NCM 102

HIGH RISK Children

HIGH RISK INFANT (Part 1)

COMMON HEALTHPROBLEM DURING INFANCY

FAILURE TO THRIVE
 A condition in which a child fails to gain weight and is persistently less than the fifth percentile on
standard growth chart
 Persistent deviation from established growth curve.
 Delay in physical growth and weight gain might lead to cognitive impairment or even death
 4 principal factors for human growth:
1. Food
2. Rest and activity
3. Adequate secretions of hormones
4. Satisfactory relationship with care giver
 Classified as:
1. Organic (OFTT) - due to pathologic condition such as problem in absorption and
hormonal dysfunction
2. Nonorganic (NFTT) – due to psychosocial factor disrupted maternal child relationship
3. Idiopathic(IFTT) - Unexplained by the usual organic and environmental etiologies but
usually classified as NFTT
 A thorough history is the best guide to establishing the etiology of the failure to thrive:
 Poverty is the greatest single risk factor worldwide and in the United States
 Nutritional deficiency is the fundamental cause
 Assessment findings
 Poor muscle tone, loss of subcutaneous fats, skin breakdown
 Rumination – common characteristic; voluntary regurgitation
 Lethargic- unresponsive
 Positive delay in growth and development
 Signs of disturbed maternal – child interaction
 Diminished or nonexistent crying
 Radar gaze - wide-eyed gaze and continual scan of environment
 Characteristics of the individual providing care:
1. Difficulty perceiving and assessing the infant’s needs
2. Frustrated and angered at the infant’s dissatisfied response
3. Frequently under stress and in crisis, with emotional, social and financial problems
 All children with failure to thrive need additional calories for catch-up growth :
 Treatment depends on the cause
 Medical disorder - specific treatment is given Parent-child relationship - Family
counseling
 Nutritious, high-calorie feedings
 Nursing Interventions
 Provide consistent caregiver.
 Provide sufficient nutrients.
 Make feeding a priority intervention.
 Keep an accurate record of intake.
 Weigh daily.
 Introduce positive feeding environment
 Establish a structured routine
 Hold the young child for feeding
 Maintain eye-to-eye contact
 Maintain a calm, even temperament
 Provide a quiet, non stimulating environment
 Talk to child giving appropriate directions and praise for eating
  Increase stimulation appropriate to the child’s present developmental level.
 Provide the parent an opportunity to talk.
 When necessary, relieve the parent of childrearing responsibilities until able and
ready emotionally to support the child.
 Demonstrate proper infant care by example, not lecturing.
 Supply the parent with emotional support with fostering dependency.
 Promote the parent’s self-respect and confidence by praising achievements with
child.

HYDROCEPHALUS
 Description: An imbalance of cerebrospinal fluid (CSF) absorption or production caused by:
malformations, tumors, hemorrhage, infections, or trauma
 Results in head enlargement and increased ICP
 Types:
 COMMUNICATING- occurs as a result of impaired absorption within the subarachnoid
space.
 NONCOMMUNICATING- blockage in the ventricular system that prevents CSF from
entering the subarachnoid space
 Assessment:
1. Increased head circumference
2. Thin, widely separated bones of the head that produce a cracked pot sound (Macewen's
sign) on percussion
3. Anterior fontanel tense, bulging, and nonpulsating
4. Dilated scalp veins
5. Sunsetting eyes
6. Behavior changes, such as irritability and lethargy
7. Headache on awakening
8. Nausea and vomiting
9. Ataxia- lack of coordination of muscle movement
10. Nystagmus- involuntary movement of the eyes
11. Late signs: High, shrill cry and seizures.
 Diagnostic Test: CT scan, MRI, Skull X-ray
 Transillumination- holding a bright light such as a flashlight or specialized light (Chun
gun) against the skull in a darkened room; a skull filled with fluids rather than solid brain
substance
 Management - treatment depends to cause
 Surgical interventions
 GOAL: Prevent further CSF accumulation by bypassing the blockage and
draining the fluid from the ventricles to a location where it may be reabsorbed.
a) Ventriculoperitoneal shunt -the CSF drains into the peritoneal cavity
b) Atrioventricular shunt -CSF drains into the right atrium of the heart
c) Acetazolamide (diamox)- promote the excretions of excess fluids
 Preoperative interventions
a) Give small frequent feedings as tolerated until a preoperative NPO status
is prescribed.
b) Reposition head frequently and use an egg crate mattress under the
head to prevent pressure sores.
c) Prepare the child and family for diagnostic procedures and surgery
 Postoperative interventions
a) Monitor vital signs and neurological signs.
b) Position the child on the unoperated side
c) Observe for signs of increased ICP
d) elevate head 15-30 degrees
e) Monitor for signs of infection
f) Measure head circumference.
 g) Provide comfort measures; expected level of functioning
h) Administer medications as prescribed, diuretics, antibiotics, or
anticonvulsants.
i) Instructions on parents re: wound care, shunt revision
j) Availability of support groups; community agencies
k) Instruct the parents on how to recognize shunt infection or malfunction
o In an infant- irritability, lethargy, and feeding poorly
o In a toddler- headache and a lack of appetite
o In older children- an alteration in the child's level of
consciousness.
SPINA BIFIDA
 Description: A central nervous system defect results from failure of the neural tube to close
during embryonic development generally in the lumbosacral region
 Causes:
 Actual cause is unknown; multiple factors
 Genetic – if a sibling has had neural tube defect
 Environmental factors
 Medications , viral infection and radiation
 Types:
1. Spina bifida occulta- Posterior vertebral arches fail to close in the lumbosacral area.
 Spinal cord and meninges remains in the normal anatomic position
 Defect may not be visible dimple or a tuff of hair on the spine
 Asymptomatic may have slight neuromuscular deficits
 No treatment if asymptomatic aimed at specific symptoms
2. Spina bifida cystica- Protrusion of the spinal cord and/or its meningeswith varying degrees of
nervous tissue involvement.
a) Meningocele
 part of spinal protrudes through opening in the spinal canal
 sac is covered with thin skin no nerve roots involved
 no motor or sensory loss Good prognosis after surgery
b) Myelomeningocele (meningomyelocele)
 with spinal nerves roots in the sac
 have sensory or motor deficit
 below site of the lesion
 80% have multiple handicaps
 Assessment- Depends on the spinal cord involvement
1. Visible spinal defect
2. Motor/sensory involvement
a) Flaccid paralysis of the legs
b) Altered bladder and bowel function
c) Hip and joint deformities
d) Hydrocephalus

 Diagnostics:
 Prenatal- ultrasound, amniocentesis
 Postnatal
 xray of spine
 ct scan
 myelogram-uses a special dye and an X-ray (fluoroscopy) to provide a very
detailed picture of the spinal cord and spinal column
 encephalogram
 urinalysis, BUN, Creatinine clearance
 Management:
1. Surgery- closure of sac within 48 hours, shunt, orthopedic
2. Drug therapy- Antibiotic, Anticholinergic
  Nursing Management:
1. Prevent trauma to the sac
a) cover with a sterile, moist (normal saline), non adherent dressing
b) change the dressing every 2 to 4 hours as prescribed, keep area free from
contamination
c) place in a prone position to minimize tension on the sac
d) head is turned to one side for feeding
e) Administer meds
2. Prevent Complication
a) Use aseptic technique to prevent infection.
b) Assess the sac for redness, clear or purulent drainage, abrasions, irritation, and
signs of infection.
c) Clean intermittent catheterization
d) Perform neurological assessment
e) Assess for physical impairments such as hip and joint deformities
3. Provide adequate nutrition
4. Provide sensory stimulation
5. Provide emotional support to parents and family
6. Provide discharge teachings
 wound care
 ROM, PT
 signs of complications
 medication regimen
 positioning – feeding ,diaper change

MENINGITIS
 Description: inflammations of meninges of the brain and spinal cord
 Cause by bacteria, viruses, other microorganism
 as a primary disease or as a result of complications of neurosurgery, trauma, infection of the
sinus or ears, or systemic infections.
 H Influenzae Meningitis – the most common form; between 6 to 12 months
 Bacterial meningitis - Haemophilus influenza type B, Streptococcus pneumoniae, or
Neisseria meningitidis
 Viral meningitis is associated with viruses such as mumps, herpesvirus, and enterovirus.
 Assessment
 Fever, chills, headache,
 high-pitched cry, irritability
 Vomiting, Poor feeding or anorexia
 Bulging anterior fontanel in the infant
 Signs of meningeal irritations
 Nuchal rigidity – stiff neck
 Positive Kernig sign- Severe stiffness of the hamstring muscle causes an inability
to straighten the leg when the hip is flexed to 90 degrees.
 Opisthotonos
a) arching of the back
b) head and heels bent backward
c) and body arched forward
 Brudzinski sign - Flexion at the hip in response to forward flexion of the neck
 Interventions
1. Provide isolation and maintain it for at least 24 hours after antibiotics are initiated.
2. Administer antibiotics and antipyretics as prescribed.
3. Perform neurological assessment and monitor for seizures and complications
4. Assess for changes in level of consciousness and irritability.
5. Monitor intake and output.
6. Assess nutritional status.
7. Determine close contacts of the child with meningitis because the contacts will need
prophylactic treatment.
8. Meningococcal vaccine is recommended to protect against meningitis.