PEDIATRIC NURSING

SRG Integrals 2nd Ed. Pediatric Nursing 274

 I. PEDIATRIC NURSING

PEDIATRIC NURSING
 the application of nursing knowledge in the psychomotor, psychosocial and cognitive
development of children and the utilization of nursing process in the care of clients from birth to
adolescence period.

(a) PRINCIPLES OF GROWTH AND DEVELOPMENT

Definition of Terms
 Growth: Increase in size of a structure. Human growth is orderly and predictable, but not even; it follows
a cyclical pattern.
 Development: Maturation of physiologic and psychosocial systems to more complex state.
 Phylogeny: Development or evolution of a species or group; a pattern of development for a species
 Ontogeny: Development of an individual within a species

(b) GENERAL PRINCIPLES OF GROWTH AND DEVELOPMENT (PILLITERI, 2002)

 Continuous Process – growth and development is an ongoing process from conception to death
 Orderly Sequence – follows a predictable sequence of growth and development
 Cephalocaudal – head to toe
 Proximo-distal – trunk to periphery
 Gross to Refined Skills – simple to complex motor skills
 Different Rates – development occurs over a period rather than a certain point of time depending on
the child’s ability.
 Absent Neonatal Reflexes – neonatal reflexes must be lost before development can proceed.
 Practice – behaviour and skill is learned by practice
(c) DEVELOPMENTAL THEORIES

PIAGET’S COGNITIVE THEORY

SENSORIMOTOR STAGE ( 0-2 years)
 Mainly by reflexes
 Repetition of acts
PRE – CONCEPTUAL OPERATIONS ( 2-4 years)
 No cause and effect reasoning; egocentrism; use of symbols; magical thinking
INTUITIVE STAGE ( 4-7years)
 Beginning of causation
CONCRETE OPERATIONS ( 7-11 years)
 Uses memory to learn
 Aware of reversibility
 Inductive reasoning
FORMAL OPERATIONS ( 11-15 years)
 Reality, abstract thought
 Can deal with past, present and future
 Deductive reasoning

SRG Integrals 2nd Ed. Pediatric Nursing 275

 Theories PSYCHOSEXUAL MODEL (Freud) PSYCHOSOCIAL MODEL (Erikson) INTERPERSONAL MODEL DEVELOPMENTAL TASK
(Sullivan) (Havighurst)
0– 18 months ORAL: Pleasure gratification through TRUST vs. MISTRUST 1. INFANCY INFANCY AND EARLY CHILDHOOD
mouth Significant relations: MOTHER - others will - Learning to walk
Behaviors: Psychosocial virtues: Hope and faith satisfy the - Learning to take solid
- Dependency, eating, crying, Maladaptations and malignancies: needs foods
biting sensory distortion - withdrawal - NEED FOR - Learning to control the
- Distinguishes between self and SECURITY: elimination of body waste
mother develops a sense of trust, - Learning sex difference
- Develops body image, security and self-worth and sexual modesty
aggressive drives when this occurs - Learning to relate
emotionally to parents
18 mo. – 3 years ANAL: Pleasure through elimination or AUTONOMY vs. SHAME and DOUBT 2. CHILDHOOD
retention of feces Significant relations: PARENTS - Learns to delay need
Behaviors: Psychosocial virtues: Willpower and gratification
- Control of holding on or letting determination Toddler- child learns to
go Mal-adaptations and malignancies: communicate needs
- Develops concept of power, impulsivity and compulsion through the use of words
punishment ambivalence, Pre-school – development
concern with cleanliness or of body image and self-
being dirty perception
- Organizes and uses
experiences
- Begins using selective
inattention and
dissociates those
 Theories PSYCHOSEXUAL MODEL (Freud) PSYCHOSOCIAL MODEL (Erikson) INTERPERSONAL MODEL DEVELOPMENTAL TASK
(Sullivan) (Havighurst)
experiences that
cause physical or
emotional discomfort
and pain.
3 – 6 years Phallic / Oedipal: INITIATIVE vs. GUILT 3. JUVENILE
Pleasure through Significant relations: FAMILY - Learns to relate to peers
genitals Psychosocial virtues: Purpose and - Competition,
Behaviors: courage compromise, cooperation
- Touching of Mal-adaptations and malignancies: 4. PRE – ADOLESCENCE
genitals Ruthlessness; inhibition - Learns to relate to friends
- Erotic attachment to parent of of same sex
opposite sex (Oedipus/ Electra
Complex)
- Develops fear of punishment
by parent of same sex, guilt,
sexual identity

6 - 12 years Latency: Energy used to gain new skills
in social relationships and knowledge
Behaviors:
- Sense of industry and mastery
- Learns control over aggressive
destructive impulses
- Acquires friends
INDUSTRY vs. INFERIORITY
Significant relations: NEIGHBORHOOD
and SCHOOL
Psychosocial virtues: Competence
Mal-adaptations and malignancies:
Narrow virtuosity - inertia
5. EARLY ADOLESCENCE
- Learns independence and
how to relate to opposite
sex
MIDDLE CHILDHOOD
- Learning physical skills
necessary for games
- Learning to get along
with age – mates
- Achieving personal
independence
- Learning appropriate
 Theories PSYCHOSEXUAL MODEL (Freud) PSYCHOSOCIAL MODEL (Erikson) INTERPERSONAL MODEL DEVELOPMENTAL TASK
(Sullivan) (Havighurst)
masculine or feminine
social roles

12 – 18 years Genital: Sexual pleasure through IDENTITY vs. ROLE CONFUSION 6. LATE ADOLESCENCE / ADOLESCENCE
genitals Significant relations: PEER GROUPS and YOUNG ADULT - Achieving new and more
Behaviors: ROLE MODEL - Develops intimate mature relations with age
- Becomes independent of Psychosocial virtues: Fidelity and relationship with person of mates or both sexes
parents Loyalty the opposite sex - Accepting one’s physique
- Responsible for self Mal-adaptations and malignancies: - Becomes economically, and using the body
- Develops sexual identity, Fanaticism - repudiation intellectually and effectively
ability to love and work emotionally self-sufficient - Achieving emotional
independence from
parents and other adults
- Selecting and preparing
for an occupation
- Preparing for marriage
and family life
18 – 25 years INTIMACY vs. ISOLATION 7. MIDDLE AGE EARLY ADULTHOOD
Significant relations: PARTNERS and - Learns to be - Selecting a mate
FRIENDS interdependent and - Learning to live with a
Psychosocial virtues: Love assumes responsibility for partner
Mal-adaptations and malignancies: others - Starting a family
Promiscuity – exclusivity - Rearing Children
- Managing a home
 Theories PSYCHOSEXUAL MODEL (Freud) PSYCHOSOCIAL MODEL (Erikson)
25 – 65 years GENERATIVITY vs. STAGNATION
Significant relations: HOUSEHOLD and
WORKMATES
Psychosocial virtues: Care, Altruism
Mal-adaptations and malignancies:
Overextension - rejectivity
INTEGRITY vs. DESPAIR
INTERPERSONAL MODEL
(Sullivan)
8. SENESCENCE
- Develops an acceptance
of responsibility for what
life is and was and of its
place in the flow of history
DEVELOPMENTAL TASK
(Havighurst)
- Getting started in an
occupation
- Taking on civic
responsibilities
- Finding a congenial social
group
MIDDLE AGE
- Achieving adult civic and
social responsibility
- Establishing and
maintaining an economic
standard of living
- Relating oneself to ones
spouse as a person
- Accepting and adjusting
to the physiologic
changes of middle age
- Adjusting to aging
parents
LATER MATURITY
 Theories PSYCHOSEXUAL MODEL (Freud) PSYCHOSOCIAL MODEL (Erikson) INTERPERSONAL MODEL DEVELOPMENTAL TASK
(Sullivan) (Havighurst)
65 years and above Significant relations: MANKIND and - Adjusting to decreasing
“MY KIND” physical strength and
Psychosocial virtues: Wisdom health
Mal-adaptations and malignancies: - Adjusting to retirement
Presumption - despair and reduced income
- Adjusting to death of the
spouse
- Establishing an explicit
affiliation with ones age
group
- Meeting social and civil
obligations

Table 1.1 Developmental Task from Infancy to Adulthood

 KOHLBERG’S STAGES OF MORAL DEVELOPMENT
LEVEL STAGE / YEARS CHARACTERISTICS
STAGE 1 : 2-3 PUNISHMENT OR OBEDIENCE
PRE-CONVENTIONAL

YEARS (heteronomous morality)

A child tells him the right thing because he was told to do so to avoid
punishment.
STAGE 2: 4-7 INDIVIDUALISM / INSTRUMENTALISM/ EXCHANGE
YEARS Child carries out actions to satisfy his own needs rather than the society’s.
The child does something for another if he gets something in return.
Stage 3: 7-10 Good Boy / Girl
Orientation To Interpersonal Relations Of Mutuality
Conventional

A Child Follows Rules Because Of A Need To Be A Good Person In Own

Eyes And In The Eyes Of The Other
Stage 4: 10-12 Law And Order
Maintenance Of Social Order; Fixed Rules And Authority
Child Follows Rules Of Authority Figures As Well As Parents To Keep The
System Working
Stage 5: Older Social Contact
Conventional

Than 12 Utilitarian Law Making Perspective

A Child Follow Standards Of Society For The Good Of People
Post-

Stage 6: Older Principled Conscience

Than 12 Universal Ethical Principle Orientation
Child Follows Internalized Standards Of Conduct
Table 1.2 Kohlberg’s Moral Development
 AGE PHYSIOLOGIC GROSS MOTOR FINE MOTOR LANGUAGE and PLAY
SOCIALIZATION
INFANT a. Weight: 2 – Holds head up 1 – follows object 2 – makes cooing sounds SOLITARY PLAY
4-6 mo. – wt. 3 – Holds head & chest to midline 3 – laughs out loud 2 – enjoys bright colored
doubles ( 2lb/mo) up 3 – follows object 6 – says vowel sounds mobiles
1 year – wt. triples 5 – Turns front to back past midline 7 – stranger anxiety 3 – hand regard
(1lb/mo) 6 – Turns both ways 6 – palmar grasp 9 – first words 4 – handles rattles
b. Height: (Roll-over) 7 – transfer (da-da) 10 – plays pat-a-cake
increases by 50% 7 – Sits with support objects between 12 – says two words plus & peek-a-boo
by 1st year 8 – Sits without hands ma-ma & da-da 12 – plays pots and pans; Pull
c. Heart Rate: support 10 – pincer grasp toys
120 – 160 bpm 9 – Creeps or Crawl 12 – holds cup
d. RR: 10 – Pulls self to and spoon well
30 – 60 cpm standing
11 – Cruises; stands
with support
12 – Stands Alone
TODDLER a. Weight: 15 – Walks alone; 15 – scribbles 18 – begins to use short PARALLEL PLAY
Birth weight seats self to chair; voluntarily sentences - Pushtoys
quadrupled by 2 ½ creeps upstairs 24 – can unscrew 24 – gives first name - Riding toys
years 18 – can run and jump lids and turn 3 yrs – gives full name; - Puzzles, blocks, finger,
a. Heart Rate: into place doorknobs repeats 3 numbers; paints, crayons
110 bpm 24 – walks up stairs 30 – draws simple vocabulary increases to 900
b. RR: alone with both feet lnes or crosses words
26 cpm on the same step at a with pencil
c. Primary time
dentition 30 – jumps down from
completed by stairs
2 ½ years
d. Period of
slow growth

PRE-SCHOOL a. Weight: 3 – walks up stairs 3 – copies circles, - Understands COOPERATIVE PLAY

4-6 lb wt. Gain per - Stands on ONE may add facial concept of - Rules and ritual
year FOOT features cooperation and dominate play
 AGE PHYSIOLOGIC GROSS MOTOR FINE MOTOR LANGUAGE and PLAY
SOCIALIZATION
a. Height: 2 ½ - Jumps off 1 compromise - Board games, painting
inches per year STEP 4 – copies a - Enjoys family
b. Heart Rate: - Rides Bicycle square; traces activities
90 - 100 bpm 4 – walks down stairs diamond - Masters arithmetic
c. RR: - Hops on 1 foot 5 – hand and reading
24 - 25 cpm 5 – skips and hops on dominance
alternate feet - Ties shoes
- Balances on
ONE FOOT
- Jumps rope
- Throws and
catches ball

SCHOOL-AGE - Period of - Jumps, - can tie - talks in full COMPETITIVE PLAY

pubertal tumbles, skips shoelaces sentences - Collects items such as
development and hops - draw a - can tell time in cards, dolls, rocks and
- Can walk a person in hours marbles
straight line good - use of swear words - Interested in games
detail - Gang age involving rules and
fairness

Table 1.3 Growth and Developmental Milestones

(e) PEDIATRIC NUTRITIONAL REQUIREMENTS
a. INFANT
 Birth to 6 months
 Breast milk is a complete and healthful diet
 May include 0.25 mg fluoride, 400 IU vitamin D, and iron after 4 months
 Commercial iron-fortified formula is an acceptable alternative
 Supplementation Juices may be introduced at 5-6 months

 6 - 12 months
 Breast milk or formula continues to be primary source of nutrition.
 Introduction of solid foods starts with cereal (usually rice cereal), which is continued until 18
months.
 Introduction of other food is arbitrary; most common sequence is fruits, vegetables, meats.
 Decrease amount of formula to about 30 oz. as foods are added.
 Iron supplementation can be stopped.
 Finger foods such as cheese, meat, carrots can be started around 10 months.
 Chopped table food or junior food can be introduced by 12 months
 Weaning from breast or bottle to cup should be gradual during second 6 months. NURSING ALERT:
Introduce one
b. TODDLER new food a week
to assess for food
 Caloric requirement is approximately 100 calories/kg/day allergy
 Increased need for calcium, iron, and phosphorus.
 Needs 16 - 24 oz milk/day.
 Appetite decreases
 Able to feed self.
 Negativism may interfere with eating.
 Initial dental examination at 3 years.

c. PRE-SCHOOL
 Caloric needs diminish in relation to body size: 85 kcal/kg/day
 “Junk” food may become a problem; excess sugar, starches, fat.
 Obesity is a risk in this age group.
 Nutrition education should be integrated into school program.
d. SCHOOL-AGE
 Boys requires more calories
 Increased need for Iron during pre-pubertal period
 Adequate Calcium intake to ensure good teeth
 Involve children in planning and preparing meals

e. ADOLESCENT
 Nutritional requirements peak during years of maximum growth: age 10-12 in girls, 2 years later in
boys
 Appetite increases.
 Inadequate diet can retard growth and delay sexual maturation.
 Food intake needs to be balanced with energy expenditure
 Increased needs include calcium for skeletal growth
 IRON for increased muscle mass and blood cell development.
 ZINC for development of skeletal and muscle tissue and sexual maturation.
 AGE FEARS

1. Separation from parents

INFANT - Searches for parents with eyes.
- Shows preference for parents.
- Develops stranger anxiety around 6 months (peaks at 8 months).
2. Pain

1. Learning to tolerate and master brief periods of separation is important developmental

task.

2. Increasing understanding of object permanence helps toddler overcome this fear.

TODDLER
3. Potential patterns of response to separation
a. Protest: screams and cries when mother leaves; attempts to call her back.
b. Despair: whimpers, clutches transitional object, curls up in bed, decreased
activity, rocking.
c. Denial: resumes normal activity but does not form psychosocial
relationships; when mother returns, child ignores her
1. Fear of the Dark
PRE-SCHOOL 2. Fear of Abandonment
3. Fear of Mutilation
SCHOOL- Section I.01 More realistic fears than younger children; include death, disease or bodily injury,
AGE punishment; school phobia may develop, resulting in psychosomatic illness.

1. Threats to body image: acne, obesity

ADOLESCEN
T 2. Injury or death

3. The unknown
Table 1.4 Childhood Fears

CHILD’S CONCEPT OF DEATH

1. Toddlers - may insist on seeing a significant other long after that person’s
death.
2. Preschoolers - See death as temporary; a type of sleep or separation.
3. School-age – See death as a period of immobility; Feel death is punishment.
4. Adolescents - Have an accurate understanding of death.
PEDIATRIC MEMORY AIDS

REMEMBER: INFANTS luvs to play!

I mmitates acts or noises
N utrition through breastmilk
F inger foods @ 10 months
A lone in playing (solitary play)
N ote for height and weight
changes
T eething begins @ 6th month
S ucking gives gratification

L ength x 50% @ 1st year

U p alone @ 12th month
V ision: follows objects 180
S tranger anxiety

P incer grasp @ 10th month

L ower Incisors erupt before upper incisors
A llow cruising @ 11th month
Y ells (cries) withoutparents (parent preference)
REMEMBER: TODDLERS needs praise!
T emper tantrum
O ffer choices
D iet preference unpredictable
S afety is a priority

N o” attitude
E xplores genitals
E elimination training (Bowel Training)
D evelopmental task : autonomy vs shame and doubt
S eparation anxiety

P arallel play
R ituals and routines
A ccident – prone
I nvolve parents in child care
S ibling rivalry
E xplain procedures

REMEMBER: PRE-SCHOOLERS are imaginative!

I maginative thinking
M utilation, fear of
A ssociative play
G rowth rate slows
I nitiative vs. guilt
N o new teeth develops
A ppetite is not large
T elling tall tales
I maginary friends
O edipus and Electra Complex
N eeds explanations
REMEMBER: SCHOOLERS experience school-phobia!
S tructured activities
C ompetitive play
H ero worship
O ral meds preferred
O bserve for pre-pubertal changes
L earns to live with others

A lways active
G rows steadily
E xplain pre-pubertal changes

P roblem solving develops industry

H angs out with same sex
O besity is common
B ehavior problems are common (bullying etc.)
I ndustry vs. Inferiority
A ccomodation develops

REMEMBER: Adolescents goes in pairs!

T each stress management and coping techniques
E mancipates from parent
E xercise is important
N utrition includes adequate calories
A cceptance through peers
G rowth spurt
E encourage decision making

P romote safety
A ttachment to opposite sex
I dentity vs. role confusion/diffusion
 R espect Independece
S ubstance abuse must be addressed.

II. NEONATAL CARE

(a) IMMEDIATE CARE
PRIORITY: A – Airway NURSING ALERT:
When performing ORONASAL
B – Breathing suctioning, suction gently and
quickly 5- 10 seconds only.
C – Circulation Vigorous and prolonged
suctioning can stimulate
T – Thermoregulation vagus nerve that would lead
to bradycardia.

 Four Mechanisms of Heat Loss

Convection
 From body surface to cooler surrounding air.
 Depending on air currents or velocity of air flow
 Eliminating drafts such as from windows, air conditioners, reduces convection heat loss.
Conduction
 Transfer of body heat to cooler solid object in contact with the NB
 Cold counter, cold metal
 Covering these with warm blanket prevent conduction heat loss
Radiation
 Transfer of body heat to a cooler solid object NOT in contact with the baby
 Cold window or air conditioner
 Move infant away from the object
Evaporation
 Loss of heat though conversion of a liquid to a vapor.
 NB are wet by the AF, they should therefore be dried immediately especially the head to
prevent heat loss.

Nursing Prevention of Heat Loss

 Place the newborn near the mother’s skin
 Dry the newborn immediately
 Wrap him with warm and dry sheets
 Put him under a droplight
 Close windows and door

(b) INITIAL ASSESSMENT

APGAR Scoring
  A system of assessing the general physical condition of a newborn infant.

SIGN SCORE: 0 SCORE: 1 SCORE: 2

A ppearance Pale / Blue Blue Extremities Completely Pink
P ulse (Heart Rate) Absent < 100 bpm > 100bpm
Grimace (Response to
No Response Grimace Cough / Sneeze
Stimuli)
A ctivity (Muscle Tone) Flaccid Some Flexion Well Flexed
R espiration Absent Weak Good Cry

Table 2.1 APGAR Scoring

*Score: 8 – 10 Indicates Good Extra-uterine Adaptation

4–7 Indicates a Guarded Condition: Needs Airway Clearance and O2
Supplementation
<4 Serious Danger: Needs RESUSCITATION

(c) BALLARD SCALE

 maturity rating scale used to estimate
NURSING ALERT:
newborn’s gestational age When performing
BALLARD assessment, the
infant must be awake
and lying in supine
position.
 BP measurement of
newborns is not routinely
done except if congenital
heart anomalies are
(c) GENERAL ASSESSMENT suspected
 A. Vital signs:
Respiratory Rate:
Apical Pulse:
Temperature:
Blood Pressure:
30 to 60 cycles per minute
120-160 bpm (awake)
180 bpm (crying)
110 bpm (sleeping)
36 - 36.8C
80/46 mmHg

B. Anthropometric Measurements:
Weight - 2,500 – 4,000 g
Length -18 – 21 inches
Head Circumference -13 – 14 inches / 33- 35 cm.
Chest Circumference -12 – 13 inches / 30 – 33 cm.

C. Gestational Age
 Preterm - more than 20 weeks but less than 38 weeks AOG
 Term – 38 -40 weeks AOG
 Postterm – 40 weeks and above

GESTATIONAL AGE BY WEEKS

FINDINGS 0-36 37-38 39 and Over

Anterior transverse Occasional creases Sole covered with
SOLE CREASES
crease only in anterior ⅔ creases
BREAST NODULE
2 4 7
DIAMETER (mm)
SCALP HAIR Fine and fuzzy Fine and fuzzy Coarse and silky
Stiffened by thick
EARLOBE Pliable; no cartilage Some cartilage
cartilage
Testes in lower canal; Testes pendulous,
MALE: TESTES AND
scrotum small: few scrotum full:
SCROTUM Intermediate
rugae extensive rugae

FEMALE: EXTERNAL
STRUCTURES Doesn’t cover the Slightly covering Completely covers
( Labial folds) clitoris the clitoris the clitoris

Table 2.2 Clinical Criteria for Gestational Age Assessment

(d) SKIN
 NORMAL
SKIN Pink all over the body
Acrocyanosis – blue extremities; due
to immature peripheral circulation
DEVIATIONS FROM NORMAL
Central Cyanosis –
indicates decreased
oxygenation or airway
obstruction
Pallor – indicative of
anemia due to
excessive blood loss;
dec. iron stores of fetus
Gray Skin – indicative of Infection.
Refer ASAP
Pathologic Jaundice – occurs within
the 1st 24 hours
- indicative of Rh/ ABO
Incompatibility, Hemolysis

Hemangiomas – vascular tumors of

the skin
NURSING ALERT: Continue
observing the neonate and wrap 3 types:
in a warm blanket.
Nevus Flammeus – (port wine stain)
macular purple or dark red lesion
usually found in the face and buttocks.
Physiologic Jaundice – occurs within Strawberry hemangiomas – elevated
48-72 hours caused by immature areas formed by immature capillaries
liver. and endothelial cells associated with
Nursing Interventions: high level of estrogen in uteru.
- Provide continous feeding * It may disappear within 1 year.
asap to speed up passage of Cavernous hemangiomas – dilated
meconium. vascular spaces.
- Expose to morning sunlight / - It may or may not disappear.
droplight. * Bleeding could pose a problem at
Vernix Caseosa – Cheesy-like the later years
substance.
* Allow it to remain to provide
insulation.
Milia – Immature sebaceous gland
usually seen in cheek, chin and nose.
Disappear by 2-4 weeks. Do not prick
or remove, it could be an entry for
microorganism
Lanugo – fine downy hair usually
found in shoulders, back, and upper
arm.
* The more lanugo the lower the age
of gestation.
Erythema Toxicum – (flea bite rash)
appears in 1st to 4th day caused by
eosinophils reacting to the
environmentas part of growing
immune system.
* No clinical significance.
 NORMAL DEVIATIONS FROM NORMAL
Mongolian Spots – deep blue
pigmentation appears on the
buttocks. Disappears by school age. *
No clinical significance.

HEAD A. Fontannel - Bulging

s fontanels
- should be flat, soft and firm indicates
Anterior – diamond – shaped. Closes presence of
by 12 - 18 mo. fluid and
Posterior – triangle - shaped. Closes increased ICP
by 2-3 mo. - Depressed
B. Cranial fontanels indicates
Sutures dehydration
- may override at birth
Caput succedanum- edema of the
scalp crossing the suture lines. - Widely separated sutures
* disappears within 1 week indicates fluid accumulation,
Craniotabes – localized softening of abnormal brain development
the cranial bone due to pressure of & increased ICP.
fetal skull against the pelvic bone. - Cephalhematoma – collection
of blood within the
periosteum of skull bone due
to rupture of blood vessel
during vaginal delivery. Self
resolving and does not cross
the suture line.
EYES Color gray Large cornea – congenital glaucoma
Absence of tears Purulent discharge – eye infection,
Searching nystagmus Gonorrheal conjunctivitis
Cornea round and adult size White Pupil – congenital cataract
Pupil should be dark Yellow Sclera – Increased bilirubin
EARS Pinna top is horizontal line with outer
cantus of the eye Low set ears- indicates chromosomal
Flexible cartilage abnormalities e.g Down Syndrome
( Trisomy 21), Patau Syndrome
(Trisomy 13)

Absent of Moro reflex in response to

loud noise - may indicate congenital
deafness
NOSE Appear large for face Blockage at the rear of the nose –
Patent nostrils choanal atresia
MOUTH AND Epstein Pearl – caused by excessive Oral Thrush – candida infection, must
THROAT load of calcium in utero. No clinical be reported immediately
significance.
 NORMAL DEVIATIONS FROM NORMAL
Inability to pass NGT –
may indicate
tracheoesophageal
atresia and fistula
High-pitched cry –
Increased ICP
NECK Short, thick, usually surrounded by Resistance to flexion – congenital
skin folds torticollis
Fractured clavicle
No tonic neck reflex
CHEST
Witch Milk – thin watery fluid from Asymmetry of the chest
the breast of newborn due to
withdrawal to maternal hormones. (i) Depressed sternum
Slight sternal retractions evident
during inspiration
ABDOMEN Scaphoid or Sunken Abdomen –
Slightly protuberant Diaphragmatic Hernia or missing
abdominal contents
Spleen and liver is palpable
Bleeding, Malodorous Cord -
Umbilical cord: AVA no bleeding, no omphalitis
odor

(+) Abdominal reflex – reflects

integrity of spinal nerve T8 – T10
GENITALIA MALE: MALE:
- urethral opening at the tip of - Hypospadias – ventral
glans penis urethral opening
- palpable testes - Epispadias – dorsal urethral
- (+) cremasteric reflex = intact opening
SN T8-T10 - Cryptochirdism –
FEMALE: undescended testes
- usually edematous labia and FEMALE:
clitoris - imperforate hymen: absence
- urethral meatus behind of vaginal opening
clitoris - fused labia
- pseudomenstruation – d/t - meconium in the vaginal
withdrawal of maternal area: rectovaginal fistula
hormones
EXTREMITIES Ten fingers and toes Polydactyly – extra digit in fingers and
Full range of motion toes
Nail beds are pink, with transient Syndactyly - fused or webbed digits
Cyanosis immediately after birth Amelia and phocomelia – caused by
(b) Equal brachial pulses thalidomide
(c) Sole usually flat exposure during pregnancy.
Abnormally short or absent
extremeties.
Yellowing of nail beds
Unequal gluteal folds – congenital hip
 NORMAL DEVIATIONS FROM NORMAL
dislocation
Sole covered with creases

Table 2.3 Assessment of the Newborn’s Skin

(e) PROTECTION FROM INFECTION AND INJURY

 Eye Care
 0.5 % Erythromycin Ointment
 1 to 2 cm from inner to outer canthus
 Done to prevent Opthalmia Neonatorum
 Vitamin K Administration
 Vit K (Aquamephyton) .5 to 1 mg
 Administered IM @ right or left vastus lateralis
 Given to prevent transient deficiency of coagulation factors
 Immunization
**included in CHN
 Bathing
 Cord Care
 AVA (2 arteries, 1 vein)
 1 A, 1 V: Polycystic Kidney Disease
 Newborn Screening
 Newborn Screening Act of 2004: To promote and protect to health of the people
 Taken after the 24th hour of life using heel-prick technique to determine 5 life-threatening
Metabolic Disorders:
a. CH (Congenital Hypothyroidism)
- Complication: Severe Mental Retardation
b. CAH ( Congenital Adrenal Hyperplasia)
- Complication: Death
c. GAL (Galactosemia)
- Complication: Cataracts, Death
d. PKU (Phenylketonuria)
- Complication: Severe Mental Retardation
e. G6PD Deficiency
- Complication: Severe Anemia, Kernicterus

(f) PROVISION OF OPTIMUM NUTRITION

 Milk Code of the Philippines Executive Order No. 51 (E.O. 51)
BREASTMILK FORMULA – MILK
ADVANTAGE Readily available Permits the father to feed
Economical Mother can take medications
 Promotes facial muscles, jaw and teeth Fewer feedings
Mother infant bonding Feeding in public cant cause
Reduced incidence of allergies embarassment
Reduced incidence of maternal breast cancer
Transfer of maternal antibodies:
- IgA
- Lactoferrin
- Lysozyme
- Leukocytes
- Macrophages
DISADVANTAGES Cost
Prevents other from feeding the infant Requires preparation and effort
Requires refrigeration and storage
Limits paternal role in feeding Without maternal antibodies
No beneficial effects to the mother
Compels the mother to monitor her diet
carefully

Maybe difficult to a working mother

CONTRAINDICATIONS Mothers with:

- HIV Infection
- Under Chemotherapy and Radiation
- Breast cancer
Table 2.3 Breastfeeding vs. Bottle Feeding

(g) Promotion of Parent-Infant Bonding

Republic Act 7600: Rooming In and Breastfeeding Act of 1992
 Babies born in private and government hospitals should be roomed-in with their
mothers to promote breastfeeding and ensure safe and adequate nutrition to
children.

(h) TRANSITIONAL AND BEHAVIORAL ASSESSMENT

Period of Reactivity
 30 minutes after birth
 Awake and active
 VS are increased
 Mother infant bonding: breastfeeding and rooming-in of infant

Resting Period
 2 to 4 hours
 VS returning to baseline
 1 ½ sleep and difficult to be aroused

Second Period of Reactivity

 4 to 6 hours
III. COMMON PEDIATRIC DISORDERS
A. RESPIRATORY DISORDERS
(a) EPIGLOTTITIS
 Inflammation of the epiglottis
 H. influenzae Type b ; Strep pneumoniae
 Age 2-5
 Abrupt onset; winter
 Considered an emergency situation
Assessment:
 Fever
 Sore, red and inflamed throat
 Drooling, difficulty of swallowing
 Inspiratory stridor
 Muffled voice
 Nasal flaring
Nursing Intervention
 maintain patent airway
 assess respiratory status and breath sounds
 use of accessory muscles; presence of stridor
 assess temperature
 do not attempt to visualize the posterior pharynx or obtain throat culture by stimulating gag
reflex – BQ
 do not force child to lie down
 do not restrain
 administer antibiotics; IV fluids
 cool mist oxygen
 high humidification
 have resuscitation equipment available
 immunization

(b) LARYNGOTRACHEOBRONCHITIS (LTB)

 Inflammation of the larynx, trachea, bronchi
 Most cparainfluenza virus
 Gradual onset ; preceded by URI
Assessment:
 Fever
 irritability and restlessness
 hoarse voice
 inspiratory stridor and suprasternal retractions
 crackles and wheezing
 cyanosis
Implementation:
 patent airway
 vital signs
 elevate HOB
 humidified oxygen; IVF
  nebulized epinephrine
 resuscitation equipments available

(c) BRONCHITIS
 infection of the major bronchi
Assessment:
 cough, worse at night; becomes productive
 in 2-3 days
Implementation:
 Monitor for respiratory distress
 Increased fluid intake
 Acetaminophen as ordered

(d) BRONCHIOLITIS/RESPIRATORY SYNCYTIAL VIRUS (RSV)

 Inflammation of the bronchioles; production of mucus
 that occludes bronchiole tubes and small bronchi
 RSV – highly communicable, usually transferred by hands
Assessment:
 URI
 Lethargy, poor feeding, tachypnea
 Expiratory wheezes and grunt
 Diminished breath sounds
The child with RSV:
 Isolate in a single room or place with same patient
 good handwashing
 nurses caring for these children do not care for other
 high risk children
 wear gowns when soiling may occur
 Ribavirin (antiviral) – may be aerosol
 nurses wearing contact lenses must wear goggles – ribavirin
 may dissolve contact lenses

(e) PNEUMONIA
 inflammation of the alveoli
 inhalation of causative agent à bloodstream
 Primary atypical pneumonia – most common cause of
 pneumonia between 5-12 years

Implementation:
 antimicrobial therapy
 Oxygen
 cool humidification
 encourage child to lie on the affected side
 isolation procedures as needed
 Antipyretics
 IVF; liberal fluid intake
(f) ASTHMA
 chronic inflammatory disease of airways
 commonly caused by physical and chemical irritants common
 symptoms – coughing in the absence of respiratory infection, especially at night

Assessment:
 episodes of wheezing, breathlessness, dyspnea, chest tightness
 SOB, cough, wheezing
 child speaks in short, broken phrases
 retractions
 exercise induced bronchospasm
 severe spasm or obstruction
Implementation:
 continuously monitor respiratory status
 administer quick-relief (rescue) medication
 initiate an IV line; prepare to correct
 dehydration, acidosis or electrolyte imbalance

Medications
Quick relief
 To treat symptoms and exacerbations
 Short acting beta 2 agonists
 Anticholinergics – for relief of acute
 bronchospasm (ipratropium bromide)
Long term control
 Corticosteroids
 Long acting b2 agonist
 Long acting bronchodilator
 Nebulizer, MDI ( metered dose inhaler)
 Used to deliver many medications
 Non-CFC (chlorofluorocarbon) – albuterol
 Chest physiotherapy
 Includes breathing exercises
Home care measures:
 instruct in measures to eliminate allergens
 avoid extremes of environmental temperature
 avoid exposure to individuals with a viral infection
 instruct the child in how to recognize early symptoms
 instruct the child in the cleaning of devices used for inhaled medications
 keep immunization up to date

(g) OTITIS MEDIA

 Infection of the middle ear occurring as a result of a blocked Eustachian tube,
preventing normal drainage
 Common complication of acute respiratory infection (ARI)
 Infants and children more prone because is ET shorter, wider, straighter
 Assessment:
 Fever
 irritability and restlessness
 rolling of head from side to side
 pulling or rubbing the ear
 earache; signs of hearing loss
 purulent ear discharge
 otoscopic exam
Intervention
 Encourage fluids
 upright position when feeding
 avoid chewing – increases pain
 have the child lie with the affected ear down
 instruct on appropriate technique to clean drainage from the ear with sterile cotton swabs
 administer analgesics and antibiotics (10-14 days)
 screening for hearing loss
 otic medications
 If younger than age 3 – auditory canal is straightened by pulling the pinna down and
back
 If older than 3 years – pull pinna up and back
 Myringotomy
 Insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep ear
aerated
 Keep ears dry
 Earplugs should be worn during bathing, shampooing, swimming

(h) TONSILLITIS AND ADENOIDITIS

Assessment:
 persistent or recurrent sore throat
 enlarged bright red tonsils ; with exudates at times
 Dysphagia
 mouth breathing; unpleasant mouth odor
 fever; cough
Preop Management:
 assess for presence of infection
 assess bleeding and clotting studies
 assess for loose teeth
 prepare the child for a sore throat
 prepare the child for throat culture
Postop Management:
 Position – prone or side lying to facilitate drainage
 have suction equipment available
 monitor for signs of hemorrhage
 may give ice chips and apply ice collar
 provide clear, cool, noncitrus and non carbonated drinks
 avoid milk products intially – will coat the throat
 avoid red liquid
 discourage coughing or clearing of the throat
 B. CARDIOVASCULAR DISORDERS

Congenital Heart Defects

 Cyanotic Congenital Heart Defects
(a) TETRALOGY OF FALLOT
4 Defects:
 Ventricular Septal Defect
 Overriding of the aorta
 Pulmonary valve stenosis
 Enlarged right ventricular wall
Assessment:
 Primary sign – cyanosis at birth
 Hypoxic spells – usually initiated by
crying Clinical Findings
 Fainting – due to cerebral hypoxia  Loud harsh widely transmitted
 Stunted growth, clubbed fingers murmur or soft scratchy, localized
and toes systolic murmur in the left 2nd, 3rd
 Squatting position – characteristic or 4th parasternal intespace
position to relieve dyspnea  Echocardiography: Reveal right side
 Clubbing of fingers of heart enlargement, decrease size
 Polycythemia of pulmonary artery and reduce
blood flow to lungs
Management:
 Decrease hypoxic spells – minimize or avoid crying
 Place in knee chest position
 Administer O2 as needed
 Morphine sulfate to reduce symptoms
 Propanolol (Inderal) for vessel dilatation
 “Blalock-Taussig” temporary or palliative repair creating shunt between
aorta and pulmonary artery

(b) TRICUSPID ATRESIA

 Condition in which tricuspid valve did not form an opening
between the right atrium and right ventricle
 2% of congenital heart defects
Assessment:
 Profound cyanosis and dyspnea at birth
 Emergency management needed asap.
Management:
 IV infusion of prostaglandin
 Surgery: Fontan Procedure (Glenn Shunt Baffle)
making of venacave-to-pulmonary artery shunt

(c) TRANSPOSITION OF THE GREAT VESSELS

  aorta arises from the right ventricle; pulmonary artery arises from the left ventricle
 degree of cyanosis depends on the abnormal connections
Assessment:
 cyanotic at birth ( most important clinical sign)
 develop polycythemia thus at risk for emboli and thromboses
 may develop CHF or pulmonary vascular obstruction

Implementation:
 Require emergency medical treatment
 Cardiac catheterization
 Balloon atrial septostomy

(d) TOTAL ANOMALOUS VENOUS RETURN

 Condition in which all the pulmonary venous blood returns to
the heart
 Absent spleen is often associated
Assessment:
 Cyanosis and severe respiratory distress
Management:
 Prostaglandin IV to keep ductus arteriosus open.
 Surgical intervention asap
 Surgery of choice: atrial septal pull through.

(e) TRUNCUS ARTERIOSUS

 Single vessel arising from the ventricles just above a large VSD
Assessment:
 retarded growth; enlarged liver and heart
 usually infants die within the first year

 Acyanotic Congenital Heart Defects

(a) PATENT DUCTUS ARTERIOSUS
 Most common congenital heart defect
Assessment:
 Symptoms depend on size of the vessel and age of the child
  May have no symptoms; indication may be a “machinery like murmur”
 Increasing dyspnea, full bounding pulse, wide pulse pressure

Prognosis:
 Spontaneous closure after infancy rarely occurs
 Without treatment – life expectancy short
Management:
 Oral of IV Indomethacin (prostaglandin inhibitor) to promote ductus closure
 Interventional cardiac catheterization with Dacron coated stainless coil insertion by
6 mos to 1 year
 Surgical closure by ductal ligation

(b) ATRIAL SEPTAL DEFECTS

 10% of all forms of congenital heart disease
 Allows oxygenated blood returning from the lungs to
pass into the right atrium
 Left to right shunting ( oxygenated to
 deoxygenated)
Assessment:
 Harsh systolic murmur in 2nd or 3rd interspace
(pulmonic area), enlarge right side of heart by
echocardiography
Management:
 Surgical closure of defect by 1—3 years of age.

(c) VENTRICULAR SEPTAL DEFECT

 Constitute 20% of all forms of CHD
 Allows systemic venous and oxygenated
 arterial blood to mix
Assessment:
 Asymptomatic at birth; 4-8 weeks old may demonstrate
easy fatigue, loud harsh pansystolic murmur at 3rd or 4th
interspace, and palpable thrill
Management:
 Require no specific treatment and often close
spontaneously. Large defects can be repair by
interventional cardiac catheterization.

(d) COARCTATION OF THE AORTA

 Narrowing of the lumen of the aorta
 may be an isolated defect or associated with other cardiac
malformation
Assessment:
 Absent, weak or diminished femoral pulse
  measure BP in both arms and a leg and to assess the pulse in both upper and lower extremities
Management:
 surgical repair – only permanent treatment; usually deferred until 3 years of age by
interventional angiography

(e) PULMONIC VALVE STENOSIS

 Narrowing of the valve or the pulmonary artery distal to the
valve
Assessment:
 Asymptomatic or have signs of mild right sided heart failure;
typical systolic ejection murmur can be heard at the upper left
sternal border
Management:
 may vary depends on the severity of stenosis. “Balloon
angioplasty” is the procedure of choice.

(f) AORTIC VALVE STENOSIS

 Stricture of the aortic valve that prevents blood from passing
freely
Assessment:
 Mild to moderate asymptomatic; typical murmur, a rough systolic
sound heard loudest in the 2nd right interspace.
 Thrill present at the suprasternal notch.
 If severe: faint pulse, hypotension, tachycardia and inability
to suck forlong period
Management:
 Beta blockers and calcium channel blockers to reduce cardiac
hypertrophy.
 “Balloon valvuloplasty” is the surgical treatment of choice.

CARDIOVASCULAR DEFECTS MANAGEMENT

 Monitor vital signs closely
 Monitor respiratory status
 Auscultate breath sounds for crackles, rhonchi or rales
 If respiratory effort is increased, place child in reverse Trendelenburg
position
 Administer humidified oxygen
 Monitor for hypercyanotic spells:
 Place infant in a knee chest position
 Administer 100% oxygen by mask
 Administer morphine as ordered
 IVF as prescribed
 Assess for signs of CHF
 Assess peripheral pulses
 Keep child stress free as possible; allow maximal rest

CARDIAC SURGERY
Postoperatively:
 Monitor for signs of discomfort
 Monitor for signs of sepsis (fever, lethargy, diaphoresis, altered LOC)
  Monitor lines, tubes or catheters ; remove promptly
 Administer pain medications; note effectiveness
 Encourage rest periods
 Facilitate parent-child contact as soon as possible
Home Care
 omit activities in which child could fall for 2-4 weeks
 avoid crowds for 2 weeks after discharge
 no added salt diet
 do not put creams, lotions or powders on the incision site
 child may return to school 3rd week after discharge
 no physical education for 2 months
 follow up check-up 2 weeks after hospitalization
 avoid immunizations, invasive procedure and dental visits for 2 months
 advise parents regarding importance of dental visit every 6 month

C. Acquired Heart Diseases

(a) CONGESTIVE HEART FAILURE
 inability of the heart to pump sufficiently to meet the metabolic demands of the body
 infants – most commonly caused by congenital heart defects
 combination of both left sided and right sided heart failure

Assessment:
 tachycardia
 tachypnea
 profuse scalp sweating especially in infants
 fatigue and irritability
 sudden weight gain
 respiratory distress
Management:
Goal of treatment: To improve cardiac function, remove accumulated fluid and sodium, decrease
cardiac demands, improve tissue oxygenation

 Monitor vital signs closely and for early signs of CHF

 Monitor for respiratory distress
 Monitor I and O; weigh diapers
 Monitor daily weight to assess for fluid retention; weight gain of 0.5 kg ( 1 lb /day)
 Monitor for facial or peripheral edema , auscultate lung sounds
 Elevate HOB
 Maintain neutral thermal environment to prevent cold stress in infants
 Administer cool, humidified oxygen
 Organize nursing activities to allow uninterrupted sleep
 Maintain adequate nutritional status
 Provide rest; decrease environmental stimuli
 Feed when hungry and soon after awakening
 Infant should be well rested before feeding
 Provide small, frequent feedings
 Administer sedation
 Administer digoxin
 Check with physician parameters for witholding digoxin
 Note that infants rarely receive more than 1 mL (50 ug or 0.05 mg) of digoxin
  Administer diuretics; monitor for hypokalemia
 Administer potassium supplements
 Monitor serum electrolytes
 Restrict fluid in acute stages
 Check with physician regarding sodium restriction; infant formulas have
slightly more sodium than does breast milk

Home care Instructions for Administering Digoxin

 administer 1 hr before or 2 hrs after feeding; do not mix medication with
food or drink
 if the child vomits, do not administer a second dose
 if more than 2 consecutive doses have been missed,
 notify MD; do not increase or double the dose for missed doses
 keep the medication in a locked cabinet
 if the child becomes ill, notify MD

(b) RHEUMATIC FEVER

 An inflammatory autoimmune disease
 Affects connective tissue of the heart, joints, subcutaneous tissues and blood vessels of the CNS
 Most serious complication – RHD affecting the cardiac valves
 Presents 2-6 weeks following an untreated Group A beta
 Hemolytic streptococcal infection

Asssessment:
 Signs of carditis: SOB, edema of the face, abdomen or ankles, precordial pain
 Signs of polyarthritis: edema, inflammation of the large joints, joint pain
 Erythema marginatum: macular rash on trunk and extremities
 Subcutaneous nodules
 Fever
 Elevated ASO ( Anti streptolysin O)
 Elevated ESR ( Erythrocyte Sedimentation Rate)
 Elevated CRP ( C- Reactive Protein)
Management:
 Assess vital signs
 Control joint pain and inflammation with massage
 Febrile phase – provide bed rest
 Limit physical exercise in child with carditis
 Administer antibiotics (penicillin) as prescribed
 Administer salicylates and anti-inflammatory agents
 Instruct parents about the importance of follow up and need for antibiotic prophylaxis for
dental work, infection, invasive procedures
 Advise child to inform the parents if anyone in school develops a strep throat infection

(C) KAWASAKI DISEASE

 known as mucocutaneous lymph node syndrome
 acute systemic inflammatory illness
 unknown cause
 cardiac involvement – most serious complication

Assessment:
 fever
  conjunctival injection
 red, cracked lips; “strawberry tongue”
 Swollen hands, rash, enlargement of the cervical lymph nodes

Implementation:
 monitor temperature frequently
 assess heart sounds and rhythm
 assess extremities for edema, redness, desquamation
 monitor mucus membrane for inflammation
 weigh daily
 administer IV immune globulin
 instruct parents in the administration of prescribed meds
 aspirin – need to monitor bleeding

D. HEMATOLOGIC DISORDERS
(a) LEUKEMIA

the most frequent type of childhood cancer

Brain tumors – 2nd
Etiology:
 Environmental - Viruses
 Familial/genetic
 Host factors
STAGES OF TREATMENT
1. INDUCTION
 Goal: to remove bulk of tumor
 Methods: surgery, radiotherapy, chemotherapy, BM transplant
 Effects: often the most intensive phase
 Side Effects potentially life threatening
2. CONSOLIDATION
 Goal: to eliminated any remaining malignant cells
 Methods: chemo/radio
 Side effects will still be evident
3. MAINTENANCE
 Goal: to keep the child disease free
 Chemotherapy
 This phase may last several years
4. OBSERVATION
 Goal: to monitor the child at intervals for evidence of recurrent
 disease and complications of treatment
 Method: treatment is complete
 Child may continue in this stage indefinitely

LATE EFFECTS OF TREATMENT

 Impaired growth and development and CNS damage
 Impaired pubertal development
 Development of secondary malignancy
 Psychologic problems related to living with a life threatening disease and complex
treatment regimen

NURSING INTERVENTION
 Help child cope with intrusive procedures
  Provide information geared to developmental level and Emotional readiness
 Explain what is going to happen, why it is necessary, how it will feel
 Allow child to handle to handle and manipulate equipments
 Allow child some control in situations
 Positioning, selecting injection site
 Support child and parents
 Maintain frequent clinical conferences to keep all informed
 Always tell the truth
 Acknowledge feelings and encourage child/family to express them
 Provide contact with another parent or support group
 Minimize side effects of treatment
A. Skin breakdown
 Keep clean and dry; wash with warm water; no soaps or creams
 Do not wash off radiation marks
 Avoid all topical agents with alcohol
 Do not use heating pads or hot water bottle
B. Bone marrow suppression
 Provide frequent rest periods
 Avoid crowds
 Evaluate any potential site of infection
 Monitor temperature
 Avoid use of aspirin
 Select activities that are physically safe
C. Nausea and vomiting
 Administer antiemetic at least half an hour before chemotherapy
 Eat light meal prior to administration of therapy
 Administer IVF if needed
D. Alopecia
 Reduce trauma of hair loss
 Buy wig before hair falls out
 Discuss various head coverings
 Avoid exposing head to sunlight
E. Nutrition deficits
 Establish baseline
 Provide high calorie, high protein
F. Developmental delay
 Facilitate return to school as soon as possible
 Discuss limit setting, discipline

LEUKEMIA
 Most common form of childhood cancer
 Peak 3-5 years
 Proliferation of abnormal wbc that do not mature beyond the blast phase
 Blast cells – infiltrate other organs – liver, spleen, lymph tissue
Types:
 Acute Lymphocytic leukemia (ALL)
 80-85%
 Acute
 75% chance of surviving

 Acute nonlymphocytic leukemia

  Includes granulocytic and monocytic types
 60-80% will obtain remission
 30-40% cure rate
Assessment:
 Anemia, weakness, pallor, dyspnea
 Bleeding, petecchiae, spontaneous bleeding, ecchymoses
 Infection, fever, malaise
 Enlarged lymph node
 Enlarged spleen and liver
Management:
 Diagnosis: blood studies, Bone Marrow Aspiration (BMA)
 Treatment stages
A. Induction
C. CNS prophylaxis
D. Maintenance
Nursing Intervention:
 Provide care for the child receiving chemo and radiotherapy
 Provide support for the family/child
 Support child during painful procedures
 Use distraction, guided imagery
 Allow the child to retain as much control as possible
 Administer sedation prior to procedure as ordered

(b) SICKLE CELL DISEASE

 Hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin (HgbS)
 HgbS sensitive to changes in the oxygen content of the red blood cell
 Insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and
clumped together, obstructing capillary blood flow
 The sickling response – reversible under adequate oxygenation
 Sickle cell crises – vaso-occlusive crisis, splenic sequestration, aplastic crisis
Assessment:
1. Vaso-occlusive crisis
 Most common type of crisis
 Caused by stasis of blood with clumping of the
 Cells in microcirculation, ischemia and infraction
 Fever, pain and tissue engorgement
2. Splenic sequestration
 Pooling of blood in the spleen. Profound anemia, hypovolemia, and shock

3. Aplastic crisis
 Caused by the diminished production and increased destruction of RBCs, triggered by viral
infection or the depletion of folic acid
 Profound anemia and pallor
Implementation:
 Administer oxygen and blood transfusions
 Administer analgesics
 Maintain adequate hydration and blood flow with IV normal saline as prescribed and with
oral fluids
 Assist the child to assume a comfortable position so that the child keeps the extremities
extended to bed no more than 30 degrees
 Avoid putting strain on painful joints
  Encourage consumption of a high calorie, high protein diet with folic acid supplementation
 Administer antibiotics as prescribed
 Monitor for signs of increasing anemia and shock (pallor, vital sign changes)

(c) IRON DEFICIENCY ANEMIA

 Iron stores are depleted, resulting in a decreased supply of iron for the manufacture for of
hemoglobin in RBCs
 Results from blood loss, increased metabolic demands, syndromes of GI malabsorption, dietary
inadequacy
Assessment:
 pallor
 weakness and fatigue
 irritability
Implementation:
 Increase the oral intake of iron
 Instruct the child and parents in food choices that are high in iron
 Administer iron supplements as prescribed
 Liquid iron prep stains – stains teeth; with straw
 Side effects of iron therapy

(d) APLASTIC ANEMIA

 a deficiency of circulating erythrocytes resulting from the
 arrested development of RBCs within the bone marrow
 causes: exposure to toxic agents, viruses, infection, autoimmune disorders, allergic states
 definitive diagnosis: Bone Marrow Aspiration (BMA)
 Therapeutic management: blood transfusions, splenectomy, corticosteroids,
immunosuppressive therapy, bone marrow transplantation
Assessment
 Pancytopenia
 Petechiae, purpura, bleeding, pallor, weakness, tachycardia
 and fatigue

Implementation:
 Blood transfusion
 corticosteroids and immunosuppresives
 splenectomy
 bone marrow transplant
 Medic Alert bracelet

(e) HEMOPHILIA
 x linked recessive trait
 Hemophilia A – deficiency of Factor VIII
 Hemophilia B – deficiency of factor IX
 Males inherit hemophilia from their mothers and females inherit the carrier status from
their fathers
Assessment:
 prolonged bleeding after minor injury
 At birth after cutting cord
 Following circumcision
 Following IM immunization
 Increase bruising as child learns to crawl and walk
  Abnormal bleeding in response to trauma
 Joint bleeding – pain, tenderness, swelling limited range of motion
 Tendency to bruise easily
 Prolonged PTT
 Normal BT, PT, platelet count
Implementation:
 prepare to administer Factor VIII concentrate /cryoprecipitate
 Thaw slowly
 Gently rotate bottle
 Infuse immediately; deteriorates at room temperature
 monitor for bleeding
 monitor for joint pain; immobilize the affected extremity if joint pain
occurs
 assess neurological status ( child at risk for intracranial bleeding)
 monitor urine for hematuria
 Control bleeding by immobilization, elevation, application of ice; apply
pressure (15 mins) for superficial bleeding
 instruct parents regarding activities of the child
 avoidance of contact sports

(f) BETA THALASSEMIA MAJOR

 Cooley’s anemia
 autosomal recessive disorder
 characterized by reduced production of one of the globin chains in the synthesis of
hemoglobin
 incidence highest in Mediterranean descent
Assessment:
 severe anemia
 Pallor
 failure to thrive
 Hepatosplenomegaly
 microcytic, hypochromic RBCs
Implementation
 Instruct the administration of folic acid (Vit B9)
 administer blood transfusion as prescribed
 Monitor for iron overload
 iron overload – chelation therapy with deferoxamine
 genetic counseling

(g) IDIOPATHIC THROMBOCYTOPENIC PURPURA

 increased destruction of platelets with resultant platelet count less than 100,000/mm3
 characterized by petechiae and ecchymoses of skin
 exact mechanism unknown
 often preceded by a viral illness
 spleen not enlarge
Assessment:
 petechiae: spider web appearance of bleeding under the skin due to small size of platelets
 Ecchymosis
 blood in any body secretions, bleeding from mucus membranes, nosebleeds
  diagnostic test: platelet count decreases, anemia
Management:
 steroids and immunosuppressives
 platelet transfusion
 surgery; splenectomy
Nursing Intervention
 control bleeding
 Administer platelet transfusion as ordered
 Apply pressure to bleeding sites as needed
 Position bleeding part above heart level if possible
 Prevent bruising
 Protect from infection
 Measure normal circumference of extremities for baseline
 Administer meds orally, rectally or IV rather than IM; hold pressure on site for 5 mins
 Avoid aspirin
 Provide client teaching and discharge planning
 Pad crib and playpen
 Provide soft toys
 Provide protective headgear during toddlerhood
 Use soft toothbrush
 Avoid contact sports

E. GASTROINTESTINAL DISORDERS
(a) CLEFT LIP AND CLEFT PALATE
 1 in 1000 births
 multifactorial
 common among children with chromosomal abnormalities
 results from failure of the embryonic structures of the face to unite
 may occur separately or may combine to produce a single unilateral or bilateral cleft from the lip
through the soft palate
 interfere with the child’s capacity to meet oxygenation and nutritional needs
 may seriously hamper normal bonding process of children with parents

Assessment:
 facial abnormality visible at birth
 cleft lip or palate or both, unilateral or bilateral
 difficulty sucking
 inability to form airtight seal around nipple
 formula/milk escapes through nose in infants with cleft palate
 predispose to infection – communication between mouth and nose
  difficulty swallowing
 abdominal distension related to excessive insertion of air
Management:
 team approach : otolaryngologist, audiologist, pediatrician, dentist, orthodontist, speech
therapist
 Surgical correction:
 early correction – prevent speech defects (cleft palate)

CHEILOPLASTY
 Correction of cleft lip
 Unite edges to allow lips to be both functional; aesthetic reasons
 Performed usually at age 2 ½ months

CLEFT PALATE REPAIR (PALATOPLASTY)

 not done until age 18 months – anticipation for speech development
 child should be weaned and able to take liquids from a cup before palate
repair

NURSING INTERVENTION:
Cleft Lip (PreOP)
 feed in upright position
 burp frequently
 press cleft lip together with fingers – to encourage sucking and to strengthen muscles
 if unable to suck, use a rubber tipped syringe; drip onto side of mouth
 finish feeding with water to wash away formula in palate area
 provide small, frequent feedings
 provide emotional support for parents

Post OP: Cleft Lip repair

 maintain patent airway
 monitor amount of swallowing to detect hemorrhage
 do not place in prone position or with pressure on cheeks
 avoid any tension and straining on suture line
 prevent crying
 keep child comfortable and contented
 use elbow restraint
 keep suture line clean – clean after each feeding with saline, peroxide or water to remove
crusts
 pain relief

Nursing Intervention:
Pre-Op cleft palate repair
 prepare parents to care fro child after surgery
 instruct concerning feeding methods and positioning
Post-Op cleft palate repair
 position on side for drainage of blood
 have suction available
 prevent injury or trauma on suture line
 Use cups only for liquids; no bottles
 avoid straws, utensils, popsicle sticks, chewing gum
 provide soft toys
  Use elbow and wrist restraints
 Provide liquid diet initially then soft diet
 Give water after each feeding to clean suture line
 Hold and cuddle

(b) ESOPHAGEAL ATRESIA and TRACHEOESOPHAGEAL FISTULA

ESOPHAGEAL ATRESIA
 congenital defect; upper segment of the esophagus ends in a blind pouch

TRACHEOESOPHAGEAL FISTULA
 defect in which embryonic structures fail to divide into a separate esophagus and
trachea
 opening between two structures
 usually occur together
Assessment:
 copious oral and nasal secretions –first sign of a defect
 choke or cough
 when suctioning or gavage is attempted – catheter cannot pass into
stomach
Medical and Surgical intervention
 prevention of aspiration
 drainage tube may be placed in the blind pouch –
 to suction secretions
 esophageal atresia – medical emergency
 (end to end anastomoses)
 feeding tube maybe inserted into the stomach through
 gastrostomy until repair heals
Nursing intervention:
 Provide nutrition
 Provide gastrostomy tube feeding until anastomosis site has healed
 Start oral feedings when infant can swallow well
 Promote respiratory function
 Position properly

(c) PYLORIC STENOSIS

 narrowing of the outlet of the stomach
 caused by excessive growth of circular muscles that surrounds the pylorus
 hypertrophy develops over 4-6 weeks of life when symptoms begin to appear
 more common in Caucasian; first born, full term boys

Assessment:
 olive size mass or bulge
under right rib cage -BQ
 vomiting – projectile; non
bilous
 peristaltic waves during and
after feeding
 failure to thrive
  dehydration  Increased Hct
 diagnostic tests:  Metabolic alkalosis
 UGIS – narrowing of diameter  Decreased serum Na, K, Cl
of pylorus

Nursing intervention:
Pre-Op:
 Replace fluids and electrolytes
 Prevent vomiting
 Give thickened feedings
 High Fowler’s
 Place on right side after feeding
 Minimize handling
 Strict I and O monitoring, daily weights, urine sp gravity
Post Op
 Advance diet as tolerated
 Place on right side after feeding
 Observe incision for signs of infection
 Provide client teaching and discharge planning

(d) INTUSSUSCEPTION
 telescoping of bowel into itself
 ileocecal region
 edema, necrosis of bowel, obstruction
 most common at age 6 months
 more in boys than in girls
 associated with cystic fibrosis
Assessment:
 piercing cry
 sausage shape mass in the abdomen upon palpation - BQ
 severe abdominal pain (pulls leg up)
 vomiting of bile stained fluid
 bloody mucus in stool
 “currant jelly” stool - BQ
Management:
 barium enema
 surgery

(e) HIRSCHSPRUNG’S DISEASE

 absence of autonomic parasympathetic ganglion cells in large intestines
 results in decreased motility in that portion of the colon and signs of functional obstruction
Assessment:
 failure or delay in passing meconium
 abdominal distension
 failure to pass stool
 temporary relief following rectal exam
 loose stools – only liquid can pass thru
 ribbon like stools - BQ
 nausea, anorexia, fecal vomiting
 weight loss, failure to grow
 volvulus – bowel twists upon itself
  diagnostic tests: rectal biopsy – confirms presence of aganglionic cells

Nursing intervention:
 Enema as ordered
 Mineral oil or isotonic saline
 Do not use water or soap suds – water intoxication
 Use volume appropriate to weight of child
o infants – 150-200ml
o children – 250-500 ml
 Administer TPN as ordered
 Provide low residue diet
 provide client teaching and discharge teaching
 Colostomy care

(f) IMPERFORATE ANUS

 During embryonic life – membrane that separates the rectum and anus is absorbed
 Absorption fails to occur -> imperforate anus
 Anus appear as a dimple
 Fistula may be present – rectovaginal, rectourethral
Assessment:
 inspection of anus, check rectum for patency
 insert rectal thermometer
 absence of stool during 1st 24 hours
 development of a distended abdomen
Medical Intervention:
 surgery
 anoplasty – if possible
 temporary colostomy
 if with distension – nasogastric suction

Nursing intervention:
 keep operative site clean
 observe infant for signs of hypovolemic shock and infection
 if anoplasty heals – regular dilatation of anus to prevent stricture
 after surgery – side lying or prone with hips elevated

(g) CELIAC DISEASE

 malabsorption syndrome characterized by intolerance of gluten,
 found in rye, oats, wheat and barley
 familial disease
 more common in Caucasians
 cause unknown
 flat mucosal surface and atrophy of villi of the intestine
 reduced absorptive surface -> marked malabsorption of fats

Assessment:
 chronic diarrhea
 failure to thrive
 Steatorrhea
 Distended abdomen
  Abdominal pain, irritability, listlessness, vomiting
 Symptoms of ADEK deficiency
 Diagnostic tests:
 pancreatic enzymes
 jejunal or duodenal biopsies
Management:
 diet therapy
 gluten free diet
 TPN in children
Nursing Intervention:
 gluten free diet (BROW – Barley, Rye, Oatmeal, Wheat)
 supplemental fat soluble vitamins
 client teaching
 gluten free diet
 importance of reading the label
 avoidance of infection
 adhering to diet even if symptoms are controlled
 importance of long term follow up

(h) APPENDICITIS
 Inflammation of the appendix
 Ischemia, gangrene, rupture, peritonitis – if untreated
 School age children – most common surgical procedure -BQ
 Due to mechanical obstruction or anatomic defects
Assessment:
 diffuse pain RLQ
 nausea, vomiting
 guarding of abdomen
 rebound tenderness
 decreased bowel sounds
 fever
 diagnostic tests:
 Complete blood count (CBC) reveals increase WBC
 elevated acetone in urine
Nursing Intervention:
 antibiotics/ antipyretics as ordered
 no enemas may cause rupture
 no heating pads
 routine preop care
 Post op care:
 semi-Fowler’s position
 Monitor NGT
 Monitor penrose drains
(i) PARASITISM
 roundworms, pinworms
Assessment:
 pinworms – anal itching, disturbed sleep
 roundworms – colic , abdominal pain, lack of appetite, weight loss
 Nursing intervention:
 obtain stool culture
 observe all excreta for worms
 Scotch tape swab
 Instruct parents to change clothing, bed linens, towels and launder in hot water
 Instruct all family members to scrub hands and fingernails prior to eating and after using toilet

F. INTEGUMENTARY DISORDERS
(a) ECZEMA
 atopic dermatitis - often the first sign of an allergic
predisposition in a child
 usually manifests during infancy
Asssessment:
 erythema, weeping vesicles that rupture and crusts
 severe pruritus; scratching causes thickening and
darkening
 dry skin, sometimes urticaria
Medical Intervention:
 topical steroids
 Antihistamines
 coal tar preparation
 colloid baths
 diet therapy: elimination of offending food
Nursing Intervention:
 avoid heat and prevent sweating
 check materials in contact with child’s skin (sheets, lotions, soap
 avoid frequent baths
 avoid use of soap
 provide lubricant immediately after bath
 administer topical steroids as ordered
 use cotton instead of wool
 keep child’s nails short; use elbow or glove restraints if needed
 apply wet saline or Burrow’s solution compresses

(b) DIAPER RASH

 contact dermatitis
 plastic/rubber pants and linings of disposable diapers
  exacerbate the condition by prolonging contact with moist, warm environment
 skin further irritated by acidic urine
Assessment:
 Erythema /excoriation in the perineal area
 irritability
Nursing intervention:
 keep area clean and dry; clean with mild soap and water after each stool and soon as child
urinates
 take off diaper and expose area to air during the day
 client teaching:
 Proper hygiene
 Avoid use of plastic pants or disposable diapers with a plastic lining
 Avoid commercially prepared diaper wipes containing alcohols
 Avoid cornstarch; good medium for bacteria

G. MUSCULOSKELETAL DISORDERS
CARE OF THE CHILD WITH A CAST
 if cast is of plaster – will remain wet for at least 24 hrs
 use only the flats of their hands to move children
 casts must remain open to the air until dry
 casted extremities are elevated to help blood return and reduce swelling
 Initial chemical hardening reaction may cause a change in an infant’s body
 Choose toys too big to fit down cast
 Do not use baby powder near cast – medium for bacteria
 Prepare for anticipated casting by having child help apply cast in a doll

Diagnoses and interventions:

 Potential for alteration in tissue perfusion related to constriction
of cast
 Check color, sensation and motion distal to the cast every half hour
 Check pedal or radial pulse
 Check for tightness by slipping finger under edge; if impossible – cast is too tight
 Ask child to move toes or fingers
 Elevate casted extremity
 Potential for alteration in skin integrity
 Remove plaster flakes from skin
 Handle wet cast carefully so as not to cause indentations
 Expose wet cast to air to hasten drying
 Support heavy cast with sling or pillow to decrease pressure of cast edges
 Check cast for foul or musty odors
 Potential for fear and loneliness
 Encourage expression of feelings
 Provide diversional play
 Encourage friends and family to visit children as often
 Provide educational opportunity for
  children confined for long periods
 Potential for knowledge deficit of family
 Encourage discussion of feelings and fears
 Provide information and reassurance as appropriate
 Involve family in child’s care in hospital
 Prepare family for some emotional regression

(a)CONGENITAL HIP DISLOCATION

 displacement of the head of the femur from the acetabulum
 present at birth although not always diagnosed
 familial disorder
 unknown cause; may be fetal position in utero
 acetabulum is shallow and the head of femur is cartilaginous at birth
Assessment:
 maybe unilateral or bilateral
 limitation of abduction (cannot spread legs to change diaper
 Ortolani’s click
 With an infant supine, bend knees and place thumb on bent knees, fingers at hip joint
 Bring femur 90 degrees to hip, then abduct
 Audible click – dislocation
 Galeazzi’s test
 With infant on back, bend knees
 Affected knee will be lower because the head of the femur
 Dislocates towards the bed of gravity
 additional skin folds with knees bent
 when lying on abdomen, buttocks of affected side will be flatte
 Trendelenburg test – if child can walk
 Have child stand on affected leg only
 Pelvis will dip on normal side as child attempts to stay erect
Management:
 Goal : to enlarge and deepen the socket
 Early treatment: positioning the hip in abduction with the head of the femur in the
acetabulum and maintaining it in position for several months
 Traction and casting (hip spica)
 Surgery
Nursing intervention:
 Maintain proper positioning: keep legs abducted
 Use triple diapering
 Use Frejka pillow splint (jumperlike suit to keep legs abducted)
 Place infant on abdomen with legs in “frog” position
 Use immobilization devices
 Provide adequate nutrition
 Provide sensory stimulation
 Client teaching and discharge planning:

(b) CLUBFOOT (Talipes)

 abnormal rotation of foot at ankle
Varus – inward rotation; bottom of feet face each other
Valgus – outward rotation
Calcaneous – upward rotation; would walk on heels
Equinas – downward rotation; would walk on toes
 * NOTE: Most common – talipes equinovarus
Assessment:
 foot cannot be manipulated by passive exercises into correct position
Management:
 Exercises
 Casting
 Denis Browne splint (bar shoe)
 surgery and casting

Nursing Intervention:
 perform exercises as ordered
 provide cast care
 child who is learning to walk must be prevented from trying to stand; apply restraints if
necessary
 provide diversional activities
 provide skin care
 client teaching

(c) SCOLIOSIS
 lateral curvature of the spine
 most commonly in adolescent girls
 familial pattern; associated with other nueromuscular condition
 idiopathic majority
Assessment:
 failure of curve to straighten when child bends forward with knees straight and arms hanging
down feet
 uneven bra strap marks
 uneven hips
 uneven shoulders
 asymmetry of rib cage
 xray: reveals curvature

Management:
 stretching exercises
 Milwaukee brace – worn 23 hours/day for 3 years
 plaster jacket vest
 spinal fusion

Nursing Intervention:
 teach/encourage exercise
 provide care for the child with Milwaukee brace
 Child wears brace 23 hours/day
 Monitor pressure points
 Promote positive body image with brace
 Provide cast care
 Assist with modifying clothing for immobilization devices
 Adjust diet with decreased activity
 Provide client teaching and discharge instructions
o Exercise
o Cast care
  Correct body mechanics
 Alternative education for long term hospitalization
 Availability of community agencies

(d) JUVENILE RHEUMATOID ARTHRITIS

 systemic, chronic disorder of connective tissue
 autoimmune reaction
 results from eventual joint destruction
 affected by stress, climate and genetics
Types:
A. Monoarticular JRA
 Fewer than 4 joints involved (usually legs)
 Asymmetric
 Good prognosis
 Mild signs of arthritis
B. Polyarticular JRA
 Multiple joints affected
 Symmetrical
 Involvement of TMJ
 Remissions and exacerbations
 poor prognosis
C. Systemic disease with polyarthritis (Still’s disease)
 Fever, rash, Lymphadenopathy, anorexia, weight loss
 xacerbations and remissions
Assessment:
 No specific diagnostic tests
 Erythrocyte Sedimentatio Rate (ESR), Anti Streptolysin O , (ASO), Rheumatoid Factor
(RF) - not specific
Intervention
 Drugs: ASA, corticosteroids
 NSAIDS
 Physical therapy – strengthening muscles, preventing deformities
 Splints – used for knees, wrists and hands to reduce pain and prevent or reduce flexion
deformities
Nursing intervention:
 Assess joints for pain, swelling, tenderness
 Promote maintenance of joint mobility
 ROM exercises
 Isometric exercises
 change position frequently; alternate sitting, standing, lying
 promote comfort and relief
 provide firm mattress
 maintain proper body alignment
 keep joints mainly in extension, not flexion
 cold treatments: in acute episodes
 focus on child’s strength

H. GENITO-URINARY DISORDERS

(a) UNDESCENDED TESTES (Cryptorchidism)

 Unilateral or bilateral absence of testes in scrotal sac
  Testes normally descend at 8 months of gestation
 Increased incidence in those with genetic disorder
 75% will descend spontaneously by age 1 year
Assessment:
 unable to palpate testes in scrotal sac
Management:
 if testes remains in abdomen, damage to testes is possible because of increased
Medical Management:
 if testes remains in abdomen, damage to testes is possible because of increased chorionic
gonadotropin
 “Orchipexy”: surgical procedure to retrieve and secure testes placement; performed between
ages 1-3 yrs
Nursing Management:
 Provide treatment options
 Support parents if surgery will be done
 Post op: avoid disturbing the tension mechanism
 Avoid contamination of incision

(b) HYPOSPADIAS
 urethral opening located anywhere along the ventral surface of penis
Assessment:
 Urinary meatus misplaced
 Inability to make straight stream of urine
Management:
 minimal defects – no intervention
 neonatal circumcision delayed, tissue maybe needed for corrective repair
 surgery at age 3-9 months
Nursing Intervention:
 diaper normally
 provide support for parents
 post op: check pressure dressing
 monitor catheter drainage

(c) PHIMOSIS
 an abnormal narrowing of the foreskin so that it cannot be retracted over the glans penis
 may be present at birth or may develop as a result of poor hygiene with accumulation of smegma
Management:
 Prevention – regular pulling the foreskin back and cleaning
 Circumcision
Nursing intervention:
 circumcision care
 Close observation for bleeding
 Ice application
 Administration of analgesics

(d) ENURESIS
 involuntary passage of urine after the age of control is expected (4 years)
Types:
A. Primary :in children who have never achieved control
B. Secondary: in children who have developed complete control
  May occur anytime but most frequent at night
 More common in boys
 No organic cause
Etiologic possibilities:
 Sleep disturbances
 Delayed neurologic development
 Immature development of bladder
 Psychologic problems
Assessment:
 PE normal
 History of repeated voluntary urination management:
 bladder retention exercises
 Drug therapy
 TCA – imipramine
 Anticholinergics

Nursing Intervention:
 Provide information/counseling to family:
 Confirm that this not conscious behavior and that the child is not purposely misbehaving
 Assure parents that they are not responsible and that this is a relatively common problem
 Involve child in care; give praises and support with small accomplishments
 Age 5-6 years – can strip wet beddings
 Age 10-12 years – can do laundry and change bed
 Avoid scolding and belittling the child

(e) EXSTROPHY OF THE BLADDER

 congenital malformation ; nonfusion of abdominal and anterior walls of the bladder during
embryologic development
 anterior surface of bladder lie open on abdominal wall

Assessment:
 Associated structural changes
 Prolapsed rectum
 Inguinal hernia
 Widely split symphysis
 Rotated hips
 Associated anomalies
 Epispadias
 Cleft scrotum or clitoris
 Undescended testes
 Chordee (downward deflection of the penis)
Management:
 reconstructive surgery
 urinary diversion
 delayed until 3-6 months
Nursing intervention: Preop:
 Provide bladder care; prevent infection
 Keep area as clean as possible
  Change diaper frequently; keep loose fitting
 Wash with mild soap and water
 Cover exposed bladder with vaseline gauze
Postop:
 Design play activities to foster toddler’s need for autonomy
 child will be immobilized for extended period of time
 Prevent trauma; as child gets older and more mobile, trauma is more likely

(f) NEPHROTIC SYNDROME

 autoimmune process
 structural alteration of glomerular membrane
 results in increased permeability to plasma proteins
 course: exacerbations and remissions over a period of months to years commonly affects
preschoolers; boys >girls

Assessment:
 Proteinuria
 Hypoproteinemia
 Hyperlipidemia
 Dependent edema
 Puffiness around the eyes in morning
 Ascites
 Scrotal edema
 Ankle edema
 anorexia, vomiting, diarrhea
 Pallor, lethargy
 Hepatomegaly

Management:
 Drug therapy
 Corticosteroids
 Antibiotics
*diuretics are not given because it can lead to hypotension

Nursing Intervention:
 Provide bed rest to conserve energy
 Find activities for quiet play
 Provide high protein, low sodium diet – during edema phase
 Maintain skin integrity
 Avoid IM injections – meds not absorbed in edematous tissues
 Obtain morning urine for protein studies
 Provide scrotal support
 Monitor I and O, vital signs
 Weigh daily
  Administer medications as ordered
 Protect from sources of infection

(g) ACUTE GLOMERULONEPHRITIS

 immune complex disease 2-3 weeks post streptococcal infection (GAHBS)
 Occurs more frequently in boys; 6-7 years
 self limiting : usually resolves in 14 days

Assessment:
 History of strep infection (URTI or impetigo)
 Edema, anorexia, lethargy
 Hematuria or dark colored urine
 Fever
 Hypertension
 Diagnostic tests:
 Urinalysis – RBC, WBC, protein, cellular casts
 Urine specific gravity increased
 BUN, creatinine increased
 ESR elevated
 Hgb, Hct decreased
Management:
 Antibiotics for prophylaxis
 Antihypertensives
 Digitalis – if with CHF
 Fluid restriction
 Peritoneal dialysis – if severe renal complication occurs
Nursing Management:
 Monitor I and O, BP
 Weigh daily
 Provide diversional activity
 Provide client teaching and discharge planning
 Medication administration
 Prevention of infection
 Signs of renal complications
 Importance of long term follow up

(h) WILM’S TUMOR (NEPHROBLASTOMA)

 large, encapsulated tumor that develops in the renal parenchyma
 more frequently in left kidney
 originates during fetal life
  peak age : 1-3 years
Assessment:
 non tender mass, usually midline near liver
 Hypertension
 Hematuria
 Test: Intravenous Pyelogram (IVP)
Management:
 Surgery
 NO PALPATION of the abdomen

J. NEURO-SENSORY DISORDERS
CRANIAL DEFECTS:

(a) CRANIOSYNOSTOSIS
 one or more of the sutures close too soon
 ICP increases; interferes with normal brain growth that may lead to mental retardation
Assessment:
 Suture lines of the skull manually palpated
 Radiographs are made to confirm
(b) MICROCEPHALY
 The brain fails to grow
 May be due to a chromosomal defect or from drugs, toxins or radiation
 Mental Retardation (MR)
(c) HYDROCEPHALUS
 Imbalance of CSF absorption or production
 Caused by malformations, tumors, hemorrhage, infection, trauma

Types:
Communicating – impaired absorption within subarachnoid space
Non-communicating – obstruction of CSF flow within theventricular system

Assessment:
 Infant – increased head circumference
 Macewen’s sign – cracked-pot sound on percussion of bones of head
 Anterior fontanel tense, bulging
 Scalp veins dilated
 Frontal bossing, sunsetting eyes
 Child – behavior changes
 Headache, nausea and vomiting
 Ataxia, nystagmus

Surgical Implementation:
Goal: to prevent further CSF accumulation by bypassing the blockage and draining the fluid from
the ventricles to a location where it may be reabsorbed
VP Shunt – CSF drains into the peritoneal cavity from the lateral ventricle
AV Shunt – CSF drains into the right atrium

PostOP Care:
  Keep child flat as prescribed – to avoid rapid reduction of intracranial fluid
 Observe increase ICP – if present, elevate head of the bed no more than 30-45
 Monitor for infection
 Measure head circumference
 Monitor I and O
 Provide comfort measures; administer medications (diuretics, antibiotics, or
anticonvulsants)
 Toddler – headache and anorexia is the earliest common signs of shunt malfunction

(c) SPINA BIFIDA

 CNS defect that occurs as a result of neural tube failure to close during embryonic development
 Defect closure usually done during infancy
Types:
1. Spina Bifida Occulta
 Posterior vertebral arches fail to close in the lumbosacral area
 Spinal cord intact; not visible
 Meninges not exposed on the skin surfaces
2. Spina Bifida Cystica
A. Meningocele
 Protrusion involves meninges and a sac-like cyst
 Lumbosacral area
B. Myelomeningocoele
 Protrusion of meninges, CSF, nerve roots, portion
of spinal cord
 Sac covered by a thin membrane and may rupture or
leak
 Neuro deficit evident
Assessment:
 Depends on spinal cord involvement
 Visible spinal defect
 Flaccid paralysis of legs
 Bladder and bowel incontinence

Implementation:
 Evaluate sac; measure lesion
 Neuro check frequently
 Monitor for increase ICP
 Measure head circumference; assess fontanels (if
still open)
 Protect the sac
 Cover with sterile, moist (normal saline) non-adherent dressing
 Change dressing every 2-4 hours or as needed
 Place prone position
 Head is turned to one side for feeding
 Diapering may be C/I until defect repaired
 Always obsrve aseptic technique when providing care
  Watch for early signs of infection
 Administer antibiotics as prescribed
 Administer anticholinergics – improve urinary continence
 Administer laxatives and antispasmodics as prescribed

(e) MENINGITIS
 infectious process of the CNS caused by bacteria and viruses
 acquired as a primary or as a result of complications
 diagnosis – CSF analysis (increase pressure, cloudy CSF, high protein, low glucose)
 bacterial or viral
Assessment:
 signs and symptoms vary depending of age group
 fever, chills
 vomiting, diarrhea
 poor feeding or anorexia
 altered LOC
 bulging anterior fontanel
 nuchal rigidity

Implementation:
 RESPIRATORY ISOLATION; maintain for at least 24 hours after antibiotics are initiated
 administer antibiotics as prescribed
 monitor VS and neuro status
 Monitor I and O
 assess nutritional status
 determine close contacts of the child with meningitis

(f) SEIZURE DISORDERS

 Sudden transient alterations in brain function resulting from excessive levels of electrical activity in
the brain
Assessment:
 obtain information from parents about the time of onset,
 precipitating events and behavior before and after the seizure
Implementation:
- seizure precautions:
 Raise side rails
 Pad side rails
 Place waterproof mattress on bed
 Instruct child to swim with companion
 Alert caregivers to the need for special precautions
Emergency Treatment for Seizures:
 Ensure patency of airways
 If the child is standing or sitting, ease the child down to the floor
 place pillow or folded blanket under the child’s head
 loosen restrictive clothing
 clear area of any hazards
 if vomiting occurs, turn child to one side
 do not restrain child; do not place anything in the child’s mouth
 Remain with the child until fully recovers
  Prepare to administer medications

(g) CEREBRAL PALSY

 disorder characterized by impaired movement and posture resulting from an abnormality in the
extrapyramidal motor system
 spastic type- most common

Assessment:
 extreme irritability and crying
 feeding difficulties
 stiff and rigid arms and legs
 delayed gross development
 abnormal motor performance
 alterations of muscle tone
 abnormal posturing
 persistence of primitive reflexes

Implementation:
 early recognition
 PT, OT, speech therapy, education and recreation
 assess the child’s developmental level and intelligence
 early intervention
 encourage communication and interaction with the child on a functional level
 provide safe environment
 position upright after meals
 provide safe, appropriate toys for age and developmental level