Systemic Bullets
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CARDIO
CONGENITAL HEART DISEASE
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
PATENT DUCTUS ARTERIOSUS Most common congenital heart defect Symptoms depend on size of the vessel and age of the child May have no symptoms; indication may be a murmur Increasing dyspnea, full bounding pulse, wide pulse pressure Spontaneous closure after infancy rarely occurs Without treatment life expectancy short
ATRIAL SEPTAL DEFECTS 10% of all forms of congenital heart disease Allows oxygenated blood returning from the lungs to pass into the right
atriumVENTRICULAR SEPTAL DEFECT
constitute 20% of all forms of CHD allows systemic venous and oxygenated arterial blood to mix may produce no symptoms at all require no specific treatment and often close spontaneously
COARCTATION OF THE AORTA narrowing of the lumen of the aorta may be an isolated defect or associated with other cardiac malformation Assessment: measure BP in both arms and a leg and to assess the
pulsein both upper and lower extremities
surgical repair only permanent treatment; usually deferred until 3 yearsof age
PULMONIC VALVE STENOSIS usually do not produce symptoms; typical murmur
AORTIC VALVE STENOSIS mild to moderate asymptomatic; typical murmur
CYANOTIC DISEASES
TETRALOGY OF FALLOT1. VSD2. Overriding of the aorta3. Pulmonary valve stenosis4. 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
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Decrease hypoxic spells do not permit child to cry Place in knee chest position O2 as needed
TRANSPOSITION OF THE GREAT VESSELS
aorta arises from the right ventricle degree of cyanosis depends on the abnormal connections
Assessment: cyanotic at birth
develop polycythemia 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
TOTAL ANOMALOUS VENOUS RETURN condition in which all the pulmonary venous blood returns to the heart
cyanosis and severe respiratory distress emergency surgical intervention
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 position2. Administer 100% oxygen by mask3. Administer morphine as ordered4. IVF as prescribed
Assess for signs of CHF Assess peripheral pulses Keep child stress free as possible; allow maximal rest
CARDIAC SURGERYPostoperatively:
monitor for signs of discomfort monitor for signs of sepsis (fever, lethargy, diaphoresis, altered LOC)
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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
CONGESTIVE HEART FAILURE inability of the heart to pump sufficiently to meet the metabolic demands
of the body infants most commonly caused by congenital heart defects combination of both left sided and right sided heart failure goal of treatment: to improve cardiac function, remove accumulated fluid
and sodium, decrease cardiac demands, improve tissue oxygenation
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
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monitor serum electrolytes restrict fluid in acute stages check with physician regarding sodium restriction; infant formulas have
slightlymore sodium than does breast milk
Home care Instructions for Administering Digoxin administer 1 hr before or 2 hrs after feeding do not mix medication with food or drink if the child vomits, do not administer a second dose if more than 2 consecutive doses have been missed, notify MD; do not
increase or double the dose for missed doses keep the medication in a locked cabinet if the child becomes ill, notify MD
RHEUMATIC FEVER
an inflammatory autoimmune disease affects connective tissue of the heart, joints, subcutaneous tissues andblood 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
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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
Physiology of DIGESTIVE SYSTEM
Mechanical functions of digestion immature at birth
No voluntary control over swallowing until 6 weeks
Stomach capacity decreasedRelaxed sphincter contributes to tendency to regurgitate
Liver functions immature throughout infancy
Gastric acidity low in infants rises until age 10
Digestive processes are mature by toddlerhood
Assessment:
Presenting problem
a. Vomitingb. Abnormal bowel habits: diarrhea, constipation, bleeding
c. Weight loss, failure to thrived. Pain
Nutritional history
Physical Examination:
General appearance:
a. Height and weightb. Measure mid arm circumferencec. Observe color: jaundice
Mouth: dentition
Abdomen
a. Skin integrityb. Abdominal distension; visible peristaltic wavesc. Inspect for herniasd. Auscultate bowel sounds ( every 10-30 seconds)e. Palpate for tendernessf. Liver span (inferior edge palpated 1-2 cm below RCM)g. Spleen (felt on inspiration 1-2 cm below left costal margin)
DISORDERS OF THE TEETH
DENTAL CARIES
erosion of the enamel and dentine of teeth
results from combination of fermenting sugars and starched
and acid forming organisms
Prevention:
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dental hygiene
regular dental hygiene
good nutrition
fluoridation
CLEFT LIP AND CLEFT PALATE
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 childs 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
Cleft palate repair
not done until age 18 months anticipation for speech development
child should be weaned and able to take liquids from a cup before
palate repair
NURSING INTERVENTION:
Cleft Lip (PreOP)
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feed in upright position
burp frequently
press cleft lip together with fingers to encourage sucking and to
strengthen muscles
if unable to suck, use a rubber tipped syringe; drip onto side
of mouth
finish feeding with water to wash away formula in palate area
provide small, frequent feedings
provide emotional support for parents
Post OP: Cleft Lip repair
maintain patent airway
monitor amount of swallowing to detect hemorrhage
do not place in prone position or with pressure on cheeks
avoid any tension on suture line
avoiding straining on suture line
prevent crying
keep child comfortable and contented
use elbow restraint
keep suture line clean clean after each feeding with saline,
peroxide or water to remove crusts
pain relief
Nursing Intervention: Preop cleft palate repair
prepare parents to care fro child after surgery
instruct concerning feeding methods and positioning
Post Op cleft palate repair
position on side for drainage of blood
have suction available
prevent injury or trauma on suture line
1. Use cups only for liquids; no bottles2. avoid straws, utensils, popsicle sticks, chewing gum3. provide soft toys
4. Use elbow and wrist restraints5. Provide liquid diet initially soft normal diet6. Give water after each feeding to clean suture line7. Hold and cuddle
ESOPHAGEAL ATRESIA and TRAACHEOESOPHAGEAL FISTULA
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
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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
Medical and Surgical intervention
prevention of aspiration
drainage tube may be placed in the blind pouch to suction secretions
esophageal atresia medical emergency
- end to end anastomoses
feeding tube maybe inserted into the stomach through gastrostomy until
repair heals
Nursing intervention:
provide nutrition1. Provide gastrostomy tube feeding until anastomosis site has healed2. 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 toappear
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 pylorusb. Decreased serum Na, K, Clc. Increased Hctd. Metabolic alkalosis
Nursing intervention: Preop
replace fluids and electrolytes
prevent vomiting
1. Give thickened feedings2. High Fowlers
3. Place on right side after feeding4. Minimize handling5. Strict I and O, daily weights, urine sp gravity
Nursing Intervention: post Op
Advance diet as tolerated
Place on right side after feeding
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Observe incision for signs of infection
Provide client teaching and discharge planning
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 enema2. surgery
Nursing Intervention:1. provide routine pre and post op care2. monitor for peritonitis
HIRSCHSPRUNGS 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 orderedA. Mineral oil or isotonic saline
B. Do not use water or soap suds water intoxicationC. Use volume appropriate to weight of child
infants 150-200mlchildren 250-500 ml
administer TPN as ordered
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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 possibletemporary 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 cleanb. 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:
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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 RLQ
nausea, vomiting
guarding of abdomen
rebound tenderness
decreased bowel sounds
fever
diagnostic tests:
1. CBC2. elevated acetone in urine
Nursing Intervention:
antibiotics/ antipyretics as ordered
no enemas
no heating pads
routine preop care
post op care:
1. semi-Fowlers position2. Monitor NGT3. Monitor penrose drains
PARASITISM
roundworms, pinworms
Assessment:
pinworms anal itching, disturbed sleep
roundworms colic , abdominal pain, lack of appetite, weight loss
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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 careb. Urine and blood glucose monitoringc. Nutrition managementd. Effects of infection and exercise on CHO metabolisme. 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
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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 distress2. Increased fluid intake3. Acetaminophen
BRONCHIOLITIS/RESPIRATORY SYNCYTIAL VIRUS (RSV) Inflammation of the bronchioles; production of mucus that occludes
bronchiole tubes and small bronchi RSV highly communicable, usually transferred by hands
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Assessment: URI Lethargy, poor feeding, tachypnea Expiratory wheezes and grunt Diminished breath sounds
The child with RSV: isolate in a single room or place with same patient good handwashing nurses caring for these children do not care for other high risk children wear gowns when soiling may occur ribavirin may be aerosol nurses wearing contact lenses must wear goggles ribavirin may
dissolvecontact lenses
PNEUMONIA inflammation of the alveoli
inhalation of causative agent 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
Medications1. Quick relief To treat symptoms and exacerbations Short acting b2 agonists Anticholinergics for relief of acute bronchospasm (ipratropium bromide)
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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
Home care measures: instruct in measures to eliminate allergens avoid extremes of environmental temperature avoid exposure to individuals with a viral infection
instruct the child in how to recognize early symptoms instruct the child in the cleaning of devices used for inhaled medications keep immunization up to date
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 medications1. If younger than age 3 auditory canal is straightened by pulling the pinna
down and back2. 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
TONSILLECTOMY AND ADENOIDECTOMYAssessment:
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persistent or recurrent sore throat enlarged bright red tonsils ; with exudates at times dysphagia mouth breathing; unpleasant mouth odor fever; cough
Preop: assess for presence of infection assess bleeding and clotting studies assess for loose teeth prepare the child for a sore throat
Postoperatively:
Position prone or side lying to facilitate drainage
have suction equipment available monitor for signs of hemorrhage may give apply ice collar discourage coughing or clearing the throat provide clear, cool, noncitrus and non carbonated drinks avoid milk products intially will coat the throat avoid red liquids do not give child any straw, forks, or sharp objects administer paracetamol as ordered instruct parents to notify MD if bleeding, persistent earache or fever
occurs
instruct parents to keep child away from crowds until healing occurred
HEMATOLOGIC SYSTEM
LEUKEMIA the most frequent type of childhood cancerBrain tumors 2nd
Etiology:1. Environmental
2. Viruses3. Familial/genetic
4. Host factors
STAGES OF TREATMENT1. 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
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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
5. LATE EFFECTS OF TREATMENT
Impaired growth and development
CNS damage
Impaired pubertal development
Development of secondary malignancy
Psychologic problems related to living with a life threatening disease and
complex treatment regimen
NURSING INTERVENTION1. Help child cope with intrusive procedures
Provide information geared to developmental level and emotional
readiness
Explain what is going to happen, why it is necessary, how it will feel
Allow child to handle to handle and manipulate equipments
Allow child some control in situations
- positioning, selecting injection site
2. Support child and parents
Maintain frequent clinical conferences to keep all informed
Always tell the truth
Acknowledge feelings and encourage child/family to express them
Provide contact with another parent or support group
3. Minimize side effects of treatmenta. Skin breakdown
Keep clean and dry; wash with warm water; no soaps or creams
Do not wash off radiation marks Avoid all topical agents with alcohol
Do not use heating pads or hot water bottle
b. Bone marrow suppression
Provide frequent rest periods
Avoid crowds
Evaluate any potential site of infection
Monitor temperature
Avoid use of aspirin
Select activities that are physically safe
c. Nausea and vomiting
Administer antiemetic at least half an hour before chemotherapy
Eat light meal prior to administration of therapy
Administer IVF if needed
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d. Alopecia
Reduce trauma of hair loss
Buy wig before hair falls out
Discuss various head coverings
Avoid exposing head to sunlight
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
2. Acute nonlymphocytic leukemia
Includes granulocytic and monocytic types
60-80% will obtain remission
30-40% cure rate
Assessment:1. anemia, weakness, pallor, dyspnea
2. Bleeding, petecchiae, spontaneous bleeding, ecchymoses3. Infection, fever, malaise4. Enlarged lymph node5. Enlarged spleen and liver6. Bone pain
Management:1. diagnosis: blood studies, BMA2. Treatment stagesa. Inductionb. CNS prophylaxis
c. Maintenance
Nursing Intervention:1. Provide care for the child receiving chemo and radiotherapy2. Provide support for the family/child3. Support child during painful proceduresa. Use distraction, guided imagery
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b. Allow the child to retain as much control as possiblec. Administer sedation prior to procedure as ordered
Sickle Cell Disease
hemoglobin A is partly or completely replaced by abnormal sickle
hemoglobin (HgbS) HgbS sensitive to changes in the oxygen content of the red blood cell
Risk factors: African American
Insufficient oxygen causes the cells to assume a sickle shape and thecells become rigid and clumped together, obstructing capillary blood flow
The sickling response reversible under adequate oxygenation
Sickle cell crises vaso-occlusive crisis, splenic sequestration, aplasticcrisis
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 asprescribed and with oralfluids
Assist the child to assume a comfortable position so that the child keepsthe extremities extendedto bed no more than 30 degrees
avoid putting strain on painful joints
encourage consumption of a high calorie, high protein diet with folic acidsupplementation
administer antibiotics as prescribed
Monitor for signs of increasing anemia and shock (pallor, vital signchanges)
IRON DEFICIENCY ANEMIA
Iron stores are depleted, resulting in a decreased supply of iron for the
manufacture for themanufacture of hemoglobin in RBCs
Results from blood loss, increased metabolic demands, syndromes of GImalabsorption, dietaryinadequacy
Assessment:
pallor
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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 arresteddevelopment of RBCs within the bone marrow
causes: exposure to toxic agents, viruses, infection, autoimmunedisorders, allergic states
definitive diagnosis: BMA
Therapeutic management: blood transfusions, splenectomy,corticosteroids, immunosuppressive therapy, bone marrow transplantation
Assessment
Pancytopenia
Petecchiae, purpura, bleeding, pallor, weakness, tachycardia andfatigue
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 thecarrier status from their
fathers
Assessment:
prolonged bleeding after minor injury1. At birth after cutting cord2. Following circumcision3. Following IM immunization4. 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 /cryoprecipitatea. Thaw slowlyb. Gently rotate bottle
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c. Infuse immediately; deteriorates at room temperature
monitor for bleeding
monitor for joint pain; immobilize the affected extremity if joint painoccurs
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
BETA THALASSEMIA MAJOR
Cooleys anemia
autosomal recessive disorder
characterized by reduced production of one of the globin chains in the
synthesis of hemoglobin incidence highest in Mediterranean descent
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
IDIOPATHIC THROMBOCYTOPENIC PURPURA
increased destruction of platelets with resultant platelet count less than100,000/mm3
characterized by petechiae and ecchymoses of skin
exact mechanism unknown often preceded by a viral illness
spleen not enlarge
Assessment:
petechiae: spider web appearance of bleeding under the skin due tosmall 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
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control bleeding1. Administer platelet transfusion as ordered2. Apply pressure to bleeding sites as needed3. 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 sitefor 5 mins
Avoid aspirin
Provide client teaching and discharge planning1. Pad crib and playpen2. Provide soft toys3. Provide protective headgear during toddlerhood4. 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 childs 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 childs nails short; use elbow or glove restraints if needed apply wet saline or Burrows solution compresses
DIAPER RASH
contact dermatitis
plastic/rubber pants and linings of disposable diapers
exacerbate the condition by prolonging contact with
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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 hygiene2. Avoid use of plastic pants or disposable diapers with a plastic lining3. Avoid commercially prepared diaper wipes containing alcohols
4. Avoid cornstarch; good medium for bacteria
MUSCULOSKELETAL SYSTEM
Care of the child with a Cast
if cast is of plaster will remain wet for at least 24 hrs use only the flats of their hands to move children casts must remain open to the air until dry
casted extremities are elevated to help blood return and reduce swelling Initial chemical hardening reaction may cause a change in an infants
body Choose toys too big to fit down cast do not use baby powder near cast medium for bacteria prepare for anticipated casting by having child help apply cast in a doll
Diagnoses and interventions:
1. Potential for alteration in tissue perfusion related to constriction of cast Check color, sensation and motion distal to the cast every half hour
Check pedal or radial pulse Check for tightness by slipping finger under edge; if impossible cast is
too tight Ask child to move toes or fingers Elevate casted extremity
2. Potential for alteration in skin integrity Remove plaster flakes from skin Handle wet cast carefully so as not to cause indentations Expose wet cast to air to hasten drying Support heavy cast with sling or pillow to decrease pressure of cast edges
Check cast for foul or musty odors
3. Potential for fear and loneliness Encourage expression of feelings Provide diversional play Encourage friends and family to visit children as often Provide educational opportunity for children confined for long periods
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4. Potential for knowledge deficit of family Encourage discussion of feelings and fears Provide information and reassurance as appropriate Involve family in childs care in hospital Prepare family for some emotional regression
CONGENITAL HIP DISLOCATION displacement of the head of the femur from the acetabulum present at birth although not always diagnosed familial disorder unknown cause; may be fetal position in utero acetabulum is shallow and the head of femur is cartilaginous at birth
Assessment: maybe unilateral or bilateral limitation of abduction (cannot spread legs to change diaper)
Ortolanis clicka. With an infant supine, bend knees and place thumb on bent knees,fingers at hip joint
b. Bring femur 90degrees to hip, then abductc. Palpable click dislocation Barlows testa. With infant on back, bend kneesb. 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 walka. Have child stand on affected leg onlyb. 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 abducted1. Use triple diapering2. Use Frejka pillow splint (jumperlike suit to keep legs abducted)3. Place infant on abdomen with legs in frog position4. 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 otherValgus outward rotationCalcaneous upward rotation; would walk on heelsEquinas downward rotation; would walk on toes
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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 kneesstraight 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 bracea. Child wears brace 23 hours/dayb. Monitor pressure pointsc. 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 instructionsa. Exerciseb. Cast carec. Correct body mechanicsd. Alternative education for long term hospitalizatione. Availability of community agencies
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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 prognosis3. Systemic disease with polyarthritis (Stills 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:
Assess joints for pain, swelling, tenderness promote maintenance of joint mobility
a. ROM exercisesb. Isometric exercises change position frequently; alternate sitting, standing, lying promote comfort and relief provide firm mattress maintain proper body alignment keep joints mainly in extension, not flexion cold treatments: in acute episodes focus on childs strength
GENITOURINARY SYSTEM
Nephrons continue to develop after birth
GFR is 30% below adult level at birth
reaches normal level by age 2 years
tubular function immature at birth; reach adult levelby age 2 years
urethra shorter in children and more prone to ascending
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infection
UNDESCENDED TESTES (Cryptorchidism)
unilateral or bilateral absence of testes in scrotal sac
testes normally descend at 8 months of gestation
increased incidence in those with genetic disorder 75% will descend spontaneously by age 1 year
Assessment:
unable to palpate testes in scrotal sac
Management:
if testes remains in abdomen, damage to testes is possible because ofincreased
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 overthe glans penis
may be present at birth or may develop as a result of poor hygiene withaccumulation of smegma
Management: Prevention regular pulling the foreskin back and cleaning
circumcision
Nursing intervention:
circumcision care:1. Close observation for bleeding
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2. Ice application3. 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 control2. 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 disturbances2. Delayed neurologic development
3. Immature development of bladder4. Psychologic problems
Assessment:
PE normal
History of repeated voluntary urination management:
bladder retention exercises
drug therapy1. TCA imipramine2. Anticholinergics
Nursing Intervention: Provide information/counseling to family:1. Confirm that this not conscious behavior and that the child is not
purposely misbehaving2. 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 accomplishments1. Age 5-6 years can strip wet beddings2. Age 10-12 years can do laundry and change bed
Avoid scolding and belittling the child
EXSTROPHY OF THE BLADDER congenital malformation ; nonfusion of abdominal
and anterior walls of the bladder during embryologicdevelopment
anterior surface of bladder lie open on abdominal wall
Assessment:
Associated structural changes1. Prolapsed rectum2. Inguinal hernia3. Widely split symphysis
4. Rotated hips
Associated anomalies1. Epispadias2. Cleft scrotum or clitoris3. Undescended testes4. Chordee (downward deflection of the penis)
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Management:
reconstructive surgery
urinary diversion
delayed until 3-6 months
Nursing intervention: Preop:
Provide bladder care; prevent infectiona. Keep area as clean as possibleb. Change diaper frequently; keep loose fittingc. Wash with mild soap and waterd. Cover exposed bladder with vaseline gauze
Postop:
Design play activities to foster toddlers 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. Proteinuria2. Hypoproteinemia3. Hyperlipidemia4. Dependent edema
Puffiness around the eyes in morning
Ascites
Scrotal edema
Ankle edema5. anorexia, vomiting, diarrhea6. Pallor, lethargy7. Hepatomegaly
Management:
drug therapy1. Corticosteroids2. Antibiotics3. Thiazide diuretics
Nursing Intervention:
Provide bed rest1. Conserve energy2. Find activities for quiet play
Provide high protein, low sodium diet during edema phase
Maintain skin integrity
Avoid IM injections meds not absorbed in edematous tissues
Obtain morning urine for protein studies
Provide scrotal support
Monitor I and O, vital signs
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Daily weight
Administer as ordered
Protect from sources of infection
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, lethargy3. Hematuria or dark colored urine4. Fever
5. Hypertension6. 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 daily3. Provide diversional activity4. Provide client teaching and discharge planning
Medication administration
Prevention of infection Signs of renal complications
Importance of long term follow up
WILMS TUMOR (NEPHROBLASTOMA)
large, encapsulated tumor that develops in the renal parenchyma,
more frequently in left kidney
originates during fetal life
peak age : 1-3 years
Assessment:
non tender mass, usually midline near liver hypertension
hematuria
test: IVP
Nursing intervention:1. Do not palpate abdomen to avoid dissemination of CA cells2. Handle child carefully when bathing and giving care
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7. Toddler headache and anorexia earliest common signs of shuntmalfunction
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 surfaces2. 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 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-adherentdressing
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
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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, precipitatingevents and behavior before and after the seizure
seizure precautions:1. Raise side rails2. Pad side rails3. Place waterproof mattress on bed4. Instruct child to swim with companion5. Alert caregivers to the need for special precautions
Emergency Treatment for Seizures:
Ensure patency of airways If the child is standing or sitting, ease the child down to the floor place pillow or folded blanket under the childs head loosen restrictive clothing clear area of any hazards if vomiting occurs, turn child to one side do not restrain child; do not place anything in the childsmouth Remain with the child until fully recovers Prepare to administer medications
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
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assess the childs 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