoplastyo Done w/in 4 6 monthso To save speech

Signs and symptomso Evident at birtho Milk from nostrils spillso Cold is commono Frequent URTI and otitis media

Post cheilo prone


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Nutrition use paper cup/ plastic cup/ soup spoon

Condition to consider for suspension of operation

If child has a cold/ nasopharyngitis may lead to general septicemia

General management

Maintenance of patent airway Proper nutrition

o NPO 4 hours post opo Clear liquid

Popsicle except red and brown in color Flavore gelatin No ice cream

Observe for bleedingo Frequent swallowing

Protect suture lines specially LOGAN BARo Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles more

microorganism trappedo Prevent crying by attending to needs

Therapeutic Management

Emotional support

Proper Nutrition

Cleft lip nipple (long tip, made by silicon)

Prevent Colico Burp frequentlyo One at the middle of the feedingo Another at the end of the feedingo Upright sitting positiono Pat at the back lower to uppero Prone positiono Right sidelying position facilitates gastric emptying

Educate parents Apply elbow restraints so the baby can easily adjust post op

NECK

Check for symmetry

Congenital Torticollis/ Wryneck

Birth injury of sternocleidomastoid due to excessive traction during cephalic delivery

A case of incompetence to the one giving birth

Managemento Passive stretchingo Exercise daily

o

Surgery Complication

o Scoliosis

Congenital Cretinism/ Congenital Hypothyroidism

Absence or non functioning thyroid gland

Causeso Due to delayed diagnosis, thyroid is covered by sternocleidomastoid muscleo Hypothyroidism


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o Thyroid dysgenesis (absence of thyroid)o Baby receive maternal thyroxin

Earliest Signs and Symptomso Change in suckingo Change in cryingo Excessive sleeping (16-20 hours/ day)o

Constipationo Edema moon faced babyo Mental retardation late sign

Diagnostic Testo Radioimmunoassay Testo Protein bound iodine

Treatmento Synthroid / sodium levothyroxine for life

CHEST

Witch Milk

Transparent Liquid coming out from newborns breast related to hormonal changes

ABDOMEN

Abdominal Assessment

Inspection

Auscultation

Percussion

Palpation

Diaphragmatic Hernia

Protrusion of stomach contents through a defect in diaphragm due to failure of pleuroperitonealcanal to close

Signs and Symptomso Sunken abdomeno Signs of RDSo Right to left Shunting

Treatment diaphragmatic repair w/in 24 hours

Omphalocele

Protrusion of stomach content between the junction of abdominal wall and umbilicus

If small surgery

If large suspend surgery

Apply wet dressing

GASTROINTESTINAL SYSTEM

Functionso Assist in maintaining fluid and electrolytes and acid and base balanceo Processes and absorbs nutrients to maintain and support growth and developmento Excrete wasted products from the digestive process

Supplementary Feeding


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Begin 4 6 months

As early as 4 months

Usually at 6 months

Principleso Solid food are often according to the following sequence

Cereals rich in iron

Fruits

VegetablesMeat

o Begin with small quantitieso Finger food are offered @ 6 monthso Soft table food is offered @ 1 yearo Diluted citrus/ fruit juices @ 6 monthso Offer new food one at a time with an interval of 4 7 days or 1 weeko Never offer half cooked egg may lead to gastroenteritis/ salmoneliosis

Major Concepts of Fluid and Electrolyte Balance

Distribution of Body Fluidso Fluids are greater in ECF in infant and childreno

Newborns are candidate for dehydrationo Total Body fluid is 65 85% of their body weight in infants and children

Acid Base Imbalance

Depending upon the followingo Chemical bufferso Renal and respiratory system involvemento Dilution of strong acids and bases in blood

Imbalance of Acido Respiratory Acidosis

Carbonic acid excess LTB RDS Hypoventilation COPD

o

Respiratory Alkalosis Carbonic acid deficit Hyperventilation Fever, encephalitis

o Metabolic Acidosis Base bicarbonate deficit Diarrhea Severe malnutrition and dehydration celiac

o Metabolic Alkalosis Base bicarbonate excess due to uncontrolled vomiting NGT aspiration Gastric lavage Pyloric stenosis

Conditions that Produce Fluids and Electrolyte Imbalance

Vomiting

Forceful expulsion of stomach content

Signs and symptomso Nauseao Abdominal crampingo Flushing of face


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o Watery eyes

Assessmento Frequencyo Forces

Projectile increase ICP/ Pyloric stenosis Non projectile

Alertso Vomiting is an initial symptom of GI Obstructiono Vomitus of upper GI can be blood tinged but bot bile streakedo Vomitus of lower GI is biliouso Projectile vomiting is a sign of increased ICP or GI Obstructiono Abdominal distention is the major symptom of lower GIT obstruction

Managemento Bananao Rice cerealo Apple sauceo Toast

Diarrhea

Exaggerated excretion of intestinal contents Acute diarrhea is associated with the following

o Gastroenteritis/ salmonelliasiso Antibiotic use penicillin, tetracyclineo Dietary indigestion

Chronic non specific diarrheao Food intoleranceo CHO/ CHON malabsorptiono Excessive fluid intake

Assessmento Frequencyo Consistency (best criteria)o Appearance of green colored stool

Complicationso Mild dehydration 5% weight losso Moderate dehydration 10% weight losso Severe dehydration 15% weight loss

Signs of dehydrationo Tachycardia earliest signo Tachypneao Hypotensiono Increase tempo Sunken fontanelo Sunken eyeballo Poor skin turgoro Absence of tearso

Scanty urineo Oliguria severe dehydrationo Weight losso Prolonged capillary refill time

Managemento NPOo IV infusiono KCl given by doctors

Assess child for ability to void before giving KCl may lead to hyperkalemia Normal K Value 3.5 5.5


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o Order Na Bicarbonate, administer slowly to prevent cardiac overload

Gastric Motility Disorders

Hirschprungs Disease/ Congenital Aganglionic Megacolon

Absence of ganglion cells needed for peristalsis

Assessmento Neonatal Period

Abdominal distention Failure to pass meconium within 24 hours

o Early childhood Ribbon like stool Constipation Foul smelling stool Diarrhea Vomitus of fecal materials

Diagnostic Procedureso Barium enema reveals narrowed portion of the bowelo Rectal biopsy reveals absence of ganglion cellso Abdominal x- ray reveals dilated loops on intestineso Rectal manometry reveals failure of intestinal sphincter to relax

Therapeutic Managemento NGT Feeding

NGT Measurement

Infant nose-ears middle of xiphoid process and umbilicus

Adult nose ears xiphoid processo Surgery

Temporary colostomy Anastomosis and pull through procedure

o Diet Increase CHON Increase Calorie

residue diet pasta foods no raisin/ prunes

Gastroesophageal Reflux

presence of stomach content on esophagus

Assessmento chronic vomitingo failure to thrive syndrome organico esophageal bleeding manifested by melena and hematemesis

Complicationso esophagitiso aspiration pneumoniao esophageal cancer

Diagnostic Procedureo barium esophogramo esophageal manometry reveals lower esophageal pressureo intraesophageal pH content reveals pH of distal esophagus

Medicationso anticholinergics

bathanechol/ urecholine

esophageal tone and peristaltic activity Methachlopromide (Reglan)

esophageal pressure by relaxing pyloric and duodenal segments


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peristalsis without stimulating secretions H2 Blocker/ histamine Receptor Antagonist

gastric acidity and pepsin secretion Maalox/ Cimetidine (Tagamet)/ Ranitidine (Zantac)

Neutralizes gastric acid between feedings

Surgery: Nissen Fundoplication

Dieto Thickened feeding with rice cereal prevents vomitingo Feed slowlyo Burp often every 1 ozo Positioning

< 9 mos infant sit/ infant supine > 9 mos prone with head on mattress slightly elevated on a 30 angle

Obstructive Disorders

Pyloric Stenosis

hypertrophy of the muscle of pylorus causing narrowing and obstruction

Assessment

o

Projectile vomitingo Failure to gain weighto Metabolic alkalosiso Peristaltic wave visible from left to right across epigastrumo Palpation of olive shaped mass

Diagnostic Procedureo ABGo Serum Electrolyte - Na and K, Clo Ultrasoundo X-ray of upper abdomen with barium swallow

Managemento Pyloromyotomy/ Fredet Ramstedt Operation

Intussusception Telescoping or invagination of one portion of the bowel into the other

Peritonitis danger of intussusception

Emergency for URT epiglottitis

Emergency for GIT peritonitis

Signs and symptomso Acute paroxysmal abdominal paino Currant jelly stool caused by inflammation and bleedingo Sausage shaped mass

Non congenital

Caused by fast eating and positioning

Managemento Hydrostatic reduction with barium enema

o

Surgery Anastomosis

Inborn Errors of Digestion

Phenylketonuria/ PKU

Deficiency of the liver in Phenylalanine Hydroxylase Transferase (PHT)

PHT is a liver enzyme that coverts protein into amino acid

9 Essential Amino Acidso Tyrosine / phenylalanine


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o Histidineo Isoleucineo Leucineo Lysineo Methionine/ cysteineo Threonineo Tryptophano Valine

Tyrosine or Phenylalanine responsible for the melanin production

Signs and Symptomso Fair complexiono Blond hairo Blue eyeso Infantile eczemao Mousy/ musty odor urineo Seizure due to Phenyl Pyruvic Acid goes to braino Mental retardation

Guthrie Testo Specimen Bloodo Preparation Increase Fluid Intake

Managemento Diet

phenylalanine diet indefinitely Chicken, meat, peanuts, milk, legumes, cheese contraindicated Lofenalac special formula

Celiac Disease/ Malabsorption Syndrome; Gluten Induced Enteropathy

Sensitivity or immunologic response to protein

Assessmento Early signs

Diarrhea, failure to regain weight following diarrheal episode Constipation Vomiting Abdominal pain Steatorhea

o Late signs Behavioral changes: irritability and apathy Muscle wasting and loss of subcutaneous fats

o Celiac Crisis Development of infection by a child having a celiac disease Acute vomiting and diarrhea

Diagnostic Procedureo Stool analysiso Serum antiglandin and antireticulin antibodieso Sweat test

Therapeutic managemento Vitamin supplementso Mineral supplementso Steroid

Poisoning

Common accident in toddlers poisoning

Common accident in infants falls


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Principleso Determine the substance taken and assess LOCo Unless poisoning was corrosive, caustic (strong alkali, such as lye) or hydrocarbon,

vomiting is the most effective way to remove the poison from the body Strong acid poisoning give weak acid to neutralize strong acid

o Syrup of ipecac oral antiemetic to cause vomiting after drug overdose or poisoning

15 ml adolescent, school age and preschool 10 ml infanto Universal Antidote

Activated charcoal Milk of magnesia Burned toast

Charcoal absorbs toxic substanceo Never administer the charcoal before ipecac because giving charcoal first will absorb

the effect of ipecaco Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)o Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and prevent poison

absorption

Tracheostomy set will be at bed side

Lead Poisoning

Pencil, paint, crayon Lead

Destruction of RBC Functioning

Hypochromic Microcytic Anemia

Destroys Kidney Function

Accumulation of ammonia

Leading to Encephalitis (Late stage)

Severe mental retardation

Assessmento Beginning symptoms of lethargyo Impulsiveness and learning difficultyo As lead , severe encephalopathy with seizure and permanent mental retardation

Diagnostic procedureo Blood smearo Abdominal x-rayo Lone bone

Managemento Chelation binds with the lead and excreted via kidneyso Ca EDTA/ BAL/ Dimercapro

Nephrotoxic

ANOGENITAL

Female

Pseudomenstruationo Slight vaginal bleeding related to hormonal changes

Rape/ Child Abuseo If the client came with a laceration and bleeding at the perineumo Report rape within 48 hours


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o Preschool are proneto rape because of their innocenceo CBQ Report rape cases to barangay chairman first or bantay bata

Male

Cryptorchidismo Undescended testes or empty scrotum or ectopic testes

Common in preterm babies Testes is palpable at lower quadrant

Surgery: Orchioprexy

Preop warm the room and hands

Epispadiaso Urinary meatus is located at the dorsal or above the glans penis

Hypospadiaso Urinary meatus is located at the ventral or below the glans peniso Hypospadias is usually accompanied by Chordee ( A fibrous band causing penis to

curved downward)o Both are manage by surgery

Phimosiso Tight foreskino

This will cause infectiono Circumcision as management

Hydroceleo Fluid filled scrotumo Flashlight/ transillumination test to determine

Varicoceleo Enlarged vein of the epididymis

RENAL DISORDERS

RenalDisorder

Causes Assessment Findings Treatment Nursing Care

Nephrotic

Syndrome

Infection Anasarca

Massive proteinuriaMicroscopic or nohematuria serum CHON serum lipidNormal or BPFatigue

Prednisone Skin Care

Weigh the client dailywith the same clothing CHON(Normal Diet) Na K

AcuteGlomerulonephritis

AutoimmuneGroup A betahemolyticstreptococcus

Primary peripheralperiorbital edemaModerate ProteinuriaGoss hematuria(smokey urine) serum K

FatigueHPN

AntiHPNHydralazineApresoline

ComplicationHypertensive

Encephalopathy

Monitor weightSkin CareMonitor BP andneurological status K Fe

Na

BACK

Check for flatness and symmetry of the back

Spina Bifida Occulta

Failure of the posterior lamina or vertebral to fuse

Sampling of the lower back


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Abnormal tufts of hair

Spina Bifida Cystica

With Sac

Typeso Meningocele protrusion of CSF and Meningeso

Myelomeningocele CSF, Meninges and Spinal cordo Ecephacele

cranial meningocele - CSF and meninges Myelomeningocele - brain, CSF , meninges

Common Complicationo Infectiono Rupture of Sac

Treatmento Surgery to prevent infection: post op prone position

Scoliosis

Lateral curvature of the spine, common in school age because of heavy bags

Uneven hemline Tell the child to bend forward, one hip higher than at the other and one shoulder is most

prominent

Typeso Structuralo Postural

Managemento Conservative

Exercise Avoid obesity

o Preventive Milwaukee Braces worn 23 hours a day

o Corrective: Surgery

EXTREMITIES

Count the number of digits

Digits

Syndactyl webbing of the digits (foot ginger like foot)

Polydactyl extra digits

Olidactyl lacks digits

Erb Duchennse Paralysis/ Brachial Plexus Injury

Birth injury of breech delivery

Signs

o

Inability to abduct the arm from the shoulder, rotate the arm extremely and supinatethe forearm

o Asymmetrical or absence of moro reflex

Managemento Abduct the arm from the shoulder with the elbow flexed

Congenital Hip Dislocation

Congenital hip dysplasia

When the head of the femur is outside the ascetabulum


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2 typeso subluxated most commono dislocated

Signs and Symptomso Shortening of the affected lego Assymetrical gluteal foldo

Limited movement earliest signo + ortolanis sign abnormal clicking of during abductiono when able to walk the child limps (Trendelenburg sign) late sign

Management facilitate abductiono Triple the diapero Carry the babyo Frejka Splinto Pavlik Harnesso Hip Spica Cast

Talipes

Club foot

4 typeso

Equinos plantar rotation/ horse foot (most common)o Calcenuous dorsiflexion/ the heel is held lower than the foot/ the anterior portion of

the foot is flexed towards the anterior lego Varus foot turns ino Valgus foot turns out

Assessmento Make a habit of straightening the legs and flying it to the midline position

Managemento Corrective shoes : Dennis Brown Shoeso Spica Cast

For immobilization Maintain bone alignment Prevent muscle spasm

If there is a blood mark on the cast mark a pen to determine whether there isa hemorrhage Neurovascular check

Circulation

Motion

Sensation

CRUTCHES

Wait is on the palm not the axilla

Exercise squeeze ball

Different Crutches and Gait

Swing Through

Advance both crutches

Lift both feet/ swing forward/ land feet in front of crutches


Lift both feet/ swing forward/ land feet in front of crutches

Swing To



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Lift both feet/ swing forward/ land feet next to crutches


Lift both feet/ swing forward/ land feet next to crutches

Three point gait

Advance left foot and both crutches

Advance right foot Advance left foot and both crutches

Advance right foot

Four Point Gait

Advance right crutch

Advance left foot

Advance left crutch

Advance right crutch

Two Point Gait

Advance left foot and right crutch

Advance right foot and left crutch

Advance left foot and right crutch Advance right foot and left crutch

Other Crutch Maneuvering Technique

To Sit Down

Grasp the crutches at the hand pieces for control

Bend forward slightly while assuming a sitting position

Place the affected leg forward to prevent weight bearing and flexion

To Stand Up

Move forward to the edge of the chair with the strong leg slightly under the seat

Place both crutches in the hand on the side of the affected extremity

Push down on the hand piece while raising the body to a standing position

To Go Downstairs

Walk forward as far as possible to the step

Advance the crutches to the lower step. The weaker leg is advanced first and then the strongerleg. In this way, the stronger extremity shares the work of raising and lowering the patientsbody weight with the arms

To Go Upstairs

Advance the stronger leg first up to the next step

Then advance the crutches and the weaker extremity (strong leg goes up first and comes downlast.)

A memory device for the patient is UP WITH THE GOOD, DOWN WITH THE BAD

WALKER

A walker provides more support than cane and crutches

The patient is taught to ambulate with a walker as followso Patient must hold the walker on the hand grips for stabilityo Lift the walker, placing it in front of you while leaning your body slightly forwardo Walk into the walker, supporting your body weight on your hands while advancing the

weaker leg, permitting partial weight bearing or non weight bearing leg as prescribed


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o Balance yourself on your feeto Lift the walker and place it in front of you again and continue the pattern of walking.

CANE

Used to help patient walk with greater balance and support and to relieve the pressure on the

weight bearing joints by redistributing the weight. Quad Cane (four footed cane) is hold on the hand of affected extremity.

METHODS OF TRANSFERRING A PATIENT FROM THE BED TO A WHEELCHAIR

Weight bearing transfe4r from bed to chair. The patient stands up, pivots his back is oppositethe new seat and sits down.

(Left) Non-weight bearing transfer from chair to bed. (Right) With legs braced.

(Left) Non-weight bearing transfer combined method. (Right) Non-weight bearing transfer, pullup method.

THERAPEUTIC EXERCISEExercise Description Purpose ActionPassive carried out by the

therapist or the nursewithout assistancefrom the patient

To retain as muchjoint range of motionas possibleTo maintaincirculation

Stabilize the proximaljoint, and support thedistal part. Move thejoint smoothly, slowlyand gently through itsfull rang of motionAvoid producing pain.

Active Assistance Carried out by thepatient with the

assistance of thetherapist or the nurse

To encourage normalmuscle function

Support the distal partand encourage the

patient to take thejoint actively throughits ROM. Give no moreassistance than isnecessary toaccomplish the action.Short periods ofactivity should befollowed by adequaterest periods.

Active Accomplished by thepatient withoutassistance, activitiesinclude turning fromside to side and fromback to abdomen andmoving up and down inbed

To increase musclestrength

When possible, activeexercise should beperformed againstgravity. The joint ismoved through fullROM withoutassistance. (make surethat the patient doesnot substitute anotherjoint movement forthe one intended)

Resistive An active exercisecarried out by the

To provide resistanceto increase muscle

The patient moves thejoint through its ROM


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patient workingagainst the resistanceproduced by eithermanual or mechanicalmeans

power while the therapistresist slightly at firstand the progressivelyincreasing resistance.Sandbags and weightscan be used and are

applied at the distalpoint of the jointinvolved. Themovement should beperformed smoothly.

Isometric/ MuscleSetting

Alternately contractingand relaxing a musclewhile keeping the partin fixed position;performed by thepatient

To maintain strengthwhen a joint isimmobilized

Contract or tighten themuscle as much aspossible withoutmoving the joint. Holdfor several seconds,and then let go andrelax. Breathe deeply.

TRACTION

Use to reduce dislocation

Principles of Traction

The client should be in dorsal or supine position

For every traction, there is always a counter traction

Line of pull should be in line with deformity

For traction to be effective it must be continuous

Weight must be freely hanging

Types of Traction

Straight traction weight of the body serves as counter pull

Skin traction applied directly to the skino Bryants Traction

use to immobilize for < 2 years old at a 90 angle with buttocks off the bedo Bucks extension

For > 2 years old

Halo traction immobilize the spine

Skeletal tractiono Nursing responsibilities

Assess for circulatory and neurology impairment It can lead to HPN

Be careful to carry out nursing functions by not moving the weights

AUTOIMMUNE SYSTEM

Types of Immunityo Passive Natural

Developed via exposure to a diseaseo Active Natural

Transplacental transfer, IgA from breastmilko Passive Artificial


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Vaccinationo Active Artificial

Anti Rabies Serum

Pediatric Nursing - Continuation From N.U.R. Online Review

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Transcript of Pediatric Nursing - Continuation From N.U.R. Online Review