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
o Number of deaths per 1000 live births during
1st year of life.
o Infant mortality rate is an indicator of how
healthy the nation is.
o This rate is used to compare national health
care to previous years and to other
countries.
o There has been a great decrease in the
number of deaths over the past century.
In 1997, 6.9 per 100 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
Injuries cause more death and disabilities in children
than any diseases.
Some examples include:
o Motor vehicle accidents are the leading
cause of death in children over 1 year of
age.
o Majority of deaths are due to no use of
seatbelts.
Drowning is 2nd leading cause of death in boys 1-14;
both sexes 15-24 years old. Drowning is the 3rd
leading cause of death for girls 1-14.
Burns are the 2nd leading cause of death from injury in
girls and the 3rd in boys from 1-14 years old.
Childhood Morbidity (Illness)
An illness or injury that limits activity, requires medical
attention or hospitalization, or results in a chronic
condition.
Examples:
o Congenital heart defects
o Asthma
o Cerebral Palsy
o Cystic Fibrosis
Concerned with helping to decrease these statistics
as children miss school and other activities when ill.
Advanced Practice roles for nurses in Child health nursing
Family nurse practitioner
Neonatal nurse practitioner
Pediatric nurse practitioner
Nurse midwife
Growth and Development
Growth: used to show an increase in physical size or
a significant change.
Includes:
o Height
o Weight
o Head circumference

Development: Used to denote an increase in skill or

ability to finction.
Measured by:
o Observing child do specific tasks
o Parents description of childs ability
o Using standardized testing (Denver II
screening test)
Principles of Growth and development
G & D is a continuous process from birth to death
o Rate of growth varies at different times
G & D proceeds in an orderly manner
o Growth from smaller to larger
o Development: from sitting to crawling to
walking
Different children pass through the predictable stages
at different rates
All body systems do not develop at the same time.
CNS, Cardiac develops quickly.
Lungs are typically the last to develop.
Development is Cephalicaudal, which is the 3rd principle of G
& D. Head to toe.
Development goes from proximal to distal, which is the 4th
principle.
Example: Development proceeds from gross to
refined.
A child cannot learn tasks until the nervous system is
ready.
Neonatal reflexes must be lost before development
can proceed.
Factors that influence growth and development
Genetics
Gender
Health
Intelligence
Temperament
Inborn in all of us
A way of reacting to the world around us
Reaction Patterns:
Activity level
o Level of activity differs widely among
children
Rhythmicity
o Have a regular rhythm is physiologic terms
Approach
o Childs response to a new situation
Adaptability
o Is the child able to adapt to new situations?
Intensity of reaction
Distractibility
Attention span and persistence
Mood quality
Categories of temperament
The Easy Child
o Easy to care for if they have predictable
rhythmicity, approach and easily adapt to
new situations, have a mild to moderate
intensity of reaction, and an overall positive
mood quality.
o 40-50% of children fall into this category
The Difficult child

Children are difficult if irregular in habits,

have negative mood quality, and withdraw
from new situations
o 10% of children fit this image.
Slow to warm up child
o Describes children who are overall fairly
inactive, respond only mildly, adapt slowly to
new situations, and have a general negative
mood.
o 15% of children display this pattern.
Other factors that impact growth and development
Environment
Socioeconomic level
Parent-child relationship
Position of birth in the family
Health
Nutrition
As a child normally develops somewhat predictably in
growth and physical development, he also matures
emotionally, intellectually, and spiritually along certain
paths.
o

Review:

Eriksons theory of Psychosocial development

Piagets theory of cognitive development
Kohlbergs theory of Moral development
Assessment of the Child

Basic Principles
Know norms; child vs. adult
A & P variations are farthest from adult norms at birth
o Most of these variations mature quickly in
the first year
o By 5-7 years of age, body is that of a Small
adult; 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, intellectually, and spiritually along certain
paths.
Try to see the childs world and body through his/her
mind. If you do this, you will connect with the child.
Approach to exam
Always think of where the child is developmentally.
Approach must be individualized
Usually the child will be frightened and anxious. May
lack verbal skills to express fear or ask for
information.
Use both hands on child when possible comforting
touch.
o Place left hand on shoulder while
auscultating the heart.
o Move unhesitatingly, firmly, and gracefully.
o Talk pleasantly and reassuringly.
Instructions to the child:
o Use a directive voice
o Have specific instructions
o Do not ask, but instead tell a child

Example: Say Roll over on your

belly rather than Will you roll over
on your belly?

Physical Exam
Can take place almost anywhere
o On parents lap
o On the floor
o Examiners lap
Conducting the exam
Perform the least distressing procedures first and the
most distressing last.
o Heart and lungs; have the child lie down.
o Abdomen, throat, and ears (throat and ears
are the worst)
o Genitalia and rectum
Physical exam technique
Inspection
o Observe before you touch
Auscultation
o Use diaphragm of stethoscope for high
pitched sounds (bowel sounds)
o Use bell of stethoscope to help localize
sounds for infant
Palpation
o Use pads of fingers to determine tenderness
and pulsations
o Use palmar surface of fingers to determine
masses and organ enlargement
o Observe reaction to palpation rather than to
ask if it hurts (dont suggest that it does)
Percussion
o A more advanced technique usually done by
physicians and advanced practice nurses.
The general survey
Vital signs
General appearance
Mental status
Body measurements
Vital signs
Temperature
o Body temperature in infants is less constant
than in adults
o Use ax/tympanic for children less than 4
years of age
o Values are the same as in adults
Axillary: hold childs arm firmly
Tympanic:
o Less than 3 years of age
Insert gently into ear
Pull down on ear
o Over 3 years of age
Pull up on ear
Rectal temperature
o Most hospitals are done only with doctors
order, or there is a standing order.
o Lubricate tip well
o Insert 1 inch

Pulse
Apical is best
May use femoral arteries, brachial arteries
Radials only in older children (at least 2
years old)
Respirations
o The younger the child, the more abdominal
breathing
o Observe the abdomen instead of the chest in
infants and small children
o May need to auscultate the chest or put the
stethoscope in front of the mouth and nose.
Oxygen saturations
Blood pressure
o Wide enough to over 75% of the upper arm
o Narrow cuff elevates reading, wide cuff
lowers reading
o In infants less than 1 year:
Thigh BP = arm BP
o Older than 1 year:
Systolic in thigh is 10-40 mm Hg
higher than in arm
Diastolic is same in thigh and arm
o If BP in thigh is less than in arm:
Cardiac anomaly or decreased
circulation to extremities
Be sure to use correct size cuff
Use the same extremities, the same
size cuff, and same position
whenever possible when trending
values for an individual patient.
o Diastolic BP
Diastolic pressure reaches about
55 mm Hg at one year of age
Gradually increases to 70
throughout childhood
o The most common cause of hypertension in
children are:
Anxiety (increases BP in children)
Renal disease (78%)
Coarctation of the aorta (2%)

o
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General appearance
To form a general impression of childs health and
well-being
To pin-point specific areas that may require more
detailed assessment
Initial observations
Degree of illness or wellness
Mood
State of nutrition
Speech, cry, facial expression, posture
Apparent chronological and emotional age
Respiratory pattern
Parent and child interaction
Parent and child interaction
Amount of separation tolerated
Displays of affection
Response to discipline
Look for signs of:

Anxious parents
Disengaged parents
Stressed families
Possible abusive parents (no separation
anxiety when removed from parent, or overaffectionate)

Child cries or clings to parent

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 questions easily?
Assess appropriateness of behavior
Assess memory
Assessing Growth/Body measurements
Height, weight, head circumferenceimportant
indicators of growth
Measured and plotted on standard growth charts
These charts are used to determine if the baby/childs
growth is falling within the accepted percentile for age
Length

Birth to 36 months
o Fully extend the body by:
Holding the head midline
Grasping the knees together gently
Pushing down on the knees until
the legs are fully extended and flat
against the table.
o Hold pencil at right angle to the table and
mark the head and toes (which are pointed
toward the ceiling)

Height

Childs back is to the wall, with heels, buttocks, and

back of the shoulders touching the wall and the
medial melleoli touching if possible.
Check for bending of the knees, slumping of the
shoulders, or raising the heels of the feet

Weight

Birth to 36 months, weigh nude

Older children with panties and light gown
Balance (or zero) scale prior to weighing

Head circumference
Measure at greatest circumference
Slightly above the eyebrows and pinna of the ears
o Around the occipital prominence at the back
of the skull
o Compare to 36 months
Denver Developmental
The standard for measuring the attainment of
developmental milestones throughout infancy and
childhood.
Designed for birth to 6 years

Includes screening for:

o Personal social skills
o Fine motor adaptive
o Language
o Gross motor
Denver screening for articulation and eyes

Example of DDST for One year of age:

Personal/Social
o Drink from a cup, imitate activities, play ball
with examiner, indicate wants, play pat-acake
Fine motor/adaptive
o Scribbles, puts block in cup
Language
o Dada/Mama specific, one word
Gross motor
o Stands alone
More on DDST:
Only a measure of developmental attainmentnot a
measure of intelligence
Not a highly specific test
o Most normal children score as normal
Not very sensitive
o Many children with mild developmental
delays also score normal
Only a screening test
Other more sophisticated tests are available if delay
is suspected even when DDST is normal.
Heart Murmurs
50% 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
normal; therefore always report when one is heard.
Abdomen
Protuberant abdomen is typical in most children until
adolescence.
If child is ticklish on palpation, hold his/her hand over
yours to reduce apprehension and increase relaxation
of the abdominal musculature.
Neuromuscular
If possible, watch the child standing upright. Have
them walk, stoop, and touch their toes
Checking for scoliosis.
More tidbits:
Always think of childs development when assessing
Know the BP and pulse variations
When there is an abnormal finding ALWAYS gather
more data
Weight is a huge concern for children. Many
medications are weight dependent.
The Denver Developmental is not very precise; its
more of a screening tool
As it says, the Denver Developmental is only
developmentalnot a cognitive or an IQ test.
For breath sounds:

Encourage the child to blow out your light,

in your pen light or flashlight. This will almost
always produce full inspiration.
Care for the Hospitalized child

General communication guidelines

Pay attention to infants and younger children through
play or by occasionally directing questions or remarks
to them.
Include older children as active participants.
With children of all ages, the nonverbal components
of the message conveys the most.
Communicate at the childs level
o Developmentally and physically
Communication Guidelines
Allow children time to feel comfortable
Avoid sudden or rapid movements, extended eye
contact, or other gestures that may be seen as
threatening.
Talk to the parent if the child is initially shy
Communicate through puppets, dolls, or stuffed
animals before questioning a young child directly.
Give older children the opportunity to talk without the
parents present
Speak in a quiet, unhurried, and confident voice.
Speak clearly, be specific, and use simple words and
short sentences.
Be honest with children
Offer a choice only when one exists.
Allow them to express their concerns and fears
Use a variety of communication techniques; if one
technique doesnt work, try another.
Infant

One month to one year old

Eriksons developmental task: Trust vs. Mistrust
o Task: Attachment to the mother
o Resolution of crisis: Trust in persons; faith
and hope about the environment and future.
o Unsuccessful resolution of crisis: General
difficulties relating to persons effectively;
suspicion; trust-fear conflict, fear of the
future.

Infant: communication
Forms first social relationships
Communicates needs and feelings through nonverbal
behaviors and vocalizations
o Smile and coo when content
o Cry when distressedhunger, pain, body
restraint, loneliness
Respond to adults nonverbal behaviors
o Become quiet when cuddled, patted, or
receive other forms of gentle, physical
contact.
o Get comfort from the sound of voice
usually respond to any gentle firm handling
until they reach the age of stranger anxiety
(5-8 months).

Infant: Stressors of Hospitalization

Separation anxiety
Stranger anxiety
Painful, invasive procedures
Immobilization
Separation Anxiety
Occurs as early as 4 months old; infants face shows
disapproval as primary caregiver walks away.
Three stages of separation anxiety:
o Protest
Cries loudly; rejects attempt to be
comforted by anyone but the
caregiver
o Despair
Crying stops and depression is
evident
Much less active
Uninterested in food or play
Withdraws from others
o Detachment (denial)
Shows increased interests in
surroundings
Interacts with strangers or familiar
caregivers
Forms new but superficial
relationships
Appears happy
Detachment usually occurs after
prolonged separation from parents;
rarely seem in hospitalized children.
Behaviors represent a superficial
adjustment to loss.
Interventions for separation anxiety:
o Encourage parents to room-in with infant
o Involve parents in childs care whenever
possible
o Keep parent in infants line of vision
o If parent is unable to be with infant, place
familiar object with infant (stuffed toy, etc.)
o Support sibling and grandparent visitation
Stranger anxiety
Occurs as early as 5 months
Usually peaks at 8 months
Behaviors exhibited by infant:
o Cries
o Screams
o Searches for parent with eyes
o Clings to parent
o Avoids and rejects contact with strangers
Interventions for stranger anxiety:
o Holding out hands and asking the child to
come will usually not work. If infant must be
handled, better to pick up firmly without
gestures.
o Observe position in which parents hold infant
and imitate this.
o Hold infants where they can see their
parents

Are usually more at ease upright than

horizontal.

Fear of proceduresinterventions
During procedure, use sensory soothing measures
(Stroking skin, talking softly, giving pacifier)
Cuddle and hug after stressful procedure or
encourage parent to do so if present.
Older infants may associate objects, places, or
persons with prior painful experiences and will cry
and resist at the sight of them
o Keep frightful objects out of view
o Perform painful procedures in separate
room, not in crib,
o Use non-intrusive procedures whenever
possible.
Immobilization
Infants explore life through activity and mobility. If
taken away:
o Feel helpless
o May have difficulty with language skills
o May have problems mastering
developmental tasks
o Problems with motor skills
o Immobility impacts development.
Immobilization interventions:
o Play therapy
o Transport infant outside of room by wagon of
by carrying
o Spend time interacting with infant
o Encourage caregivers to do the same
Toddler

Ages one to three years old

Eriksons developmental task: Autonomy vs. shame
and doubt.
o Task: Gaining some basic control over self
and environment
o Resolution of Crisis: Sense of self-control
and adequacy; will power
o Unsuccessful resolution of crisis:
Independence-fear conflict; severe feelings
of self-doubt.
Developing a sense of autonomy
He wants to make choices and like the word No!
Is egocentric
Focus communication on toddler
o Toddler not interested in the experiences of
others

Stressors of hospitalization
Separation anxiety
Loss of control
Painful, invasive procedures
Bodily injury
Fear of dark
Separation anxiety
Verbally attack stranger (Go away!)
May physically attack stranger (kicks, bites, hits)
Tries to escape to find parent

Tries to physically force parent to stay (clings)

May have temper tantrums or refuse care
Behaviors may last from hours to days

Separation anxietyinterventions
Childs reaction to separation
o Toddler might ignore parent.
Other strategies are same as for infant.
Feels more secure with familiar item
Allow them to touch and examine articles that will
come into contact with them
Be direct and concrete
They interpret words literally.
Loss of control
Very threatening to the toddler
Many hospital situations decrease amount of control a
child feels
Loss of control occurs due to:
o Restriction or limitation of movement
o Altered routines and rituals
Eating
Toileting
Sleeping
Bathing
Play
o When routines are disrupted, problems can
occur in these areas
Interventions
o Promote freedom of movement
Encourage parent-child contact
Transport in carriage, wheelchair,
carts, etc.
Maintain childs routine
Encourage as much independence
as possible (allow child to wear
clothes from home, etc.)
Bodily Injury/Invasive procedures
Concept of body very poor
Intrusive procedures (examining ears) create much
anxiety
React with intense emotional upset and physical
resistance
Interventions:
o Tell child its ok to yell, cry, or do whatever is
needed during procedure
o Explain procedure in relation to childs
senses
o Ignore temper tantrums
o Use distraction techniques (Sing song with a
child)
Fear of the dark
Keep night light on in room at all times
Encourage parents to room-in with child
Preschool
3-6 years of age
Eriksons developmental task: Initiative vs. Guilt
o Task: Becoming purposeful and directive

Resolution of Crisis: ability to initiate ones

own activities; sense of purpose.
o Unsuccessful resolution of crisis:
aggression-fear conflict; sense of
inadequacy or guilt
Developing a sense of initiative
Preschooler is:
o Egocentric
o Has increased language skills
o Concept of time and frustration tolerance is
limited
o Illness and hospitalization may be viewed as
punishment
o

Fears of hospitalization
Separation anxiety and fear of abandonment
Loss of control
Bodily injury
Painful, invasive procedures
Fears of the dark, ghosts, monsters
Separation anxiety- preschooler
Tolerate separation better than toddlers; may develop
substitute trust in other significant adults
However, they may show other behaviors:
o Refuse to eat
o Have difficulty sleeping
o Cry quietly for parents
o Constantly ask when parent will be visiting
o May express anger
Interventions:
o Have parents bring in familiar articles from
homepictures/radio
o If child has attachment to special item, have
it brought in
o Same strategies for toddlers
Loss of control
Egocentric and magical thinking; perception of actual
events are more frightening
o Typical fantasy: Illness is a punishment for
their misdeeds
Purely verbal instructions do not help them, have
them practice on doll or toy.
Bodily injury
Differentiate poorly between themselves and outside
world.
Fear of mutilation
Take things literally Stick for blood
Fear if when given a shot, when needle is removed,
their insides will leak everywhere (put a band aid in
place).
Interventions:
Point out on drawing, doll, or child where procedure is
performed
Emphasize that no other body part will be involved
Use non-intrusive procedures when possible
Apply adhesive bandage over puncture site
Encourage parental presence
Allow child to wear underpants with gown

Explain unfamiliar situations, especially noise or lights

Involve child in care whenever possible (hold
equipment, remove dressing)
Praise child for helping and attempting to cooperate
Never shame child for lack of cooperation

School age child

6-12 years old
Eriksons developmental task: Industry vs.
Inferiority
o Task: developing social, physical, and school
skills
o Resolution of Crisis: competence, ability to
learn and work
o Unsuccessful resolution of crisis: Sense of
inferiority; difficulty learning and working
Developing a sense of industry and concrete thought
Has increased language skill
o Interest in acquiring knowledge
o Improved concept of time
o Increased self-control
o Developing relationships with peers; peers
are very important at this stage.
Usually will want explanations and reasons for why
things are being done
Want to know more about procedures, activities, and
objects
Have a greater concern for privacy and body integrity
Usually easier to communicate with than previous age
groups
o Concrete thinkers; no abstract thought
Stressors of hospitalization
Separation anxiety
Loss of control
Bodily injury
Painful, invasive procedures
Fear of death
Separation anxiety
Younger school age children miss their parents more
than older children
Middle/late react more to separation from peers and
usual activities
o May feel lonely, bored, isolated, depressed
due to separation, not the illness.
o May try to be brave and strong.
o May be irritable with parents
Interventions
o Make environment as home-like as possible
Continue school lessons
Have friends visit or call on phone
Decorate walls with cards
Bodily injury
Less concerned with pain, more concerned about
disability or death
Take very active interest in their health
Request facts
Invasive procedures

Want to know about a procedure (will it hurt? Whats it

for?)
Tolerate intrusive procedures well
By age 9 or 10 should less fright to pain

Adolescent
Ages 12-20 years
Eriksons developmental task: Identity vs. Role
confusion
o Task: developing sense of identity
o Resolution of Crisis: sense of personal
identity
o Unsuccessful resolution of crisis: confusion
about who one is; identity submerged in
relationships or group memberships
Developing a sense of identity and abstract thought
Fluctuate between child and adult thinking and
behavior
o Need to express their feelings, for some this
comes easily, for others it does not.
o Major sources of concern for this age group
are attitudes and feelings toward sex,
substance abuse, relationships with parents,
peer-group acceptance, and developing a
sense of identity.
Stressors of hospitalization
Loss of control
Altered body image, disfigurement
o Do not want to look different
Separation from peer group
Loss of control
o Anything that interferes with sense of
independence
o Patient role fosters dependency
o May withdraw, be uncooperative, angry,
frustrated.
Altered body image
o Very relevant at this stage
o Any change that makes them different from
peers is seen as a major tragedy
o Insecure with their bodies due to the many
changes
o May react with know it all attitude (but may
be afraid, deep down)
o Privacy is very importantmay need to give
them some time alone.

Cystic Fibrosis
Epidemiology
Affects approximately 30,000 children and adults in
the US today or 1 in 2500 live births
Occurs most commonly in whites, rarely in blacks and
Asians
More than 10 million Americans (1 in 31 or 3.3%) are
symptom free carriers of the defective CF gene
Survival

In 1955, few children with CF lived to attend

elementary school. Today, the median age of survival
is 32 years.
In this decade, many CF survive into their 40s.

Etiology

An inherited (genetic) disease

CF is an autosomal-recessive disease (this means an
individual must inherit 2 defective CF genes, one from
each parent)
The defective gene in CF occurs in Chromosome 7
The gene causes the dysfunction of the exocrine
glands

What are exocrine glands?

Glands that secrete things such as:
o Lungs
o Pancreas
o Sweat glands
o Salivary glands
o Digestive glands
Pathophysiology
CF causes the body to produce an abnormally thick,
sticky mucus which:
o Clogs the lungs and leads to life-threatening
lung infections;
o Obstructs the pancreas, preventing enzymes
from reaching the intestine to help break
down and digest food
Primary symptoms:
o Thick, sticky mucus
o Salty taste on skin
Marked electrolyte changes in sweat glands
o Chloride in sweat is 2-5X above normal
Lung involvement
Thick tenacious mucus polls in the bronchial tree and
obstructs bronchioles
Results in:
o Bronchiectasis: Chronic dilation of the
bronchi. Involves a chronic cough that
produces mucopurulent sputum. Over time
results in destruction of the bronchial walls.
o Pneumonia: Staph Aureus, pseudomonas,
and H. Influenzae
Symptoms over time include:
o Clubbing of fingers
Clubbing is related to lack of tissue
perfusion
Symptoms over time:
Easily fatigued
Physical growth stunted
Chest may become enlarged from over inflation of
alveoli because air cannot be pushed past the thick
mucus on expiration (barrel chested)
Increased carbon dioxide in blood (hypercapnia
and/or chronic acidosis)
Pancreas involvement

Thick secretions mix with pancreatic enzymes and

block the pancreatic duct.
Therefore:
o Essential pancreatic enzymes cannot flow
into the duodenum to aid with digestion
(lipase, trypsin, and amylase)
o Fats, proteins, and some sugars cannot be
digestedare excreted in stools:
o Stools (The 4 Fs in CF)
Frothy (bulky/large)
Foul smelling (comparable to a cats
stool)
Fat containing greasy
Steatorrhea
Floaters
Clogged ducts causes back pressure on the acinar
cells (they make the enzymes)
The cell lining of pancreas is damaged
Over time the acinar cells atrophy and no longer
produce the enzymes

Symptoms related to Pancreatic Involvement

Protuberant abdomen because bulk of stool is setting
in the intestines
Signs of malnutritiononly benefit from 50% of food
taken in
Fat soluble vitamins are not absorbed A, D, E, K
In infants, thick, sticky stools (meconium) which may
cause intestinal obstruction
o One of the first signs of CF in infants
Sweat gland involvement
The structure of the sweat glands is not changed,
however:
Level of chloride to sodium in the perspiration is
increased 2 5 times above normal
Some parents report they knew their newborn had the
disease because when they kissed their child they
could taste such strong salt in their perspiration
How is CF diagnosed?
By the history (cough, stool, abdomen, hx. of
pneumonia)
The abnormal concentration of chloride in sweat
The absence of pancreatic enzymes in duodenum
(can be tested through NG tube)
Pulmonary involvement
Common complaints that bring these patient to the doctor
Newborn that loses 5-10% of weight after birth but
does not gain it back
Feeding problemskids are always hungry because
of their poor digestive function
Frequent respiratory infections
Cough
Diagnostic tests
A sweat test is a test for the chloride content of sweat
Infants may not be tested until 6-8 weeks of age.
(they dont sweat a great deal)
o Normal concentration of Chloride in sweat is
20 mEq/L

A level of 50-60 mEq/L suggests CFtest is

repeated
o A level >60 mEq/L = CF
Duodenal analysis of secretions for detection of
pancreatic enzymes
Stool analysis: for fat content (although appearance
may be enough)
Pulmonary testingchest x-rays or PFTs
o

Therapeutic management
Maintain respiratory function
o Keep bronchial secretions as moist as
possible to facilitate drainage:
Moistened oxygen: Oxygen is
supplied to children by mask,
prongs, ventilators, or neubulizers,
and rarely by tent
Aerosol therapy- 3-4 times/day via
neubulizer to provide antibiotics and
bronchodilators
o Never give cough syrups or codeine
Aggressive chest physiotherapy- usually needed 3-4
times a day
Activity- need frequent position changes, especially
when in bed. Helps facilitate drainage of various
lobes, as well as prevent skin breakdown.
Respiratory hygiene: frequent mouth care,
toothbrushing and good-tasting mouthwash.
Need frequent check-ups and current
immunizations/vaccines
Adequate rest and comfort
o Dyspnea can lead to exhaustion
o Need periods of rest during the day:
Rest period before meals so not too
tired to eat
Rest periods before chest
physiotherapy
Promote optimal nutrition
o Pancreatic enzyme supplements with meals
and snacks
Pancreatic enzyme: Cotazym 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 size
and foul odor.
o High calorie, high protein, moderate fat diet
o Multivitamins and E, others when deficient.
During hot months, extra salt may be added to food to
replace that which is lost through perspiration
Keep room temp at 72 degrees and have water
available at all times. Parents need to supervise kids
playing outdoors to prevent overheating.
Keep well hydrated all of the time!
Complications
Infertility in males related to blocking of vas deferens
from tenacious seminal fluid
Infertility in females related to tenacious cervical
secretions that block sperm penetration

Rectal prolapse in infants from straining to pass hard

stool. Loss of blood supply to prolapsed rectal
mucosa can occur if not replaced promptly and
properly.
Hypercapnia/respiratory acidosis from inability to
adequately exhale carbon dioxide
Exhaustion, slow growth patterns
Skin irritation in diaper area from stool that is irritating
due to acidic nature of stools
Socialization and peer acceptance difficulties
Cor Pulmonale (right sided heart failure) from
increased respiratory resistance
Anemia and bruising
Frequent respiratory infections and compromised
immunity
Portal hypertension related to obstruction of bile ducts
area of biliary fibrosis biliary cirrhosis
Pneumothorax related to rupture of pulmonary blebs

Parental involvement
Parents assume a great deal of responsibility when
taking care of a CF child.
o Need to encourage a balance of work, the
child, and the rest of the family
o Encourage involvement of support group
o Requires extensive involvement of the
discharge planner
Nursing Diagnoses
Ineffective airway clearance r/t thick mucus in the
lungs
Ineffective breathing pattern r/t thick tracheobronchial
secretions and airway obstruction
High risk for infection r/t presence of mucus
secretions conductive to bacterial growth
Altered nutrition: Less than body requirements r/t
inability to digest nutrients
Fear/Anxiety (parent or child) r/t prognosis and effect
of illness on growth and development
Knowledge Deficit (parent or child)
Summary
CF is an inherited genetic disorder
Causes the exocrine glands to produce thick
secretions
Primary body organs involved are lungs and
pancreas.
Prone to respiratory infections r/t mucus.
Digestion problems r/t pancreatic enzymes.
Treatment centers around control and management.
No cure for the disease.

Eriksons Stages
Infant

One month to one year old

Eriksons developmental task: Trust vs. Mistrust
o Task: Attachment to the mother
o Resolution of crisis: Trust in persons; faith
and hope about the environment and future.

Unsuccessful resolution of crisis: General

difficulties relating to persons effectively;
suspicion; trust-fear conflict, fear of the
future.
Developmental tasks: Learning to eat solid
foods

Toddler

Ages one to three years old

Eriksons developmental task: Autonomy vs. shame
and doubt.
o Task: Gaining some basic control over self
and environment
o Resolution of Crisis: Sense of self-control
and adequacy; will power
o Unsuccessful resolution of crisis:
Independence-fear conflict; severe feelings
of self-doubt.
o Developmental tasks:
Learning to walk
Learning to use fine muscles
Toilet training
Learning to communicate

Preschool
3-6 years of age
Eriksons developmental task: Initiative vs. Guilt
o Task: Becoming purposeful and directive
o Resolution of Crisis: ability to initiate ones
own activities; sense of purpose.
o Unsuccessful resolution of crisis:
aggression-fear conflict; sense of
inadequacy or guilt
o Developmental tasks:
Independence of self-care
Learning sexual role identity
Forming reality concepts
Internalizing concepts of right and
wrong
Learning to identify with family
members and others.
School age child
6-12 years old
Eriksons developmental task: Industry vs.
Inferiority
o Task: developing social, physical, and school
skills
o Resolution of Crisis: competence, ability to
learn and work
o Unsuccessful resolution of crisis: Sense of
inferiority; difficulty learning and working
o Developmental tasks:
Acquiring game skills
Learning to relate positively with
peers
Building a wholesome self-concept
Refining communication skills
Adolescent
Ages 12-20 years

Eriksons developmental task: Identity vs. Role

confusion
o Task: developing sense of identity
o Resolution of Crisis: sense of personal
identity
o Unsuccessful resolution of crisis: confusion
about who one is; identity submerged in
relationships or group memberships
o Developmental tasks:
Forming peer relationships
Responding to an appropriate
sexual role
Attaining emotional independence
Achieving a sense of economic
independence

Cardiac defects in children

Alteration in Fluid-gas transport
Cardiac Defects in children:
Divided into two major groups:
o Congenital cardiac defects
o Acquired heart disease
Congenital Heart Disease
Anatomic abnormality present at birth; the heart has
not developed as it should in utero.
Thus, the heart is unable to adjust to life outside of
mom
Results in abnormal cardiac function
Acquired Cardiac disease
Abnormalities that occur after birth
o Can occur by self
o Can occur with other congenital heart
defects
o Example; Rheumatic disease is the 2nd
largest cause of cardiac problems in children
over 5)
Both congenital and acquired heart disorders can lead to
heart failure
Assessment of cardiac function
History
o History of heart disease in the family
o Contact with known teratogens, such as
rubella during pregnancy
o Presence of chromosomal abnormalities
(Downs)
o Poor weight gain and/or feeding behavior
o Exercise intolerance and/or fatigue during
feeds
o Sweating during feeding
o Frequent respiratory infections
o Respiratory difficulties, such as tachypnea,
dyspnea, and shortness of breath.
o Recent streptococcal infection (may lead to
valve damage)
Physical exam

Begins with observation of general

appearance, then the specifics
o Use general assessment techniques but look
specifically for the following:
o Inspection:
Nutritional state: failure to thrive or
poor weight gain
Skin color: cyanosis and pallor
Chest deformities- enlarged heart
Unusual pulsations of neck veins
seen in some patients
Respiratory pattern- tachypnea,
dyspnea, presense of expiratory
grunt
Clubbing of fingers (now rarely
seen in children d/t advances in
surgical techniques)
o Palpation
Quality and symmetry of pulses
o Auscultation
Heart rate and rhythm
Presence of murmurs
o Height and weight
o Position of comfort
Remember, squatting/fetal positions
are often comfortable for a child
with a CHD.
Tests of cardiac function
o Electrocardiography
Records electricity generated by the
beating heart
Painless but scary, child must be
still
o Exercise stress test
Monitoring of heart rate, BP, ECG,
and oxygen consumption at rest
and during exercise on a tread mill
or bicycle
o Chest x-ray
Shows accurate picture of heart
size and contour; size of the heart
chambers
Used more as a screening tool
o Echocardiography
Ultrasound (high frequency sound
waves produce an image of heart
structures)
The primary diagnostic test for
heart disease.
o

Cardiac catherization
Radiopaque catheter is inserted through peripheral
blood vessel into heart
o Contrast material is injected and films taken
(called angiography)
Reasons for performing:
o Diagnose specific heart disease
o Measure pressures and O2 sats
o Visualize heart structures
o Determine blood flow patterns
Preparation for Cardiac cath

Although done frequently, there are some risks.

Typical reactions include:
o Acute hemorrhage from entry site (usually
femoral artery)
o Low grade fever (reaction to contrast media)
o Nausea
o Vomiting
o Loss of pulse in the catheterized extremity
o Transient dysrhythmias (d/t ventricular
irritability)
Done on an outpatient basis
NPO for 2-4 hours before
Older children should see the cath lab before
procedure
Accurate height and weight (for medications)
Most children are sedated to decrease anxiety

Post catheterization care

Are usually on a cardiac monitor and pulse oximeter
for the first few hours of recovery.
Know the baseline pulse/BP before the procedure to
compare
Most important nursing responsibility is observation of
the following for signs of complications:
o Pulses, especially below the catheterization
site, for equality and symmetry (pulse just
distal to site may be weaker for the first few
hours but gradually increase in strength.
Observations of:
Temperature and color of the affected extremity.
Coolness or blanching may indicate arterial
obstruction.
Vital signs are taken every 15 minutes. Special
emphasis on heart rate. Must take for one full
minute.
Assess blood pressure, especially for hypotension.
o Hypotension could indicate:
Hemorrhage
Too much medication
Dehydration
Dressing, for evidence of bleeding.
Fluid intake, both IV and oral, to ensure adequate
hydration.
o Remember sensible and insensible fluid loss
(breathing too quick!).
Hypoglycemia, especially in infants.
Interventions
Child must keep extremity straight 4-6 hours after
venous catheterization and 6-8 hours for arterial cath.
Childs diet can be resumed as soon as tolerating sips
of clear liquid
Keep site clean and dry
Encourage child to void.
Congenital heart disease
Incidence: 4-10 per 1000 live births
The major cause of death in the first year of life
o Other than prematurity/low birth weight
More than 35 well recognized defects

Statistics improving due to more surgeries/treatments

that help prevent death.

Most of this blood shunts through the ductus

arteriosis into descending aorta, and back into the
placenta.

Etiology

Not known in 90% of cases

Factors associated:
o Maternal rubella during pregnancy
o Maternal alcoholism
o Maternal age over 40
o Maternal insulin-dependent diabetes
More likely to have other defects such as Down
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.
Review of prenatal circulation- 3 essential structures
Ductus venosus (DV): opening between umbilical vein
and inferior vena cava.
o The ductus venosus is a vessel that allows
blood to bypass the fetus's liver. It carries
blood with oxygen and nutrients from the
umbilical cord straight to the right side (right
atrium) of the fetus's heart. The ductus
venosus closes shortly after birth, when the
umbilical cord is cut and blood flowing
between the mother and fetus stops.
Foramen ovale: opening between the right and left
atriumbypasses fetal lungs.
o The foramen ovale is an opening in the wall
that separates the upper right and left heart
chambers (atria). This opening allows blood
to flow to the left side of the heart without
going to the lungs. Before birth, the foramen
ovale is kept open by the pressure of blood
that passes through it. When the baby takes
the first breath, blood begins to flow through
the lungs, and the foramen ovale closes
Ductus arteriosis (DA): Opening between pulmonary
artery and descending aorta; allows fetal blood to
bypass the lungs.
o There is still very little blood getting into the
fetal lungsjust enough to help it grow in
utero, even though they are collapsed until
birth.
Purpose of these structures
Allow most of blood to bypass the liver and lungs.
Fetal circulation
Oxygenated blood from placenta to ductus venosus
inferior vena cava right atrium.
Blood then shunts over to the left atrium through the
foramen ovale.
Then over to the left ventricle aorta
head/extremities.

The unoxygenated blood returns to the right atrium

via the superior vena cava flows into the right
ventricle exits thought the pulmonary artery (which
is connected to the aorta).

Birth changes
Infant cries, lungs expand
Ductus arteriosis closes as resistance decreases
though the pulmonary vasculature (infants now need
to use their own lungs)
Clamping cord causes ductus venosus to clot (infant
needs to use own liver)
Venous return from lungs causes increase in left
atrium pressure.
Increased left atrium pressure causes left to right
blood flow through patent foramen ovale (which is a
bad thingwe no longer want to bypass the lungs)
The foramen ovale is a one way valve so it closes
permanently.
Birth changes, summary
Ductus venosus
o Clots to form ligamentus teres
Foramen ovale
o Closes to form interatrial septum
Ductus arteriosis
o Closes to form ligamentum arteriosus
Altered hemodynamics
Important to remember pressure gradients as blood
will always flow (or shunt) from an area of higher to
lower pressure.
Heart defects cause a change in the direction of this
normal flow of blood; create symptoms, especially
those associated with congestive heart failure.
Congenital heart defects
Usual causeheart structure fails to progress beyond
earlier
Was once classified as Cyanotic and Acyanotic
New classifications below
Classification of Congenital heart disease
Increase in pulmonary blood flow
Decrease in pulmonary blood flow
Obstruction to blood flow from ventricles
Mixed blood flow
Defects with increased pulmonary blood flow
Ventricular septal defect
o Hole between the ventricles
Atrial septal defect
o Hole between the atrias
Patent Ductus Arteriosis (PDA)
o Allows blood to flow from higher pressure
aorta to the lower pressure pulmonary artery,
causing a left to right shunt.
Atrialventricular septal defect
o Most likely to be a low artrial and a high
ventricular defect.

More blood to the lungs than needed.

These defects allow blood to flow from area of higher

pressure (left side of the heart), to area of lower
pressure (right side of the heart).
This creates increased blood volume on the right side
of the heart which increases pulmonary blood flow.
Usually results in CHF.
o Pulmonary hypertension and cor pulmonae
are frequent disorders associated with this.

Defects causing Decreased pulmonary blood flow

Tetralogy of the Fallot
o Pulmonic Stenosis: Narrowing of the
pulmonary artery or valve
o Ventricular septal defect
o Overriding of the aorta: position of the aorta
is not correct. Blood may be shunted from
both ventricles.
o Hypertrophy of the right ventricle
Clinical symptoms:
O2 sats below 80%
Clubbing of fingers and
toes
Polycythemia (increased
hct)
Anoxia aeb: dizziness &
convulsions
Squatting
Stunted growth
Tricupsid Atresia
o Extremely serious.
o Tricupsid valve is completely closed.
o No blood flow from the right atrium to the
right ventricle
o Blood passes through patent foramen ovale
into the left atrium and through a ventricular
septal defect to the right ventricle and out to
the lungs.
Defects causing obstruction to blood flow from ventricles
Coarctation of the aorta
o A segment of the aorta is too narrow, near
the insertion of the ductus arterious.
o High blood pressure develops
o Left ventricle is enlarged
o Oxygenated blood to the body is reduced.
Pulmonary stenosis
o Narrowing of the pulmonary artery or
pulmonary valve just distal (under/below) to
the valve.
o Eventually causes right ventricular
enlargement (hypertrophy)
Aortic stenosis
o Narrowing of the aortic valve
o Prevents blood from passing freely from left
ventricle unto aorta.
o Causes left ventricular hypertrophy from
increased pressure in the left ventricle.
Mixed blood flow
Cardiac anomalies that involve the mixing of blood
from the pulmonary and systemic circulation in the
heart chambers.

Results in deoxygenation of systemic blood flow.

Cyanosis is not always visible.

Mixed blood flow involves:

Transpositions of the Great Arteries
o Aorta arises from the right ventricle instead
of the left
o Pulmonary artery arises from the left
ventricle
o Blood enters the heart from the vena cava.
o Goes to the right atrium to the right
ventricle then goes out the aorta to the
body completely deoxygenated.
o Very incompatible with life
o Surgery indicated
Total Anomalous Pulmonary Venous Return
o Pulmonary veins return to the right atrium or
the superior vena cava instead of to the left
atrium as they normally would. (The
oxygenated blood keeps going back into the
lungs)
o Blood must be shunted across a patent
foramen ovale or ductus arteriosus in order
to reach the systemic circulation.
Truncus Arteriosus
o One major artery or trunk arises from the
left and right ventricles in place of a separate
aorta and pulmonary artery.
o Usually accompanied by a VSD.
o Restructure common trunk to create two
separate vessels (2 separate trunks)
Hypoplastic left heart syndrome
o Left ventricle of the heart is non-functional.
o Unable to effectively pump blood into the
systemic circulation.
o Right ventricle enlarges as it tries to do all of
the work.
o Transplant or the 3 Staged Norwood
procedures performed.
Two principle clinical consequences of defects
Heart failure
Hypoxemia
Heart Failure
Results when myocardium of heart cannot circulate
and pump enough blood to supply oxygen and
nutrients to body cells
Blood pools in the heart or in pulmonary or venous
systems
To increase cardiac output, the heart compensates in
several ways:
o Muscle fibers lengthen, causing ventricles to
increase and handle more blood with each
stroke (ventricular hypertrophy).
o Heart rate can also increase
Eventually the heart can no longer compensate
blood pools, unable to be pushed forward effectively.
First signs of CHF
Tachycardia, at rest and on slight exertion
Tachypnea

Scalp sweating, especially in infants

Fatigue and irritability
Sudden weight gain
Respiratory distress

Implementation in CHF
Reduce workload of the heart:
Decrease extra fluid (diuretics)
o
Strengthen cardiac function (digoxin)
o
Decrease afterload with vasodilators
o
Afterload is the amount of force
needed for left ventricle to push
blood through the body.
Decrease cardiac demands
Allow for uninterrupted sleep periods
o
Small frequent feedings or gavage
o
The more food in the stomach, the
more cardiac work it is to digest.
Reduce respiratory distress
Count respirations carefully
o
Humidified O2
o
Semi or high Fowlers
o
Hypoxemia
Color is not a great indicator
SaO2 of 80-85%-- Saturation of Oxygen (arterial
blood/Hemoglobin)
Polycythemia (increase of the RBCs d/t chronically
low oxygen saturations)
Clubbing
Squatting to increase venous return
Hypercyanotic spells
Surgical intervention
Early intervention prior to hypoxic episodes preferred
Mortality rates vary from 2% to 25%
Surgery should be done in major centers

Alteration in Nutrition and Elimination

Overview of function of GI system
Responsible for taking in and processing nutrients for
all parts of the body.
Any problems can quickly affect other systems of the
body
In children, can affect overall health, growth, and
development
Overview of nutrition
Infants
o First 6 months can live off of breast milk or
commercially prepared formula with iron
added
o May need to have Fluoride added if not
already in the water.
Cows milk is not recommended until 1 year of age d/t
allergies
First year is one of rapid growth
o High protein
o High calories

A little about obesity

o A baby who is overweight by the age of one
will usually struggle with weight as an adult.

Introducing solid foods

5-6 months: iron-fortified infant cereal mixed with
breast milk, orange juice, or formula.
7 months: vegetables
8 months: fruit
9 months: meat
10 months: egg yolk
Toddler Nutrition
Appetite is usually smaller than infant because they
are growing at a less rapid rate
Tend to play with their food
Want to feed themselves. Do not want to be fed.
May also choose the same foods over and over.
Preschooler and Nutrition
Still not very big eaters at this age
Parents should attempt to make meal times a
pleasant experience for children.
School age children and nutrition
Good appetites
Should begin the day with breakfast
Usually hungry after school
Adolescents and nutrition
Growing 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
This is a time when binging and unhealthy dieting
may occur (even with athletes)
Tend to not eat enough iron, calcium, and zinc
Physiological differences: Adults vs. Children
Internal distribution of water
o Fluid is a greater fraction of their total body
weight as compared to adults
Infants: 75-80% TBW
2 years: 60% TBW
Amounts stay approximately the
same through later childhood and
adult life
o Body water is also distributed differently in
infants than older children.
Infants have more interstitial fluids
Extracellular fluid compartment in
infants includes 35-45% body water
Insensible water loss
o Loss of fluid through lungs and skin
o Insensible water losses per unit of body
weight are higher for an infant and younger
child than an adult.
Total body surface is larger in
infants/children
Body surface is the
percentage of skin

compared to total body

weight.
Infants have more skin for
their size. The more skin,
the more fluid loss through
skin
Infants and children have rapid
respiratory rate and metabolic rate
o All of these factors contribute to greater fluid
loss through evaporation.
o In addition, treatments or other conditions
may increase fluid output
Activity, fever, diarrhea, vomiting
Kidney function
o During the first 2 years, kidneys are not
mature
Do not excrete waste products
efficiently
Difficulty concentrating or diluting
urine
Sodium regulation mechanisms are
not mature
o Nurses want to make sure that kidneys are
working before adding potassium to I.V.
fluids.
Other imbalances
o Children are also more readily susceptible to
imbalances in:
Serum glucose
Calcium
Potassium

Glucose

Infants and children have

o Higher glucose needs due to high metabolic
rate
o Low glycogen stores
o Hypoglycemia a threat under periods of
stress

Calcium

Infants and children have:

o Regulation of calcium less exact in infant
than in older child or adult
o When stressed, more growth hormone (GH)
is secreted
GH increases result in increased
calcium deposits in bone
Infant unable to keep up with these
increased demands
Hypocalcemia results.

Potassium
Potassium concentration easily affected by decreased
intake or intestinal illnesses (diarrhea)
Decreased K can lead to cardiac arrhythmias
K must fall below 3 mEq/L before symptoms show
Critical!

Any condition that interferes with normal water

and electrolyte intake or causes excessive losses
will produce a more rapid depletion of fluid and

electrolyte stores in the infant and child than it

will in the adult.
Example:
Adults, when they do not eat for a day due to GI
upset, and whose kidneys are normal, will have 14%
less body fluid by the end of the day
Infants who do not eat for a day, and whose kidney
function is normal, will be 40% short of fluid by the
end of the day!
Urine output norms
Infants: 2-3ml/kg/hr
Toddlers/preschoolers 2ml/kg/hr
School age: 1-2ml/kg/hr
Adolescents: 0.5-1ml/kg/hr
Physical assessment
Skin
o Color indicates the state of perfusion
o As extracellular fluid volume decreases (as
with dehydration), peripheral circulation
decreases.
o Note the following:
Warmth
Skin color: from pink to pale as
peripheral circulation decreases
(cyanosis is a late sign)
Hands will get cold before core
temperature
Cap refill increases <2 seconds
Turgor:
o In dehydrated states:
Skin is unusually dry
Tenting of skin (is a later sign)
The best place to check skin turgor
is the abdomen and medial area of
the thighs
Skin temperature
o Decreases in fluid status; results in
vasoconstriction of small arterioles
o Vasoconstriction causes a decrease in skin
temperature
o Extremities usually remain cold even if the
child has a fever
Mucous membrane
o Mouth is the most mucous membrane to
assess for fluid deficit.
o Note:
Amount of saliva in mouth
Lips and nares may be dry
Mucous membranes may be
cracked.
Wrinkled tongue can indicate
dehydration
Be sure dryness is not due to
excessive mouth breathinglook at
other variables as well.
Head Assessment
o Eyes
Usually lack luster
May appear sunken and dark

After 4 monthsif the infant does

not produce tears, could indicate
dehydration
o Fontanels
Should be soft and flat
Sunken can represent dehydration
(especially anterior)
Vital signs
o Pulse:
Usually the most sensitive index of
fluid status
Pulse over 160 for infants and 120
for children could indicate
hypovolemia
Pulse will usually be weak and
thready
o Respirations
When fluid volume is decreased,
children tend to compensate for
changes in the blood by
hyperventilating. This can lead to
the development of cherry red lips
o Blood pressure
Usually the last vital sign to show
any changes. When it falls, its
usually hours after changes in pulse
and respiration
o Weight
The single most important
variable to follow in planning
treatment of fluid imbalances
o Intake and output
Record all intake
Output usually a decrease in
urine output and an increase in
specific gravity (the higher the
specific gravity, the more
dehydrated the person is).
Every hour is documented
o Output
Weigh diapers
1 gm = 1 ml
document all stools, vomiting,
wound drainage, perspiration
o Behavioral assessment
Changes seen with fluid volume
deficit usually include:
Anorexia
Drawn, flaccid expressions
Decreased levels of
activity
Increased seeking of
comfort and attention

Diarrhea
Increase in stool frequency and content of water
Caused by abnormal intestinal water and electrolyte
transport
More water in the intestines
Acute diarrhea
Major cause of infant mortality in developing countries

Most cases caused by infectious agents, viral or

bacterial, and parasites
Chronic diarrhea is more likely related to
malabsorption or inflammatory cause

Infectious causes of acute diarrhea

Viruses
o Rotavirus is responsible for 50% of hospital
admissions for dehydration and diarrhea
Also a nosocomial infection
Bacteria
o Salmonella
o Campylobacter (ingested by contaminated
food)
o Clostridium difficile (C-Diff)
Food poisoning
Staphylococcus
Clostridium perfringens
Clostridium botulinum
Parasites
Giardia lamblia
Cryptosporidium
Etiology

Spread 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 (the younger the
infant, the less developed the immune system).

Assessment of mild diarrhea

Fever of 101-102 degrees F may be present
Anorexia
Irritable
Appear unwell
Episodes of diarrhea consist of 2-10 stools per day
Mucous membranes are dry
Pulse rapid
Skin feels warm
Skin turgor is not yet decreased at this time
Urine output usually normal
Skin color is pale
Therapeutic management of mild diarrhea
Is not serious at this stagechildren can be treated at
home
Rest the GI tract for at least one hour; then offer water
or oral hydration solutions such as pedialye.
o Approximately 1 tablespoon every 15
minutes x 4
o Then 2 tablespoons every hour x 4
o If retained, give small sips of fluid; avoid
giving large amounts of fluid. Give in small
doses
o Do not give OTC drugs such as Imodium
or Kaopectate because theyre too strong
for little tummies
o Depended on developmental age of child;
instruct on good handwashing technique.

Severe diarrhea
May result from mild or may appear on its own
Temp: 103-104F
Pulse and respirations are weak and rapid
Skin is pale and cool
Infants may appear apprehensive, listless, lethargic
(appears as a hypovolemic state)
Obvious signs of dehydration
o Depressed fontanel
o Poor skin turgor
o Sunken eyes
Bowel movement every few minutes
Stool is liquid green, may be mixed with mucus and
blood (because the intestines are inflamed and
irritated)
Stool may be passed with explosive force
Urine output scanty and concentrated
Lab findings:
o Increased hematocrit, hemoglobin, serum
protein levels
o Falsely high because the percentage is low
Loss of 2.5-5% of body weight- mild dehydration
Severe diarrhea can cause of loss of 5-15% of body
weight quickly
Any infant who has lost more than 10% if body weight
requires immediate treatment
Therapeutic measures
Assessment of the fluid and electrolyte imbalance
Rehydration
Maintenance of fluid therapy
Reintroduction of adequate diet
Antimicrobial agents if necessary
Nursing considerations: assessment
Observe general appearance and behavior
Assess for dehydration
o Decreased urine output
o Decrease in weight
o Dry mucous membranes
o Poor skin turgor
o Sunken fontanel in infant
More severe dehydration
o Increase in pulse
o Increase in respirations
o Decreased blood pressure
o Prolonged cap refill time
o All signs of impending hypovolemic shock
o Also assess for septic shock

Celiac Disease
Sensitivity or immunological response to the gluten
factor of protein
When gluten is ingested, a autoimmune response
destroys part of the small intestine mucosal
Body is unable to properly digest food and absorb
nutrients, especially fats
As a result, these children develop:
o Steatorrhea (bulky, foul-smelling, fatty stools)
o Deficiency of fat-soluble vitamins (A, D, E, K)
o Protuberant abdomen
o Rickets (disease in bone formation) due to a
loss of vitamin D
o Hypoprothrombinemia may occur due to loss
of vitamin K (need Vitamin K to make
prothrombin in the liver)
o May also have iron deficiency anemia and
low albumin (blood carrier molecule that
helps maintain blood volume and blood
pressure) levels.
Assessment of Celiac disease:
These children may be anorexic and irritable
A typical celiac baby:
o Would be fit and well until after the ingestion
of gluten-containing solids (usually between
6 and 18 months of age)
o Then the baby would develop pale, bulky,
offensive smelling stools (steatorrhea),
become miserable and lethargic
They gradually fall behind other children in their age
in height and weight
Appear skinny with spindly extremities and wasted
buttocks
Face, however, may be plump and well-appearing
Diagnosis of Celiac disease:
History
Clinical symptoms
Serum analysis of antibodies against gluten
Biopsy of intestinal mucosa (too determine degree of
inflammation)
Stool may be collected for fat content analysis
Children are also put on a gluten-free diet and
observedresponse to this diet is usually very
dramatic
Continue children on a gluten-free diet for life
Need to take water-soluble forms of vitamins A and D
May also need to take iron and folate to correct
anemia

Nursing goals
Urine output is more than 1ml/kg/hr
Bowel movements are formed and fewer than 4 per
day
Stool tests negative
Blood pH more than 7 (to prevent metabolic acidosis)
Specific gravity < 1.030

Gluten is not found in rice or corn.

Malabsorption syndromes
Celiac Disease
Short bowel syndrome

Short Bowel syndrome and its causes

A decrease in the amount of absorptive surface

Celiac crisis:
Can occur when any child with celiac disease
develops an infection
Usually experiences acute vomiting and diarrhea
o Cause electrolyte and fluid imbalances

Caused by congenital malformations such as

gastroschisis (infant born with some or all of intestinal
contents outside of body; loses absorptive surface),
or intestinal atresia.
May be seen in children with intestinal ischemia due
to malroation (twisting of intestines), intussusception
(the slipping of one part of an intestine into another
part just below it; ensheathed), and volvulus (infection
which makes bowel obsolete).
Occasionally seen in patients with chronic irritable
bowel disease (IBD).
Necrotizing entercolitis in preemies (tissue death in
bowels due to colonization/infection and/or
inflammatory changes).

Care of the infant/child with Short bowel syndrome:

Parenteral nutrition
Enteric feedings if tolerated
Monitor for vitamin and mineral deficiencies
Mortality-related complications of SBS
Sepsis
Liver and biliary tract infections associated with TPNcauses cholestasis
o Seen in children under 4 years of age
o Leads to liver failure
Obstructive disorders
Hypertrophic pyloric stenosis
Intussusception
Pyloric stenosis
Pyloric sphincter is the opening between the lower
portion of the stomach and the beginning portion of
the intestine (duodenum).
If there is hypertrophy (increase in size) or
hyperplasia (excessive proliferation of normal cells in
normal tissue) of the muscle surrounding the
sphincter, there will be problems with the stomach
emptying called pyloric stenosis.
At 4-6 weeks of age, infants begin to vomit with feeds
Vomiting grows increasingly forceful until it is
projectile; can project up to 3-4 feet (this is the most
common symptom)
Occurs most frequently in first born white males
o 1:150 males
o 1:750 females
Cause is unknown, but is probably inherited
Vomitus usually smells sour (because of increased
gastric acid)
Diagnosis of pyloric stenosis
Made primarily from history
When the parent says their infant is vomiting, we
need to find out:
o What is the duration, intensity, frequency,
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
drink; there is usually an olive-sized mass in the right

upper quadrant which becomes more prominent with

drinking the water (seen on the outside of the body).
May also confirm with ultrasound

Therapeutic management of pyloric stenosis

Surgical correction: pyloromyotomy
o Muscle of pylorus is split allowing for a larger
lumen
o Is usually done laparoscophy
o Prognosis is excellent
Nursing care postoperatively for pyloric stenosis:
Feedings usually begun 4-6 hours post-op with 1 tsp
(5 ml) of 5% glucose in saline hourly by bottle for four
feeds
If no vomiting, 2 tablespoons given hourly for the next
four feeds
Next, half-strength formula is given every 4 hours
By 24 to 48 hours, infants are taking their full formula
diet or being breastfed. Usually discharged after 48
hours.
Do not give more fluid than ordered; risks for breaking
open the newly operated areas.
IV fluids decreased as oral amount increases
Infants need to be bubbled/burped well after each
feeding to decrease swelling; we dont want air or gas
to be in tummies
Lay them on their side, preferably right side, to
aid the flow of fluid through the pylorus via
gravity
Monitor daily weights
Usually no vomiting occurs after the surgery. If it
does, report immediately! Feeding regimen may need
to be adjusted.
Some infants experience diarrhea due to the rapid
functioning of pyloric sphincter
Elevate the head of the bed
Monitor intake and output carefully; weigh all diapers
Nursing care for the pyloric sphincter incision
Care of the operative site:
o Observe for any drainage or signs of
inflammation
o Care of incision as dictated by hospital policy
o Keep diaper folded low to prevent
contamination of incision
o Change diapers frequently
Intussusception
Invagination of one portion of the intestine to another
(telescoping is a good synonym for it)
Generally occurs at 6-12 months
Typically idiopathic in patients under 12 months
May be related to another disorder in patients over 12
months.
Treatment of intussusception:
Surgery
Reduction by fluid/air/barium (done in radiology)
Motility disorders

Hirschsprungs disease (once known as Congenital

Aganglionic megacolon)
GERD (low esophageal and gastric mobility)

Hirschsprungs Disease (Congenital Aganglionic

megacolon)
Absence of ganglionic innervation to a portion of the
bowel
Peristalsis does not occur in non-innervated bowel
areas
Patients have chronic constipation or ribbon-like
stools
Treatment of Hirschsprungs disease
Surgery to remove the agangilionic colon segment
May be done in 2 stages, with a temporary colostomy
for 6-8 months to allow bowel to rest.
Meckels Diverticulum
In embryonic life, the intestine is attached for the
umbilicus by a duct
This duct becomes a ligament near term
In 2-3% of infants, this duct remains open as a pouch
off of the ileum
Problems associated with Meckels diverticulum
Some gastric mucosa (which secretes acidic fluids)
may be displaced
This may allow acidic, irritating secretions to flow into
the intestine
This irritates the bowel, leading to ulceration and
bleeding
Appendicitis symptoms
Can serve as a lead point causing intussusception
(from weakened area)
A fibrous band extending from the diverticulum to the
umbilicus can act as a constricting band around the
bowel

Cleft palate repairs are done at 18-24 months, so that

anatomic changes in the palate contour are complete.
Recovery is usually excellent
Remember, these are typically stages surgeries

Tracheoesophageal Fistula and Esophageal 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.
These defects may occur separately or in
combination
About half of the infants with TEF or EA also have
associated anomalies, especially congenital heart
disease and anorectal malformations.
Clinical manifestations of TEF and EA
Excessive salivation (drooling)
A newborn with drooling that is accompanied with
choking, coughing, and sneezing, especially when
fed.
Fluid returns through the nose and mouth
Infant becomes cyanotic and may stop breathing
Most are corrected with one surgery or two or more
staged surgeries.
Alteration in Activity and Mobility
Why study this topic?
Quest for mastery at every stage of development is
related to mobility.
Infant:

Speech, language, and overall development require

sensorimotor activity.

Toddler

Explore and imitate behaviors, a must for autonomy.

Treatment of Meckels diverticulum

The diverticulum (pouch) is surgically resected.

Preschooler
To express initiative, requires vigorous activity.

Structural defects
Cleft lip and palate
Esophageal atresia
Tracheoesophageal fistula

School-age
Strongly influenced by physical achievement and
competition

Cleft lip and palate

Cleft lip occurs when there is a failure of the fusion of
the maxillary and median nasal processes.
Cleft palate occurs when there is a failure of the
fusion of the palatal process (roof of the mouth)
Associated Nursing Diagnoses for Cleft lip and palate
Risk for fluid volume deficit
Risk for altered nutrition; less than body requirements
Risk for aspiration
Treatment for cleft lip and palate
Special nipples before surgery and while recovering
Cleft lip surgery is usually done between birth and 10
months of age

Adolescent
Relies on mobility to achieve independence.
Effects of Immobility:
Affects all body systems in some way.
Major physical consequences that impact children
are:
o Significant loss of muscle strength,
endurance, and muscle mass (atrophy)
o Bone demineralization leading to
osteoporosis
o Loss of joint mobility and contractures.
Other effects:
o Metabolism
Decreased metabolic rate
o Cardiovascular system
Pooling of blood in extremities

Postural hypotension
Blood clots
Dependent edema
Respiratory system
Decreased chest expansion
Can lead to increased secretions,
pneumonia
GI system
Constipation
Urinary system
Difficulty voiding
UTIs (d/t retention and urinary
stasis)
Integumentary
Decreased circulation and
increased pressure can lead to
ulcers.
Behavioral changes in Immobilized children:
Restlessness
Lack of concentration
Depression
Regression
Egocentrism
Decreased communication
Feel isolated
May become angry, aggressive or
quiet and passive

o
o

Effects of Immobility and the family:

Financial strain
Siblings may feel ignored
Guilt
Caregiver becomes worn out
Common Musculoskeletal problems
Traumatic injury
o Soft tissue injuries to the muscles, ligaments,
and tendons are common in children.
o In young children they occur from mishaps
during play.
o For older children and adolescents, they
occur during sports.
Soft Tissue Injuries
Contusions (bruise)
o Damage to soft tissue, subcutaneous
structures, and muscles
o Injured area is ecchymotic (black and blue
discoloration) due to blood leaking into
tissues; swollen and painful.
Cannot tell how long ago injury
occurred by the bruise.
o Immediate treatment is application of cold.

Sprains
o

Occur when trauma to a joint is so severe

that a ligament is partially or completely torn
or stretched. Usually involves damage to
blood vessels, muscles, tendons, and
nerves.
Child may describe a snap, pop, or tearing.

Therapeutic management of soft tissue injuries

The first 6-12 hours is the most critical for almost all
soft tissue injuries.
Basic principles include RICE or ICES
o R.I.C.E.: Rest, ice, compression, elevation
o I.C.E.S.: Ice, compression, elevation,
support
Ice immediately; do not apply for more than 30
minutes
o Reverse effects: vasodilation occurs
Elevate the extremity above heart level.
Torn ligaments, especially those in the knee, are
usually made immobile with a cast or splint for 3-4
weeks.
Passive leg exercises, gradually increased to active
leg exercises, begun as soon as sufficient healing has
occurred.
Fractures
Common injury at any age but more likely to occur in
children and older adults
Usually due to traumatic incidents at home, school, in
a motor vehicle, or associated with recreational
activities
Rarely occur in infants unless there is an underlying
hematology disorder
Toddlers- be suspicious of fractures at various stages
of healing
School-age childrenusually due to bicycleautomobile or skateboard injuries
Adolescents: bikes, motorcycles, sports
Common Fracture sites:
Forearm: falling on the outstretched hand.
Clavicle fractures are common
Hip fractures are rare
Auto/pedestrianfrom 4 to 7 years of age
o Triad of injury:
Level of the bumper, fractured
femur
Hood of the automobile, injury to
childs truck
Contralateral (Originating in or
affecting the opposite side of the
body) head injury due to impact
Types of fractures in children
Bends: Deformity without breaking (think of a young,
green stick that wont break, but it bends)
Buckle fractures: Compression of the porous bone,
raised or buldging projection at site. (not broken all
the way through)
Greenstick fracture: incomplete fracture, bone is
angulated beyond limits of bend.
Complete fracture: Divides bone fragments
Complete fractures
Transverse: straight up and down
o Crosswise, at right angles to the long axis of
the bone

o
o

Oblique: Slanting but straight, between a

horizontal and perpendicular direction
(diagonal).
Spiral: slanting and circular, twisting along
the bone shaft
Comminuted: broken into pieces (crushed).

Fractures, continued
Closed or simple
Open or compound (protruding through the skin)
Growth plate or Epiphseal injuries
Weakest part of long bones
Frequent 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
Associated problems with fractures in general
Muscles contract and spasm
Bones are pulled out of alignment
Severe hemorrhage in tissues, especially with femur
fractures
Vascular injuries
o Femur fracture may cause injury to sciatic
nerve
o Bone marrow is high vascularized
5 Ps of Ischemia
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Nursing actions for fractures
Support the injured limb; splint, DO NOT MOVE OR
STRAIGHTEN OUT THE BONE.
Ask the child to point to where it hurts
Ask the child to wiggle fingers or toes
Check distal pulses
Get historical information from someone who
witnessed the injury if possible.
Diagnostic Evaluation
History may be lacking!
o Young children cannot tell
o Older children may not tell the truth in fear of
repercussions
Radiography is the most useful tool
Therapeutic management of fractures
Reduction: regain alignment and length; setting
bone.
Immobilization: retains alignment and length
Restore function
Prevent further injury
Bone healing and remodeling
Rapid in children

Due to thickened periosteum (the fibrous

membrane that forms the covering of bones).
o Generous blood supply from bone marrow
New bone cells are formed in immense numbers
almost immediately after the injuryimmediate
treatment is detrimental
Examples of healing times for femoral shaft in
different age groups:
o Neonatal period: 2-3 weeks
o Early childhood: 4 weeks
o Later childhood: 6-8 weeks
o Adolescents: 8-12 weeks
o The general rule of thumb is that the
younger the child is; the quicker the bones
heal.
o

Delays in healing
Gaps between fragments delays or prevent healing
Prompt healing with end-to-end apposition (two
normally contiguous parts)
o Though, may cause bony overgrowth and
greater length of extremity
Angulated deformity may remodel in young children.
Careful reduction and follow-up to prevent permanent
disability.
Fracture complications
Circulatory impairment
Nerve compression syndromes
Non-union
Pulmonary emboli (fat, blood, and air)
Circulatory impairmentvery important
Absence of pulse, discoloration, swelling, pain
Report immediately to practitioner
Take steps to improve circulation (take action!)
o Loosen ace wrap
Most common lawsuits against nurses
Compartment syndrome
Typically caused by blunt trauma
Pressure rises within this space with tight dressings
or casts, hemorrhage, trauma, burns, and injury
Most common symptoms
o First sign: Pain out of proportion to injury
o Second sign: Tenseness on palpation
o Third sign: motor weakness
Non-union fractures
Failure of bone fragments to unite
Failure to unite due to any of the following:
o Separation of bone fragments at fracture site
o Hematoma (swelling of comprising a mass of
extravasated blood, usually clotted, caused
by a break in a blood vessel)
o Extra tissue between bone fragments
o Necrosis of bone tissues or infection
o Interruption of blood supply
Bone grafting may be required
Pulmonary Emboli
Blood, air, or fat (fat tends to occur faster)

May not occur for 6-8 weeks after injury

Fat emboli, first 24 hours usually in adolescents
Signs and symptoms:
o Dyspnea
o Chest pain
o Onset of sudden pain
Nursing interventions
o First: Elevate the head
o Second: Administer oxygen
o Notify physician immediately

Cast care
Risk for altered peripheral tissue perfusion related to
pressure from cast
Expected outcomes:
o No pain or numbness in extremity
o Distal nail beds blanches and refills in less
than 3 seconds
o Pedal pulses palpable
o Area surrounding case is warm and pink
Interventions:
o Keep extremity elevated
o Check circulation every 15 minutes during
the first hour, every hour for 24 hours, then
every 4 hours thereafter
o Assess for numbness or tingling (children
under 6 or 7 may not be able to express this)
o Edema that does not improve with elevation
should be reported
o Assess for the 5 Psif any of these
symptoms are present, requires immediate
attention!
Can lead to permanent paralysis of
extremity.
Risk for impaired tissue integrity related to pressure
from cast
o Edges of cast are usually covered by a fold
of stockinet
o If no stockinet, adhesive tape strips are
applied to prevent skin irritation (petaling)
o If the cast is surrounding the genital area, or
there is any chance of cast coming into
contact with stool or urine, need to cover
with plastic. Prevention is very important as
once urine has penetrated a cast, there is no
way to remove it.
Can clean cast with a damp cloth when soiled with
food
Knowledge deficit related to cast care
o Instruct parents/child on how to care for cast
o Instruct on 5 Ps

Most casts in place to 6-8 weeks

Removed with electric cast cutter
Skin usually looks macerated and dirty, a good bath
will remove dirt.
o Atrophy will resolve in its own
Once healing takes place, the extremity is as strong
as beforebut children will usually favor the
extremity. Allow them to regain full use on their own
time schedule.

Scoliosis
Lateral (sideways) curvature of the spine
May involve all or only a portion of the spinal column
Functional scoliosis (in response to another condition)
o Occurs as a compensatory mechanism
o Usually due to unequal leg lengths
o Created a pelvic tilt that is C-shaped
o Must correct the initial problem
A lift placed in one shoe
Remind the child to maintain good
posture (walking with book on head
3 x daily for 10 minutes)
Sit-ups and push-ups are good
exercises

Structural scoliosis
Permanent curvature of the spine with damage to the
vertebrae
Spine has an S-shaped appearance
Usually there is a family history
5x more common in girls than boys
Usually peaks between 8-15 years (school age)
Diagnosis is made on physical exam by having the
child bend forward
X-rays confirm diagnosis
Therapeutic management:
o If spinal curve is less than 20 degrees, no
therapy except close observation until the
child reaches 18 years of age)
o If greater than 20 degrees, may use braces,
traction, surgery, or combination.

Casting complications
Continued swelling could cause cast to become a
tourniquet.
o This is why we wait a day or two to cast
Parents should receive verbal and written instructions
Teach neuro/circulation checks to parents (5 Ps)
Document parents response to teaching. Always
have parents re-demonstrate

Nursing care of the immobilized child: Goals and

interventions
Goal One: Increase physical mobility related to
mechanical restrictions, physical disability
o Transport child by gurney, stroller, wagon,
bed, WC 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
Goal Two: Assist child to maintain optimal autonomy
o Provide mobilizing devices (crutches, WC)
o Assist with acquiring specialized equipment
o Instruct in use of equipment
Encourage activities that require mobilization
Allow as much freedom as possible and encourage
normal activities
Encourage child to participate in own care
Allow child to make choices

Cast removal

High Risk for Impaired Skin integrity

Goal: Maintain skin integrity

o Place child on pressure-reducing mattress
o Change position frequently, unless
contraindicated
o Protect pressure points with proper
positioning and cushioning
o Inspect skin surfaces for signs of breakdown
o Eliminate mechanical factures that cause
friction
o Good skin care
o Gently massage skin area until
contraindicated

High risk for injury

Child will experience no physical injury
o Teach correct use of devices (child and
parent)
o Assist with moving and/or ambulating
o Remove hazards from environment
o Modify environment as needed
o Keep call button within reach
o Keep siderails up at all times
o Help child use bathroom or commode if
possible
o Implement safety measures appropriate to
childs developmental stage
o Diversional activities
Muscular Dystrophies
The largest group of muscle disorders of childhood
Three types:
Congenital myotonic dystrophy
o Begins in utero
o Newborn may already have significant
myotonia (muscle weakness)
o Usually die before one year of age due to
respiratory failure
Assessory muscles for respiration
fail
Facioscapulohumeral Muscular dystrophy
Begins after 10 years of age
Facial weakness is the predominant symptom
Very slow progression of symptoms
Less disability than the other types
Normal lifespan is possible.
Pseudohypertrophic Muscular Dystrophy/ Duchennes
Disease
Most common form of MD
Symptoms usually appear by age 3 years
Occurs only in boys
Late in meeting motor milestones
Muscle weakness gradually becomes more
pronounced
Usually wheelchair-dependent by adolescence
Heart and respiratory failure may occur by early
adulthood

Cerebral Palsy
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 2:1000 births
Most common permanent disability of childhood
Incidence and Causes of CP
Most frequently associated with brain anoxia that
leads to cell destruction
o Symptoms can range from very mild to quite
severe, depending on the extent of brain
damage
Also can be caused by:
o Kernicterus (a form of jaundice from
hyerbilirubinemia; staining of the brain with
bilirubin)
o Meningitis (viral is the most common)
Occurs most frequently in very low weight infants
(born prematurely), or those small for their age.
o Their lungs havent been fully developed
CP has increased over the past decade due to:
o Preemies are living longer
o Multiple births from artificial reproductive
technologies
o Prenatal technology
Types of CP
Two main categories based in type of neuromuscular
involvement
o Pyramidal or spastic (50-70% of children
with CP)
o Extrapyramidal (outside of the pyramidal
tracts of the CNS)
Ataxic (awkward, unsteady gait)
Dyskinetic (defect in ability to
perform voluntary movement)
Athetoid (slow, irregular, twisting,
snakelike movements occur in the
upper extremities, esp. in the hands
and fingers)
Mixed
Spastic or pyramidal CP
Pyramidal system: conveys nerve impulses that
create voluntary movements
Problems in this area result in:
o Hypertonicity: excessive tone in the
voluntary muscles
o Abnormal clonus: rapidly alternating
involuntary contraction of skeletal muscle
o Exaggeration of deep tendon reflexes
Abnormal reflexes such as a
positive Babinski reflex
Continue to have neonatal reflexes past usual age
(tonic neck reflex)
Arch their back and extend arms/legs abnormally
when held in a ventral suspension position

Fail to do a parachute reflex if lowered suddenly (do

not extend arms/hands in front of self)
Assume a scissors gait due to tight adductor thigh
muscles which cause their legs to cross when held
upright.
May have tightening of heel cord which causes the
child to walk on toes; unable to stretch heel to touch
the ground.
Spastic involvement may affect:
o Both extremities on one side (hemiplegia)
o All four extremities (Quadriplegia)
o Primarily lower extremities (paraplegia or
diplegia)
Children with quadriplegia:
o Usually have impaired speech
o Swallowing is difficultdrool, problems
eating
o May have cognitive impairment

Extrapyramidal CP
Extrapyramidal nerve tract conveys nerve impulses
that effect autonomic movements:
o Help coordinate body movements
o Maintain skeletal muscle tone
o Play major role in equilibrium
Ataxia (defective muscular coordination)
Dyskinetic (a defect in the ability to perform voluntary
movements)
Athetoidwormlike
o Limp and flaccid muscles as an infant
o Later, child makes slow, writhing motions (in
place of voluntary muscles)
o May involve all four extremities, face, neck,
tongue
o Due to poor tongue and swallowing
movements, child may have poor speech
and problems with drooling
Concerned about aspiration
o With emotional stress, involuntary
movements may become irregular and jerky
Ataxic
o Children have an awkward, wide-based gait
o On neurologic exam, unable to touch fingerto-nose or due rapid, repetitive movements
Mixed
o Combination of more than one condition
listed above
Diagnostic evaluation for diagnosis of CP
Neurological exam
Historyespecially born prematurely
Ultrasound of brain
CT scan
MRI
Physical findings that may suggest CP
Delayed motor development
Abnormal head circumference (head is typically
larger)
Abnormal postures
Abnormal reflexes
Abnormal muscle performance and tone

25-75% of children have cognitive defects

may have visual problems

Medical management of CP
Overall goaldevelop a rehabilitation plan to promote
optimum function
Multidisciplinary teams
o OT, PT, Speech
As child grows, would include therapeutic exercises,
splints, braces
Antispasmodic drugs may also be used (Baclofen),
but may have little effect
Surgery to lengthen heel tendons may be done
Wheeled walkers or scooter boards
Cerebellar pacemakers may decrease spasticity in
some children
o Also called Baclofen pumps
Nursing Diagnoses
Altered growth and development
Impaired physical mobility
Self-care deficits (bathing/toileting/dressing)
Self-esteem disturbance
Impaired social interactions
General interventions
Promote maximal functioning of joints
Provide adaptive equipment for activities of daily
living
o Modified utensils for eating
o Push panels for computer
o Electric switches for battery operated toys
Position to prevent contractures
o Perform active and passive ROM exercises,
must be done daily
Provide adequate nutritionoften have difficulty
swallowing
Encourage verbalization of feelings about altered
body image
Encourage social interaction with peers
Teach patient and family how to maintain
independence
Identify support groups
Long term care for CP
Sometimes children are not diagnosed with CO until
2-4 years later. This can be upsetting to parents. Will
need much support and education.

Febrile convulsions
Febrile convulsions
Seizures associated with high fever (102-104 degrees
F)
Most common in preschool children or between 5
months and 5 years of age
Usually no more than 5-7 of these episodes occur in a
childs life
Seizure activity

Seizure usually lasts 15-20 seconds

Shows an active tonic-clonic pattern (alternately
contracting and relaxing the muscles)
EEG tracing usually normal
Usually a family history
Seizures subside once the fever is gone

Prevention of Febrile convulsions

Give Tylenol to keep fever below 101
Often fever develops during the night when
parent/caregiver is not with child
If child has one febrile seizure, no further treatment
given other than to advise parents to administer
Tylenol to keep fever below 101
If more than one seizure, child may be put on
Phenobarbital (controversial)
Therapeutic management of seizures
Teach parents that after the seizure subsides, they
should:
o Sponge the child with tepid water
Do not put child in bathtub
Do not use rubbing alcohol or cold
water
Do not give Tylenol right after the
seizure (not awake enough to
swallow)
If unable to decrease temperature by sponging,
advise parents to:
o Put a cool washcloth on childs forehead,
axillary, and groin areas (which are
temperature receptors)
Healthcare facility will:
Determine underlying cause
Lumbar 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.

Bacterial meningitis
Infections or inflammation of the cerebral meninges (the
membranes covering the brain and spinal cord)
90% of cases are between 1 month and 5 years
Peak incidence is in the winter.
Causative organisms (95% of cases)
o H. Influenzae (type B)
o Streptococcus pneumoniae
o Neisseria meningitis- epidemic form; droplet
from nasophargeal secretions
MUST be put on droplet isolation
Pathophysiology of Bacterial meningitis
Pathologic 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

Produces an inflammatory effect that leads to thick

exudates that blocks CSF flow.
Brain becomes edematous, covered with purulent
exudate.
Spreads VERY quickly through CNS

Clinical signs in Children and Adolescents

Usually have 2-3 days of a cold, upper respiratory
infection and occasionally and ear infection.
Become VERY irritable due to headache
May have convulsions
photophobia
As the disease progresses, more signs of meningeal
irritability occurs:
o Positive Brudzinskis (image on page 674)
When childs head is flexed forward
(while laying on back), both hips,
knees and ankles flex. This shows
meningeal irritation
o Positive Kernigs (image on page 674)
Flex childs hips and knee (while
laying on back)
Then extend legthis will cause
pain, resistance and spasm which
indicate irritation.
o Nuchal rigidity occurs (neck stiffness)
o In the newbornpoor sucking, weak cry,
lethargy
Diagnostic EvaluationLumbar Puncture
Obtained by history and analysis and CSF via Lumbar
puncture
o Culture and gram stain identify causative
organism
Blood cell countWBC elevated
Lowered glucose
o Increased metabolic rate due to the body
and brain trying to fight off infection; draws
glucose out of blood for energy.
Protein content increased
o Due to extra cells and metabolism occurring
in the CNS
Therapeutic Management
Medical emergency!
o Directly put on droplet isolation precautions
o IMMEDIATE antimicrobial therapy
o Hydration
o Ventilation (not in all cases)
o Reduction of increased ICP
o Management of shock and Disseminated
intravascular coagulation (DIC)
Tidbits on DIC: Normally, when you
are injured, certain proteins are
turned on and travel to the injury
site to help stop bleeding. However,
in persons with DIC, these proteins
are abnormally active. Small blood
clots form throughout the body.
Overtime, the clotting proteins
become "used up" and are

unavailable during times of real

injury
This disorder can result in clots or,
more often, bleeding. Bleeding can
be severe.
Control of seizures, temperature

Photo of Disseminated intravascular coagulation

Increased Intracranial Pressure

Not a single disorder, but a sign that may occur with

many neurological disorders
One such cause is a brain tumor
The rate at which symptoms develop is:
o Cause
o Ability of childs skull to expand to
accommodate the increased pressure
The younger the child, the more
flexible the skull
o Location
o Size and growth rate of tumor
Children with open fontanels withstand more pressure
than older children

Signs of ICP:
Increased head circumference
o >2cm/month in the first 3 months
o >1cm/month in the 2nd three months
o >0.5cm/month for the ext six months
Fontanel changes
o Anterior fontanel tense and bulging; closes
late
Vomiting
o Occurs without nausea (rarely with nausea)
o Occurs upon awakening in the morning or
after a nap
The fluid is not moving when
sleeping
o May be projectile
Eye changes

Diploplia (double vision) from pressure on

abducens nerves
o White of sclera evident over top of cornea
(sunset eyes)
o Limited visual fields
o Papilledema (retinal edemacannot see on
physical assessment; need special
equipment)
Visual sign changes
o Elevated temperature and blood pressure
(body regulators are compressed)
o Increase in pulse pressure (the gap
between the systolic and diastolic)
o Decreased pulse and respirations due to the
growing pressure on brain stem which
controls:
Cardiac rate and respirations
Pain
o Headache on awakening and standing.
Increases with valsalva maneuver) or
holding breath
Each increased intrathoracic
pressure
Mentation
o Irritability, decreased level of consciousness,
altered LOC
Later signs:
o Personality changes
o Seizures
o Head tilt (because of heavy tumor)
o Decreased LOC
o Decreased motor response to stimuli
o Decreased sensory response to painful
stimuli
o Alterations in pupil size and reactivity
o Cheyne-stokes respirations
o Decerebrate or decorticate posturing (pg.
1674)
This is very bad
o

Glasgow coma scale

Most widely used of the pediatric coma scales
Standardized scale to describe and interpret the
degree of LOC in persons with brain injury
The lower the score, the deeper the coma
3 parts:
o eye opening
o verbal response
o motor response
highest score is 15
lowest score is 3
Medical management is based on these scores
Brain Tumors

The most common solid tumor that occurs in children,

secondary to leukemia
Tends to occur between 1 and 10 years of age (5years is the peak)
In children, tends to occur in areas of the brain where
they are difficult to remove.

Signs and symptoms due to increased intracranial

pressure (ICP)

Treatment of Brain tumors

4-6 months may pass from first symptom before
diagnosed
diagnostic tests:
o skull films
o bone scan
o MRI
o Cerebral angiography (difficulty getting dye
through due to abnormal vascularization)
o CT scan
Therapeutic management of brain tumors
Includes a combination of surgery, radiotherapy, and
chemotherapy
Preoperative care
o Will usually receive a stool softenerdo not
want child to strain after their brain is
operated on
o A portion of the head is shaved; very
traumatic for adolescent
o If going to the ICU after surgery, have child
meet the ICU staff
Postoperative care
Positioning
o Depends on location of tumor; usually on the
opposite side of incision
o Bed is flat or slightly elevated
o DO NOT lower the head of the bed
o Child will be very lethargic due to brain
swelling
Assess VS every 15 minutes initially until stable.
Eventually will decrease to every 4 hours
Monitor IV fluids very carefully. Too much fluid can
cause edema in the brain
o We dont want the child to be dehydrated,
but we do want them on the drier side
Prevent nausea and vomiting
Therapeutic management of ICP
Identify source and remove ASAP
Keep coughing, vomiting, and sneezing to a minimum
Place child in a semi-fowlers position (infant seat for
infants)
Monitor IV fluids very carefully
Meds:
o Corticosteriods (Decadron)reduces
inflammation
o Osmotic diuretic (mannitol)pulls fluid out of
tissues
Will usually insert foley catheter prior to administration
for accurate I & Os

Down syndrome

A generalized syndrome1:800 to 1:1000 live births

Etiology unclear
90% + cases attributable to an extra chromosome 21
(trisomy 21)
Statistically greater risk if mother is over 35, but 80%
born to women under the age of 35.
Paternal age may also be a factor
Degree of physical and cognitive development
impairment related to the percentage of cells with
abnormal chromosomal makeup

Clinical manifestations of Down syndrome

Intelligence varies from severely affected to nearnormal intelligence
Social: 2-3 years behind mental age, especially in
childhood
Congenital anomalies: 30-40% has a congenital heart
disease, especially septal defects. May also have GI
and ortho alterations.
Respiratoryinfections very prevalent
o Due to hypotonia; swallowing muscles are
weakprone to aspiration
Growthrate reduced in height and weight as
children; but often overweight as teens/adults
Sexual developmentmay be delayed, incomplete,
or both
Physical manifestations
Headseparated 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
(simian line)
Feet: wide space between great and first toes, plantar
crease between great and second toes.
Hypotonia
Prognosis with Down syndrome
Improved in recent years
Significantly lower than for the general population
Survival at one year with CHD: 76%; at 20 years of
age: 53%
Survival at one year without CHD: 91%; at 20 years of
age: 82%
Dramatic increase in mortality after the age of 44,
virtually all have neuro changes similar to Alzheimers
disease
Possible nursing diagnoses for DS
Potential 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
Down syndrome
Altered growth and development related to impaired
cognitive functioning

Potential for injury due to hypotonia/cognitive

impairments high risk for falls
Fetal Alcohol syndrome

Characteristic facial and associated features due to

excessive ingestion of alcohol by mother during
pregnancy
Degree of alcoholism not related to defects of FAS
Is related to livers ability to detoxify
Circulating (unmetabolized) alcohol has an affinity for
brain tissue

Newborns with FAS

Measures to prevent seizures
Avoid overstimulation (can bring on seizure)
Provide sedation
Anticonvulsants as ordered and indicated
Major features of FAS
Facial: thinned upper lip with vertical ridge, short
upturned nose
Neuro: mental retardation, motor retardation,
microcephaly, poor coordination, hypotonia, hearing
disorders
Behavior: irritable, hyperactive
Growth: Prenatal growth retardation (IUGR),
persistent lag after birth, very small and thin

Hydrocephalus

Caused by imbalance in production and absorption of

CSF
CFS accumulates within ventricular system of brain,
producing dilation of ventricles.

Mechanisms of Fluid imbalance in Hydrocephalus

Tumor of choroid plexus (the area that produces CSF
in brain) may cause increased secretion of CFS.
Choroid tumors are rare, but structural malformations
may cause impaired absorption or obstruction to
outflow of CSF.
Imbalance of secretion and absorption of CFS causes
CFS to accumulate in the ventricles, which dilate and
compress against cranium
Skull also enlarged
Most are a result of developmental malformations (in
ventricular system)
Usually presents in infancy, but can also be up to
early childhood
Other causes: infections, neoplasms, trauma, brain
damage
Clinical manifestations of hydrocephalus
Influenced by acuity of onset and presence of preexisting structural lesions
In infancy, head grows at an abnormal rate
Anterior fontanel tense, bulging, dilated scalp veins
(due to the skin stretching)

Manifestations of Hydrocephalus in childhood

Caused by increased ICP
Headache upon awakening with improvement
following emesis or upright posture
Papilledema (edema and inflammation of optic nerve)
Strabismus
Ataxia
Irritability/lethargy
Confusion
Incoherence
Diagnosis
Head circumferences
Associated Neuro signs
CT, MRI, skull x-ray
Dye inserted into ventricle through anterior fontanel
will not appear in CSF from lumbar puncture if noncommunicating
Therapeutic management
Relief of hydrocephalus
Treatment of complications
Management of issues related to psychomotor
alterations
Surgical treatment
Direct removal of obstruction if present (cyst,
neoplasm, Hematoma)
A shunt is inserted under the skin the drain ventricles,
may include a reservoir to add medications and
remove fluid.
More on Shunts
Valves open at a predetermined intraventricular
pressure and close when the pressure falls below that
level (prevents backflow)
Ventriculo-Peritoneal (VP) shunt is preferred for
infants and young children
Ventriculo-Atrial (VA) shunt (ventricle to right atrium)
reserved for older children who have attained most of
their growth and for children with abdominal
pathology (perforation of bowel, etc.)
Complications of shunts
Mechanical obstruction within ventricles from tissue or
exudates, displacement related to growth, thrombus
(clot)
Often presents as an emergency; increased ICP and
worsening of neuro status
Infectionthe most serious complication. May occur
at any time but the greatest risk is 1-2 months after
placement. (tubing colonized with bacteria)
Postoperative care after shunt placement
Position on un-operated side
May need to keep flat to avoid too rapid reduction of
intracranial fluid
Observe for signs of increased ICP
o If increased ICP occurs, elevated the HOB to
15-30 degrees to enhance gravity flow
through the shunt
Monitor I & Os carefully, may be on a fluid restriction

Presence of bowel sounds determined before feeding

infant with VP shunt (in case the bowel was
perforated at the time of placementdo not want shit
leaking into the tube)

Signs of CSF infection

Elevated vital signs
Poor feeding
Decreased LOC
Seizures
Associated nursing diagnoses
Potential for injury related to increased ICP
Potential for infection related to presence of
mechanical drainage system
Altered family processes related to having a child with
a chronic illness
Neural Tube Defects

Spina Bifida: defect in closure of the vertebral column

with varying degrees of tissue protusion
Spina Bifida Occulta:
o Posterior vertebral arches fail to close in the
lumbrosacral area
o Spinal cord remains intact and usually is not
visible.
o Meninges are not exposed on the skin
surface
o Neurological deficits are not usually present
Spina Bifida cystica:
o Protrusion of the spinal cord and/or its
meninges occurs
o Defect results in incomplete closure of the
vertebral and neural tubes, resulting in a
sac-like protrusion in the lumbar or sacral
area, with varying degrees of nervous tissue
involvement
Meningocele:
o Protrusion involves meninges and a sac-like
cyst that contains CSF in the midline of the
back, usually the lumbosacral area
o Spinal cord is not involved
o Neurological deficits are usually not present.
Myelomeningocele:
o Protrusion of meninges, CSF, nerve roots,
and a portion of the spinal cord occurs.
o The sac (defect) is covered by a thin
membrane that is prone to leakage and
rupture
o Neurological deficits are present.

Clinical manifestations
Vary according to degree of spinal defect
Neuro dysfunction related to anatomic level of defect
and nerves involved
Defective nerve supply to bladder often causes urine
dribbling or overflow incontinence
Poor anal-sphincter tone; lack of bowel control and
rectal prolapse

There may be saddle anesthesia with bladder and

anal sphincter paralysis
May also have ortho involvement; joints, kyphosis,
scoliosis, hip dislocations

Diagnostic evaluation
Clinical manifestations
Meningeal sac (can be transilluminated)
Ultrasound prenatally
Care of the myelomeningocele sac
Evaluate the sac and measure the lesion
Protect the sac; cover with a sterile, moist (normal
saline) dressing. May include an antibiotic in the
solution. Change every 2-4 hours.
Device to maintain body temperature without clothing
or covers that irritate the sac.
Place in prone position to minimize tension on the sac
and the risk of trauma; the head is turned to one side
for feeding.
Assess for early signs of infection; elevated
temperature, irritability, lethargy, nuchal rigidity.
Associated Nursing Diagnoses
Potential for infection related to presence of infective
organisms, nonepithelialized meningeal sac
Potential for trauma r/t delicate spinal lesion
Potential for impaired skin integrity r/t paralysis,
continual dribbling of urine or feces
Potential for trauma r/t impaired cerebrospinal
circulation
Potential for injury r/t neuromuscular impairment