Study guide Exam 4

❖ Cerebral Palsy (CP): Clinical manifestation and nursing care

● A nonprogressive impairment of motor function, especially that of muscle control, coordination & posture
○ Abnormal perception and sensation; visual, hearing, and speech impairments; seizures; and
cognitive disabilities
○ Clinical manifestations are divided into 4 major classifications: spastic, dyskinetic, ataxic, and
mixed
■ Spastic (pyramidal):
■ MC
■ Hypertonia/spasticity of affected limbs, permanent contractures, primitive reflexes
continue past normal age
● Moro, tonic neck, Babinski are the persistent primitive reflexes
● Unable to sit without support at age 8 months
■ Can present as tetraplegia (all 4 limbs), diplegia (2 limbs), triplegia( 3 limbs), or
monoplegia (1 limb)

■ Dyskinetic (nonspastic, extrapyramidal)

■ Athetoid & dystonic
■ Has slow wormlike movements of the extremities, trunk, face, and tongue and drooling
and speech problems, leads to chorea (involuntary and irregular muscle movement)
■ Ataxic (nonspastic, extrapyramidal)
■ Has rapid repetitive movements; a wide gait; and an inability to hold onto objects.
(General)Possible signs include:
➢ Delayed Gross Motor Development
■ A universal manifestation
● Delay in all motor accomplishments
● Increases as growth advances
● Delays more obvious as growth advances
➢ Abnormal Motor Performance
■ Very early preferential unilateral hand preference
● Abnormal and asymmetric crawl
● Standing or walking on toes
● Uncoordinated or involuntary movements
● Poor sucking
● Feeding difficulties
● Persistent tongue thrust
➢ Alterations of Muscle Tone
■ Increased or decreased resistance to passive movements
■ Opisthotonic posturing (arching of back)
■ Feels stiff on handling or dressing
■ Difficulty in diapering
■ Rigid and unbending at the hip and knee joints when pulled to sitting position (early
sign)
➢ Abnormal Postures
■ Maintains hips higher than trunk in prone position with legs and arms flexed or drawn
under the body
■ Scissoring and extension of legs with feet plantar flexed in the supine position
■ Persistent infantile resting and sleeping position
■ Arms abducted at shoulders
■ Elbows flexed
■ Hands fisted
➢ Reflex Abnormalities
■ Persistence of primitive infantile reflexes
■ Obligatory tonic neck reflex at any age
■ Non Persistence beyond 6 months old
■ Persistence or hyperactivity of the Moro, plantar, and palmar grasp reflexes
■ Hyperreflexia, ankle clonus, and stretch reflexes elicited in many muscle groups on fast,
passive movements
➢ Associated Disabilities*
■ Altered learning and reasoning
■ Seizures
■ Impaired behavioral and interpersonal relationships
■ Sensory impairment (vision, hearing)
➢ Early Signs
■ Failure to meet any developmental milestones, such as rolling over, raising head, sitting
up, crawling
■ Persistent primitive reflexes, such as Moro, atonic neck
■ Poor head control (head lag) and clenched fists after 3 months old
■ Stiff or rigid arms or legs; scissoring legs
 ■ Pushing away or arching back; stiff posture
■ Floppy or limp body posture, especially while sleeping
■ Inability to sit up without support by 8 months old
■ Using only one side of the body or only the arms to crawl
■ Feeding difficulties
■ Persistent gagging or choking when fed
■ After 6 months old, tongue pushing soft food out of the mouth
■ Extreme irritability or crying
■ Failure to smile by 3 months old
■ Lack of interest in surroundings
❖ Nursing Care
➢ frequent rest periods should be arranged to avoid fatigue
➢ a diet should be tailored to the child's activity and metabolic needs
■ Meeting the child's nutritional needs may be a challenge because of GER (or GERD),
feeding and swallowing difficulties, chronic constipation, and subsequent anorexia
■ Gastrostomy feedings may be necessary to supplement regular feedings
◆ jaw control is often compromised, more normal control can be
achieved if the feeder provides stability of the oral mechanism from
the side or front of the face (manually feed by
➢ Safety precautions are implemented, such as having children wear protective helmets if they are
subject to falls or capable of injuring their heads on a hard object
➢ Medications
■ Prevent painful muscle spasms
● Baclofen pump (intrathecal)
● Botox injections
■ Antiepileptics
➢ Promote socialization experiences with other affected and unaffected children
■ Recreation and after-school activities should be considered for children who are
unable to participate in the regular athletic programs and other peer activities.
● Second biggest nursing care is to help improve self-esteem of the child and
support caregivers
■ Children with mild to moderate cognitive involvement are generally able to participate in
regular classes
■ Provide support and education to the child and family

❖ Guillain-Barre’ syndrome (GBS): Clinical manifestation and nursing care

Also known as (Infectious Polyneuritis)
● The hallmark of GBS is acute peripheral motor
weakness.
● The paralysis usually occurs approx. 10 days after a
nonspecific viral infection
Initial symptoms
■ Muscle tenderness
■ Paresthesia and cramps
(sometimes)
■ Proximal symmetric muscle
weakness
 ■ Ascending paralysis from lower extremities
■ Frequently involves muscles of trunk and upper extremities and those supplied by
cranial nerves (especially facial)
■ Flaccid paralysis with loss of reflexes
■ May involve facial, extraocular, labial, lingual, pharyngeal, and laryngeal muscles
■ Intercostal and phrenic nerve involvement:
● • Breathlessness in vocalizations
● • Shallow, irregular respirations
➢ Other Manifestations
■ Tendon reflexes depressed or absent
■ Variable degrees of sensory impairment
■ Muscle tenderness or sensitivity to slight pressure
■ Urinary incontinence or retention and constipation
❖ Nursing Care
➢ Nursing care is primarily supportive and is the same as that required for children with
immobilization and respiratory compromise.
➢ The emphasis of care is on:
■ Close observation to assess the extent of paralysis and on prevention of complications,
including aspiration, ventilator associated pneumonia (VAP), atelectasis, DVT, pressure
ulcer, fear and anxiety, autonomic dysfunction, and pain.
➢ A key to recovery in the child with GBS is the prevention of muscle and joint contractures, so
passive range-of-motion exercises must be carried out routinely to maintain vital function.
➢ Cognitive function remains intact; therefore, it is important for nursing care to involve
communication with the child or adolescent regarding procedures and treatments that may be
frightening
➢ Tx is supportive: steroids, IVIG, plasmapheresis, respiratory support
■ Gabapentin and carbamazepine may be used to manage neuropathic pain in patients
with GBS.

❖ Latex allergies and foods that may cause allergic reactions

High-risk and latex-allergic individuals must be managed in a latex-free environment. Take care that they do not
come in direct or secondary contact with products or equipment containing latex at any time during medical
treatment:
➢ Spina bifida (SB)
➢ Urogenital anomalies
➢ Imperforate anus
➢ Tracheoesophageal fistula
➢ VATER* association
 ■ • Preterm infants
■ • Ventriculoperitoneal shunt
■ • Cognitive impairment
■ • Cerebral palsy (CP)
■ • Spinal cord injuries (SCIs)
■ • Multiple surgeries
■ • Atopy

❖ Allergic reactions range from urticaria, wheezing, watery eyes, and rashes to anaphylactic shock (worst
one)
➢ BE SURE TO HAVE EPI PENS or Epinephrine if suspected allergic reaction
❖ Foods and Latex Allergy (the book only mentions these p. 1956)
➢ milk, kiwi, bananas, or chestnuts

❖ Medication calculations and administration through G Tube

Metric equivalents:
1 mcg = 1,000 mg (or 0.001)
2.2 lb / 1 kg = client weight in lb / x kg
16 oz / 1 lb = client weight in oz / x oz (you add them to the lbs before turning to kg)
Dimensional analysis: (desired x quantity / have)

Daily maintenance fluids (distribute x into 10 x + 10 x + remainder x.Ex. 30 kg= 10 kg + 10 kg +10 kg)
100 ml/kg for the first 10 kg of body weight
50 ml/kg for the second 10 kg of body weight
20 ml/kg for the remaining kilograms of body weight

Med. administration through a G tube

1. Check steps for tube placement
2. Assess patient for drug-food allergy/interactions and contraindications
3. If enteral feeding is in progress, please stop the feeding 30 minutes prior to medication administration
4. Check MAR against physician order using 6 rights of medication
5. Crush each individual tablet into a fine powder and mix each individual medication with 30 ml water before
administering them. *****
● Keep in mind liquid form is the preferred form of administering medications through a G tube
6. Identify patient using two identifiers
7. Position head of bed 30-45 degrees unless contraindicated
8. Flush the feeding tube with 30ml warm water before and after administering medications. Flush with 15-30ml
water between medications.
● Gravity does the job for these kinds of administrations.
9. Maintain Fowler's position for 30-60 minutes after medication administration.
10. Document medication given, dosage, date, time, route, and amount of flush used.

❖ Baclofen pump use and nursing management

Intrathecal baclofen therapy is best suited for children with severe

spasticity that interferes with activities of daily living (ADLs) and
ambulation
➢ Patients may be screened before pump placement by
the infusion of a “test dose” of intrathecal baclofen delivered via a
lumbar puncture.
■ Relief of spasticity occurs for several hours
after the infusion. If a favorable response is noted, the patient is
considered a candidate for pump placement
➢ Close monitoring for side effects (hypotonia,
somnolence, seizures, nausea, vomiting, headache) is necessary
➢ withdrawal of intrathecal baclofen may result in
adverse effects, such as rebound spasticity, pruritus, hyperthermia,
rhabdomyolysis, disseminated intravascular coagulation, multiorgan
failure, and death; in some cases, intrathecal baclofen withdrawal may
mimic sepsis.
➢ Treatment of withdrawal centers on reestablishing the
medication dosage, with improvements observed within 1 to 2 hours. Hospitalization and surgery
may be required for withdrawal as a result of pump or catheter failure
 ❖ Spinal Cord injuries ( T1): Clinical manifestation and nursing care
Clinical Manifestations
➢ Higher injury—more extensive damage
➢ High cervical cord injury affects the phrenic nerve, paralyzes diaphragm → ventilatory
dependency
➢ the initial response to acute SCI is flaccid paralysis below the level of the damage.
■ This stage is often referred to as spinal shock syndrome
■ Manifestations include the absence of reflexes at or below the cord lesion, with
flaccidity or limpness of the involved muscles, loss of sensation and motor function, and
autonomic dysfunction (symptoms of hypotension, low or high body temperature, loss
of bladder and bowel control, and autonomic dysreflexia)
➢ Corresponding nerves affect muscles, upper chest, mid-back, and abdominal muscles.
■ Arm and hand function is usually normal.
■ Injuries usually affect the trunk and legs (also known as paraplegia).
■ Most likely use a manual wheelchair
❖ Nursing Care
➢ Initial management is stabilization and transport to a pediatric trauma center environment
■ ABCs
■ Manage the spinal shock
➢ Management is complex and controversial
■ IV steroids given to children and adolescents
■ Surgery is considered for decompression
➢ Nursing considerations
■ Stabilize, carefully assess, prevent complications, maintain maximum function
■ Major complication: autonomic dysreflexia
■ Neurogenic shock
 ■ Rehabilitation involves evaluation and support
➢ Ensuring adequate initial stabilization of the entire spinal column with a rigid cervical collar with
supportive blocks on a rigid backboard

❖ Spinal Muscular Atrophy (SMA): Clinical manifestation and nursing care

Clinical Manifestations
➢ Type 1 (Werdnig-Hoffmann Disease)
■ Clinical manifestations within first few weeks or months of life
■ Onset within 6 months of life
■ Inactivity the most prominent feature
■ Infant lying in a frog-leg position with legs externally rotated, abducted, and flexed at
knees
■ Generalized weakness
■ Absent deep tendon reflexes
■ Limited movements of shoulder and arm muscles
■ Active movement usually limited to fingers and toes
■ Diaphragmatic breathing with sternal retractions (diaphragmatic paralysis may occur)
■ Abnormal tongue movements (at rest)
■ Weak cry and cough
■ Poor suck reflex
■ Tiring quickly during feedings (if breastfed, may lose weight before noticeable)
■ Growth failure (nutritional)
■ Alert facies
■ Normal sensation and intellect
■ Affected infants not able to sit alone, roll over, or walk
■ Early death possible from respiratory failure or infection
➢ Type 2 (Intermediate Spinal Muscular Atrophy)
■ Onset before 18 months old
■ Early: Weakness confined to arms and legs
■ Later: Becomes generalized
■ Legs usually involved to greater extent than arms
■ Prominent pectus excavatum
■ Movements absent during complete relaxation or sleep
■ Some infants able to sit if placed in position, but few can ambulate
■ Life span from 7 months to 7 years, although many have normal life expectancy
➢ Type 3 (Kugelberg-Welander Disease; Mild Spinal Muscular Atrophy)
■ Onset of symptoms after 18 months old
■ Normal head control and ability to sit unassisted by 6 to 8 months old
■ Thigh and hip muscles weak
■ Scoliosis common
■ Failure to walk a common presentation
■ In those who manage to walk:
● • Waddling gait
● • Genu recurvatum
● • Protuberant abdomen
● • Ambulation becoming increasingly difficult
● Confinement to a wheelchair by second decade
 ● • Deep tendon reflexes possibly present early but disappear
➢ Nursing Care
■ Special attention should be directed to preventing muscle and joint contractures,
promoting independence in the performance of ADLs, and becoming incorporated into
the mainstream of school when possible
■ Promote respiratory function, safety, nutrition, & prevent infection and complications
■ assess adequate oxygenation, especially during the sleep phase when shallow breathing
occurs and hypoxemia may develop. Home pulse oximetry may be used to assess the
child during sleep and provide noninvasive mechanical ventilation as necessary
● management of orthoses and other orthopedic equipment as required.
● verbal, tactile, and auditory stimulation are important aspects of
developmental care

❖ Gower sign ( Transfer Technique): Clinical manifestation and nursing care

Clinical Manifestation of DMD (Duchenne Muscular Dystrophy)
❖ Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic
manner of rising from a squatting or sitting position on the floor

❖ Duchenne Muscular Dystrophy (DMD): Clinical manifestation and nursing care

Characteristics
➢ most severe and the most common MD of childhood. It is inherited as an X-linked recessive
trait, and the single-gene defect is located on the short arm of the X chromosome
➢ Early-onset, usually between 3 and 7 years old
■ Most children with DMD reach the appropriate developmental milestones early in life,
although they may have mild, subtle delays
➢ Progressive muscular weakness, wasting, and contractures
■ Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms
noted
➢ Calf muscle pseudohypertrophy in most patients
➢ Loss of independent ambulation by 9 to 12 years old
➢ Slowly progressive, generalized weakness during teenage year
 ● Relentless progression of muscle weakness; possible death from respiratory or
cardiac failure
● Waddling gait
● Lordosis
● Frequent falls
● Gower sign (child turns onto side or abdomen; flexes knees to assume a
kneeling position; and then with knees extended, gradually pushes torso to
an upright position by “walking” the hands up the legs)
● Enlarged (hypertrophied) muscles (especially calves, thighs, and upper arms);
feel unusually firmer woody on palpation
● Later stages—profound muscular atrophy
● Mental deficiency (common)
◆ • Mild (≈20 IQ points below normal)
◆ • Mental deficit present in 25% to 30% of patients
● Complications:
◆ • Contracture deformities of hips, knees, and ankles
◆ • Disuse atrophy
◆ • Cardiomyopathy
◆ • Obesity and at times undernutrition
◆ • Respiratory compromise and cardiac failure
Nursing Care
■ Therapeutic management: Primary goal is to maintain function in unaffected muscles as
long as possible
● Keep the child as active as possible
● Range of motion, bracing, the performance of activities of daily living, surgical
release of contractures as needed
■ Help child and family cope with chronic, progressive, debilitating disease
■ Help design a program to foster independence and activity as long as possible
■ Teach child self-help skills
■ Arrange for appropriate health care assistance as the child's needs intensify (home
health, skilled nursing facility, respite care for family, etc.)
■ Medications: corticosteroids

❖ Drugs: Propylthiouracil (PTU): Clinical manifestation and adverse reaction

Children being treated with propylthiouracil or methimazole must be carefully monitored for s/s
● Sore throat, fever -> can lead to neutropenia,
○ these children should be seen by a practitioner if such symptoms occur.
○ Parents and children should be taught to recognize and report symptoms immediately

❖ Graves disease (Hyperthyroidism): Clinical manifestation and nursing care

Clinical Manifestations
➢ Cardinal Signs
■ Emotional lability
■ Physical restlessness,
characteristically at rest
■ Decelerated school performance
 ■ Voracious appetite with weight loss in 50% of cases
■ Fatigue
➢ Physical Signs
■ Tachycardia
■ Widened pulse pressure
■ Dyspnea on exertion
■ Exophthalmos (protruding eyeballs)
■ Wide-eyed, staring expression with eyelid lag
■ Tremor
■ Goiter (hypertrophy and hyperplasia)
■ Warm, moist skin
■ Accelerated linear growth
■ Heat intolerance (may be severe)
■ Hair fine and unable to hold a curl
■ Systolic murmurs
➢ Thyroid Storm
■ Acute onset:
● • Severe irritability and restlessness
● • Vomiting
● • Diarrhea
● • Hyperthermia
● • Hypertension
● • Severe tachycardia
● • Prostration
■ May progress rapidly to:
● • Delirium
● • Coma
● • Death
❖ Nursing Care
➢ Nursing care focuses on treating physical symptoms before a response to drug therapy is
achieved.
■ Children with hyperthyroidism need a quiet, unstimulating environment that is
conducive to rest.
■ Increased metabolic rate may cause heat intolerance and increased food intake in these
patients.
■ Mood swings and irritability can disrupt relationships, creating difficulties within and
outside the home.
● Nurses can help parents understand the medical reason for behavior changes
and offer ways to minimize them.
■ School consultation is important to provide education and suggest ways to assist a child
after diagnosis.
■ Nurses should know the side effects of antithyroid drug therapy:
● urticarial rash, fever, arthralgias, vasculitis, liver dysfunction, and
agranulocytosis. Lymphadenopathy, edema, and diminished taste can also
occur.
 ❖ Hypoparathyroidism/ Hyperparathyroidism and Vitamin D tx: Clinical manifestation and nursing
care
HYPOparathyroidism
➢ Clinical Manifestations
■ Pseudohypoparathyroidism
● Short stature
● Round face
● Short, thick neck
● Short, stubby fingers and toes
● Dimpling of skin over knuckles
● Subcutaneous soft tissue calcifications
● Intellectual disability is a prominent feature
■ Idiopathic Hypoparathyroidism
● None of the above physical characteristics observed
● May include papilledema
● May have intellectual disability
■ Both
● Dry, scaly, coarse skin with eruptions
● Hair often brittle
● Nails thin and brittle with characteristic transverse grooves
● Dental and enamel hypoplasia
● Muscle contractions:
◆ • Tetany
◆ • Carpopedal spasm
◆ • Laryngospasm (laryngeal stridor)
◆ • Muscle cramps and twitching
◆ • Positive Chvostek sign or Trousseau sign
◆ • Paresthesias, tingling
● Neurologic:
◆ • Headache
◆ • Seizures (generalized, absence, or focal)
◆ • Swings of emotion
◆ • Loss of memory
◆ • Depression
◆ • Confusion possible
● Gastrointestinal:
◆ • Muscle cramps
◆ • Diarrhea
◆ • Vomiting
◆ • Retarded skeletal growth
➢ Nursing Care
■ Nursing care includes institution of seizure and safety precautions
● reduction of environmental stimuli
● observation for signs of laryngospasm, such as stridor, hoarseness, and a feeling
of tightness in the throat.
◆ A tracheostomy set and injectable calcium gluconate should be
available for emergency use.
 ◆ The administration of calcium gluconate requires precautions against
extravasation of the drug and tissue destruction
HYPERparathyroidism
➢ Clinical Manifestations
■ Gastrointestinal
● Nausea
● Vomiting
● Abdominal discomfort
● Constipation
■ CNS
● Delusions
● Confusion
● Hallucinations
● Impaired memory
● Lack of interest and initiative
● Depression
● Varying levels of consciousness
■ Neuromuscular
● Weakness
● Easy fatigability
● Muscle atrophy (especially proximal muscles of lower limbs)
● Tongue twitching
● Paresthesias in extremities
■ Skeletal
● Vague bone pain
● Subperiosteal resorption of phalanges
● Spontaneous fractures
● Absence of lamina dura around teeth
■ Renal
● Polyuria
● Polydipsia
● Renal colic
● Hypertension
➢ Nursing Care
■ The initial nursing objective is RECOGNITION of the disorder.
● Because secondary hyperparathyroidism is a consequence of chronic renal
failure, the nurse is always alert to signs that suggest this complication,
especially bone pain and fractures.
● Because urinary symptoms are the earliest indication, assessment of other
body systems for evidence of high calcium levels is indicated when polyuria and
polydipsia coexist.
◆ Clues to the possibility of hyperparathyroidism include change in
behavior, especially inactivity; unexplained gastrointestinal
symptoms; and cardiac irregularities
Vitamin D:
❖ The nurse educates the family about continuous daily calcium and vitamin D.
 ❖ Because vitamin D toxicity can be a serious consequence of therapy, parents are advised to watch for
signs that include weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Polyuria,
polydipsia, and nocturia are signs of early renal impairment.
❖ Insulin injection sites
Keypoints:
● ALWAYS rotate injection sites
● Abdomen is most common and fastest absorption site
● when injecting, use a 45°
○ Pinch the skin and let go once the needle is in
● DO NOT USE DORSOGLUTEAL ON INFANTS AND TODDLERS, CONSIDER FOR OLDER CHILDREN

❖ Growth and development school-age and adolescent

Growth and development

■ Middle Childhood - Frequently referred to as the school-age, this period of

development is one in which the child is directed away from the family group and
centered around the wider world of peer relationships. There is steady advancement in
physical, mental, and social development with emphasis on developing skill
competencies. Social cooperation and early moral development take on more
importance with relevance for later life stages. This is a critical period in the
development of a self-concept.
● 6-11/12 years old
■ Later Childhood
● Prepubertal - 10-13 years old
 ● Adolescence - 13-18 years old - transitional period that begins at the onset of
puberty and extends to the point of entry into the adult world—usually high
school graduation. Biologic and personality maturation are accompanied by
physical and emotional turmoil, and there is redefining of the self-concept. In
the late adolescent period, the young person begins to internalize all previously
learned values and to focus on an individual, rather than a group, identity.

Communication Related to Development of Thought Processes

➢ School-age children
■ Younger school-age children rely less on what they see and more on what they know
when faced with new problems
■ Explain what, how, and why (using concrete terms)
● They are interested in the functional aspect of all procedures, objects, and
activities. They want to know why an object exists, why it is used, how it works,
and the intent and purpose of its user. They need to know what is going to take
place and why it is being done to them specifically
■ Allow the child to touch and “practice” with medical equipment
● For example, to explain a procedure such as taking blood pressure, show the
child how squeezing the bulb pushes air into the cuff and makes the “arrow”
move. Let the child operate the bulb. An explanation for the procedure might
be as simple as, “I want to see how far the arrow moves when the cuff squeezes
your arm.” Consequently, the child becomes an enthusiastic participant.
■ Ensure that personal possessions will not be harmed or lost
■ Use therapeutic play
➢ Adolescence
■ Be honest with the patient
■ The patient may require a detailed explanation of treatments
■ Be aware of privacy needs; allow time for the patient to speak without parents in the
room
■ Plan for developmental regression during times of stress
● As children move into adolescence, they fluctuate between child and adult
thinking and behavior. They are riding a current that is moving them rapidly
toward a maturity that may be beyond their coping ability. Therefore, when
tensions rise, they may seek the security of the more familiar and comfortable
expectations of childhood
■ Privacy and confidentiality are of great importance when communicating with
adolescents because it is consistent with developmental maturity and autonomy. Explain
to parents and teenagers the legal and ethical protections and limits of confidentiality
■ Interview Initiation
● If the parents and teenager are together, talking with the adolescent first has
the advantage of immediately identifying with the young person, thus
fostering the interpersonal relationship. However, talking with the parents
initially may provide insight into the family relationship. In either case, give
both parties an opportunity to be included in the interview
■ Importance of peers
❖ NPH and regular insulin and peak times ( long-acting, intermediate, and short-acting)
!!! Check injectable medications on ATI med dosage
● Standard measure is in Units (U-100)
● Insulin is SUB-Q only

⚠️
Remember for insulin drawing:

⚠️
**WHEN DRAWING UP TWO TYPES OF INSULIN, CLEAR FIRST (fast-acting) THEN CLOUDY (NPH)**

⚠️
If necessary, roll the vial, then wipe the surface before using an insulin based syringe and inject air
USE ONLY INSULIN SYRINGES. MAKE SURE THEY HAVE THE U-BASED MEASUREMENT.
❖ Ketoacidosis: Hypoglycemia and Hyperglycemia and DKA : Clinical manifestation and nursing care
➢ Ketoacidosis - When insulin is absent or insulin sensitivity is altered, glucose is unavailable for
cellular metabolism, and the body chooses alternate sources of energy, principally fat.
■ Consequently, fats break down into fatty acids, and glycerol in the fat cells is converted
by the liver to ketone bodies (β-hydroxybutyric acid, acetoacetic acid, acetone)
■ The ketone bodies in the blood (ketonemia) are strong acids that lower serum pH,
producing ketoacidosis
➢ Clinical Manifestations
■ Hyperglycemia >330
■ Acidosis pH 7.3 and Bicarb 15
■ This results in the body breaking down fat for energy and ketones accumulating in the
blood, urine and lungs
■ Kussmaul respirations & acetone breath
➢ Nursing Care
■ Nursing: Admitted to PICU.
■ Rapid isotonic fluid replacement. Add glucose to IVF when sugar reaches 250mg
■ Monitor glucose levels hourly and prn
■ Administer regular insulin continuously
❖ Hypoglycemia and Hyperglycemia
 ❖ Botulism: Clinical manifestation and nursing care
➢ Botulism is a rare poisoning caused by toxins produced by Clostridium botulinum
bacteria.
➢ PEDIATRIC EMERGENCY

General Signs
■ Weakness
■ Dizziness
■ Headache
■ Difficulty talking and speaking
■ Diplopia
■ Vomiting
■ Progressive, life-threatening respiratory paralysis
➢ Infant Botulism*
● Caused by ingestion of honey on children < 1 year od age
■ Constipation (a common symptom)
■ Generalized weakness
■ Decrease in spontaneous movements
■ Diminished or absent deep tendon reflexes
■ Loss of head control
■ Poor feeding
■ Weak cry
■ Reduced gag reflex
■ Progressive respiratory paralysis
❖ Nursing Care
 ➢ IV botulism immune globulin (BIG-IV [BabyBIG]) to treat infants
➢ Trivalent equine botulinum antitoxin and bivalent antitoxin to treat older children
➢ Supportive measures—respiratory support
➢ Continue therapy until paralysis abates
➢ Supportive measures
■ Respiratory support
■ Nutritional support
■ Prevention of complications
■ Emotional support
■ Family support and education

❖ Parathyroidectomy: medication use for Hypocalcemia

■ surgery to remove the parathyroid glands or parathyroid tumors
➢ Objective of treatment is to maintain normal serum calcium and phosphate levels with minimum
complications.
■ Acute or severe tetany is corrected immediately by IV and oral administration of calcium
gluconate and follow-up daily doses to achieve normal levels.
● 2 x daily calcium measurements are taken to monitor the efficacy of therapy
and prevent hypercalcemia
❖ When diagnosis is confirmed, vitamin D therapy is begun.
➢ Vitamin D therapy is somewhat difficult to regulate because the drug has a prolonged onset and
a long half-life.
● Watch for s/s of vitamin D toxicity

❖ Myelomeningocele: Clinical manifestation and nursing care and feeding pre/post operative
➔ Myelomeningocele is the MOST serious form of spina bifida and most
common
● Part of the group of spina bifida cystica
Clinical Manifestations
◆ Cranioschisis: A congenital skull defect through which various tissues
protrude
◆ Exencephaly: Brain totally exposed or extruded through an associated
skull defect; fetus usually aborted
◆ Anencephaly: If fetus with anencephaly survives, degeneration of the
brain to a spongiform mass with no bony covering; incompatible with
life usually beyond a few days to weeks
◆ Encephalocele: Herniation of brain and meninges through a defect in
the skull, producing a fluid filled sac; can be frontal or posterior.
○ SB
○ Meningocele
○ Myelomeningocele

Nursing care:
● Immediate Nursing management is the protection of the site from trauma (prone position)
● keep the sac from drying out with saline-soaked sterile gauze
● Risk of latex allergy due to multiple exposures from catherizations and surgeries
 ● Abdominal assessment revealing bladder distention, even with a wet diaper, may indicate urinary overflow
in a retentive bladder.
● Head circumference measurement
!!! Feeding a baby with myelomeningocele involves putting the head on the side while remaining prone , hence
early repair is done.
Pre-op:
● the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent
dressing.
○ The moistening solution is usually sterile normal saline.
■ Dressings are changed frequently ( q 2-4 hrs), and the sac is closely inspected for leaks,
abrasions, irritation, and any signs of infection.
○ Early s/s include high temperature (axillary) , irritability, lethargy ,
increased ICP (which are also s/s of hydrocephalus)
○ NO RECTAL TEMPERATURES
○ Contraindications include putting diapers, cuddling the baby,
performing range of motion exercises that go beyond some extremities
■ Consulation with PT
Post-op:
● Vital signs
● I & O’s
● providing nourishment
● observing s/s of infection
● close observation of CSF leakage
● PRONE positioning
● Feedings can be resumed once there are no complication observed
● Educate parents and make them involved in care (CIC techniqued is taught often)

❖ Spina Bifida occulta/ cystica: Clinical manifestation and nursing care

Spina Bifida Cystica (combines both meningocele and

myelomeningocele)
● refers to a visible
defect with an external saclike protrusion
➢ Sensory disturbances usually parallel
to motor dysfunction
➢ Below second lumbar vertebra:
■ • Flaccid, partial paralysis of
lower extremities
■ • Varying degrees of
sensory deficit
■ • Overflow incontinence
with constant dribbling of urine
■ • Lack of bowel control
■ • Rectal prolapse
(sometimes)
■ • Below third sacral vertebra:
■ • No motor impairment
 ■ • May have saddle anesthesia with bladder and anal sphincter
■ Paralysis
➢ Joint deformities (sometimes produced in utero):
■ • Talipes valgus or varus contractures
■ • Kyphosis
■ • Lumbosacral scoliosis
■ • Hip dislocation or subluxation

❖ Spina Bifida Occulta - Frequently no observable manifestations

➢ May be associated with one or more cutaneous manifestations:
■ • Skin depression or dimple
■ • Port-wine angiomatous nevi
■ • Dark tufts of hair
■ • Soft, subcutaneous lipomas
➢ May have neuromuscular disturbances:
■ • Progressive disturbance of gait with foot weakness
■ • Bowel and bladder sphincter disturbances

❖ Infant reflexes primitive

 ❖ Diabetes Mellitus: Clinical manifestation and nursing care
Type I diabetes is characterized by destruction of the pancreatic beta cells, which produce insulin; this usually leads
to absolute insulin deficiency.
➢ Type 1 diabetes has two forms.
■ Immune-mediated DM results from autoimmune destruction of the beta cells; it
typically starts in children or young adults who are slim, but it can arise in adults of any
age.
■ Idiopathic refers to no known cause
Type II diabetes usually arises because of insulin resistance in which the body fails to use insulin properly
combined with relative (rather than absolute) insulin deficiency.
 ❖ Usually, sedentary lifestyle and obesity are the highest risks that contribute to type II
❖ There can also be idiopathic
Clinical Manifestations
● Classic signs: Thirst, polyuria, N/V/abdominal pain, dry mucous membranes, confusion, weakness,
lethargy
● Cardinal feature is hyperglycemia BG >250 mg/dL
● Hgb A1C > 6.5%

➢ Type I
■ Polyphagia
■ Polyuria
■ Polydipsia
■ Weight loss
■ Enuresis or nocturia
■ Irritability; “not himself” or “not herself”
■ Shortened attention span
■ Acetone breath (fruity smell)
■ Lowered frustration tolerance
■ Dry skin
■ Blurred vision
■ Poor wound healing
■ Fatigue
■ Flushed skin
■ Headache
■ Frequent infections
■ Hyperglycemia
● • Elevated blood glucose levels
● • Glucosuria
■ Diabetic ketosis
● • Ketones and glucose in urine
● • Dehydration in some cases
■ Diabetic ketoacidosis (DKA)
● • Dehydration
● • Electrolyte imbalance
● • Acidosis
● • Deep, rapid breathing (Kussmaul respirations)
➢ Type II
● Increased thirst
● Dry mouth
● Increased urination
● Sudden weight loss
● Headaches
● Fatigue
● Blurry vision
● Frequent infections (or slow healing sores)
● Pain/ tingling on hands and feet (pins and needles)
Nursing care:
● DKA is a medical emergency -> admit to PICU immediately
○ Once that is stabilized, I&O’s and insulin regimen begin
● Diabetes care:
○ The use of medical bracelets for diabetes is important
○ I&Os, daily weights
○ NUTRITION management is the biggest focus for DM
○ Glucose monitoring- goal is 80-120 mg/dL
■ Administration of insulin for every blood sugar check if needed
○ EDUCATION (new or onset) is the second biggest focus for patients with DM
■ It involves teaching parents and children about counting calories (like in a diary), glucose
monitoring, and self-injections of insulin.
Developmental issues in DM
● Infant: relies on the parent for care. Provide support for caregivers. Increased risk of adverse
consequences
● Toddlers: Inconsistent food intake, temper tantrums. Help parents establish routines, rituals, discipline.
● Preschoolers: Start to notice they are different, want to actively participate in care but do not have fine
motor skills. Use play therapy and encourage participation.
● School-age: Can participate in daily care, may feel different from peers. Encourage school attendance and
participation in activities. Practice injections on dolls.
● Adolescents: Undergoing rapid physical, emotional and cognitive growth. Slowly turn care over to
adolescents. Assess for risk-taking behaviors. Promote Identity/ Independence
 ❖ Growth Hormone deficiency: GH replacement and GH stimulation test
Hypopituitarism—Growth Hormone (GH) Deficiency
➢ Diagnostic evaluation
■ Family history
■ Growth patterns and health history
■ Definitive diagnosis based on radioimmunoassay of plasma GH levels
■ Hand x-rays to evaluate growth potential versus ossification
■ Endocrine studies to detect deficiencies
➢ Replacement -
■ replacement of GH, which is successful in 80% of affected children.
● Biosynthetic GH is administered subcutaneously on a daily basis
■ Other hormone replacements as needed
● Thyroid extract
● Cortisone
● Testosterone or estrogens and progesterone
➢ GH stimulation testing is usually required for diagnosis.
■ GH stimulation testing involves the use of pharmacologic agents such as levodopa,
clonidine, arginine, insulin, propranolol, or glucagon, followed by the measurement of
GH blood levels
● Children with poor linear growth, delayed bone age, and abnormal GH
● stimulation tests are considered GH deficient

❖ Folic acid and fetal growth development

Neural Tube Defects
❖ Cause: Occurs as a result of Folic Acid (Folate) deficiency
➢ Especially at week 4 where neural tubes emerge on the embryo

➢ One vitamin supplement that is recommended for all women of childbearing age is a daily dose
of 0.4 mg of folic acid, the usual RDA.
■ Folic acid taken before conception and during early pregnancy can reduce the risk of
neural tube defects such as spina bifida by as much as 79%.
Mini map for hormones secreted by the anterior/posterior pituitary: