PEDIATRICS NURSING DISORDERS

HYDROCEPHALUS
 A condition caused by the imbalance in the production and absorption of CSF
 Enlargement of the ventricles - due to unfused Fontanelles (Anterior 18 and Posterior
12)
 Three causative factors: production, absorption, obstruction (most common) of CSF
 The earliest sign is enlarged head circumference 
Causes:
 Tumor
 Infection - most common is Meningitis
 Trauma
 Secondary to Congenital Condition: 
 Arnold Chari Malformation - an abnormal descension of the cerebellum
into the foramen magnum, which compresses the flow of CSF.
 Dandy-Walker Syndrome - abnormal enlargement of the cerebellum
leading to compression 

Pathway of CSF
Choroid plexus - makes up CSF (found within the ventricles)
CSF 
Lateral Ventricles
Third ventricle
Aqueduct of Sylvia
Fourth ventricle
Subarachnoid space
Spinal Cord
Lymphatic system

4 ventricles in the brain 

ICP (Intracranial Pressure)

 5 - 15 mmhg 
 Normal ICP is dependent on the normal production and flow of CSF
Early signs:
 Altered LOC - earliest sign in ICP, meningitis GBS, stroke, myelomengocele 
 Mental status changes
 restlessness
 confusion
 irritability

Late signs:
 Projectile vomiting
 Nausea
 Vital signs: increased BP (150/80), decreased PR and RR

Types
1. Communicating - Impaired absorption/production
2. Noncommunicating - obstruction 
Manifestations
1. Increased Head Circumference (earliest sign)
2. Bulging fontanels/sutures
3. Dilated Scalp Veins
4. High Pitched Shrill Cry
5. Increased ICP
6. Sunset Eyes - classic sign of hydrocephalus, pupils are at the bottom  

Diagnostic Evaluation
1. CT Scan 
2. MRI
3. Skull XRAY
4. Transillumination Test
 Bright light is directed to the head of the patient
 To check the amount of CSF

Management 
1. Support head well - use palms or fingertips in handling the head
 To prevent extra strain on the neck
2. Provide adequate nutrition - small frequent feeding
3. Remove obstructing mass
4. Shunting - to provide primary drainage 
 Ventriculoperitoneal shunt (VP) - from the ventricle to peritoneal shunt
 Glucose in the CSF can lead to Infection, Peritonitis, Carditis  
 Monitor for signs of increased ICP for possible shunt malfunction
 Ventriculoatrial shunt (VA) - from ventricles to atria of the heart 
 Can lead to endocarditis because the catheter passes through the
endocardium
 Monitor for signs of increased ICP

Post OP Care
1. Flat in bed for 24 hours on unoperative side - to make sure that shunt won’t be
dislodged 
2. Observe signs for increased ICP (Shunt Malfunction): Projectile vomiting, Irritability
seizures
3. MIO
4. Administer Drugs:
a. Acetaminophen
b. Antibiotics 
5. Observe for abdominal distention
6. Provide Skin care
7. Inspect surgical site

An infants who was born with meningomyelocele develops hydrocephalus. On the return
from the operating room, the infant has a ventriculoperitoneal (VP) shunt in place. 
Nursing care for the infant during the first 24 hours would involve:
a. Sedating the infant frequently for pain
b. Placing the infant in a high fowler's position
c. Position the infant on the side that has the shunt
d. Monitoring the infant for increased intracranial pressure
Answer: D, monitor for IICP for possible shunt malfunction

A nurse is performing an assessment on an infant with a diagnosis of hydrocephalus.

The nurse assesses for the major sign associated with hydrocephalus when the nurse
A. Test the urine for protein
B. Takes the apical pulse
C. Palpates the anterior fontanel
D. Takes the blood pressure 
Answer: C

A nurse has provided discharge instructions to the parents of an infant who had a
ventriculoperitoneal shun to procedure performed for the treatment of hydrocephalus.
Which statements indicates an accurate understanding of the presence of shunt
malfunction?
A. “If my infant has a high, pitched cry. I shall call the doctor.”
B. “I should position my infant on the side with the shunt when sleeping
C. “My infant will pass urine more often now that the shunt is in place
D. “I coils call y doctor if my infant refuses baby food”
Answer: A

MENINGITIS
 Inflammation of the Meninges
Causative Agent: Neisseria Meningitidis (bacterial, most fatal, most common)

Is there increased ICP? yes

Infection → bacteria in blood (vascular dissemination) → crosses blood-brain barrier →

inflammation → Pus-formation → edema → obstruction (may also cause hydrocephalus) →
increased ICP

Normal CSF - clear, cloudy, high glucose, low protein

CSF in meningitis - cloudy, low glucose, increased protein

Manifestations
Infection
Seizures
Fever
Chills
IICP
Vomiting
High, Pitched shrill cry
Bulging Fontanels in infants
Irritability
Meningeal irritation
Nuchal Rigidity - stiff neck
Opisthotonic Posture
(+) Kernigs sign - passively move up the leg, child complains of pain
(+) Brudzinski sign
Diagnostic Test
1. Lumbar puncture - decrease glucose, increased CHON
2. CSF culture - to identify the causative agent
3. Blood culture - increased WBC

Lumbar Puncture - to confirm, distinguish

 Pre-Position: C-curve, Fetal, Knee Chest, Shrimp
 Site: L3-L4, L4-L5
 Post-Position: Flat on Bed with Pillows 2-3 hours to prevent spinal headache and CSF
leakage

You are a nurse caring for a patient post lumbar puncture. What is your initial nursing
interventions?
A. Position the patient flat on bed, with pillows for 2-3 hours to prevent spinal headache and
CS leakage
B. Offer glass of water
C. Document the procedure
D. Monitor the vital signs 
Answer: B

Management
1. Antibiotic Therapy
2. Vancomysin, Given IV or intrathecal administer as soon as it is ordered
3. Continue 10-14 days
4. Anticonvulsants - dilantin
5. Universal Precautions - enforce strict handwashing
6. Protective Isolation - Maintain respiratory Isolation for minimum of 24 hours
7. Seizure Precaution - minimize stimuli
8. Position: Fowlers

A lumbar puncture is performed on a child suspected of having meningitis.

Cerebrospianl fluid is obtained for analysis. A nurse reviews the results of the CSF
analysis and determines that which of the following results would verify the diagnosis?
Answer: B. Cloudy CSF, elevated CHON, and decreased glucose

SPINA BIFIDA
 Failure of the neural tube to close
 Group of neural tube disorders
 Neural tube → CNS 
Brain - anencephaly, encephaly

2 Types of Spina Bifida 

1. Spina Bifida Occulta - tufts of hair at site, dimpling, (-) sac, no redness, no need surgery
2. Spina Bifida Cystica - with
a. Meningocele - positive translumination (flashlight)
i. CSF
ii. Meninges
b. Myelomeningocele - negative translumination (flashlight)
i. CSF
ii. Meninges
 iii. Spinal Cord
iv. Nerve root
Causes:
 Late maternal age
 Vit. Deficiency - folic acid (B9)
 Genetic influence
 Bacterial - most common, clear, increased glucose
 Fungal - least common

Functions of lower spine: movement and bladder 

Diagnostic Test
1. Amniocentesis - to determine AFP done 16-18 AOG
 Increased = spina bifida
 Decreased = down syndrome 
2. Ultrasound - detects signs of Spina Bifida while baby is still in the womb
3. Transillumination (Flash Light)
(+) → meningocele
(-) → myelomeningocele

Spina Bifida Cystica Manifestations

1. Visible spinal defect - very soft sac
2. Flaccid paralysis
3. Altered Bladder and Bowel Function - Neurogenic bladder
4. Hip and Joint Deformities

Surgery is the management 

Maintain the integrity of the sac
Phagocytosis

Management
1. Promote sac care - prevent drying of the sac. Moist non-adherent sterile gauze. Chang
the dressing q 2-4 hours
2. Provide meticulous care - prevent stool and urine contamination. No diapers until
repaired
3. Positon: PRONE (watch out for SIDS)
4. Check for early signs of infection Inspect for leaks
5. Prevent complications: 
a. short-term: Meniningits
b. long term: Hydrocephalus

Post Op Care
 Monitor V/S
 MIO
 Adequate nutrition
 May be placed side-lying unless contraindicated

A nurse is performing an admission assessment on a newborn with diagnosis of spina

bifida (myelomeningocele). The nurse assesses for a major symptom associated with
this type of spina bifida when the nurse:
 a. Checks the capillary refill of the nailbeds of the upper extremities
b. Test the urine in blood
c. Palpates the abdomen for masses
d. Checks for responses for painful stimuli from the torso downward
Answer: D, during paralysis movement, sensation, and sweating is gone 

DOWN SYNDROME (Trisomy 21)

Caused by an extra chromosome on the 21st pair.
Common to infants born to mother less than 20 y.o. and over 45 y.o.

Manifestation
 Inner epicanthal eye folds
 Flat, broad nasal bridge
 Protruding tongue
 Broad short neck
 Protruding abdomen
 Short, stubby fingers
 Simian Crease
 Gap between the two big toes
 Small genitalia
 Low set ears
 Brushfield spots 

Associate Problems:
1. Cardiac defects - VSD, ASD
2. Feeding defects
3. Delayed developmental skills
4. Mental retardation
5. Respiratory problems - pneumonia
6. Cancer - leukemia, lymphoma 

Management
Parental support
Monitor for signs of cardiac difficulties
Help the child reach optimal level of functioning
CONGENITAL HEART DEFECTS

RHEUMATIC FEVER
 Systemic inflammatory disease affecting heart, joints, CNS and subcutaneous tissue.
 Can lead to rheumatic heart disease → congestive heart failure 
Causative agent: Group A Beta-hemolytic Streps (GABHS)
 Sorethroat (pharyngitis - most common, laryngitis, tonsillitis 
 Can cause carditis, SLE

Manifestations
Major characteristics:
 Carditis - endocarditis → left sided heart failure → mitral valve
 Migratory polyarthritis 
 Sydenham chorea
 Erythema marginatum
  Subcutaneous nodules

Minor Characteristics
 Arthralgia - joint pain 
 Fever  
Diagnostics:
1. ESR (Erythrocyte sedimentation rate) - nonspecific, elevated when there is an infection 
2. ASO (Anti Streptolysin O Titer) (Specific) - increased when the cause is GABHS

Management
 Prevent cardiac Damage, strict bed rest, monitor apical pulse (digoxin, lasix, K+
supplement)
 Relieve discomfort 
 Use bed cradle

Administer medication 
1. Benzanthine Penicillin (Pen-G)
2. Aspirin/salicylates - analgesics
3. Prednisone
4. Digoxin
5. Oxygen

A nurse receives a phone call from the admitting of ice and is told that a child with
rheumatic fever will be arriving in the nursing unit for admission. On admission, the
nurse prepares to ask the mother which question to elicit assessment info specific to the
development of R.F.?
A. “Did the child have a sore throat or an unexplained fever within the last 2 months?”
B. “Has the child had any nausea or vomiting?”
C. “Has the child complained of headaches?”
D. “Has the child complained of back pain?”
Answer: A

KAWASAKI DISEASE
 Also known as Mucocutaneous lymph node syndrome 
 Non-specific disease affecting the mucous membranes, linings of a blood vessel, and
heart
 Cause: unknown, alteration of the immune system
 Deadlier than the rheumatic disease
 No cure but is congenital 

Altered immune response → antibody-antigen reaction → inflammation → Aneurysm → Platelet

accumulation → Thrombi formation → Obstruction in heart and blood vessels

Manifestations:
1. Acute Stage (Inflammation or Rupture of BV) - high-grade fever lasting for 5 days
(unrelieved by any antipyretics)
 Strawberry tongue 
 Polymorphous rash → ruptured blood vessels → petechiae 
 Conjuctival inflammation
 Enlargement of the cervical lymph nodes
2. Sub Acute Stage (Massive Dehydration)
 Cracking of lips
 Desquamation of the palms and soles: Peeling
 Swollen reddened joint
 Joint pain
 Thrombocytosis

3. Convalescent Stage (Reoslution)

 Child appears normal but signs of inflammation may be present
 Give aspirin to prevent clot formation 
 Ig → Anti-inflammatory 

SICKLE CELL DISEASE

 Presence of abnormally shaped RBC’s
Cause:
 Autosomal recessive trait

Decreased RBC 
Normal RBC - 120 days, Oval, Pliable
Abnormal - dies every 12 days, crescent, rigid → obstruction → hypoxia

hgA/ Hemoglobin - maintains normal shape of RBS

hgS/ Sickle cell  - sensitive to oxygen and rigid, crescent-shaped → obstruction → Hypoxia →
ischemia (pain) → necrosis/gangrene  

Vasocclusive crisis → pain 

Managemnt:
1. Administer Oxygen - to prevent further sickling, corrects ischemia but does not reverse 

Predisposing Factors
1. Low level of O2
2. Dehydration
3. Cold weather
4. High altitude
5. Severe Emotional stress
6. Vigorous exercise
7. Anemia

No sickling will take place unless there is exposure to predisposing factors

Which one is the most likely to cause sickling

A. Cold Weather
B. Flying on a plane
C. Extreme Exercises
D. Swimming in Public pools
Answer: D because there is not enough oxygen
 1. Anemia - pallor, fatigue, dyspnea, restlessness
2. Infection
3. Platelets - epistaxis, easy bruising, hematoma, petechiae, purpura, hematuria, melena

Which is most likely to kill a patient with leukemia?

A. Anemia
B. Infection
C. Bleeding
D. Bone Pain
Answer: B

LEUKEMIA
 Pancytopenia 
 Bone pain 

What will mots likely kill the patient with leukemia?

A. Anemia
B. Infection
C. Bleeding
D. Bone pain
Answer: C