Overview of Child Health Nursing Child Health Nursing Focuses on protecting children from illness and injury Assists children to obtain optimal levels of wellness Primary roles of the Pediatric Nurse Care provider Educator Advocate Pediatric Health Statistics Infant Mortality Number of deaths per 1000 live births during o 1st year of life. o Infant mortality rate is an indicator of how healthy the nation is o !his rate is used to compare national health care to previous years and to other countries !here has been a great decrease in the o number of deaths over the past century In "##$% &# per "'' live births Childhood Mortality For children older than one year% death rates have always been less than those for infants In later adolescence% there is a sharp rise in deaths Injuries; the leading killer in childhood In(uries cause more death and disabilities in children than any diseases )ome e*amples include+ Motor vehicle accidents are the leading o cause of death in children over " year of age o Ma(ority of deaths are due to no use of seatbelts ,rowning is -nd leading cause of death in boys "."/0 both se*es "1.-/ years old ,rowning is the 2rd leading cause of death for girls "."/ 3urns are the -nd leading cause of death from in(ury in girls and the 2rd in boys from "."/ years old Childhood Morbidity (Illness) An illness or in(ury that limits activity% re4uires medical attention or hospitali5ation% or results in a chronic condition E*amples+ Congenital heart defects o Asthma o Cerebral 6alsy o Cystic Fibrosis o Concerned with helping to decrease these statistics as children miss school and other activities when ill d!anced Practice roles for nurses in Child health nursing Family nurse practitioner Neonatal nurse practitioner 6ediatric nurse practitioner Nurse midwife "ro#th and $e!elo%ment 7rowth+ used to show an increase in physical in physical size or size or a significant change Includes+ Height o 8eight o Head circumference o • •
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,evelopment+ 9sed to denote an increase in skill or ability to finction finction Measured by+ o Observing child do specific tas:s o 6arents description of child;s ability o 9sing standardi5ed testing <,enver II screening test= Princi%les of "ro#th and de!elo%ment 7 > , is a continuous process from birth to death ?ate of growth varies at different times o 7 > , proceeds in an orderly manner 7rowth from smaller to larger o ,evelopment+ from sitting to crawling to o wal:ing ,ifferent children pass through the predictable stages at different rates All body systems do not develop at the same time CN)% Cardiac develops 4uic:ly 4uic:ly @ungs are typically the last to develop $e!elo%ment is Cephalicaudal , which is the 2rd principle of 7 > , Head to toeB $e!elo%ment goes from proximal from proximal to distal, distal, which is the /th principle E*ample+ ,evelopment proceeds from gross to refined refined A child cannot learn tas:s until the nervous system is ready Neonatal refle*es must be lost before development can proceed &actors that influence gro#th and de!elo%ment 7enetics 7ender Health Intelligence 'em%erament Inborn in all of us A way of reacting to the world around us eaction Patterns Activity level o @evel of activity differs widely among children ?hythmicity o Have a regular rhythm is physiologic terms Approach Child;s response to a new situation o Adaptability Is the child able to adapt to new situations o Intensity of reaction ,istractibility Attention span and persistence Mood 4uality Categories of tem%erament !he EasyB Child o Easy to care for if they have predictable rhythmicity% rhythmicity% approach and easily adapt to new situations% have a mild to moderate intensity of reaction% and an overall positive mood 4uality 4uality o /'.1'D of children fall into this category !he ,ifficultB child •
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Children are difficultB if irregular in habits% have negative mood 4uality% 4uality% and withdraw from new situations "'D of children fit this image o )low to warm upB child ,escribes children who are overall fairly o inactive% respond only mildly% adapt slowly to new situations% and have a general negative mood "1D of children display this pattern o *ther factors that im%act gro#th and de!elo%ment Environment )ocioeconomic level 6arent.child relationship 6osition of birth in the family Health Nutrition As a child normally develops somewhat predictably in growth and physical development% he also matures emotionally% emotionally% intellectually% and spiritually along certain paths
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E*ample+ )ay ?oll over on your bellyB rather than 8ill you roll over on your bellyB
Physical -,am Can ta:e place almost anywhere On parents lap o On the floor o E*aminers lap o •
Conducting the e,am 6erform the least distressing procedures first and the most distressing last o Heart and lungs0 have the child lie down o Abdomen% throat% and ears
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Physical e,am techni.ue Inspection o Observe before you touch Auscultation 9se diaphragm of stethoscope for high o pitched sounds
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Eri:son;s theory of 6sychosocial development 6iaget;s theory of cognitive development ohlberg;s theory of Moral development
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Assessment of the Child +asic Princi%les now norms0 child vs adult A > 6 variations are farthest from adult norms at birth Most of these variations mature 4uic:ly in o the first year o 3y 1.$ years of age% body is that of a )mall adultB0 however% a child is not a miniature adult and should not be treated as such As a child normally develops somewhat predictably in growth and physical development% he also matures emotionally% emotionally% intellectually% and spiritually along certain paths !ry to see the child;s world and body through hisher mind If you do this% you will connect with the child • •
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%%roach to e,am Always thin: of where the child is developmentally developmentally Approach must be individuali5ed 9sually the child will be frightened and an*ious May lac: verbal s:ills to e*press fear or as: for information 9se both hands on child when possible G comforting touch o 6lace left hand on shoulder while auscultating the heart o Move unhesitatingly% firmly% and gracefully gracefully o !al: pleasantly and reassuringly Instructions to the child+ o 9se a directive voice o Have specific instructions o ,o not as:% but instead tell a child • • •
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'he general sur!ey ital signs 7eneral appearance Mental status 3ody measurements • • • •
/ital signs !emperature 3ody temperature in infants is less constant o than in adults 9se a*tympanic for children less than / o years of age o alues alues are the same as in adults A*illary+ hold child;s arm firmly !ympanic+ @ess than 2 years of age o Insert gently into ear 6ull down on ear o Over 2 years of age 6ull up on ear ?ectal temperature o Most hospitals are done only with doctors order% or there is a standing order @ubricate tip well o Insert " inch o •
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6ulse Apical is best o May use femoral arteries% brachial arteries o ?adials only in older children
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"eneral a%%earance !o form a general impression of child;s health and well.being !o pin.point specific areas that may re4uire more detailed assessment
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Child cries or clings to %arent Ignore the child temporarily Engage the parents in conversation% then place a small game% toy% or your stethoscope within reach of the child while continuing your discussion • •
Mental status Is the child alert Able to respond to 4uestions easily Assess appropriateness of behavior Assess memory • • • •
ssessing "ro#th1+ody measurements Height% weight% head circumferenceKimportant indicators of growth Measured and plotted on standard growth charts !hese charts are used to determine if the babychild;s growth is falling within the accepted percentile for age •
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Initial obser!ations ,egree of illness or wellness Mood )tate of nutrition )peech% cry% facial e*pression% posture Apparent chronological and emotional age ?espiratory pattern 6arent and child interaction • • • • • • •
Parent and child interaction Amount of separation tolerated ,isplays of affection ?esponse to discipline @oo: for signs of+ • • • •
3irth to 2& months Fully e*tend the body by+ o Holding the head midline 7rasping the :nees together gently 6ushing down on the :nees until the legs are fully e*tended and flat against the table o Hold pencil at right angle to the table and mar: the head and toes
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An*ious parents ,isengaged parents )tressed families 6ossible abusive parents
Child;s bac: is to the wall% with heels% buttoc:s% and bac: of the shoulders touching the wall and the medial melleoli touching if possible Chec: for bending of the :nees% slumping of the shoulders% or raising the heels of the feet
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3irth to 2& months% weigh nude Older children with panties and light gown 3alance
Head circumference Measure at greatest circumference )lightly above the eyebrows and pinna of the ears o Around the occipital prominence at the bac: of the s:ull Compare to 2& months o • •
$en!er $e!elo%mental !he standard for measuring the attainment of developmental milestones throughout infancy and childhood ,esigned for birth to & years •
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Includes screening for+ o 6ersonal social s:ills o Fine motor adaptive o @anguage o 7ross motor ,enver screening for articulation and eyes
-,am%le of $$S' for *ne year of age 6ersonal)ocial ,rin: from a cup% imitate activities% play ball o with e*aminer% e*aminer% indicate wants% play pat.a. ca:e Fine motoradaptive )cribbles% puts bloc: in cup o @anguage ,adaMama specific% one word o 7ross motor )tands alone o •
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Encourage the child to blow outB your light% in your pen light or flashlight !his will almost always produce full inspiration
Care for the Hospitali5ed child "eneral communication guidelines 6ay attention to infants and younger children c hildren through play or by occasionally directing 4uestions or remar:s to them Include older children as active participants 8ith children of all ages% the nonverbal components of the message conveys the most Communicate at the child;s level ,evelopmentally and physically o
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Communication "uidelines Allow children time to feel comfortable Avoid sudden or rapid movements, e*tended eye contact% or other gestures that may be seen as threatening !al: to the parent if the child is initially shy Communicate through puppets% dolls% or stuffed animals before 4uestioning a young child directly directly 7ive older children the opportunity to tal: without the parents present )pea: in a 4uiet% unhurried% and confident voice )pea: clearly% be specific% and use simple words and short sentences 3e honest with children Offer a choice only when one e*ists Allow them to e*press their concerns and fears 9se a variety of communication c ommunication techni4ues0 if one techni4ue doesn;t wor:% try another •
More on $$S' Only a measure of developmental attainmentKnot a measure of intelligence Not a highly specific test o Most normal children score as normal Not very sensitive Many children with mild developmental o delays also score normal Only a screening test Other more sophisticated tests are available if delay is suspected even when ,,)! is normal •
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Heart Murmurs 1'D of all children develop an innocent heart murmur at some point during childhood It is usually not something to be overly concerned about unless there are other symptoms Must be determines if murmur is normal0 therefore always report when one is heard •
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bdomen 6rotuberant abdomen is typical in most children until adolescence adolescence If child is tic:lish on palpation% hold hisher hand over yours to reduce apprehension and increase rela*ation of the abdominal musculature
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Neuromuscular If possible% watch the child standing upright Have them wal:% stoop% and touch their toes Chec:ing for scoliosis
One month to one year old Eri:son;s developmental tas:+ Trust vs. Mistrust !as:+ Attachment to the mother o ?esolution of crisis+ !rust in persons0 faith o and hope about the environment and future 9nsuccessful resolution of crisis+ 7eneral o difficulties relating to person;s effectively0 suspicion0 trust.fear conflict% fear of the future
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Infant communication Forms first social relationships Communicates needs and feelings through nonverbal behaviors and vocali5ations o )mile and coo when content o Cry when distressedKhunger% pain% body restraint% loneliness ?espond to adults; nonverbal behaviors o 3ecome 4uiet when cuddled% patted% or receive other forms of gentle% physical contact 7et comfort from the sound of voiceK o usually respond to any gentle firm handling until they reach the age of stranger an*iety <1.J months= • •
More tidbits Always thin: of child;s development when assessing now the 36 and pulse variations 8hen there is an abnormal finding G A@8A A@8AL) L) gather more data 8eight is a huge concern for children Many medications are weight dependent !he ,enver ,evelopmental is not very precise0 it;s more of a screening tool As it says% the ,enver ,evelopmental is only developmentalKnot a cognitive or an I test For breath sounds+ • • •
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Infant Stressors of Hos%itali4ation )eparation an*iety )tranger an*iety 6ainful% invasive procedures Immobili5ation
Are usually more at ease upright than hori5ontal
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&ear of %rocedures5inter!entions ,uring procedure% use sensory soothing soothing measures <)tro:ing s:in% tal:ing softly% giving pacifier= Cuddle and hug after stressful procedure or encourage parent to do so if present Older infants may associate ob(ects% places% or persons with prior painful e*periences and will cry and resist at the sight of them eep frightful ob(ects out of view o 6erform painful procedures in separate o room% not in crib% o 9se non.intrusive procedures whenever possible •
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Se%aration n,iety Occurs as early as / months old0 infants face shows disapproval as primary caregiver wal:s away !hree stages of separation an*iety+ o 6rotest Cries loudly0 re(ects attempt to be comforted by anyone but the caregiver ,espair o Crying stops and depression is evident Much less active 9ninterested in food or play 8ithdraws from others ,etachment
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Stranger an,iety Occurs as early as 1 months 9sually pea:s at J months 3ehaviors e*hibited by infant+ Cries o )creams o )earches for parent with eyes o Clings to parent o Avoids and re(ects contact with strangers o Interventions for stranger an*iety+ Holding out hands and as:ing the child to o comeB will usually not wor: If infant must be handled% better to pic: up firmly without gestures o Observe position in which parents hold infant and imitate this Hold infants where they can see their o parents • • •
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Immobili4ation Infants e*plore life through activity and mobility If ta:en away+ o Feel helpless o May have difficulty with language s:ills o May have problems mastering developmental tas:s o 6roblems with motor s:ills o Immobility impacts development Immobili5ation interventions+ o 6lay therapy o !ransport infant outside of room by wagon of by carrying )pend time interacting with infant o Encourage caregivers to do the same o •
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Ages one to three years old Eri:son;s developmental tas:+ Autonomy tas:+ Autonomy vs. shame and doubt. !as:+ 7aining some basic control over self o and environment o ?esolution of Crisis+ )ense of self.control and ade4uacy0 will power o 9nsuccessful resolution of crisis+ Independence.fear conflict0 severe feelings of self.doubt ,eveloping a sense of autonomy He wants to ma:e choices and li:e the word NoB Is egocentric Focus communication on toddler o !oddler not interested in the e*periences of others
Stressors of hos%itali4ation )eparation an*iety @oss of control 6ainful% invasive procedures 3odily in(ury Fear of dar: • • • • •
Se%aration an,iety erbally attac: stranger <7o awayB= May physically attac: stranger <:ic:s% bites% hits= !ries to escape to find parent • • •
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Se%aration an,iety5inter!entions Child;s reaction to separation o !oddler might ignore parent Other strategies are same as for infant Feels more secure with familiar item Allow them to touch and e*amine articles that will come into contact with them 3e direct and concrete !hey interpret words literally literally •
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2oss of control ery threatening to the toddler Many hospital situations decrease amount of control a child feels @oss of control occurs due to+ o ?estriction or limitation of movement o Altered routines and rituals Eating !oileting )leeping 3athing 6lay 8hen routines are disrupted% problems can o occur in these areas Interventions 6romote freedom of movement o Encourage parent.child contact !ransport in carriage% wheelchair% carts% etc Maintain child;s routine Encourage as much independence as possible
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+odily Injury1In!asi!e %rocedures Concept of body very poor Intrusive procedures
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?esolution of Crisis+ ability to initiate one;s own activities0 sense of purpose 9nsuccessful resolution of crisis+ o aggression.fear conflict0 sense of inade4uacy or guilt ,eveloping a sense of initiative 6reschooler is+ o Egocentric Has increased language s:ills o Concept of time and frustration tolerance is o limited o Illness and hospitali5ation may be viewed as punishment o
&ears of hos%itali4ation )eparation an*iety and fear of abandonment @oss of control 3odily in(ury 6ainful% invasive procedures Fears of the dar:% ghosts% monsters • • • • •
Se%aration an,iety6 %reschooler !olerate separation better than toddlers0 may develop substitute trust in other significant adults However% they may show other behaviors+ ?efuse to eat o Have difficulty sleeping o Cry 4uietly for parents o Constantly as: when parent will be visiting o May e*press anger o Interventions+ Have parents bring in familiar articles from o homeKpicturesradio If child has attachment to special item% have o it brought in o )ame strategies for toddlers •
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2oss of control Egocentric and magical thinking; perception thinking; perception of actual events are more frightening !ypical fantasy+ Illness is a punishment for o their misdeeds 6urely verbal instructions do not help them% have them practice on doll or toy toy •
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&ear of the dark eep night light on in room at all times Encourage parents to room.in with child • •
Preschool 2.& years of age Eri:son;s developmental tas:+ Initiative vs. Guilt o !as:+ 3ecoming purposeful and directive • •
+odily injury Differentiate poorly between themselves and outside world . Fear of mutilation !a:e things literally )tic: for bloodB Fear if when given a shot% when needle is removed% their insides will lea: everywhere
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Inter!entions 6oint out on drawing% doll% or child where procedure is performed Emphasi5e that no other body part will be involved 9se non.intrusive procedures when possible Apply adhesive bandage over puncture site Encourage parental presence Allow child to wear underpants with gown •
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E*plain unfamiliar situations% especially noise or lights Involve child in care whenever possible
School age child &."- years old Eri:son;s developmental tas:+ Industry vs. Inferiority !as:+ developing social% physical% and school o s:ills o ?esolution of Crisis+ competence% ability to learn and wor: o 9nsuccessful resolution of crisis+ )ense of inferiority0 difficulty learning and wor:ing ,eveloping a sense of industry and concrete thought Has increased language s:ill o Interest in ac4uiring :nowledge o Improved concept of time o Increased self.control o ,eveloping relationships with peers0 peers are very important at this stage 9sually will want e*planations and reasons for why things are being done 8ant to :now more about procedures% activities% and ob(ects Have a greater concern for privacy and body integrity 9sually easier to communicate with than previous age groups Concrete thin:ers0 no abstract thought o • •
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dolescent Ages "-.-' years Eri:son;s developmental tas:+ Identity vs. Role confusion !as:+ developing sense of identity o ?esolution of Crisis+ sense of personal o identity o 9nsuccessful resolution of crisis+ confusion about who one is0 identity submerged in relationships or group memberships ,eveloping a sense of identity and abstract thought Fluctuate between child and adult thin:ing and behavior Need to e*press their feelings% for some this o comes easily% for others it does not Ma(or sources of concern for this age group o are attitudes and feelings toward se*% substance abuse% relationships with parents% peer.group acceptance% and developing a sense of identity identity • •
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Stressors of hos%itali4ation @oss of control Altered body image% disfigurement o ,o not want to loo: different )eparation from peer group @oss of control Anything that interferes with sense of o independence o 6atient role fosters dependency o May withdraw% be uncooperative% angry% frustrated Altered body image o ery relevant at this stage o Any change that ma:es them different from peers is seen as a ma(or tragedy Insecure with their bodies due to the many o changes May react with :now it allB attitude
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Stressors of hos%itali4ation )eparation an*iety @oss of control 3odily in(ury 6ainful% invasive procedures Fear of death • • • • •
Se%aration an,iety Lounger school age children miss their parents more than older children Middlelate react more to separation from peers and usual activities o May feel lonely% bored% isolated% depressed due to separation% not the illness May try to be brave and strongB o May be irritable with parents o Interventions o Ma:e environment as home.li:e as possible Continue school lessons Have friends visit or call on phone ,ecorate walls with cards •
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+odily injury @ess concerned with pain% more concerned about disability or death !a:e very active interest in their health ?e4uest facts •
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In!asi!e %rocedures
Cystic Fibrosis -%idemiology Affects appro*imately 2'%''' children and adults in the 9) today or " in -1'' live births Occurs most commonly in whites% rarely in blac:s and Asians More than "' million Americans <" in 2" or 22D= are symptom free carriers of the defective CF gene •
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Sur!i!al
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In "#11% few children with CF lived to attend elementary school !oday% !oday% the median age of survival is 2- years In this decade% many CF survive into their /';s
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-tiology • •
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An inherited
3hat are e,ocrine glands7 7lands that secrete things such as+ @ungs o 6ancreas o )weat glands o )alivary glands o ,igestive glands o •
Patho%hysiology CF causes the body to produce an abnormally thic:% stic:y mucus which+ o Clogs the lungs and leads to life.threatening lung infections0 Obstructs the pancreas% preventing en5ymes o from reaching the intestine to help brea: down and digest food 6rimary symptoms+ o !hic:% stic:y mucus o )alty taste on s:in Mar:ed electrolyte changes in sweat glands o Chloride in sweat is -.1 above normal •
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!hic: secretions mi* with pancreatic en5ymes and bloc: the pancreatic duct !herefore+ o Essential pancreatic en5ymes cannot flow into the duodenum to aid with digestion
Sym%toms related to Pancreatic In!ol!ement 6rotuberant abdomen because bul: of stool is setting in the intestines )igns of malnutritionKonly benefit from 1'D of food ta:en in Fat soluble vitamins are not absorbed A% ,% E% In infants% thic:% stic:y stools
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2ung in!ol!ement !hic: tenacious mucus polls in the bronchial tree and obstructs bronchioles ?esults in+ 3ronchiectasis+ Chronic dilation of the o bronchi Involves a chronic cough that produces mucopurulent sputum Over time results in destruction of the bronchial walls o 6neumonia+ "taph #ureus, pseudomona$s, and %. &nfluenzae )ymptoms over time include+ Clubbing of fingers o Clubbing is related to lac: of tissue perfusion •
S#eat gland in!ol!ement 'he structure of the sweat glands is not changed, however( @evel of chloride to sodium in the perspiration is increased - G 1 times above normal )ome parents report they :new their newborn had the disease because when they :issed their child they could taste such strong salt in their perspiration •
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Sym%toms o!er time Easily fatigued 6hysical growth stunted Chest may become enlarged from over inflation of alveoli because air cannot be pushed past the thic: mucus on e*piration
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Pancreas in!ol!ement
Ho# is C& diagnosed7 3y the history
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Common com%laints that bring these %atient to the doctor Newborn that loses 1."'D of weight after birth but does not gain it bac: Feeding problemsK:ids are always hungry because of their poor digestive function Fre4uent respiratory infections Cough •
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$iagnostic tests A sweat test is a test for the chloride c ontent of sweat Infants may not be tested until &.J wee:s of age
A level of 1'.&' mE4@ suggests CFKtest is repeated A level P&' mE4@ CF o ,uodenal analysis of secretions for detection of pancreatic en5ymes )tool analysis+ for fat content
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'hera%eutic management Maintain respiratory function o eep bronchial secretions as moist as possible to facilitate drainage+ Moistened o*ygen+ O*ygen is supplied to children by mas:% prongs% ventilators% or neubuli5ers% and rarely by tent Aerosol therapy. 2./ timesday via neubuli5er to provide antibiotics and bronchodilators o Never give cough syrups or codeine Aggressive chest physiotherapy. usually needed 2./ times a day Activity. need fre4uent position changes% especially when in bed Helps facilitate facilitate drainage of various lobes% as well as prevent s:in brea:down ?espiratory hygiene+ fre4uent mouth care% toothbrushing and good.tasting mouthwash Need fre4uent chec:.ups and current immuni5ationsvaccines Ade4uate rest and comfort o ,yspnea can lead to e*haustion o Need periods of rest during the day+ ?est period before meals so not too tired to eat ?est periods before chest physiotherapy 6romote optimal nutrition 6ancreatic en5yme supplements with meals o and snac:s 6ancreatic en5yme+ Cota5ym or pancrease Comes in large capsule which can be opened and dissolved in a tsp of food Children usually begin to gain weight% and stools decrease in si5e and foul odor o High calorie% high protein% moderate fat diet o Multivitamins and E% others when deficient ,uring hot months% e*tra salt may be added to food to replace that which is lost through perspiration eep room temp at $- degrees and have water available at all times 6arents need to supervise :ids playing outdoors to prevent overheating overheating eep well hydrated all of the time •
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?ectal prolapse in infants from straining to pass hard stool @oss of blood supply to prolapsed rectal mucosa can occur if not replaced promptly and properly Hypercapniarespiratory acidosis from inability to ade4uately e*hale carbon dio*ide E*haustion% slow growth patterns ):in irritation in diaper area from stool that is irritating due to acidic nature of stools )ociali5ation and peer acceptance difficulties Cor 6ulmonale
Parental in!ol!ement 6arents assume a great deal of responsibility when ta:ing care of a CF child Need to encourage a balance of wor:% the o child% and the rest of the family o Encourage involvement of support group o ?e4uires e*tensive involvement of the discharge planner •
Nursing $iagnoses Ineffective airway clearance rt thic: mucus in the lungs Ineffective breathing pattern rt thic: tracheobronchial secretions and airway obstruction High ris: for infection rt presence of mucus secretions conductive to bacterial growth Altered nutrition+ @ess than body re4uirements rt inability to digest nutrients FearAn*iety
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Summary CF is an inherited genetic genetic disorder Causes the e)ocrine glands to produce thic: secretions 6rimary body organs involved are lungs and pancreas. 6rone to respiratory infections rt mucus. ,igestion problems rt pancreatic rt pancreatic enzymes. !reatment centers around control and management No cure for the disease disease • •
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-riksons Stages
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Infant Com%lications Infertility in males related to bloc:ing of vas deferens from tenacious seminal fluid Infertility in females related to tenacious cervical secretions that bloc: sperm penetration •
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One month to one year old Eri:son;s developmental tas:+ Trust vs. Mistrust o !as:+ Attachment to the mother o ?esolution of crisis+ !rust in persons0 faith and hope about the environment and future
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9nsuccessful resolution of crisis+ 7eneral difficulties relating to person;s effectively0 suspicion0 trust.fear conflict% fear of the future ,evelopmental tas:s+ @earning to eat solid foods
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Ages one to three years old Eri:son;s developmental tas:+ Autonomy tas:+ Autonomy vs. shame and doubt. o !as:+ 7aining some basic control over self and environment o ?esolution of Crisis+ )ense of self.control and ade4uacy0 will power 9nsuccessful resolution of crisis+ o Independence.fear conflict0 severe feelings of self.doubt o ,evelopmental tas:s+ @earning to wal: @earning to use fine muscles !oilet training @earning to communicate
Preschool 2.& years of age Eri:son;s developmental tas:+ Initiative vs. Guilt o !as:+ 3ecoming purposeful and directive o ?esolution of Crisis+ ability to initiate one;s own activities0 sense of purpose 9nsuccessful resolution of crisis+ o aggression.fear conflict0 sense of inade4uacy or guilt o ,evelopmental tas:s+ Independence of self.care @earning se*ual role identity Forming reality concepts Internali5ing concepts of right and wrong @earning to identify with family members and others
Eri:son;s developmental tas:+ Identity vs. Role confusion o !as:+ developing sense of identity o ?esolution of Crisis+ sense of personal identity 9nsuccessful resolution of crisis+ confusion o about who one is0 identity submerged in relationships or group memberships o ,evelopmental tas:s+ Forming peer relationships ?esponding to an appropriate se*ual role Attaining emotional independence Achieving a sense of economic independence
Cardiac defects in children Alteration in Fluid.gas transport Cardiac $efects in children ,ivided into two ma(or groups+ *ongenital cardiac defects o #c+uired heart disease o •
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School age child &."- years old Eri:son;s developmental tas:+ Industry vs. Inferiority !as:+ developing social% physical% and school o s:ills ?esolution of Crisis+ competence% ability to o learn and wor: o 9nsuccessful resolution of crisis+ )ense of inferiority0 difficulty learning and wor:ing o ,evelopmental tas:s+ Ac4uiring game s:ills @earning to relate positively with peers 3uilding a wholesome self.concept ?efining communication s:ills • •
dolescent Ages "-.-' years •
Congenital Heart $isease Anatomic abnormality present at birth0 the heart has not developed as it should in utero !hus% the heart is unable to ad(ust to life outside of mom ?esults in abnormal cardiac cardiac function •
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c.uired Cardiac disease Abnormalities that occur after birth Can occur by self o Can occur with other congenital heart o defects E*ample0 ?heumatic disease is the - nd o largest cause of cardiac problems in children over 1= •
+oth congenital and ac.uired heart disorders can lead to heart failure ssessment of cardiac function History History of heart disease in the family o Contact with :nown teratogens% such as o rubella during pregnancy o 6resence of chromosomal abnormalities <,own;s= o 6oor weight gain andor feeding behavior o E*ercise intolerance andor fatigue during feeds )weating during feeding o Fre4uent respiratory infections o ?espiratory difficulties% such as tachypnea% o dyspnea% and shortness of breath ?ecent streptococcal infection
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3egins with observation of general appearance% then the specifics 9se general assessment techni4ues but loo: o specifically for the following+ Inspection+ o Nutritional state+ failure to thrive or thrive or poor weight gain ):in color+ cyanosis and pallor Chest deformities. enlarged heart 9nusual pulsations of nec: veins seen in some patients ?espiratory pattern. tachypnea% dyspnea% presense of e*piratory grunt Clubbing of fingers
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Although done fre4uently% there are some ris:s !ypical reactions include+ o Acute hemorrhage from entry site
Post catheteri4ation care Are usually on a cardiac monitor and pulse o*imeter for the first few hours of recovery now the baseline pulse36 before the procedure to compare Most important nursing responsibility is observation of the following for signs of complications+ o ulses, especially below the catheterization site, for e+uality and symmetry -pulse just distal to site may be weaker for the first few hours but gradually increase in strength. •
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*bser!ations of !emperature and color of the affected e*tremity Coolness or blanching may indicate arterial obstruction ital signs are ta:en every "1 minutes )pecial emphasis on heart rate Must take for one full minute. Assess blood pressure% especially for hypotension Hypotension could indicate+ o Hemorrhage !oo much medication ,ehydration ,ressing% for evidence of bleeding Fluid inta:e% both I and oral% to ensure ade4uate hydration o ?emember sensible and insensible fluid loss
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Inter!entions Child must :eep e*tremity straight /.& hours after venous catheteri5ation and &.J hours for arterial cath Child;s diet can be resumed as soon as tolerating sips of clear li4uid eep site clean and dry Encourage child to void •
Cardiac catheri4ation ?adiopa4ue catheter is inserted through peripheral blood vessel into heart Contrast material is in(ected and films ta:en o
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Congenital heart disease Incidence+ /."' per "''' live births !he ma(or cause of death in the first year of life o Other than prematuritylow birth weight More than 21 well recogni5ed defects • •
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Pre%aration for Cardiac cath
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)tatistics improving due to more surgeriestreatments that help prevent death
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Most of this blood shunts through the ductus arteriosis into descending aorta% and bac: into the placenta
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Not :nown in #'D of cases Factors associated+ Maternal rubella during pregnancy o Maternal alcoholism o Maternal age over /' o Maternal insulin.dependent diabetes o More li:ely to have other defects such as ,own syndrome
Circulatory changes at birth In order to understand the pathophysiology of cardiac defects% it is important to understand fetal circulation and the changes that occur at birth •
e!ie# of %renatal circulation6 8 essential structures ,uctus venosus <,=+ opening between umbilical vein and inferior vena cava !he ductus venosus is a vessel that allows o blood to bypass the fetusQs liver It carries blood with o*ygen and nutrients from the umbilical cord straight to the right side
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+irth changes Infant cries% lungs e*pand ,uctus arteriosis closes as resistance decreases though the pulmonary vasculature
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+irth changes9 summary ,uctus venosus Clots to form ligamentus teres o Foramen ovale Closes to form interatrial septum o ,uctus arteriosis Closes to form ligamentum arteriosus o •
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ltered hemodynamics Important to remember pressure gradients as blood will always flow
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Congenital heart defects 9sual causeKheart structure fails to progress beyond earlier 8as once classified as CyanoticB and AcyanoticB New classifications below •
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Pur%ose of these structures Allow most of blood to bypass the liver and lungs •
&etal circulation O*ygenated blood from placenta to ductus venosus inferior vena cava right atrium 3lood then shunts over to the left atrium through the foramen ovale !hen over to the left ventricle aorta heade*tremities •
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!he uno*ygenated blood returns to the right atrium via the superior vena cava flows into the right ventricle e*its thought the pulmonary artery
Classification of Congenital heart disease Increase in pulmonary blood flow ,ecrease in pulmonary blood flow Obstruction to blood flow from ventricles Mi*ed blood flow • • • •
$efects #ith increased %ulmonary blood flo# entricular entricul ar septal defect Hole between the ventricles o Atrial septal defect Hole between the atria;s o 6atent ,uctus Arteriosis <6,A= o Allows blood to flow from higher pressure aorta to the lower pressure pulmonary artery% causing a left to right shunt. Atrialventricular septal defect Most li:ely to be a low artrial and a high o ventricular defect •
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More blood to the lungs than needed
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!hese defects allow blood to flow from area of higher pressure
$efects causing $ecreased %ulmonary blood flo# !etralogy of the Fallot o 6ulmonic )tenosis+ Narrowing of the pulmonary artery or valve entricular entricular septal defect o Overriding of the aorta+ position of the aorta o is not correct 3lood may be shunted from both ventricles o Hypertrophy of the right ventricle Clinical symptoms+ O- sats below J'D Clubbing of fingers and toes 6olycythemia convulsions )4uatting )tunted growth !ricupsid Atresia E*tremely serious o !ricupsid valve is completely closed o No blood flow from the right atrium to the o right ventricle 3lood passes through patent foramen ovale o into the left atrium and through a ventricular septal defect to the right ventricle and out to the lungs •
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$efects causing obstruction to blood flo# from !entricles Coarctation of the aorta o A segment of the aorta is too narrow% near the insertion of the ductus arterious High blood pressure develops o @eft ventricle is enlarged o O*ygenated blood to the body is reduced o 6ulmonary stenosis o Narrowing of the pulmonary artery or pulmonary valve (ust distal
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?esults in deo*ygenation of systemic blood flow Cyanosis is not always visible
Mi,ed blood flo# in!ol!es !ranspositions of the 7reat Arteries Aorta arises from the right ventricle instead o of the left 6ulmonary artery arises from the left o ventricle o 3lood enters the heart from the vena cava o 7oes to the right atrium to the right ventricle then goes out the aorta to the body completely deo*ygenated ery incompatible with life o )urgery indicated o !otal Anomalous 6ulmonary enous ?eturn 6ulmonary veins return to the right r ight atrium or o the superior vena cava instead of to the left atrium as they normally would
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Mi,ed blood flo# Cardiac anomalies that involve the mi)ing of blood from the pulmonary the pulmonary and systemic circulation in the heart chambers •
'#o %rinci%le clinical conse.uences of defects Heart failure Hypo*emia • •
Heart &ailure ?esults when myocardium of heart cannot circulate and pump enough blood to supply o*ygen and nutrients to body cells 3lood pools in the heart or in pulmonary or venous systems !o increase cardiac output% the heart compensates in several ways+ Muscle fibers lengthen% causing ventricles to o increase and handle more blood with each stro:e
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&irst signs of CH& !achycardia% at rest and on slight e*ertion !achypnea • •
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)calp sweating% especially in infants Fatigue and irritability )udden weight gain ?espiratory distress
Im%lementation in CH& ?educe wor:load of the heart+ ,ecrease e*tra fluid
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A little about obesity o A baby who is overweight by the age of one will usually struggle with weight as as an adult
Introducing solid foods 1.& months+ iron.fortified infant cereal mi*ed with breast mil:% orange (uice% or formula $ months+ vegetables J months+ fruit # months+ meat "' months+ egg yol: •
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'oddler Nutrition Appetite is usually smaller than infant because they are growing at a less rapid rate !end to play with their food 8ant to feed themselves ,o not want to be fed May also choose the same foods over and over •
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Hy%o,emia Color is not a great indicator )aO- of J'.J1D.. )aturation of O*ygen
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Surgical inter!ention Early intervention prior to hypo*ic episodes preferred Mortality rates vary from -D to -1D )urgery should be done in ma(or centers • • •
Preschooler and Nutrition )till not very big eaters at this age 6arents should attempt to ma:e meal times a pleasant e*perience for children • •
School age children and nutrition 7ood appetites )hould begin the day with brea:fast 9sually hungry after school • • •
dolescents and nutrition 7rowing so fast that they may always feel hungry May tend to eat faddish foods or those not very nutritious May rebel against a parents wishes for them to eat good food !his is a time when binging and unhealthy dieting may occur
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Alteration in Nutrition and Elimination *!er!ie# of function of "I system ?esponsible for ta:ing in and processing nutrients for all parts of the body Any problems can 4uic:ly affect other systems of the body In children% can affect overall health% growth% and development •
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*!er!ie# of nutrition Infants o First & months can live off of breast mil: or commercially prepared formula with iron added May need to have Fluoride added if not o already in the water Cows mil: is not recommended until " year of age dt allergies First year is one of rapid growth High protein o High calories o •
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Physiological differences dults !s: Children Internal distribution of water Fluid is a greater fraction of their total body o weight as compared to adults Infants+ $1.J'D !38 - years+ &'D !38 Amounts stay appro*imately the same through later childhood and adult life o 3ody water is also distributed differently in infants than older children Infants have more interstitial fluids E*tracellular fluid compartment in infants includes 21./1D body water Insensible water loss o @oss of fluid through lungs and s:in o Insensible water losses per unit of body weight are higher for an infant and and younger child than an adult !otal body surface is larger in in infantschildren 3ody surface is the percentage of s:in •
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compared to total body weight Infants have more s:in for their si5e !he more s:in% the more fluid loss through s:in Infants and children have rapid respiratory rate and metabolic rate All of these factors contribute to greater fluid o loss through evaporation In addition% treatments or other conditions o may increase fluid output Activity% Activity% fever% diarrhea% vomiting idney function o ,uring the first - years% :idneys are not mature ,o not e*crete waste products efficiently ,ifficulty concentrating or diluting urine )odium regulation mechanisms are not mature o Nurses want to ma:e sure that :idneys are wor:ing before adding potassium to I I fluids Other imbalances o Children are also more readily susceptible to imbalances in+ )erum glucose Calcium 6otassium
electrolyte stores in the infant and child than it !ill in the adult. -,am%le Adults% when they do not eat for a day due to 7I upset% and whose :idneys are normal% will have "/D less body fluid by the end of the day Infants who do not eat for a day% and whose :idney function is normal% will be /'D short of fluid by the end of the day •
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rine out%ut norms Infants+ -.2ml:ghr !oddlerspreschoolers -ml:ghr )chool age+ ".-ml:ghr Adolescents+ '1."ml:ghr • • • •
Physical assessment ):in Color indicates the state of perfusion o As e*tracellular fluid volume decreases
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"lucose •
Infants and children have Higher glucose needs due to high metabolic o rate o @ow glycogen stores o Hypoglycemia a threat under periods of stress
Calcium •
Infants and children have+ ?egulation of calcium less e*act in infant o than in older child or adult o 8hen stressed% more growth hormone <7H= is secreted 7H increases result in increased calcium deposits in bone Infant unable to :eep up with these increased demands %ypocalcemia results. results.
Potassium 6otassium concentration easily affected by decreased inta:e or intestinal illnesses
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Critical' Any condition that interferes interferes !ith normal !ater !ater and electrolyte intake or causes excessive losses !ill produce a more rapid depletion of fluid and •
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After / monthsKif the infant does not produce tears% could indicate dehydration o Fontanels )hould be soft and flat )un:en can represent dehydration
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$iarrhea Increase in stool fre4uency and content of water Caused by abnormal intestinal water and electrolyte transport More water in the intestines • •
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cute diarrhea Ma(or cause of infant mortality in developing countries •
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Most cases caused by infectious agents% viral or bacterial% and parasites Chronic diarrhea is more li:ely related to malabsorption or inflammatory cause
Infectious causes of acute diarrhea iruses o ?otavirus is responsible for 1'D of hospital admissions for dehydration and diarrhea Also a nosocomial infection 3acteria )almonella o Campylobacter
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&ood %oisoning )taphylococcus Clostridium perfringens Clostridium botulinum • • •
Parasites 7iardia lamblia Cryptosporidium • •
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)pread by contaminated food or water Also from person to person More common in crowded conditions% such as day care centers and schools Infants immune system plays a role
ssessment of mild diarrhea Fever of "'"."'- degrees F may be present Anore*ia Irritable Appear unwell Episodes of diarrhea consist of -."' stools per day Mucous membranes are dry 6ulse rapid ):in feels warm ):in turgor is not yet decreased at this time 9rine output usually normal ):in color is pale • • • • • • • • • • •
'hera%eutic management of mild diarrhea Is not serious at this stageKchildren can be treated at home ?est the 7I tract for at least one hour0 then offer water or oral hydration solutions such as pedialye o Appro*imately " tablespoon every "1 minutes * / !hen - tablespoons every S hour * / o If retained% give small sips of fluid0 avoid o giving large amounts of fluid 7ive in small doses o )o not (ive *TC dru(s such as Imodium or aopectate because aopectate because they;re too strong for little tummies ,epended on developmental age of child0 o instruct on good handwashing techni4ue •
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Se!ere diarrhea May result from mild or may appear on it;s own !emp+ "'2."'/F 6ulse and respirations are wea: and rapid ):in is pale and cool Infants may appear apprehensive% listless% lethargic
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'hera%eutic measures Assessment of the fluid and electrolyte imbalance ?ehydration Maintenance of fluid therapy ?eintroduction of ade4uate diet Antimicrobial agents if necessary • • • • •
Nursing considerations assessment Observe general appearance and behavior Assess for dehydration ,ecreased urine output o ,ecrease in weight o ,ry mucous membranes o 6oor s:in turgor o )un:en fontanel in infant o More severe dehydration o Increase in pulse o Increase in respirations o ,ecreased blood pressure o 6rolonged cap refill time o All signs of impending hypovolemic shoc: o Also assess for septic shoc: • •
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Nursing goals 9rine output is more than "ml:ghr 3owel movements are formed and fewer than / per day )tool tests negative 3lood pH more than $
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Malabsor%tion syndromes Celiac ,isease )hort bowel syndrome • •
Celiac $isease )ensitivity or immunological response to the gluten factor of protein 8hen gluten is ingested% a autoimmune response destroys part of the small intestine mucosal 3ody is unable to properly digest food and absorb nutrients% especially fats As a result% these children develop+ o )teatorrhea
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ssessment of Celiac disease !hese children may be anore*ic and irritable A typicalB celiac baby+ o 8ould be fit and well until after the ingestion of gluten.containing solids
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$iagnosis of Celiac disease History Clinical symptoms )erum analysis of antibodies against gluten 3iopsy of intestinal mucosa
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"luten is not found in rice or corn: Celiac crisis Can occur when any child with celiac disease develops an infection 9sually e*periences acute vomiting and diarrhea Cause electrolyte and fluid imbalances o •
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Short +o#el syndrome and its causes A decrease in the amount of absorptive surface •
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Caused by congenital malformations such as gastroschisis
Care of the infant1child #ith Short bo#el syndrome 6arenteral nutrition Enteric feedings if tolerated Monitor for vitamin and mineral deficiencies • •
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Mortality6related com%lications of S+S )epsis @iver and biliary tract infections associated with !6N. causes cholestasis o )een in children under / years of age o @eads to liver failure • •
*bstructi!e disorders Hypertrophic pyloric stenosis Intussusception • •
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upper 4uadrant which becomes more prominent with drin:ing the water
'hera%eutic management of %yloric stenosis )urgical correction+ pyloromyotomy o Muscle of pylorus is split allowing for a larger lumen Is usually done laparoscophy o 6rognosis is e*cellent o •
Nursing care %osto%erati!ely for %yloric stenosis Feedings usually begun /.& hours post.op with " tsp <1 ml= of 1D glucose in saline hourly by bottle for four feeds If no vomiting% - tablespoons given hourly for the ne*t four feeds Ne*t% half.strength formula is given every / hours 3y -/ to /J hours% infants are ta:ing their full formula diet or being breastfed 9sually discharged after /J hours ,o not give more fluid than ordered0 ris:s for brea:ing open the newly operated areas I fluids decreased as oral amount increases Infants need to be bubbledburped well after each feeding to decrease swelling0 we don;t want air or gas to be in tummies &ay them on their side, preferably ri(ht side, to aid the flo! of fluid throu(h the pylorus via (ravity Monitor daily weights 9sually no vomiting occurs after the surgery If it does% report immediately Feeding regimen may need to be ad(usted )ome infants e*perience diarrhea due to the rapid functioning of pyloric sphincter Elevate the head of the bed Monitor inta:e and output carefully0 weigh all diapers •
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Pyloric stenosis 6yloric sphincter is the opening between the lower portion of the stomach and the beginning portion of the intestine
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Nursing care for the %yloric s%hincter incision Care of the operative site+ o Observe for any drainage or signs of inflammation Care of incision as dictated by hospital policy o eep diaper folded low to prevent o contamination of incision Change diapers fre4uently o •
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$iagnosis of %yloric stenosis Made primarily from history 8hen the parent says their infant is vomiting% we need to find out+ o 8hat is the duration% intensity% intensity% fre4uency% description of vomitus o Is the infant ill in any other way o Many infants show signs of dehydration at the time of diagnosis A definite diagnosis is made by watching the infant drin:0 there is usually an olive.si5ed mass in the right • •
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Intussusce%tion Invagination of one portion of the intestine to another
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'reatment of intussusce%tion )urgery ?eduction by fluidairbarium
Motility disorders
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Hirschsprung;s disease
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Hirschs%rung
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'reatment 'reatment of Hirschs%rung
Cleft palate repairs are done at "J.-/ months% so that anatomic changes in the palate contour are complete ?ecovery is usually e*cellent ?emember% these are typically stages surgeries
'racheoeso%hageal 'racheoeso%hageal &istula and -so%hageal atresia Failure of the esophagus to develop normally% will end in a blind pouch or connect directly into the trachea instead of being a discrete passage !hese defects may occur separately or in combination About half of the infants with !EF or EA also have associated anomalies% especially congenital heart disease and anorectal malformations •
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Clinical manifestations of '-& and - E*cessive salivation
Meckel
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Problems associated #ith Meckel
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Alteration in Activity and Mobility
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3hy study this to%ic7 uest for mastery at every stage of development is related to mobility
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)peech% language% and overall development re4uire sensorimotor activity activity
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E*plore and imitate behaviors% a must for autonomy.
'reatment 'reatment of Meckel
Preschooler !o e*press initiative% initiative% re4uires vigorous activity activity
Structural defects Cleft lip and palate Esophageal atresia !racheoesophageal fistula
School6age )trongly influenced by physical achievement and competition
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Cleft li% and %alate Cleft lip occurs when there is a failure of the fusion of the ma*illary and median nasal processes Cleft palate occurs when there is a failure of the fusion of the palatal process
dolescent ?elies on mobility to achieve independence independence •
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ssociated Nursing $iagnoses for Cleft li% and %alate ?is: for fluid volume deficit ?is: for altered nutrition0 less than body re4uirements ?is: for aspiration • • •
'reatment 'reatment for cleft li% and %alate )pecial nipples before surgery and while recovering Cleft lip surgery is usually done between birth and "' months of age • •
-ffects of Immobility Affects all body systems in some way Ma(or physical conse4uences that impact children are+ o )ignificant loss of muscle strength% endurance% and muscle mass
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6ostural hypotension 3lood clots ,ependent edema ?espiratory system ,ecreased chest e*pansion Can lead to increased secretions% pneumonia 7I system Constipation 9rinary system ,ifficulty voiding 9!I;s
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-ffects of Immobility and the family Financial strain )iblings may feel ignored 7uilt Caregiver becomes worn out •
'hera%eutic management of soft tissue injuries !he first /!1 hours is hours is the most critical for almost all soft tissue in(uries 3asic principles include ?ICE or ICE) ?ICE+ ?est% ice% compression% elevation o ICE)+ Ice% compression% elevation% o support Ice immediately0 do not apply for more than 2' minutes o ?everse effects+ vasodilation occurs Elevate the e*tremity above heart level !orn ligaments% especially those in the :nee% are usually made immobile with a cast or splint for 2./ wee:s wee:s 6assive leg e*ercises% gradually increased to active leg e*ercises% begun as soon as sufficient healing has occurred •
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&ractures Common in(ury at any age but more li:ely to occur in children and older adults 9sually due to traumatic incidents at home% school% in a motor vehicle% or associated with recreational activities ?arely occur in infants unless there is an underlying hematology disorder !oddlers. be suspicious of fractures at various stages of healing )chool.age childrenKusually due to bicycle. automobile or s:ateboard in(uries Adolescents+ bi:es% motorcycles% sports •
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Common Musculoskeletal %roblems !raumatic in(ury o )oft tissue in(uries to the muscles% ligaments% and tendons are common in children In young children they occur from mishaps o during play For older children and adolescents% they o occur during sports •
Soft 'issue Injuries *ontusions -bruise ,amage to soft tissue% subcutaneous o structures% and muscles In(ured area is ecchymotic
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'y%es of fractures in children 3ends+ ,eformity without brea:ing
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"prains o
Common &racture sites Forearm+ falling on the outstretched hand Clavicle fractures are common Hip fractures are rare AutopedestrianKfrom / to $ years of age o !riad of in(ury+ @evel of the bumper% fractured femur Hood of the automobile% in(ury to child;s truc: Contralateral
Occur when trauma to a (oint is so severe that a ligament is partially or completely torn or stretched 9sually involves damage to blood vessels% muscles% tendons% and nerves Child may describe a snap% pop% or tearingB
Com%lete fractures !ransverse+ straight up and down Crosswise% at right angles to the long a*is of o the bone •
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Obli4ue+ )lanting but straight% between a hori5ontal and perpendicular direction
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&ractures9 continued Closed or simple Open or compound
"ro#th %late or -%i%hseal injuries 8ea:est part of long bones Fre4uent site of damage Fracture may be through degenerating cartilage cells% without damage to growth Other fractures of the epiphysis may cause growth problems such as shortening of the limb • • •
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,ue to thic:ened periosteum
$elays in healing 7aps between fragments delays or prevent healing 6rompt healing with end.to.end apposition
ssociated %roblems #ith fractures in general Muscles contract and spasm 3ones are pulled out of alignment )evere hemorrhage in tissues% especially with femur fractures ascular in(uries o Femur fracture may cause in(ury to sciatic nerve 3one marrow is high vasculari5ed o • • •
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&racture com%lications Circulatory impairment Nerve compression syndromes Non.union 6ulmonary emboli
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Circulatory im%airment5!ery im%ortant Absence of pulse% discoloration% swelling% pain ?eport immediately to to practitioner !a:e steps to improve circulation
Nursing actions for fractures )upport the in(ured limb0 splint% ,O NO! MOE O? )!?AI7H!EN O9! !HE 3ONE As: the child to point to where it hurts As: the child to wiggle fingers or toes Chec: distal pulses 7et historical information from someone who witnessed the in(ury if possible •
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$iagnostic -!aluation History may be lac:ing o Loung children cannot tell o Older children may not tell the truth in fear of repercussions ?adiography is the most useful tool •
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'hera%eutic management of fractures ?eduction+ regain alignment and length0 setting boneB Immobili5ation+ retains alignment and length ?estore function 6revent further in(ury •
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Com%artment syndrome !ypically caused by blunt trauma 6ressure rises within this space with tight dressings or casts% hemorrhage% trauma% burns% and in(ury Most common symptoms o First sign+ 6ain out of proportion to in(ury o )econd sign+ !enseness on palpation o !hird sign+ motor wea:ness • •
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Non6union fractures Failure of bone fragments to unite Failure to unite due to any of the following+ )eparation of bone fragments at fracture site o Hematoma
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+one healing and remodeling ?apid in children •
Pulmonary -mboli 3lood% air% or fat
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May not occur for &.J wee:s after in(ury Fat emboli% first -/ hours usually in adolescents )igns and symptoms+ o ,yspnea o Chest pain o Onset of sudden pain +ursin( interventions irst- #levate the head o econd- Administer oxy(en o +otify physician immediately o
Cast care ?is: for altered peripheral tissue perfusion related to pressure from cast E*pected outcomes+ o No pain or numbness in e*tremity o ,istal nail beds blanches and refills in less than 2 seconds 6edal pulses palpable o o Area surrounding case is warm and pink Interventions+ o eep e*tremity elevated o Chec: circulation every "1 minutes during the first hour% every hour for -/ hours% then every / hours thereafter o Assess for numbness or tingling
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Most casts in place to &.J wee:s ?emoved with electric cast cutter ):in usually loo:s macerated and dirty% dirty% a good bath will remove dirt o Atrophy will resolve in its own Once healing ta:es place% the e*tremity is as strong as beforeKbut children will usually favor the e*tremity Allow them to regain full use on their own e*tremity time schedule
Scoliosis ateral -sideways curvature of the spine May involve all or only a portion of the spinal column Functional scoliosis
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"tructural scoliosis 6ermanent curvature of the spine with damage to the vertebrae )pine has an ).shaped appearance 9sually there is a family history 1* more common in girls than boys 9sually pea:s between J."1 years
Casting com%lications Continued swelling could cause cast to become a tourni4uet o !his is why we wait a day or two to cast 6arents should receive verbal and written instructions !each neurocirculation chec:s to parent;s <1 6;s= ,ocument parent;s response to teaching Always have parents re.demonstrate
Nursing care of the immobili4ed child "oals and inter!entions 7oal One+ Increase physical mobility related to mechanical restrictions% physical disability !ransport child by gurney% stroller% stroller% wagon% o bed% 8C from room to play room% lobby% or other area as allowed o Change position of bed in room o Out of bed in chair% wagon% etc as allowed 7oal !wo+ Assist child to maintain optimal autonomy o 6rovide mobili5ing devices
Cast remo!al
High isk for Im%aired Skin integrity
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7oal+ Maintain s:in integrity o 6lace child on pressure.reducing mattress o Change position fre4uently% unless contraindicated o 6rotect pressure points with proper positioning and cushioning Inspect s:in surfaces for signs of brea:down o Eliminate mechanical factures that cause o friction 7ood s:in care o 7ently massage s:in area until o contraindicated
High risk for injury Child will e*perience no physical in(ury !each correct use of devices
Muscular ,ystrophies 'he largest grou% of muscle disorders of childhood 'hree ty%es Congenital myotonic dystrophy o 3egins in utero o Newborn may already have significant myotonia
&aciosca%ulohumeral Muscular dystro%hy 3egins after "' years of age Facial wea:ness is the predominant symptom ery slow progression of symptoms @ess disability than the other types Normal lifespan is possible •
Cerebral 6alsy Cerebral Palsy A group of non.progressive disorders of upper motor neuron impairment that result in motor dysfunction Can happen before% during% or after birth Occurs -+"''' births Most common permanent disability of childhood •
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Incidence and Causes of CP Most fre4uently associated with brain ano*ia that leads to cell destruction )ymptoms can range from very mild to 4uite o severe% depending on the e*tent of brain damage Also can be caused by+ o ernicterus
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'y%es of CP !wo main categories based in type of neuromuscular involvement 6yramidal or spastic <1'.$'D of children o with C6= o E*trapyramidal
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S%astic or %yramidal CP 6yramidal system+ conveys nerve impulses that create voluntary movements 6roblems in this area result in+ o Hypertonicity+ e*cessive tone in the voluntary muscles o Abnormal clonus+ clonus+ rapidly alternating involuntary contraction of s:eletal muscle E*aggeration of deep tendon refle*es o Abnormal refle*es such as a positive 3abins:i refle* Continue to have neonatal refle*es past usual age
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Pseudohy%ertro%hic Muscular $ystro%hy1 $uchenne
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Fail to do a parachuteB refle* if lowered suddenly
-,tra%yramidal CP E*trapyramidal nerve tract conveys nerve impulses that effect autonomic movements+ o Help coordinate body movements o Maintain s:eletal muscle tone o 6lay ma(or role in e4uilibrium Ata*ia
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$iagnostic e!aluation for diagnosis of CP Neurological e*am HistoryKespecially born prematurely 9ltrasound of brain C! scan M?I
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-1.$1D of children have cognitive defects may have visual problems
Medical management of CP Overall goalKdevelop a rehabilitation plan to promote optimum function Multidisciplinary teams O!% 6!% )peech o As child grows% would include therapeutic e*ercises% splints% braces Antispasmodic drugs may also be used <3aclofen=% but may have little effect )urgery to lengthen heel tendons may be done 8heeled wal:ers or scooter boards Cerebellar pacema:ers may decrease spasticity in some children Also called 3aclofen pumps o •
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Nursing $iagnoses Altered growth and development Impaired physical mobility )elf.care deficits
"eneral inter!entions 6romote ma*imal functioning of (oints 6rovide adaptive e4uipment for activities of daily living o Modified utensils for eating o 6ush panels for computer o Electric switches for battery operated toys 6osition to prevent contractures 6erform active and passive ?OM e*ercises% o must be done daily 6rovide ade4uate nutritionKoften have difficulty swallowing Encourage verbali5ation of feelings about altered body image Encourage social interaction with peers !each patient and family how to maintain independence Identify support groups • •
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2ong term care for CP )ometimes children are not diagnosed with CO until -./ years later !his can be upsetting to parents 8ill need much support and education •
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Febrile convulsions
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&ebrile con!ulsions )ei5ures associated with high fever <"'-."'/ degrees F= Most common in preschool children or between 1 months and 1 years of age 9sually no more than 1.$ of these episodes occur in a child;s life •
Physical findings that may suggest CP ,elayed motor development Abnormal head circumference
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Sei4ure acti!ity
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)ei5ure usually lasts "1.-' seconds )hows an active tonic.clonic pattern
Pre!ention of &ebrile con!ulsions 7ive !ylenol to :eep fever below "'" Often fever develops during the night when parentcaregiver is not with child If child has one febrile sei5ure% no further treatment given other than to advise parents to administer !ylenol to :eep fever below "'" If more than one sei5ure% child may be put on 6henobarbital
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'hera%eutic management of sei4ures !each parents that after the sei5ure subsides% they should+ )ponge the child with tepid water o ,o not put child in bathtub ,o not use rubbing alcohol or cold water ,o not give !ylenol right after the sei5ure
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Healthcare facility #ill ,etermine underlying cause @umbar puncture to rule out meningitis Antipyretic drugs Antibiotic therapy if needed Assure parents that febrile convulsions do not lead to brain damage and child will be well • • • • •
3acterial meningitis
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Clinical signs in Children Chil dren and dolescents 9sually have -.2 days of a cold% upper respiratory infection and occasionally and ear infection 3ecome E?L irritable due to headache May have convulsions photophobia As the disease progresses% more signs of meningeal irritability occurs+ 6ositive 3rud5ins:i;s
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$iagnostic -!aluation52umbar Puncture Obtained by history and analysis and C)F via @umbar puncture o Culture and gram stain identify causative organism 3lood cell countK83C elevated @owered glucose o Increased metabolic rate due to the body and brain trying to fight off infection0 draws glucose out of blood for energy 6rotein content increased ,ue to e*tra cells and metabolism occurring o in the CN) •
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'hera%eutic Management Medical emergency o ,irectly put on droplet isolation precautions o IMME,IA!E IMME,IA !E antimicrobial therapy o Hydration o entilation entilat ion
Infections or inflammation of the cerebral meninges (the membranes co!ering the brain and s%inal cord) #'D of cases are between " month and 1 years 6ea: incidence is in the winter Causative organisms <#1D of cases= H Influen5ae
Patho%hysiology of +acterial meningitis 6athologic organism spreads to the meninges from upper respiratory tract or by lymphatic drainage from the sinuses Once pathogen enter the meningeal space% they spread rapidly •
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6roduces an inflammatory effect that leads to thick e)udates that blocks *"2 flow. flow. 3rain becomes edematous% covered with purulent with purulent e)udate.. e)udate )preads E?L 4uic:ly through CN)
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unavailable during times of real in(ury !his disorder can result in clots or% more often% bleeding 3leeding can be severe Control of sei5ures% temperature
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6hoto of ,isseminated intravascular coagulation
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Increased Intracranial 6ressure •
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Not a single disorder% disorder% but a sign that may occur with many neurological disorders One such cause is a brain tumor !he rate at which symptoms develop is+ Cause o Ability of child;s s:ull to e*pand to o accommodate the increased pressure !he younger the child% the more fle*ible the s:ull o @ocation o )i5e and growth rate of tumor Children with open fontanels withstand more pressure than older children
,iploplia
"lasgo# coma scale Most widely used of the pediatric coma scales )tandardi5ed scale to describe and interpret the degree of @OC in persons with brain in(ury !he lower the score% the deeper the coma 2 parts+ o eye opening o verbal response o motor response highest score is "1 lowest score is 2 Medical management is based on these scores • •
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Signs of ICP Increased head circumference P-cmmonth in the first 2 months o P"cmmonth in the - nd three months o P'1cmmonth for the e*t si* months o Fontanel changes Anterior fontanel tense and bulging0 closes o late omiting Occurs without nausea
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3rain !umors
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!he most common solid tumor that occurs in children% secondary to leu:emia !ends to occur between " and "' years of age <1. years is the pea:= In children% tends to occur in areas of the brain where they are difficult to remove
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)igns and symptoms due to increased intracranial pressure
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'reatment 'reatment of +rain tumors /.& months may pass from first symptom before diagnosed diagnostic tests+ o s:ull films o bone scan o M?I o Cerebral angiography
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'hera%eutic management of brain tumors Includes a combination of surgery% radiotherapy% radiotherapy% and chemotherapy 6reoperative care 8ill usually receive a stool softenerKdo not o want child to strain after their their brain is operated on o A portion of the head is shaved0 very traumatic for adolescent If going to the IC9 after surgery% have child o meet the IC9 staff •
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Posto%erati!e care 6ositioning o ,epends on location of tumor0 usually on the opposite side of incision 3ed is flat or slightly elevated o ,O NO! lower the head of the bed o Child will be very lethargic due to brain o swelling Assess ) every "1 minutes initially until stable Eventually will decrease to every / hours Monitor I fluids very carefully carefully !oo !oo much fluid can cause edema in the brain o 8e don;t want the child to be dehydrated% but we do want them on the drierB side 6revent nausea and vomiting •
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A generali5ed syndromeK"+J'' to "+"''' live births Etiology unclear #'D U cases attributable to an e*tra chromosome -"
Clinical manifestations of $o#n syndrome Intelligence varies from severely affected to near. normal intelligence )ocial+ -.2 years behind mental age% especially in childhood Congenital anomalies+ 2'./'D has a congenital heart disease% especially septal defects May defects May also have 7I and ortho alterations ?espiratoryKinfections very prevalent ,ue to hypotonia0 swallowing muscles are o wea:Kprone to aspiration 7rowthKrate reduced in height and weight as children0 but often overweight as teensadults )e*ual developmentKmay be delayed% incomplete% or both •
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Physical manifestations HeadKseparated sagital suture Face+ flat profile Eyes+ upward% outward slant Nose+ small and depressed Ears+ small% sometimes low set Mouth+ high.arched palate% downward curve% especially when crying Hands+ broad% short% transverse palmar crease
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'hera%eutic management of ICP Identify source and remove A)A6 eep coughing% vomiting% and snee5ing to a minimum 6lace child in a semi.fowler;s position O;s • • •
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Prognosis #ith $o#n syndrome Improved in recent years )ignificantly lower than for the general population )urvival at one year with CH,+ $&D0 at -' years of age+ 12D )urvival at one year without CH,+ CH,+ #"D0 at -' years of age+ J-D ,ramatic increase in mortality after the age of //% virtually all have neuro changes similar to Al5heimer;s disease • • •
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Possible nursing diagnoses for $S 6otential for infection related to hypotonia% increased susceptibility to respiratory infection Impaired swallowing related to hypotonia% large tongue% cognitive impairment Altered family processes related to having a child with ,own syndrome Altered growth and development related to impaired cognitive functioning •
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,own syndrome
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6otential for in(ury due to hypotoniacognitive impairments high ris: for falls
Manifestations of Hydroce%halus in childhood Caused by increased IC6 Headache upon awa:ening with improvement following emesis or upright posture 6apilledema
Fetal Alcohol syndrome
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Characteristic facial and associated features due to e*cessive ingestion of alcohol by mother during pregnancy ,egree of alcoholism not related to defects of FA) Is related to liver;s ability to deto*ify Circulating
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$iagnosis Head circumferences Associated Neuro signs C!% M?I% s:ull *.ray ,ye inserted into ventricle through anterior fontanelK will not appear in C)F from lumbar puncture if non. communicating • •
Ne#borns #ith &S Measures to prevent sei5ures Avoid overstimulation
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Major features of &S Facial+ thinned upper lip with vertical ridge% short upturned nose Neuro+ mental retardation% motor retardation% microcephaly% microcephaly% poor coordination% hypotonia% hearing hypotonia% hearing disorders 3ehavior+ irritable% hyperactive 7rowth+ 6renatal growth retardation
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Hydrocephalus
'hera%eutic management ?elief of hydrocephalus !reatment of complications Management of issues related to psychomotor alterations • • •
Surgical treatment ,irect removal of obstruction if present
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More on Shunts= alves open at a predetermined intraventricular pressure and close when the pressure falls below that level
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Caused by imbalance in production and absorption of C)F CF) accumulates within ventricular system of brain% producing dilation of ventricles
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Mechanisms of &luid imbalance in i n Hydroce%halus !umor of choroid ple*us
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Com%lications of shunts Mechanical obstruction within ventricles from tissue or e*udates% displacement related to growth% thrombus
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Posto%erati!e care after shunt %lacement 6osition on un.operated side May need to :eep flat to avoid too rapid reduction of intracranial fluid Observe for signs of increased IC6 If increased IC6 occurs% elevated the HO3 to o "1.2' degrees to enhance gravity flow through the shunt Monitor I > O;s carefully% may be on a fluid restriction • •
Clinical manifestations of hydroce%halus Influenced by acuity of onset and presence of pre. e*isting structural lesions In infancy% head grows at an abnormal rate Anterior fontanel tense% bulging% dilated scalp veins
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6resence of bowel sounds determined before feeding infant with 6 shunt
Signs of CS& infection Elevated vital signs 6oor feeding ,ecreased @OC )ei5ures • • •
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!here may be saddle anesthesia with bladder and anal sphincter paralysis May also have ortho involvement0 (oints% :yphosis% scoliosis% hip dislocations
$iagnostic e!aluation Clinical manifestations Meningeal sac
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ssociated nursing diagnoses 6otential for in(ury related to increased IC6 6otential for infection related to presence of mechanical drainage system Altered family processes related to having a child with a chronic illness • •
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Care of the myelomeningocele sac Evaluate the sac and measure the lesion 6rotect the sac0 cover with a sterile% moist 6? hours: ,evice to maintain body temperature without clothing or covers that irritate the sac 6lace in prone position to minimi5e tension on the sac and the ris: of trauma0 the head is turned to one side for feeding Assess for early signs of infection0 elevated temperature% irritability% lethargy% nuchal rigidity rigidity • •
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Neural !ube ,efects
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)pina 3ifida+ defect in closure of the vertebral column with varying degrees of tissue protusion )pina 3ifida Occulta+ 6osterior vertebral arches fail to close in the o lumbrosacral area o )pinal cord remains intact and usually is not visible o Meninges are not e*posed on the s:in surface Neurological deficits are not usually present o )pina 3ifida cystica+ o 6rotrusion of the spinal cord andor it;s meninges occurs ,efect results in incomplete closure of the o vertebral and neural tubes% resulting in a sac.li:e protrusion in the lumbar or sacral area% with varying degrees of nervous tissue involvement Meningocele+ 6rotrusion involves meninges and a sac.li:e o cyst that contains C)F in the midline of the bac:% usually the lumbosacral area o )pinal cord is not involved o Neurological deficits are usually not present Myelomeningocele+ o 6rotrusion of meninges% C)F% nerve roots% and a portion of the spinal cord occurs o !he sac
Clinical manifestations ary according to degree of spinal defect Neuro dysfunction related to anatomic level of defect and nerves involved ,efective nerve supply to bladder often causes urine dribbling or overflow incontinence 6oor anal.sphincter tone0 lac: of bowel control and rectal prolapse • •
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ssociated Nursing $iagnoses 6otential for infection related to presence of infective organisms% nonepitheliali5ed meningeal sac 6otential for trauma rt delicate spinal lesion 6otential for impaired s:in integrity rt paralysis% continual dribbling of urine or feces 6otential for trauma rt impaired cerebrospinal circulation 6otential for in(ury rt neuromuscular impairment •
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