Ncma 219 Finals Complete

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Alterations with Infectious, Inflammatory and Immunologic Responses
JUVENILE IDIOPATHIC ARTHRITIS

- Juvenile idiopathic arthritis (JIA) refers to chronic childhood arthritis. A group of heterogeneous
chronic autoimmune diseases
- causes inflammation in the synovium, joints, and surrounding tissue.
- cause of JIA is unknown
- JIA starts before age 16 years with two peak onsets: between 1 and 3 and between 8 and 10 years of
age
- There is a female predominance of 2 :1.
Pathophysiology
- chronic synovial inflammation causing joint effusion and eventual erosion, destruction, and fibrosis
of the articular cartilage. Adhesions between joint surfaces and ankylosis of joints occur if the
process persists.
Clinical Manifestations
- stiffness, swelling, and loss of motion

- affected joints may be warm and tender to touch
Classification
- systemic arthritis -rheumatoid factor (RF)–negative polyarthritis - enthesitis-related arthritis

- oligoarthritis - RF-positive arthritis, psoriatic arthritis - undifferentiated arthritis
Course and Prognosis
- outcome of JIA is variable and unpredictable

- JIA is rarely life threatening
Diagnostic Evaluation
- there are no definitive tests.

- Criteria for Jia
o onset before 16 years and arthritis in one or more joints for 6 weeks or longer
o exclusion of other causes
- Laboratory test
o elevated sedimentation rate or C-reactive protein may or may not be present
o Leukocytosis is frequently present
- Tests for RF give positive results in only 10% of the children with JIA
- presence of antinuclear antibodies
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Therapeutic Management
• There is no cure for JIA.

• major goals of therapy are to control pain, preserve joint range of motion and function, minimize
the effects of inflammation, Achievement of these goals requires a family-centered approach with
collaboration among the child, family, and health care team.
Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs
- ibuprofen, naproxen, tolmetin, diclofenac, indomethacin, and meloxicam.

- NSAIDs offer an immediate analgesic effect, but the anti-inflammatory effect requires larger doses
and more time to achieve
- Patient and family education regarding potential gastrointestinal, renal, and hepatic side effects and
reduced clotting is essential
disease modifying antirheumatic drugs (DMARDs)
- methotrexate and sulfasalazine

- Methotrexate is effective, however, and the potential benefits outweigh the potential risks.
Methotrexate therapy has also improved uveitis in children with uveitis resistant to steroid
treatment
- decision to use DMARD at initiation of therapy or later in the escalation of therapy is guided by the
amount of disease activity and poor prognostic features
Glucocorticoids
- potent anti-inflammatory agents; however, systemic steroids will not cure arthritis, and the
significant adverse effects of long-term steroid use are undesirable.
- administered when there is high disease activity or poor prognostic features
- Prednisone is given orally in a burst and taper or at the lowest effective dosage. Use of an alternate-
day schedule may help reduce side effects.
Physical Management
- Physical therapy is directed toward specific joints and focuses on strengthening muscles, mobilizing
restricted joints, and preventing or correcting deformities
- the child should not be restricted from regular play, dance, exercise programs, and even individual
and team sports
- Exercising in a pool is excellent because it allows freedom of movement with support
- Range-of-motion exercises are an important aspect of therapy
Surgery
- synovectomy, an established therapeutic procedure in adults only, and are questionable in children
with arthritis
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NURSING CARE MANAGEMENT
- involves assessment of their general health, the status of involved joints, and their emotional
responses to all of the ramifications of the disease
- Relieve Pain
- Promote General Strength
o Diet and Exercise- there is no “arthritis diet” or foods to avoid that are specifically associated
with arthritis but the weight should be maintained in ideal because Excessive weight causes
additional strain on inflamed joints.
- Encourage School Attendance
- Facilitate Compliance
- Encourage Comfort Measures and Activities of Daily Living
ALLERGIC RHINITIS
- associated with numerous airway disorders, including asthma, OME, and chronic sinusitis
- Seasonal allergic rhinitis (also known as hay fever) usually follows a spring-fall pattern and is caused
by tree, grass, and weed pollens
- Year-round or perennial allergic rhinitis is more common and is triggered by household inhaled
allergens such as feathers, household dust, animal dander, air pollutants, and molds.
- Allergic rhinitis requires two conditions:
o familial predisposition to develop allergy and exposure of a sensitized person to the allergen
o Inhalants in the form of microscopic airborne particles (e.g., pollens, mold, animal danders, and
environmental dusts
PATHOPHYSIOLOGY
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- Children who have allergic rhinitis have a history of watery rhinorrhea, nasal obstruction, sneezing,
itchy throat, or nasal pruritus
- Other symptoms include snoring during sleep, fatigue, malaise, headache, and poor school
performance
- allergic shiners- dark circles beneath their eyes
- allergic gape- mouth breather
- a thorough history and physical examination

- Diagnostic tests
o nasal smear- to determine the number of eosinophils in the nasal secretion
o blood examination- for total IgE and elevated eosinophils
o skin tests- useful adjunct in establishing a definitive diagnosis for allergic rhinitis
o various challenge tests.
- directed toward avoidance of offending allergens and the use of medication and immunotherapy
- Avoidance measures involve removing allergens from the environment and are usually effective for
allergies to foods, drugs, and animals
Medications
Nasal corticosteroids
- first-line drugs used for allergic rhinitis if significant nasal symptoms are present
Other medications
- antihistamines, α-adrenergic decongestants, mast cell stabilizers, leukotriene modifiers and

ipratropium
Nursing Care Management
- An important aspect in nursing care is to counsel the parents and patient about the causes of the
condition, or triggers, and assist in the implementation of steps to avoid the triggers.
- Environmental modification
- preparation for skin tests and immunotherapy injections
- provide specific and detailed information relating to their medications.
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ATOPIC DERMATITIS (ECZEMA)

- Eczema or eczematous inflammation of the skin
- AD is a type of pruritic eczema that usually begins during infancy and is associated with an allergic
contact dermatitis with a hereditary tendency (atopy)
- AD manifests in three forms based on the child’s age and the distribution of lesions:
o Infantile (infantile eczema)—Usually begins at 2 to 6 months of age; generally undergoes
spontaneous remission by 3 years of age
o Childhood—May follow the infantile form; occurs at 2 to 3 years of age; 90% of children have
manifestations by age 5 years
o Preadolescent and adolescent—Begins at about 12 years of age; may continue into the early
adult years or indefinitely CLINICAL MANIFESTATIONS
- major goals of management are to hydrate the skin, relieve
pruritus, prevent and minimize flare-ups or inflammation, and
prevent and control secondary infection.
- Management strategies include
o avoiding exposure to skin irritants or allergens;
o avoiding overheating;
o administrating medications such as antihistamines,
topical immunomodulators and topical steroids, and
(sometimes) mild sedatives, as indicated
- tepid bath with a mild soap (Dove or Neutrogena), no soap, or
an emulsifying oil
o immediately by application of an emollient (within 3
minutes) assists in trapping moisture and preventing its
loss (WHILE THE SKIN IS STILL SLIGHTLY MOIST)
o Bubble baths and harsh soaps should be avoided.
o need to be repeated once or twice daily
o excessive bathing without emollient application only
dries out the skin

- Assessment of the child with AD includes a family history for
evidence of atopy, a history of previous involvement, and any
environmental or dietary factors associated with the present and
previous exacerbations.
- prevent or minimize the scratching- Fingernails and toenails are
cut short, kept clean, and filed frequently to prevent sharp edges.
Gloves or cotton stockings can be placed over the hands and
pinned to shirtsleeves.
- Conditions that increase itching are eliminated when possible.
Woolen clothes or blankets, rough fabrics, and furry stuffed
animals
- Assure parents
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Asthma
- Asthma is a chronic inflammatory disorder of the airways characterized by recurring symptoms,
airway obstruction, and bronchial hyperresponsiveness
- inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough,
especially at night or in the early morning
- most common chronic disease of childhood
ETIOLOGY
- complex disorder involving biochemical, genetic, immunologic, environmental, infectious,

endocrine, and psychologic factors
- Risk factors for asthma include:
o Atopy (includes a history of allergies or atopic dermatitis)
o Heredity (e.g., parent/sibling with asthma)
o Boys > girls
o Smoking or exposure to secondhand smoke
o Maternal smoking during pregnancy
o Ethnicity (African-Americans at greatest risk)
o Low birth weight
o Being overweight
Pathophysiology
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- classic manifestations
o dyspnea, wheezing, and coughing.
- older children
o chest tightness and an intermittent generalized chest pain
- common symptom of asthma is coughing
- Younger children have a tendency to assume the tripod sitting position
- older children have a tendency to sit upright with shoulders hunched over, hands on the bed or
chair and arms braced to facilitate the use of accessory muscles of respiration
- Infants may display supraclavicular, intercostal, suprasternal, subcostal, and sternal retractions
- Examination of the chest reveals hyperresonance on percussion.
- Breath sounds are coarse and loud, with sonorous crackles throughout the lung fields
diagnostic evaluation
- determined primarily on the basis of clinical manifestations, history, physical examination, and to a
lesser extent laboratory test
- Pulmonary function tests (PFTs)
o provide an objective method of evaluating the presence and degree of lung disease and the
response to therapy
o after treatment is initiated and symptoms have stabilized, and at least every 1 to 2 years to
assess the maintenance of airway function.
- peak expiratory flow rate (PEFR)
o maximum flow of air that can be forcefully exhaled in 1 second and is measured in liters per
minute.
o Each child needs to establish his or her own personal best value during a 2- to 3-week period
when the child’s asthma is stable
o used for short-term monitoring, managing exacerbations, and daily long-term monitoring
- Skin testing is useful in identifying specific allergens
- laboratory tests
o complete blood count with differential
o chest radiographs
Therapeutic Management: General
- overall goals of asthma management are to maintain normal activity levels, maintain normal
pulmonary function, prevent chronic symptoms and recurrent exacerbations, provide optimal drug
therapy with minimal or no adverse effects
Allergen Control
- Nonpharmacologic therapy is aimed at the prevention and reduction of exposure to airborne

allergens and irritants
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Drug Therapy
- categorized into two general classes:

o long-term control medications (preventive medications) to achieve and maintain control of
inflammation
o quick-relief medications (rescue medications) to treat symptoms and exacerbations
- long-term control medications
o Inhaled corticosteroid
o cromolyn sodium
o nedocromil
o long-acting β2-agonists
o methylxanthines
o leukotriene modifiers
- quick-relief (or rescue)
o Short-acting β2-agonist
o Anticholinergics
o systemic corticosteroids
Breathing Exercises and Physical Training
- help produce physical and mental relaxation, improve posture, strengthen respiratory musculature,
and develop more efficient patterns of breathing
Therapeutic Management: Specific
- home management of acute asthma begins before symptoms develop. All patients and family
members should learn how to monitor symptoms to recognize early signs of deterioration
- learn how to monitor their peak flow rate to assess the severity of the exacerbation and the
response to therapy
- Acute Asthma Care

- General Care
- Avoid Allergens
- Relieve Bronchospasm
- Maintain Health and Prevent Complications
- Promote Self-Care and Normalization
- Child and Family Support
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Basic Concepts on Oncology
Leukemia
- Leukemia is a broad term given to a group of malignant diseases of the bone marrow and lymphatic
system
- two forms are generally recognized
o acute lymphoblastic leukemia (ALL)
o acute myelogenous leukemia (AML)
Pathologic and Related Clinical Manifestations
- history, physical manifestations

- peripheral blood smear- contains immature forms of leukocyte frequently in combination with low
blood counts
- bone marrow aspiration or biopsy- Definitive diagnosis
- lumbar puncture- for CNS involvement
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acute lymphoblastic leukemia DIAGNOSTIC EVALUATION

- most common form of childhood cancer - Physical examination
- affect boy > girls - Peripheral blood smear- presence of leukemic blast cells
- Caucasian > African American and low blood counts
- Peak onset 2-5 y/o - Bone marrow aspiration- show monotonous infiltrate of
RISK FACTORS blast cells
- Lumbar puncture- to check for cns involvement
- Prenatal exposure to x-rays
- Previous chemotherapy
- Genetic conditions
Clinical manifestations
- Infiltrations of the bone marrow by non-functional leukemic cells (blast)

o Anemia- due to decreased erythrocytes
o Infections- due to neutropenia
o Bleeding- due to decreased platelets
- Elevated WBC count > 10,000/ mm3
- Hepatomegaly, splenomegaly
- Lymphadenopathy
- Bone pain
- CNS and testes- important sites for extramedullary disease- “sanctuaries” for leukemic cells
THERAPEUTIC MANAGEMENT
- involves the use of IV and intrathecal chemotherapeutic agents.
INDUCTION
- vincristine, doxorubicin, prednisone (dexamethasone)

- t-cell= cytarabine
- b-cell= cytarabine + methotrexate
- CNS prophylaxis -adults intrathecally
Post-remission
- Consolidation- increased drug doses used in induction (1- 2mos) HSCT suggested
- Maintenance- decreased doses (2-3yrs) w/ methotrexate and 6-mp (6- mercaptopurine); CNS
prophylaxis continued
REFRACTORY
- Newer or more intensive doses of chemo drugs may be tried

- HSCT- HEEMATOPEOIETIC STEM CELL TRANSPLANTATION
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Relapse
- Brain or spinal fluid

- Nelarabine for t-cell
- MoABS (monoclonal antibody) for b-cell and chimeric antigen receptor (CAR) T-cell therapy
(Kymriah)
- HSCT
ACUTE MYLELOUD LEUKEMIA
- Accounts for 20% of childhood leukemias

- Equal in males and females
Risk factors
- Constitutional chromosomal abnormalities

- Inherited gene mutations and cytopenia’s
- Therapy-related AML- chemotherapy/radiation
- Same with ALL due to infiltrations of bone marrow by myeloblast

o Fever with or without infection
o Night sweats- shortness of breath
o Weakness/fatigue - involves the use of IV and intrathecal chemotherapeutic agents
o Brushing/petechiae
o Bone/joint paint inductions
o Painless lumps - pediatrics
o Leukemia cutis- bluish or purplish o 7+3 regimen (BMA on the 14th day)
o Chloromas- blue- green in color ▪ 7+3= cytarabine continuously for 7 days along with
DIAGNOSTIC EVALUATION short infusions of an anthracycline on each of the
first 3 days
- Physical examination o Fludarabine or etoposide (for patients with poor cardiac
- Peripheral blood smear functions)
- Bone marrow aspirations - Adults- aggressive & short-course (6mos)
- Lumbar puncture o Ara-c (cytarabine)
- RT-PCR- detect multiplying cells in body
- + CHLOROMAS- BIOPY Post-remission
- Consolidation- HiDAC- high dose ara-c (for younger patients)

daunorubicin, etoposide, mitoxantrone for older; HSCT
NURSING MANAGEMENT
- Prepare the Family for Diagnostic and Therapeutic Procedures

- Provide Continued Emotional Support
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LYMPHOMAS
- The lymphomas, a group of neoplastic diseases that arise from the lymphoid and hematopoietic
systems
- divided into Hodgkin disease and NHL. subdivided according to tissue type and extent of disease
(staging).
- NHL is more common than Hodgkin disease
- striking increase in children ages 15 to 19 year
HODKIN LYMPOMA NON-HODGKIN LYMPOMA

More often localized to a single axial group of More frequent involvement of multiple
nodes (cervical, mediastinal, para-aortic) peripheral nodes
Orderly spread by contiguity Noncontiguous spread
Mesenteric nodes and waldeyer ring rarely Mesenteric nodes and waldeyer ring commonly
involved involved
Extranodal involvement uncommon Extranodal involvement common
RISK FACTORS
- FAMILY HISTORY
- INFECTIONS
- AUTOIMMINE DISORDERS
- CHEMICAL
- DIET
- SMOKING
HODGKIN DISEASE
- malignancy originates in the lymphoid system and primarily involves the lymph nodes.
- predictably metastasizes to nonnodal or extra lymphatic sites, especially the spleen, liver, bone
marrow, lungs, and mediastinum (i.e., mass of tissues and organs separating the lungs, including the
heart and its vessels, trachea, esophagus, thymus, and lymph nodes), although no tissue is exempt
from involvement
- classified according to four histologic types:
o lymphocytic predominance
o nodular sclerosis
o mixed cellularity
o lymphocytic depletion
Clinical Staging
- Each stage is further subdivided into A, B, E, or S

- Stage A denotes absence of associated general symptoms
- Stage B indicates presence of symptoms, such as night sweats, fever (100.4°F [38°C]), or weight loss
of 10% or more during the preceding 6 months
- Stage E represents extra lymphatic disease beyond the contiguous nodal disease.
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- Stage S is used when the disease involves the spleen. Subtype B has a significantly poorer prognosis
than others
- painless enlargement of lymph nodes

- enlarged, firm, nontender, movable nodes in the supraclavicular or cervical area- most common
finding
- Other signs and symptoms
o persistent, nonproductive cough- caused by Mediastinal lymphadenopathy
o unexplained abdominal pain- Enlarged retroperitoneal nodes
- Systemic symptoms
o low-grade or intermittent fever (Pel-Ebstein disease)
o anorexia, nausea, weight loss, night sweats, and pruritus
- history and physical examination

- Tests
o complete blood count
o uric acid levels
o liver function tests
o erythrocyte sedimentation rate or C-reactive protein
o alkaline phosphatase
o urinalysis
- Radiographic tests Organ involved in Hodgkin disease
o CT scans of the neck, chest, abdomen, and pelvis
o gallium or PET scan (to identify metastatic or recurrent disease)
o x-ray film
- lymph node biopsy- essential to establish histologic diagnosis and staging
- presence of Sternberg-Reed cell is considered diagnostic of Hodgkin disease because it is absent in
the other lymphomas
- bone marrow aspiration or biopsy
- chemotherapy and irradiation

o chemotherapy is the primary form of treatment, although limited irradiation may be given to
areas of bulky disease
- most effective combination of chemotherapy widely used
o MOPP (mechlorethamine [Mustargen], vincristine [Oncovin], prednisone, and procarbazine),
o ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine),
o COPP (cyclophosphamide, vincristine [Oncovin], procarbazine, and prednisone)
o CVPP/EBO (cyclophosphamide, vinblastine, procarbazine, prednisone, etoposide, bleomycin,
and vincristine)
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- preparation for diagnostic and operative procedures, explanation of treatment side effects, and
child and family support
NON-HODGKIN LYMPHOMA
- Histologic classification of childhood NHL is strikingly different from that of Hodgkin disease and
adult NHL in several respects
o The disease is usually diffuse rather than nodular.
o The cell type is evenly split between B-cell and T-cell lineages.
o Dissemination occurs earlier, more often, and more rapidly.
Staging
- Stage I—Disease is limited to one lymph node area or only one additional extralymphatic site (I-E)
- Stage II—Two or more lymph node regions on the same side of the diaphragm or one additional
extralymphatic site or organ (II-E) on the same side of the diaphragm
- Stage III—Tumor on both sides of abdomen and may have spread to an area or organ next to the
lymph nodes (IIIE), spleen (IIIS), or both (IIISE)
- Stage IV—Tumor has spread into any organ that is not right next to an involved node, and/or the
tumor has spread to the central nervous system or bone marrow
- depend on the anatomic site and extent of involvement.

- manifestations seen in Hodgkin disease may be present in NHL
- surgical biopsy
- immunophenotyping and cytogenetic evaluation
- bone marrow aspiration
- radiologic studies
o CT scans of the lungs and gastrointestinal organs
- LP- lumbar puncture
- aggressive approach using irradiation and chemotherapy

- Similar to leukemic therapy, the protocols include induction, consolidation, and maintenance
phases, some with intrathecal chemotherapy
chemotherapeutic agents
- cyclophosphamide and intermediate- or high-dose methotrexate
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Wilms’ tumor
- Wilms tumor, or nephroblastoma, is the most common kidney tumor of childhood
- associated with several congenital malformation syndromes, including
o WAGR (Wilms tumor, aniridia, genitourinary anomalies, and cognitive impairment [mental
retardation])
o Beckwith-Wiedemann syndrome (hemihypertrophy, macroglossia, omphalocele, and
visceromegaly)
- painless swelling or mass within the abdomen.

o mass is characteristically firm, nontender, confined to one side, and deep within the flank
- Other clinical manifestations
o Hematuria occurs in less than one fourth of children with Wilms tumor
o Anemia, usually secondary to hemorrhage within the tumor- results in pallor, anorexia, and
lethargy
o Hypertension, probably caused by secretion of excess amounts of renin by the tumor
o weight loss
o fever
- If metastasis has occurred, symptoms of lung involvement (metastasis- spread of cancer cells from
the place where they first formed to another part of the body)
o Dyspnea, cough, shortness of breath, and pain in the chest
- history and physical examination

- Specific tests
o radiographic studies- abdominal ultrasound, CT, and MRI of the abdomen
- Laboratory studies
o complete blood count- polycythemia
o biochemical studies and urinalysis
STAGING OF WILMS TUMOR
- Stage I—Tumor is limited to one kidney and completely resected.

- Stage II—Tumor extends beyond kidney but is completely resected; lymph nodes do not contain
tumor
- Stage III—Residual tumor confined to abdomen that may have disease in nearby lymph nodes or
abdominal space.
- Stage IV—Hematogenous metastases with disease spread to the lung, liver, bone, brain, or distant
lymph nodes
- Stage V—Bilateral renal involvement is present at diagnosis
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- Combined treatment with surgery and chemotherapy with or without irradiation
Preoperative Care
- keep explanations simple and repeat them often, with attention to what the child will experience
- usual preoperative observations, monitor blood pressure, since hypertension from excess renin
production is a possibility
- to reinforce the need for caution, it may be necessary to post a sign on the bed that reads “Do not
palpate abdomen.” Careful bathing and handling are also important in preventing trauma to the
tumor site.
- explanation of what to expect, such as major benefits and side effects of chemotherapy drugs
Postoperative Care
- nurse monitors gastrointestinal activity, such as bowel movements, bowel sounds, distention, and
vomiting
- Other considerations are frequent evaluation of blood pressure and observation for signs of
infection, especially during chemotherapy
Support the Family
BRAIN TUMORS
- Tumors of the CNS are the most common solid tumor in children
- infratentorial (below the tentorium cerebelli), which means they occur in the posterior part of the
brain, primarily in the cerebellum or brainstem
- supratentorial or lie within the midbrain structures.
- Brain tumors may be benign or malignant, although the designation of any tumor in the brain as
“benign” should be done cautiously given the vital functions the brain controls.
- Headache- most common symptoms of infratentorial brain tumors

- Infratentorial brain tumor
o nystagmus, ataxia, dysarthria, and dysmetria
- Supratentorial
o seizures, personality or behavioral changes, visual disturbances, and hemiparesis
- MRI- permits early diagnosis of brain tumors and assessment of tumor growth during or after
treatment
- CT scan- permits direct visualization of the brain parenchyma, ventricles, and surrounding
subarachnoid space, commonly used
- Other tests
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o MRI of the spine and electroencephalography

- tissue specimens obtained during surgery- Definitive diagnosis
- use of surgery, radiotherapy, and chemotherapy

- total removal of the tumor without residual neurologic damage- treatment of choice
- Assess for Signs and Symptoms

- Prepare the Family for Diagnostic and Operative Procedures
- Prevent Postoperative Complications
- Assessment
- Positioning
o Trendelenburg position is contraindicated in both infratentorial and supratentorial surgeries
o infratentorial procedure is usually positioned flat and on either side. Pillows should be placed
against the child’s back, not head, to maintain the desired position.
o supratentorial craniotomy the head is usually elevated above the heart to facilitate
cerebrospinal fluid drainage and decrease excessive blood flow to the brain to prevent
hemorrhage.
- Fluid Regulation
- Comfort Measures
- Support the Family
- Promote Return to Optimum Functioning
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Alterations in Nutrition and Gastrointestinal, Metabolism and Endocrine
Problems in Nutrition and Gastrointestinal
CLEFT LIP AND CLEFT PALATE

- Cleft lip (CL) with or without cleft palate (CP) is the most common birth defect
- Isolated CL with or without CP is more common in males, and CP alone is more common in females.
Etiology
- result from a combination of genetic and environmental factors

o genetic
o teratogens
o Alcohol use
o cigarette smoking
o prescription drugs- anticonvulsants, steroids, and retinoids, are associated with higher rates of
oral clefting
o folic acid supplements
- cleft that involves the lip and/or CP is readily apparent at birth

- cleft palate is detected through visual inspection of the oral cavity or by palpating the hard palate
and soft palate with a gloved finger
- CL diagnosed in utero through ultrasound 14th-16th weeks
Therapeutic management
- Surgical Correction: Cleft Lip

o typically occurs when the baby is between 2 and 3 months old. Surgical correction is performed
when the infant is free of any oral, respiratory, or systemic infection
o numerous techniques to repair the cleft lip defect, including Millard, Tennison-Randall, and
Fisher techniques.
o Cheiloplasty- modification of the lips
- Surgical Correction: Cleft Palate
o repair is typically completed between 6 and 12 months. early repair of the cleft palate may
restrict skeletal growth of the midface, delaying palate repair after first words emerge may
result in significant speech disorders
o according to studies children who are younger and less advanced in terms of speech
development exhibit better articulation and resonance
o Common techniques used to repair the cleft palate include Veau-WardillKilner V-Y pushback
and Furlow double opposing z-plasty
o Palatoplasty- to maximize speech production ang growth of midface.
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- nurse should encourage expression of parental grief and fears.
Feeding
- modifications to bottle selection

o Haberman bottle
- positioning the infant upright with the head supported by the caregiver’s hand or cradled in the
arm. This position helps gravity to direct the flow of liquid so that it is swallowed rather than
entering into the nasal cavity.
Preoperative Care
- instruct the parents to accustom the infant to some of the needs of the early postoperative period.
Some craniofacial surgery teams encourage the transition to cup-feeding before CP surgery, and this
feeding method is used postoperatively as well
o syringe-feeding, should be introduced several days before surgery
Postoperative Care: Cleft Lip
- Avoid the prone position to prevent suture damage.

- After CL repair (cheiloplasty), some surgeons allow the infant to return to breastfeeding or bottle
feeding, while others require syringe-feeding once the child is awake and alert.
- Careful supervision of the child is recommended to ensure that the suture line Is not damaged by an
object or fingers entering the mouth
- parents are taught how to administer the appropriate dosage of analgesic.
- Parents should be taught how to properly clean the sutures by using water or diluted hydrogen
peroxide.
- infant should be positioned to prevent airway obstruction by secretions, blood, or the tongue.
Gentle aspiration of mouth and nasopharyngeal secretions may be necessary to prevent aspiration
and respiratory complications
o Excessive swallowing may be a sign of bleeding and swallowing blood.
o Avoid the use of suction or objects in the mouth such as tongue depressors, thermometers,
spoons, or straws
Postoperative Care: Cleft Palate
- The child should be closely observed postoperatively for signs of airway obstruction, hemorrhage,
and laryngeal spasm
- Prone position
- A face mask is often used to deliver oxygen.
- tongue stitch may be used to prevent the tongue from obstructing the airway; it is taped to the
cheek
- Observe the child’s vital signs and oxygen saturation for potential airway compromise
- clear liquids for 24 hours followed by a liquid diet for 2 weeks. A soft diet may be encouraged for a
full 6 weeks following palate repair
o Acceptable feeding devices include open cup for liquids
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o rigid utensils such as spoons, straws, or hard-tipped sippy cups should be avoided to avoid
accidental injury to the repair.
- Elbow restraints can keep the hands away from the mouth, and the parents should maintain this
precaution at home until the palate is healed
DISORDER OF MOTILITY
HIRSCHSPRUNG DISEASE (CONGENITAL AGANGLIONIC

MEGACOLON)
- a congenital anomaly that results in mechanical obstruction from inadequate motility of part of the
intestine
- more common in males than in females
PATHOPHYSIOLOGY
- absence of ganglion cells ==== lack of enteric nervous system stimulation === loss of recto
sphincteric reflex === unopposed sympathetic stimulation of the intestine === increased intestinal
tone=== failure of the bowel to relax – Hirschsprung disease.
Diagnostic Evaluation Clinical Manifestations
- History and physical examination

- Barium enema
- Anorectal manometry (measure reflex pressure)
- Rectal biopsy- to confirm diagnosis
- Two stages of surgery

o 1st- temporary ostomy to relieve the obstruction
o 2nd – complete corrective surgery soave endorectal
Pull through
- Anorectal myomectomy- for very short- segment disease
- main objectives are to help the parents adjust to a

congenital defect in their child
- observation of the passage of the meconium -early diagnosis
- preparing the parents for the medical-surgical procedure
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ACUTE APPENDICITIS
- Appendicitis, inflammation of the vermiform appendix (blind sac at the end of the cecum), is the
most common cause of emergency abdominal surgery in childhood
Etiology
- hardened fecal material (fecalith) - cause of appendicitis is obstruction of the lumen of the appendix
- Swollen lymphoid tissue
- frequently occurring after a viral infection
- Enterobius vermicularis, or pinworms, which can obstruct the appendiceal lumen
Pathophysiology
- Obstructions (fecalith, parasites, microorganism, foreign body) === mucus secretions is blocked===
increased intraluminal pressure=== local inflammatory changes=== appendicitis
- first symptom of appendicitis is usually colicky, cramping, abdominal pain located around the
umbilicus
- nausea, vomiting, anorexia- occur after pain
- Blumberg sign- rebound tenderness pain on deep palpation with sudden release—may be present
- Rovsing sign- tenderness in the right lower quadrant that occurs during palpation or percussion of
other abdominal quadrant
- Psoas sign- complain of pain in the right hip caused by inflammation in the psoas or iliopsoas
muscles
- Obturator sign- discomfort felt by the patient on the slow internal movement of the hip joint while
the right knee is flexed.

- Laboratory studies
o complete blood count (CBC)- white blood cell count greater than 10,000/mm3, elevated C-
reactive protein
o urinalysis (to rule out a urinary tract infection
o in adolescent females, serum human chorionic gonadotropin (to rule out an ectopic pregnancy)
- Computed tomography (CT)- technique of choice
- ultrasound may also be helpful in diagnosing appendicitis.
- removal of the appendix (appendectomy)
- primary nursing objective is to assist in establishing a diagnosis

- Instruct the child to point with one finger to the site of the abdominal pain.
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- Light palpation will satisfactorily elicit pain without causing excessive trauma
- Do not administer any pain reliever
Hypertrophic pyloric stenosis

- Occurs when the circumferential muscle of the pyloric sphincter becomes thickened resulting in
elongation and narrowing of the pylori canal.
- usually develops in the first few weeks of life, causing nonbilious vomiting,
- projectile vomiting may develop and the infant is fussy and hungry after vomiting.
- If the condition is not diagnosed early, dehydration, metabolic alkalosis, and failure to thrive may
occur
- etiology of HPS is not known
- more common in firstborn children, and boys are affected four to six times more frequently than
girls.
- It is more likely to affect full-term infants than premature infants
Pathophysiology
- Pylorus thickens=== severe narrowing of pyloric canal=== obstruction=== projectile vomiting and
palpable olive like mass.

- olive-like mass is most easily palpated when the stomach is empty
- ultrasonography demonstrates an elongated mass surrounding a long pyloric canal
- upper GI radiography should be done to rule out other causes of vomiting.
- nonbilious vomiting
- vomiting may be projectile
- dehydration
- weight loss
- failure to thrive
- olive-shaped mass in the epigastrium just to the right of the umbilicus may be palpated
- pyloromyotomy or the Fredet-Ramstedt operative procedure is the standard therapy for this
disorder
- careful regulation of fluid therapy

- reestablishment of normal feeding patterns
- encourage the parents to become involved in caring the child
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INTUSSUSCEPTION
- telescoping or invagination of the proximal segment to a more distal segment that results in
lymphatic and venous obstruction
- Intussusception is the most common cause of intestinal obstruction in children between the ages of
3 months and 6 years
- common in males than in females and is more common in children under the age of 2 years
- cause is not known
Pathophysiology
- telescoping or invagination of bowel== lymphatic and venous obstruction=== edema increased

pressure in the area of intussusception=== pressure equals arterial pressure then blood flow
stops=== ischemia and mucus pouring in the intestine, venous engorgement causes leaking of
blood=== currant jelly stool
- sudden onset of cramping abdominal pain

- inconsolable crying
- drawing up of the knees to the chest
- bilious vomiting
- lethargy
- Palpable sausage-shaped mass in upper right quadrant
- Passage of red, currant jelly–like stools (stool mixed with blood and mucus)
- classic triad of intussusception symptoms
o abdominal pain, abdominal mass, bloody stools
- subjective finding
- barium enema
- abdominal radiograph
- rectal examination-mucus, blood
- ultrasound-guided hydrostatic (saline) enema

- pneumo enema (air enema) with or without water-soluble contrast
- IV fluids, NG decompression, and antibiotic therapy
- Surgery manually reducing the invagination and, when indicated, resecting any nonviable intestine
o If other procedures are not successful may require surgical intervention
Nursing management
- help establish a diagnosis by listening to the parent’s description of the child’s physical and
behavioral symptoms
- explain the basic defect to the parent and how it is corrected.
Passage of a normal brown stool usually indicates
that the intussusception
23 | P a g e J D M L has reduced itself.

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CELIAC DISEASE (GLUTEN-SENSITIVE ENTEROPATHY)
- also known as gluten-induced enteropathy gluten-sensitive enteropathy, and celiac sprue

- permanent intestinal intolerance to dietary gluten, a protein present in wheat, barley, rye, and oats,
that causes damage to the villi in the small intestine
- cause is unknown
- celiac disease is an immunologically mediated small intestine enteropathy
risk factors
- with autoimmune disorders

- adult’s female > males, but equal in children.
- European
Pathophysiology
- Protein gluten (barley, rye, oat, wheat)=== inability to digest gliadin component of gluten===
accumulation of toxic substance=== damage to mucosal cells == villous atrophy, hyperplasia of the
crypts and infiltrations of the epithelial cells and lymphocytes=== malabsorption
- Box 26-18
- Other symptoms- failure to thrive, chronic diarrhea, abdominal distention and pain, muscle wasting,
aphthous ulcers, and fatigue
- serologic blood test for tissue transglutaminase and

antiendomyseal antibodies in children 18 months of age
- Positive serologic markers should be followed by an
upper GI endoscopy with biopsy
- Dietary management
o gluten-free diet is prescribed
o eliminate BROW
o RICE AND CORN SUBSTITUTE
- Specific nutritional deficiencies, such as iron, folic acid,
and fat-soluble vitamin deficiencies, are treated with
appropriate supplements
- main nursing consideration is helping the child adhere to the dietary regimen.
- Advise parents the necessity of reading all label ingredients
o bread, cake, cookies, crackers, donuts, pies, spaghetti, pizza, prepared soups, hot dogs,
luncheon meats, and some prepared hamburgers
- due to inflamed bowel child must avoid high fiber foods
o nuts, raisins, raw vegetable, raw fruits w/skin
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PROBLEMS IN METABOLISM AND ENDOCRINE
Growth hormone deficiency
Dwarfism
- Short stature that results from genetic or medical condition
- Adult height 4ft 10 inc (147 cm) or less- average is 4ft or 122 cm
- Divided into two broad categories:
o Disproportionate dwarfism- some parts of the body are small and others are average size or
above average size disorder causing disproportionate dwarfism inhibit the development of
bones
o Proportionate dwarfism- proportionately small if all parts of the body are small to the same
degree and appear to be proportionate like a body of average stature. Medical conditions
present at birth or appearing in early childhood limit overall growth and development
- Average trunk size

- Short arms and legs
- Short fingers
- Limited mobility
- Disproportionately large head without prominent forehead and a flattened bridge of the nose
- Progressive development of bowed legs
- Progressive development of swayed lower pack
- Height 122cm
GIGANTISM
- Rare condition that causes abnormal growth in children. This change is most notable in term of
height but birth is affected as well
- Occurs when pituitary gland makes too much growth hormone AKA. SOMATROPIN
- Early diagnosis is important
- Prompt treatment can stop or slow the changes that may cause child to grow larger than normal
- Normal childhood growth spurt at first
ETIOLOGY
- Pituitary gland tumor

o Always cause of gigantism
o Task managed by gland:
▪ Temperature
▪ Sexual development
▪ Growth
▪ Metabolism
▪ Urine production
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Manifestations
- Child notice that they’re larger than other child of the same age
- Common symptoms
o Very large hands and feet
o Thick legs and fingers
o A prominent jaw and forehead
o Coarse facial features
o Flat noses, large head lips, tongues
- Excessive sweating
- Severe or recurrent headaches
- Weakness
- Insomnia and other sleep disorder
- Delayed puberty in both boys and girls
- Irregular menstrual periods in girls
- Deafness
Diagnostics
- Blood test
o To measure levels of growth hormones and insulin like growth factor 1 – LGF-1
- Oral glucose tolerance test
o Child drink special beverages containing glucose
o Blood sample taken before and after child drink
- MRI SCAN
o After blood test that indicate gigantism
o Scan tumor size and position
Therapeutic management
- Surgery- preferred treatment
Medications
- Bromocriptine and cabergoline

o Can be lower growth hormone levels
o Given in pill form may use with octreotide
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SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE
- Oversecretion of the posterior pituitary antidiuretic hormone (ADH) causes the disorder known as
syndrome of inappropriate antidiuretic hormone (SIADH)
- This disorder occurs with increased frequency in a variety of conditions that disrupt central nervous
system function such as infection, tumor, or surgery. It can also be the side effect of a variety of
medications
- Excess ADH causes free water to be reabsorbed from the kidneys. As increased free water circulates,
serum osmolality goes down, and urine osmolality inappropriately increases.
- Said most common cause HYPONATREMIA in pediatric population
- Clinical signs related to fluid retention and hyponatremia
CLINICAL MANIFESTATIONS
- Fluid retention
- Hyponatremia
- Swelling- brain exposed too much water
- serum sodium levels are diminished to 120 mEq/L
o anorexia, nausea, vomiting, stomach cramps, irritability, and personality change
- serious neurologic signs
o such as stupor and seizures
therapeutic management
- Fluid restriction
- Oral sodium replacement
- Hypertonic saline
o For Severe SIAD
- recognition of SIADH symptoms is the primary nursing goal.

- Close attention to measurements of intake and output weight, and monitoring for the development
of neurologic symptoms is essential
- Seizure precautions
- patient and family will need instruction regarding medication administration.
- child and family need education and support regarding the rationale for fluid restrictions
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Cretinism
- syndrome characterize by failure to grow, skin lesion, CNS dysfunction, multiple skeletal deformities.
Can occur in young child that are fed in severely deficient diet.
CUSHING SYNDROME
- Cushing syndrome is a characteristic group of manifestations caused by excessive circulating free
cortisol.
- Cushing syndrome in young children may be due to an adrenal tumor
- Cushing syndrome is uncommon in children
- it is often caused by excessive or prolonged steroid therapy that produces a cushingoid appearance
- This condition is reversible once the steroids are gradually discontinued
- physiologic disturbances, such as hyperglycemia, infection, hypertension, and hypokalemia
ETIOLOGY OF CUSHING SYNDROME
- Pituitary—Cushing syndrome with adrenal hyperplasia, usually attributed to an excess of

adrenocorticotropic hormone (ACTH
- Adrenal—Cushing syndrome with oversecretion of glucocorticoids, generally the result of
adrenocortical neoplasms
- Ectopic—Cushing syndrome with autonomous secretion of ACTH, most often caused by
extrapituitary neoplasms
- Iatrogenic—Frequently the result of administration of large amounts of exogenous corticosteroids
- Food dependent—Inappropriate sensitivity of adrenal glands to normal postprandial increases in
secretion of gastric inhibitory polypeptide
MANIFESTATIONS AND
DIAGNOSTICS
CHARACTERISTIC OF CUSHING
- Serum cortisol levels SYNDROME
- fasting blood glucose levels for hyperglycemia
- serum electrolyte levels for hypokalemia and alkalosis
- 24-hour urinary levels of elevated 17-hydroxycorticoids
and 17-ketosteroids.
- Imaging of the pituitary and adrenal glands to
assess for tumors
- x-rays examination
- dexamethasone (cortisone) suppression test
- Administration of an exogenous supply of cortisone
normally suppresses ACTH production
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- bilateral adrenalectomy
- postoperative replacement of the cortical hormones (the therapy for this is the same as that
outlined for chronic adrenal insufficiency).
- surgical extirpation or irradiation- If a pituitary tumor is found
- Giving the drug early in the day maintains the normal diurnal pattern of cortisol secretion
- An alternate-day schedule allows the anterior pituitary an opportunity to maintain more normal
hypothalamic-pituitary-adrenal control mechanisms.
- Before surgery, parents need to be adequately informed of the operative benefits and
disadvantages.
- Postoperative teaching regarding drug replacement
- use of nasogastric decompression.
o To improve Anorexia and nausea and vomiting
- use of analgesics
o for joint pain
- Parents should be aware of the physiologic reasons behind these symptoms in order to be
supportive of the child.
- Postoperative complications of adrenalectomy are related to the sudden withdrawal of cortisol.
Observe for shock-like symptoms (e.g., hypotension, hyperpyrexia)
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DIABETES MELLITUS
- DM is a chronic disorder of metabolism characterized by a partial or complete deficiency of the
hormone insulin.
- most common metabolic disease
- type 1 DM
o peak at 4 to 6 years of age and another at early puberty (10 to 14 years of age)
o boys is slightly higher than in girls
o prominent in Caucasians
- Native Americans tend to develop type 2 DM rather than type 1 DM
CLASSIFICATION
- Type 1- insulin-dependent diabetes mellitus (IDDM)

- type II- non–insulin-dependent diabetes mellitus (NIDDM)
Type 1
- autoimmune disease that arises when a person w/genetic predisposition is exposed to a precipating
event
- characterized by destruction of the pancreatic beta cells, which produce insulin; this usually leads to
absolute insulin deficiency
- two forms.
o Immune-mediated DM results from an autoimmune destruction of the beta cells
o Idiopathic type 1 refers to rare forms of the disease that have no known cause.
Type 2
- Cause unknown, genetic factors

- arises because of insulin resistance, in which the body fails to use insulin properly combined with
relative insulin deficiency
- occurs in people over 45, who are overweight, sedentary, and have a family history of diabetes
PATHOPHYSIOLOGY
Pancreas islet of Langerhans produces insulin not functional === decrease or insufficient insulin
production=== not able to use glucose in the blood=== hyperglycemia=== polyphagia, polydipsia,
polyuria.
CLINICAL MANIFESTATIONS
- hyperglycemia, acidosis, 3polys (polyphagia, polyuria, polydipsia

- Recurrent vaginal and urinary tract infections, especially with Candida albicans, are often an early
sign of type 2 DM, especially in adolescents.
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- 8-hour fasting blood glucose level of 126 mg/dl or more, a random blood glucose value of 200
mg/dl or more accompanied by classic signs of diabetes
- oral glucose tolerance test (OGTT) finding of 200 mg/dl or more in the 2-hour sample is almost
certain to indicate diabetes
- Serum insulin levels
- glucose oxidase tapes (Keto-Diastix)- Tests used to determine glycosuria and ketonuria
- Insulin Therapy
- Future Therapies
o Islet cell or whole pancreas transplantation may offer hope to patients in the future
- Monitoring
o Blood Glucose
▪ Self-monitoring of blood glucose (SMBG)
▪ (normal) range of 80 to 120 mg/dl
o Glycosylated Hemoglobin.
▪ Nondiabetic hemoglobin A1c values are generally between 4% and 6%
o Urine.
▪ detect evidence of ketonuria
▪ urine be tested for ketones every 3 hours during an illness or whenever the blood
glucose level is over 240 mg/dl when illness is not present.
- Nutrition
o Children with diabetes need no special foods or supplements. They need sufficient calories to
balance daily expenditure for energy and to satisfy the requirement for growth and
development
- Illness Management
- Prevention
o Cyclosporine, mycophenolic acid, and nicotinamide have shown promise in delaying beta cell
destruction or lowering the incidence of type 1 DM
Nursing Care
- Hospital Management
- Supportive measure
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Alterations in Perception and Coordination
Neurologic and Cognitive Dysfunction
Seizure Disorders
Seizure
- Episodes of abnormal motor, sensory, autonomic, or psychic activity (or combo) that results from
sudden excessive discharge from cerebral neurons
- Manifestations depends on region of origination
- Most common treatable neurological disorder in children
General Manifestations:
- unconsciousness/ altered consciousness

- Involuntary movement
- Changes in perception, behavior, sensation and posture
Etiology:
- Idiopathic: usually genetic in origin

- Symptomatic: associated with an acquired cause that is associated with pathologic abnormalities
- Provoked seizures are caused by a systemic, such as medication or emotional factors, or
environmental factors, such as flashing lights
- Cryptogenic seizures are those occurring with no clear cause
Seizure Classification
- partial seizures (also referred to as focal seizures), which have a local onset and involve a relatively
small location in the brain
- generalized seizures, which involve both hemispheres of the brain and are without local onset
partial seizures
- Partial seizures are subdivided: simple partial and complex partial

o Simple Partial (Jacksonian) Seizure
▪ characterized by jerking in fingers and toes
▪ May spread to involve the entire arm/leg
▪ Mistaken for acting out and bizarre behavior
o Complex Partial (psychomotor) seizure
▪ Starts with blank stare then progresses into chewing and random activity
▪ May be mistaken for drunkenness, MI, drug interaction
generalized seizures
- Myoclonic seizure
o Characterized by sudden, brief, massive muscle jerks that involve part/all of the body
o May be mistaken for clumsiness and poor coordination
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- Atonic seizure
o AKA “drop attack”; legs of child suddenly collapse; no jerky movement
o Mistaken for clumsiness/lack of normal walking ability
Other Classifications Under Two Main Types:
- Generalized Tonic-Clonic Seizure (Grand-Mal)

o Commonly mistakes with MI and stroke
o A convulsive seizure characterized by alternating muscle rigidity and jerking temporarily,
suspended breathing and altered consciousness
o Stages of grand-mal seizure
▪ Aura: signs or visual observations experienced by child that may manifest an
impending seizure
• Involves a peculiar sensation
• May be psychic/sensory
▪ Tonic Phase
• Loss of consciousness
• Body rigid
• Eyes roll up
▪ Hypertonic Phase
• Extreme muscle rigidity and hypertension
• Signals the end of continuous contraction
▪ Clonic Phase
• Alternate rigidity and relaxation
▪ Autonomic Discharge
• Hyperventilation
• Salivation and tachycardia
▪ Post Ictal Phase
• All muscle relax
• Patient becomes unresponsive
- Absence (Petit-Mal)
o Commonly mistaken as daydreaming, inattention, and ignoring
o Characterized by blank stare that lasts only a few seconds
NURSING MANAGEMENT
During Seizure
- Observe and record the sequence of signs
o Predisposing factors
o Occurrence of AURA
o The initial movements/action and type
o Area of body involved Observe and record the sequence of signs
o Eye movement and pupil size
o presence/absence of automatism; breathing pattern
o Incontinence
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o Duration (should not extend for more than a minute)

o Unconsciousness
- Provide Privacy
- Safety
o Ease to the floor
o Protect head
o No restraints
- Airway
o Place on side
o AURA: insert Oropharyngeal Airway (OPA)
o Avoid forced mouth opening
After Seizure
o paralysis/weakness
o Speaking ability
o Movements
o Sleepiness
o Cognitive status
- Airway
o Place in side-lying position: to drain secretions
o Suction
- Reorient
- Agitation
o Persuasion and gentle restrain
Epilepsy
- Group of syndromes characterized by unprovoked, recurring seizures
Etiology:
- Primary (Idiopathic)
- Secondary (known cause)/ tumor that cannot be resected
Status Epilepticus
- Acute, prolonged seizure activity

- Series of generalized seizures that occur without recovery of consciousness
ANTI-SEIZURE MANAGEMENT
- Carbamazepine (Tegretol)
- Clonazepam
- Gabapentin
- Levetiracetam (Keppra)
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- Phenobarbital (Luminal)
- Phenytoin (Dilantin) (*can cause gingival hyperplasia)
- Valproate (Depakene) (*can cause hepatotoxic)
- Vallum **DO on bedside for patients diagnosed with epilepsy + hospitalized for other reasons
Surgical Management
- If etiology is tumor, cyst, abscess, vascular anomalies
Spina Bifida
- Midline defects involving failure of the osseous spine to close
- Most common defect of CNS
- Major precipitating factor: folic acid deficiency during pregnancy
- SB is categorized into two types: SB occulta and SB cystica
o Spina Bifida Occulta
▪ Not visible externally
▪ Skin depression/dimples and dark tufts of hair
o Spina Cystica
▪ Visible defects with an external sac-like protrusion
▪ two major forms of SB cystica are meningocele, and myelomeningocele (or
meningomyelocele)
• Meningocele- Encases meninges and spinal fluid, but no neural elements
• Myelomeningocele- A serious case of spina bifida, Contains meninges,
spinal fluid, and nerves
- MRI: most sensitive tool for evaluating the defect

- CT Scan
- Ultrasound (prenatal)
- Amniocentesis (↑ AFP)
- Spina Bifida Occulta: needs no immediate surgical correction

- Meningocele & Myelomeningocele: immediate surgery
*Using non-powdered gloves
o Done 24-72 hrs (most favorable outcome)
o Child with myelomeningocele will continue to have
paralysis and loss of bladder bowel function even
after surgery
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Nursing Management
- Care of the myelomeningocele sac:

o Kept from drying
o Application of moist, non-adherent dressing
o Dressing changed every 2-4 hrs
- Pre-Op: prone position
o Diapering is contraindicated
o Gentle ROM (range of motion exercises of limbs) → prevents contractures
- Post-Op: Prone Position
o Monitor VS, I&O, signs of infection
o Measure head circumferences → complication of surgery: hydrocephalus
Hydrocephalus
- Excess of CSF in the ventricles of the subarachnoid space
Etiology:
- Overproduction of CSF in the ventricles

- Obstruction in the anatomy of the brain
- Interference with absorption of CSF
- Head enlargement → due to ↑CSF

- Bulging fontanels → ↑fluid in brain
- Dilated scalp veins - Macewen sign (cracked-pot sound) → due to separation of sutures, elicited by
percussion - Frontal “bossing”
- Sunset eyes → the cornea only appears in half
- Transillumination → when you place a flashlight onto the skull of the infant, you will see
transillumination of CSF
- Shrill, brief, high-pitched cry
- Fetal Ultrasonography - 14 wks AOG

- CT Scan
- MRI
- Skull X-ray
- Transillumination
Medications
- Acetazolamide → ↓ aqueous humor (fluid in the eye lens) production to prevent visual
interruption; prevent further fluids in the brain
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- Furosemide → prevent ↑ fluid in the body
Surgical Treatment:
- Plexectomy: removal of plexus in the brain; if etiology is overproduction

- Shunt systems
o Ventriculoperitoneal shunt: if etiology is obstruction; more common - Drill a hole in the
skull and insert the shunt in the ventricle where the CSF obstruction originates and will drain
into the peritoneal cavity ; not visible externally and is felt under the skin
o Ventriculoatrial shunt: Inserted in the ventricle and will drain in the atrium of the brain
o Complications: obstruction, infection, perforation of abdominal organs, subdural hematoma
- Endoscopic Third Ventriculostomy (bypassing the aqueduct of Sylvius)
o If etiology is obstruction
Nursing Management
- Daily head circumference measurement

- Assessment of child’s LOC (level of consciousness)
- Preparing the child for Dx exams
- Post-Op:
o Observe for signs of increasing ICP (intracranial pressure)
o Pupil dilation
o Abdominal distention
o Shunt care
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Musculoskeletal and Neuromuscular Dysfunction
Sprains and Strains

- sprain occurs when trauma to a joint is so severe that a ligament is either stretched or partially or
completely torn by the force created as a joint is twisted or wrenched.
- often accompanied by damage to associated blood vessels, muscles, tendons, and nerves
CLASSIFICATION OF SPRAINS
- Grade I—Mild injury; involves overstretching or microscopic tearing but without hemorrhage or
increased instability of the involved joint. Swelling may develop later.
- Grade II—Moderate injury; involves partial, overt tearing of the ligament with at least some
ligamentous continuity remaining; usually immediate pain and swelling with decreased function.
- Grade III—Severe injury; total loss of ligamentous continuity (i.e., disruption of one or more
ligaments or the musculotendinous unit). Pain is immediate but subsides because none of the pain
fibers is being stretched. Swelling may be minimal because hemorrhage extravasates outside of the
area into soft tissues.
- Rest Ice Compression Elevation

- Ice Compression Elevation Support
o Ice Compression Elevation Support
o Trend with ankle sprains: Encourage early mobilization and strengthening > prolonged
immobilization
o Should be iced immediately
o Rule of thumb: first 24 hrs → ice, after 24 hrs → heat
Fracture
- Damage to the bone
Types of Fractures
- fracture is complete When fracture fragments are separated

- incomplete when fracture remain attached
- The fracture line can be any of the following:
o Transverse-Crosswise - At right angles to the long axis of the bone
o Oblique-Slanting - Between a horizontal and a perpendicular direction
o Spiral-Slanting - Twisting around the bone shaft
o Closed/Simple - Does not produce a break in skin
o Open/Compound - An open wound through which the bone protrudes
o Complicated - Bone fragments cause damage to other organs/tissues
o Comminuted - Small bone fragments are broken from the fractured shaft and lie in the
surrounding tissue
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- Radiographic examination (x-ray): most useful tool for assessing skeletal trauma
- Observation of signs of injury
- Demonstrates the usual ff.

o Generalized swelling
o pain/tenderness
o Diminished functional use of affected part
o Bruising
o Severe muscular rigidity
o Crepitus (grating sensation at site)
- Goal of management:
o To reestablish alignment and length of bony fragments (reduction)
o To retain alignment and length (immobilization
o To restore functions to the injured parts
o To prevent further injury and deformity
- Fractures are splinted or casted to immobilize and protect the injured extremity
- If child is alert and no s/sx of hemorrhage → calming and reassuring

child and parents
o For a more thorough assessment to be easily accomplished
- Ask parent or an older child what happened
- If did not arrive with limb supported in some manner → carefully
- immobilize affected site
- Do not touch the child initially but ask them to point to the painful area
and wiggle fingers/toes distal to the injury
o To prevent guarded stance of child and risk of mobilizing
affected area which can worsen injury
- When calm, tell the child what will happen and what they can do
to help
- Does not need to palpate and should not move affected limb
unless properly splinted to prevent further injury
- Temporary splint should be applied carefully if the child needs to
be transported
- Reassure parents that their child will receive necessary care, incl.
pain management
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Fracture Complications:
- Circulatory impairment
o Assess: pulses of the affected area, capillary refill, temperature
- Nerve compression syndromes → assess for functionality and sensation of the limb
o Assess: sensory testing, pinprick test, ask to move affected joint
- Compartment syndromes → in the area of fracture, the muscles and nerves will have compromised
blood circulation
o Assess: Monitoring of pain and pallor, pulselessness, paresthesia, and paralysis at site
- Physeal damage → growth of bone originates from the growth plate, damage to this structure can
lead to unequal lengths of extremities
o Surgical intervention may be required if limb inequality is large enough
o May involve procedures such as epiphysiodesis (slowing the growth of the longer leg) or
needing to lengthen the bone in the shorter/affected extremity
- Nonunion → failure of a fractured bone to heal and mend after an extended period of time
o Impaired bone healing due to inadequate reduction or poor immobilization
- Malunion → fracture union with increased angulation or deformity at the fractured site
o Unsatisfactory reduction is the usual cause
o Bone did not unite properly
- Infection → Osteomyelitis (infection of the bone)
o Often secondary to bloodstream infection
o Potential problem when fracture is open
- Kidney stones
o hypercalcemia after fractures can cause calcification/ calcium stones in the urinary tract that
can lead to kidney stones
- Pulmonary emboli
o Can be blood, air, or fat emboli
o - Fat emboli is the greatest threat with a person with multiple fractures
Developmental Hip Dysplasia (DDH)
- broad term developmental dysplasia of the hip (DDH) describes a spectrum of disorders related to
abnormal development of the hip that may develop at any time during fetal life, infancy, and
childhood.
ETIOLOGY
- idiopathic
- risk factors
o breech birth
o female gender
o family history of DDH
o left hip
o first-born child
o positive clicking hips with clinical examination
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Three degrees of DDH
- Acetabular dysplasia: This is the mildest form of DDH, in which there is a delay in acetabular
development evidenced by osseous hypoplasia of the acetabular roof that is oblique and shallow.
The femoral head remains in the acetabulum with no subluxation or dislocation.
- Subluxation: The largest percentage of DDH, subluxation implies incomplete dislocation. The
femoral head remains in contact with the acetabulum, but stretched capsule and ligamentum teres
cause the head of the femur to be partially displaced. Pressure on the cartilaginous acetabulum
inhibits ossification and produces a flattening of the socket.
- Dislocation: This is the most severe form of DDH. The femoral head loses contact with the
acetabulum and is displaced posteriorly and superiorly
- Asymmetry of gluteal and thigh folds → when you lift the baby, the affected side would be higher
- Limited hip abduction, as seen in flexion → cannot be abducted fully
- Apparent shortening of femur, as indicated by level of knees in flexion
- Ortolani test → (and Barlow test) can be done to newborns
o Usually combined with Barlow’s
o “Barlow’s first before Ortolani”
o Barlow Test
▪ The femoral head is reduced back into the acetabulum
▪ identifies the unstable hip that is in a reduced position that the clinician can
passively dislocate
▪ Examiner will flex the hips and knees to 90 degrees then bring the thigh towards the
midline (adducting the hip), mild pressure is placed on the knee while directing the
force posteriorly. The femoral head will be pushed out of the socket
• Positive: ip can be popped out of socket; dislocation will be palpable
o Ortolani Test
▪ Used to confirm the findings of the Barlow; performed following the it to determine
if the hip is actually dislocated
▪ Flexing the hips and knees to 90 degrees. Reduction is done by abduction of the hip
and pushing the thigh anteriorly
• Positive: palpable, audible clunk is heard from the hip being reduced
• Hip click is a nonspecific finding
- Positive Trendelenburg sign (if child is weight bearing)
o Ask patient to stand on one leg, can hold onto something if they experience problems with
balance
▪ Negative: pelvis on the opposite side should rise a little
▪ Positive: pelvis on the opposite side drops
• Indicator for weak hip abductors on a standing leg or unstable hip due to hip
dislocation
- Radiographic examination
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Newborn-6 mos
- Hip joint is maintained by dynamic splinting, in a safe position with the proximal femur centered in
the acetabulum in a degree of flexion
- Abduction devices: Pavlik Harness (most widely used)
o With time, motion and gravity, the hips works into a more abducted, reduced position
o Does not rigidly immobilize but prevents hip extensions and adduction
o Worn continuously until hip is stable on both clinical and ultrasound exams (usually within
6-12 wks)
- Highly effective when device is well-constructed, follow up care is adequate and parents follow
instructions in its use
6-24 mo
- Surgical closed reduction and the child is placed in a spica cast for approximately 12 weeks
o To maintain hip in an appropriate, stable position and further promote hip development
- If not reducible, surgical open reduction may be necessary
Older Child
- Operative reduction
o preoperative traction, tenotomy of contracted muscles, and pelvic osteotomy often
combined with proximal femoral osteotomy is usually required
- After cast removal, range of motion exercises help restore movement
o + other rehabilitation measures may incl. Muscle strengthening, a period of crutch/walker
use, and gait training
- During the infant assessment process and routine nurturing activities

o Inspect hips and extremities for any deviations from normal
o Refer for evaluation an ambulatory child who displays a limp/waddling gait
o Assess non ambulatory child with cerebral palsy/spina bifida for evidence of hip problems
o Major nursing challenges with child in a cast/device(s):
▪ Maintenance of device
▪ Adaptation of nurturing activities to meet child’s needs
o Treatment and follow-up care are in out-patient setting
- Primary goal: teach parents to apply and maintain the reduction device
o Pavlik harness: allows for easy handling of the infant and usually produces less apprehension
in parent > heavy braces and casts
o Important: parents must understand the correct use of the device, which may/not allow for
its removal during bathing
o Removal of harness is determined individually based on the provider’s recommendations,
degree of hip instability, family’s level of understanding
o Parents should be instructed NOT to adjust the harness
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- Skin care
o Frequently (BID-TID) check for red areas under straps and at skin folds
o Gently massage healthy skin under straps OD to stimulate circulation
o Avoid lotions and powders (can cake and irritate skin)
o Always place the diaper under the straps
IDIOPATHIC SCOLIOSIS
- Scoliosis is a complex spinal deformity in three planes, usually involving lateral curvature, spinal
rotation causing rib asymmetry, and when in the thoracic spine, often thoracic hypokyphosis
- most common spinal deformity
- Standing child wearing only shorts/briefs and viewed from behind

o asymmetry of shoulder height due to curvature of the spine, scapular/flank shape, hip
height, pelvic obliquity
o Cutaneous changes may also be observed
- When the child bends forward at the waist and trunk is parallel to the floor, arms hang free (Adams
position)
o Asymmetry of rubs and flanks
- Scoliometer: used ain the initial screening to measure truncal rotation
o A primary curve and a compensatory curve will place the head in alignment with the gluteal
cleft
o With an uncompensated curve, the head and hips are not aligned
- Radiographs of child in standing position using Cobb technique → definitive diagnosis
- Risser scale: evaluate skeletal maturity on radiographs; assists in making a determination of the
likely progression of the spinal curvature
- Sexual maturity rating: to evaluate the risk of curve progression in adolescents
o All Spinal curvatures ≠ Scoliosis
▪ Curve < 10 = postural variation
▪ Curve < 25 = mild
• If nonprogressive, does not require treatment
- MRI
o Intraspinal conditions and other disease processes that may cause scoliosis must be ruled
out
- observation with regular clinical and radiographic evaluation,

- orthotic intervention (bracing), and surgical spinal fusion
Bracing and Exercise
- For moderate curves (25 to 45 degrees)

o bracing may be the treatment of choice although has not been shown to be curative; the
goal is to slow the progression of the curvature to allow skeletal growth and maturity
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operative Management
- severe curves- Curve > 45

o Surgical spinal fusion treatment
▪ Based on the magnitude, location, and type of curve; age of skeletal maturity; any
underlying/contributing disease process
o Arthrodesis
▪ realignment/straightening of the spine with internal fixation and instrumentation
combined with bone infusion
- Pre-Op Care
o Inform child and parent what will happen during the procedure
o Routine laboratory tests (CBC, urinalysis, etc.)
▪ Spinal surgery results in considerable blood loss
- Post-Op Care
o Monitor in acute care setting
o Log roll in changing positions
▪ Patient should not bend their back when changing positions
▪ Requires multiple help for positioning
▪ Prevent damage to fusion and instrumentation
o Skin care is important
o Pressure relieving mattresses
o Assessment of wound, circulation and vital signs, also assess neurological status of
extremities
Cerebral Palsy
- Disorder of posture and movement from static brain injury perinatally/postnatally, which limits
activity
- Involves disturbances of sensation, perception, communication, cognition, and behavior
- Most common permanent physical disability of childhood
- Common: low birth weight, born before 28 wks AOG, males > females, and African Americans
Classifications:
- Spastic
o Most common
o Caused by a lesion on the upper motor neuron leading into ↑ stretch reflexes, ↑ muscle
tone, and weakness
- Athetoid/Dyskinetic
o Caused by a lesion in the basal ganglia causing involuntary movement
- Dystonia
o Random uncontrolled, slow movements in limbs and trunk
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- Chorea
o Random dance-like movement
- Ataxic
o Least common
o Caused by a damage in the cerebellum causing shaky, uncoordinated movements, and
wide-based gait
o Usually cannot walk without assistance
- Mixed
o Combo of spastic and dyskinetic
o May be labeled as such when no specific pattern is dominant
o Usually cannot walk without assistance
- Neurologic exam
- Physical exam
- Neuroimaging technique (MRI)
o Predictor at term
- General movement assessment
o Strong predictive value (>2-5 y/o)
- Diagnosis cannot be confirmed until 1-2 y/o
- Permanent disorder irreversible

- Therapy: symptomatic and preventive
o Establish locomotion, communication, and self-help skills → by occupational and
physical therapy
o Gain optimum appearance and integration of motor functions
o Correct associated defects as early and effectively as possible
o Provide educational opportunities
o Promote socialization experiences
o Mobilizing devices (ankle-foot orthoses/braces)
o Surgery
o Medication
▪ Botulinum toxin type A (Botox) → inhibits release of catecholamines
▪ Dantrolene (*hepatotoxic)
▪ Baclofen → for relaxation
▪ Diazepam → for relaxation
o Physical therapy
o Speech therapy
o Occupational therapy
FINALS
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Clubfoot
- Aka talipes equinovarus (TEV)
- Complex deformity of the ankle and foot that incl. Forefoot adduction, midfoot supination,
hindfoot varus, and ankle equinus
- Involves bone deformity and malposition with soft tissue contracture
- May occur as an isolated deformity/ in association with other conditions/syndromes
- Readily apparent at birth

- Can be detected prenatally through ultrasonography
- Comprehensive physical assessment of affected foot/feet
- Goal: to achieve painless, plantigrade, and stable foot

- Treatment is ideally initiated in the newborn period
- Three stages:
o Correction of deformity
o Maintenance of the correction until normal muscle balance is regained
o Follow-up observation to avert possible recurrence of the deformity
- Ponseti Method Serial Casting
o Common approach to management and treatment
o Begun shortly after birth
o Manually invert the clubfoot and casts it
o weekly gently manipulate and stretch after casts
o Casted until max correction is achieved (usually within 6-10 wks)
o Often Percutaneous Heel Cord Tenotomy is performed after the of casting
▪ To correct the equinus deformity
▪ After, a long-leg cast is applied and left in place for 3 wks
o After completion of casting, Denis Browne bar w/ Ponseti sandals/ straight last shoes
placed in abduction are fitted
▪ To maintain correction and prevent recurrence
o Inability to achieve acceptable foot alignment indicates need for surgical intervention
Nursing Management
- Same for any child who has a cast

- Incl. both long and short term goals
- Monitor of circulation and skin integrity
- Parent education and support
o Importance of regular cast changes and their role in long-term effectiveness of therapy
- Reinforcing and clarifying the orthopedic provider’s explanations and instructions
- Teach parents care for cast/bracing
- Encourage parents to facilitate normal development within limitations imposed by

deformity/therapy
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Nursing care of a child with life threatening conditions/high acuity and

emergency situations (acute and chronic)
PEDIATRIC CRITICAL CARE
Basic physical assessment
- Vital signs
o Temperature
o Radial pulse: rate, volume, rhythm
o Respirations: rate, depth, rhythm
o Blood pressure: karotkoff’s sounds
- State of comfort- location and intensity of pain, response to medications given.

- Emotional responses- patient behavior, reactions and demeanor, and general mood
(crying/depressed)
- Skin- presence/absence of abrasions, contusions, erythema, decubitus ulcers, incision line,
color, turgor, temperature.
- Musculoskeletal: activity level, general mobility, gait, range of motion
- Neurological: pupil (size, response, equality), hand grip strength and sensation of all extremities;
ability to follow commands; level of consciousness
- Respiratory: breath sounds; sputum color and consistency; cough (productive/ non-productive)
- Cardiovascular: heart sounds; presence of pulses; edema
- Gastrointestinal: bowel pattern and sounds; presence of nausea/ vomiting; abdominal
distention; consumption of diet
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- Genitourinary- voiding, color, odor, and consistency of urine, dysuria; vaginal drainage
discomfort; penile discharge
GLASSCOWS COMA SCALE
- GCS
- consists of a three-part assessment: eye opening, verbal response, and motor response.
- created to meet a clinical need to identify criteria for the consciousness level. For clinical
purposes, the primary role of observation of the LOC is to detect a life-threatening complication
- requires observational skills and is readily reproducible between observers
- pediatric coma scale does not assess verbal responses as such but records smiling, crying, and
interaction
- The lower the score, the deeper the coma.
o A person with an unaltered LOC would score the highest 15
o a score of 8 or below is generally accepted as a definition of coma;
o the lowest score, 3, indicates deep coma or death.
EYE RESPONSE
TEST SCORE PATIENT RESPONSE PATIENT RESPONSE
ADULTY INFANT
Spontaneously 4 Open eyes Open eyes
spontaneously spontaneously
To speech 3 Open eyes in response Open eyes in response
to verbal stimulus to verbal stimulus
To pain 2 Open eyes in response Open eyes in response
to painful stimulus to verbal stimulus
None 1 Doesn’t open eyes in Doesn’t open eyes in
response to stimuli response to stimuli
- spontaneously opening of the eyes without instructing them- voluntary 4pts
- speech- opening of the eye’s response to verbal- involuntary- 3pts
- pain- opening of the eyes in response to any painful stimulus-2pts
- none- no opening of eye after several of stimulus-1pt
Verbal response
ADULTY INFANT
Oriented 5 Oriented, converse, Smiles, orients to
normally sounds, follow objects,
interacts
Confused 4 Confused, disoriented Cries but consolable,
inappropriate
interactions
Inappropriate words 3 Utters, inappropriate Inconsistently
words inconsolable, moaning
Incomprehensible 2 Moans or screams Inconsolable agitated
None 1 No response No response
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- oriented
o kapag tinanong yung adult patient tama yung sagot niya sa tanong mo.- 5pts
o Sa Infant kapag nakipag interact ka sakanila hindi umiiyak kumbaga gusto pa nila
makipag laro- 5pts
- Confused
o Adult- kapag tinanong mo yung patient ng mga simpleng tanong katulad ng anong
pangalan mo, age, kung nasaan ka. Hindi nila alam ano isasagot nila or matagal silang
mag response.- 4pts
o Infant- kapag nakipag interact ka sa infant response nila ay inappropriate or walang
gana makipag laro tas iyakin pero napapatahan mo.-4pts
- Inappropriate words
o Adult- kapag tinanong mo sila malayo yung sagot sa tanong mo, kung ano-ano
pinagsasabi kahit hindi mo tinatanong nag papansin bigyan mo ng 3pts
o Infant- hindi mo mapatahan yung bata iyak ng iyak parang tanga- 3pts yan
- Incomprehensible
o Adults- sigaw ng sigaw na walang words kala mo nasa concert eh- 2pts
o Infant- nag wawala hindi mo mapatahan o maparelax ibig sabihin ayaw niya sayo-2pts
- None
o Adults- hindi nag reresponse sa mga mabulaklak mong salita, naka mute sila- 1pt
o Infant- no response 1pt
MOTOR RESPONSE
ADULTY INFANT
Obeys 6 Response to simple Move spontaneously
stimuli
Localizes 5 Localizes pain Withdraws from touch
Withdraws 4 Withdraws form Withdraws from
painful stimuli painful stimulus
Abnormal flexion 3 Abnormal flexion to Abnormal flexion to
pain- decorticate pain-decorticate
Abnormal extension 2 Extension to painful Extension to painful
stimuli- decerebrate stimuli- decerebrate
No response 1 No response No response
- Obeys
o Adult- nag rereponse sa mga palautos mo salita-6pts
o Infant- nag momove lang sila sa reponse sa mga utos mo hindi naman yan nakakaintindi
eh-6pts
- Localizes
o Adult- hindi kayang sundin ng patient yung mga instructions mo pero kaya nyan ituro o
I localize yung pain. 5pts
o Infant- nag wiwithdraw yung infant from painful touches na ginagawa mo- 5pts
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- Withdraw
o Adult and infant- inaalis nila yung kamay mo sa katawan nila kasi may pressure or
painful stimuli silang nararamdaman.- 4pts
- Abnormal flexion
o Adult and infant- nag decorticate or nag flexed or parang pinakita yung biceps- 3pts
- Abnormal extension
o Adult and infant- nag decerebrate or nag nag extend yung kamay parang nag
cecelebrate-2pts
- No response
o Adult and infant- walang response sa painful stimuli mo baka manhind na- 1pt
Level of consciousness- LOC

Classification description
Alert - Follow commands and responds completely and appropriately
GCS SCORE- 14-15 to stimuli
- Oriented to time, place, and person
Lethargic - Limited spontaneous movement or speech
GCS SCORE- 12-13 - Easy to arouse by normal speech or touch
- Possible disorientations to time, place, or time
Obtunded - Mild to moderate reductions in arousal
GCS SCORE- 10-11 - Limited responsiveness to environment
- Able to fall asleep easily
- Answers questions with minimum response
Stuporous - State of deep or unresponsiveness
GCS SCORE- 8-9 - Arousable only to vigorous and repeated stimulation
- Withdrawal or grabbing response to stimulation
Light coma - Positive to all forms of stimuli
GCS SCORE- 4-7 -
Deep coma - Negative to all forms of stimuli
GCS SCORE- 3
FINALS
NCMA 219
TRIAGE
- Is a method of prioritizing patient care according to the type of illness or injury and the urgency
of the patients condition.
- Primary triage- detect life-threatening situations
- Secondary triage- detect and treat non-life- threatening situation
Primary triage
- AIRWAY
- BREATHING
- CIRCULATION
- DISABILITY
- ELECTROLYTE STATUS
METHODS OF TRIAGE
- START= SIMPLE TRIAGE AND RAPID TRANSPORT

o For adult patient
o Determining which of the categories the casualty should be assigned
- JumpStart
o Developed specifically for the triage of children
o Able to walk, breathing, rr, palpable pulse and age-appropriate mental status
examination
S.T.A.R.T
- minor- able to walk on command and no major injuries

- deceased- no respirations after head tilt
- immediate- respirations after head tilt
- immediate- respirations over 30 per min
- immediate- perfusions radial pulses absent (control bleeding)
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- immediate- mental status: unable to follow simple commands

- delayed- can follow commands
JUMP START
- minor- able to walk on command and no major injuries

- deceased- apneic and no pulses after head tilt
- deceased- apneic with pulses after 5 rescue breaths
- immediate- respirations after head tilt or 5 rescue breaths
- immediate- respirations less than 15 or over 45 per mins
- immediate- perfusions: radial pulses absent (control bleeding)
- immediate- AVPU- inappropriate answer
- delayed- AVPU- appropriate answer
- SALT (SORT,ASSESS,LIFE-SAVING INTERVENTIONS, TREATMENT/TRANSPORT)

o Used to treat all types of patients in all types of incidences
- HOSPITAL TRIAGE
o Prioritize the most life threatening- black to green
TRIAGE CATEGORIES (COLOR TAGGING)
- GREEN- MINOR
o Victims with relatively minor injuries and unlikely to deteriorate over days
o Walking wounded.
- YELLOW- DELAYED
o Includes serious and potentially life threatening injuries but not expected to deteriorate
over several hours
- RED-IMMEDIATE
o Includes compromise to patients ABC
o Regular medical attention within minutes for survival
- BLACK- expectant
o Victims unlikely to survive given severity of injuries
o Palliative care and pain relief should be provided
FINALS
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BASIC LIFE SUPPORT

CARDIOPULMONARY RESUSCITATION- CPR
- Is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in
which someone’s breathing or heartbeat has stopped
- 15 compression 2 rescue breaths in 2mins in total of 100 to 120 compression
- Delay in CPR
o 0-4 minutes- brain damages unlikely if cpr started
o 4-6 minutes- brain damage possible
o 6-10 minutes- brain damage probable
o >10 minutes- severe brain damage death is certain
PROCESS OF CPR
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PEDIATRIC ALGORITHM IN SHOCKING
- Shockable rhythm ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVF)
- Mag defibrillator or mag shoshock lang kapag yung rhythm ay ventricular fibrillation and
pulseless ventricular tachycardia
- Non shockable rhythm is asystole (plot line) meaning hindi kailangan ng shock because it can
further kill the patient
- Amiodaron or lidocaine treat to prevent complications such as arrythmias
- Epinephrine- it helps jumpstart the heart
o 0.01mg/kg
- 15 compression 2 rescue breaths in 2mins in total of 100 to 120 compression
FINALS
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ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVF)
- CPR Muna para malaman if shockable yung rhythm o asystole

- If VF OR PVF yung rhythm mag defibrillator or mag shock
- Tapos cpr for 2 mins and evaluate kung yung rhythm ay shockable
o If yes: mag shock then cpr for 2mins then mag bigay ng first dose ng epinephrine ever 3-
5 mins tas evaluate kung yung rhythm ay shockable parin
▪ Kapag yes ulit cpr ulit tas mag bigay ng amidorone or lidocaine
o If no at hindi shockable meaning plot line na mag bigay agad ng epinephrine for 3-5 mins
tapos cpr ulit for 2mins tapos evaluate kung yung rhythm ay shockable na or hindi
▪ Kung hindi parin mag cpr ulit for 2mins tapos evaluate ulit kapag yung rhythm ay
hindi parin shockable ulitin mo ulit yung process, epinephrine then cpr then
evaluate kapag shockable na mag defibrillator na tapos cpr then magbigay ng
amiodarone or lidocaine
ASYSTOLE
- If Nakita mong asystole yung rhythm sa monitor

- Start kana agad magbigay ng epinephrine then cpr and continue administering epinephrine for
3-5 mins
- Tapos evaluate kung yung rhythm ba ay shockable or hindi
o If yes mag defibrillator or mag shock then cpr for 2mins then magbigay ng amiodarone
or lidocaine
o If no cpr 2mins tapos evaluate if shockable na or hindi. Kapag ganon parin yung rhytm
asystole ulitin ulit yung process sa simula, epinephrine for 3-5mins habang nag cpr tapos
evaluate. ulitin yung process hanggang yung rhythm ay maging shockable.
FINALS
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Integrated management of childhood illnesses

- Is a systematic approach to children health which focuses on the whole child
- It is a strategy for reducing mortality and morbidity associated with major cause of childhood
illness
- Developed by UNICEF and WHO in 1992
HISTORY OF IMCI
- Every year almost 11 million children under the age of five around the world dies from
preventable illnesses.
- Most common causes of these deaths are:
o Acute respiratory illness- pneumonia
o Diarrhea
o Malaria
o Measles
o Malnutrition
INDICATIONS FOR IMCI
- Quality of care
o Everyday millions of parents bring their sick child to
▪ Hospitals
▪ Health centers
▪ Pharmacists
▪ Doctors
▪ Traditional healers
- Cause of the problem
o Survey reveals that many sick children
▪ Are not properly assessed and treated
▪ Parents are poorly advised
o Other causes
▪ Minimal or non-existent diagnostic support
▪ Scarce drugs and equipment’s
▪ Irregular flow of patients
o Doctors have few opportunities to practice complicated procedure
o Rely on signs and symptoms for management and makes the best use of available
resources
OBJECTIVE OF IMCI
- To significantly reduce the global mortality and morbidity associated with the major cause of
diseases in children
- To contribute to health growth and development of children
FINALS
NCMA 219
INTEGRATED CASE MANAGEMENT PROCESS
- Presented in a series of charts which show the sequence of steps and provide information for
performing children
o Assess the child or young infant
o Classify the illness
o Identify treatment
o Treat the child/refer
o Counsel the mother
o give follow-up care
- assess the child or young infant
o history taking
o asking and observing the patient’s condition
o explore possible causes
- classify the illness
o based on thorough assessment
o supported with laboratory results
o mild, moderate, severe.
- Treat the patient
o Curative method of treating the disease
o Vary on the conditions of the patient
- Counsel the patient
o Health education
o Important for the parents/caregivers who lack knowledge
FINALS
NCMA 219
MANAGEMENT OF SICK CHILD- 2 MONTHS TO 5 YEARS
At the start of the management
- Ask the mother what the child problems are

- Determine if this is an initial or follow up visit for this problem.
CHECK FOR GENERAL DANGER SIGNS GENERAL DANGER SIGNS
Ask C- CONVULSIONS
- Is the baby not able to drink or breastfeed? A- ABNORMALLY SLEEPY

- Does the child vomits everything?
- Has the child had convulsions? N- NOT ABLE TO DRINK
Look S- SEVERE VOMITING- vomits everything
- If the is abnormally sleepy or difficult to awaken !!! URGENT REFFERAL NEEDED- (except in severe
dehydration)
CONVULSIONS
- May be result of fever

- Do little harm beyond frightening the mother
- Life threatening convulsions:
o Meningitis, cerebral malaria
- All children with convulsions should be considered SERIOSLY ILL
ABNORMALLY SLEEPY
- Unconscious/lethargic
- Does not take notice any of his surroundings
- Does not respond normally to sounds or environment
- Associated with many conditions
NOT ABLE TO DRINK
- Too weak or can’t swallow

- Do not rely completely on mothers’ evidence
- Observe while she gives the child something to drink
SEVERE VOMITING
- Is important to assess because

o It is a sign of serious illness
o Child will not be able to take in medications or fluid rehydration
CHECK FOR THE MAIN SYMPTOMS
- Cough or difficulty in breathing

- Diarrhea
- Ear problem -Fever
FINALS
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COUGH OR DIFFICULTY IN BREATHING
Ask
- For how long?
Look, listen- (child must be calm)
- Respiratory rate- one full minute

o Cut- off for fast breathing
▪ 2 mos up to 12mos- 50 breaths/minute or more
▪ 12 mos up to 5 yrs- 40 breaths/ minute or more
- Chest indrawing
o The lower chest wall goes in when the child breath in
- Stridor
o A Harsh noise made when the child breath IN
o Happens when there is a swelling of larynx, trachea, epiglottis
o Considered life threatening because airway may blocked
- Wheeze
o Wheezing noise when the child breaths OUT
o Not considered a stridor
o If present, give a trial of rapid acting bronchodilator for up to 3x for 15-20minutes apart.
Recheck breaths and chest indrawing again then classify.
SIGNS CLASSIFICATION TREATMENT

• Any general danger signs- SEVERE PNEUMONIA OR VERY ➢ Give first dose of antibiotic
CANS SEVERE DISEASE ➢ Give vitamin A
• Chest indrawing ➢ Bronchodilator- for chest indrawing+wheeze
• Stridor in calm child ➢ Treat the child to prevent LBP
➢ Refer urgently to hospital
• FAST BREATHING PNEUMONIA ➢ Give appropriate antibiotic for 5 days
➢ Inhaled Bronchodilator for 5d if still wheezing
➢ Soothe the throat and relive cough with a safe
remedy
➢ Advise mother when to return immediately
➢ Follow up in 2day
• No signs of pneumonia or NO PNEUMONIA: COUGH OR ➢ Inhaled bronchodilator for 5d
very severe disease COLD ➢ Soothe the throat and relieve cough with safe
remedy
➢ REFER if with cough for 30d- automatic pink
➢ Advise mother when to return immediately
➢ Follow up in 5d
➢ if not improving follow up in 2days
FINALS
NCMA 219
AMOXICILLIN
AGE ADULT TABLET SYRUP (100
(500 mg) MG/5ml)
APPROPRIATE ANTIBIOTICS 2MOS-6MOS- ¼ 1.5ML
3-5KGS
- Amoxicillin- fist line treatment 6MOS-12MOS- ½ 2.5ML
- Cotrimoxazole- second line treatment 6-9KGS
o Determine the appropriate drug and dosage for the 12MOS-3YRS- ¾ 3.5ML
child’s age or weight 10-14KGS
o Tell the mother the reason for giving the drugs to 3YRS-5YRS 1 5ML
the child COTRIMOXAZOLE
o Demonstrate how to measure a dose TABLET SYRUP
o Watch mother practice how to measure a dose by 2MOS-6MOS- ½ 5ML
3-5KGS
herself
6MOS-12MOS-
VITAMIN A 6-9KGS
12MOS-3YRS- 1 10ML
- Given to speed up the recovery or healing process of a child 10-14KGS
- Given in 3 doses 3YRS-5YRS
o 1 capsule today – day 1
o 1 capsule tomorrow- day 2
o 1 capsule 2 weeks after- day 3
▪ 6mos-12mos- 1 capsule of 1,000 IU
▪ 12mos- 5yrs – 1 capsule of 2,000 IU
TREAT TO PREVENT LOW BLOOD SUGAR
- If able to breastfeed, ask mother to breastfeed child

- If not able to breastfeed but can swallow
o Give expressed milk or breastmilk substitute
o If not available give 30-50 cc of sugar water or milk
▪ 4tsp of sugar mix with water
o If child is not able to swallow 50 ml of milk or sugar water thru NGT
o If child is unconscious start IV infusion give 5ml/kg of 10% dextrose solution over a few
minutes or 1ml/kg of 50% dextrose solution slow push
FINALS
NCMA 219
TETRACYCLINE
- Give 2x daily for 3d

DIARRHEA - 1 tab (250)
Ask ALTERNATIVE- ERYTHROMYCIN
- For how long?
- Is there any blood in the stools?
Look, listen
- Is the child abnormally sleepy? Irritable or restless?

- Look for sunken eyes
- Is the child drinking poorly or drinking eagerly?
- Pinch the abdomen does it goes back longer than 2 seconds or less than 2 seconds

Two of the following signs: Severe dehydrations ➢ Plan c
• Lethargic or unconscious ➢ If with other severe classification refer
• Sunken eyes urgently with mother giving frequent sips
• Not able to drink or drinking poorly or ORS on the ways, advise to continue BF
• Skin pinch goes back very slowly ➢ If child is 2 yrs and with cholera in the area
give antibiotic for cholera
Two of the following signs: Some dehydrations ➢ Plan b
• Restless, irritable ➢ If with other severe classification refer
• Sunken eyes urgently with mother giving frequent sips
• Drinks eagerly, thirsty or ORS on the ways, advise to continue BF
• Skin pinch goes back slowly ➢ Advise mother when to return
immediately
➢ Follow up in 5 days if not improving
• Not enough signs to classify as some or No dehydrations ➢ Plan a
severe dehydrations ➢ Advise the mother when to return
immediately
➢ Follow up in 5 days if not improving
PLAN A REHYDRATION
- Give extra fluids:

o Breastfeed frequently and longer per feeding
o For exclusively breastfed babies, give ORS or clean water together with bm
o For non- exclusively breastfed babies give one or more of the following food-based liquids
▪ Soup, rice water, buko or ors
o Teach the mother how to mix and give ors, give the mother packets of ors to use at home
o Show the mother how to give additional fluid other than usual intake
▪ ORS
• 1 packet of ors can be diluted in 1L of water
• Up to 2y/o 50 to 100 ml of ors after each loose stools
• >2 y/o 100 to 200 ml of ors every each loose stools
- Give zinc supplements
FINALS
NCMA 219
o Tell the mother how much zinc to give (20 mg tab)

▪ 2mos-6 mos- ½ tab OD for 14d
▪ 6mos above- 1 tab OD for 14d
o Demonstrate how to give supplement
o Continue feeding Age Up to 4- 12mos- 2yrs-

o When to return-5d 4mos 12mos 2yrs 5yrs
PLAN B REHYDRATIONS Weight <6kgs 6- 10 - 12- <
<10kgs <12kgs 20 KGS
- Determine amount of ORS to be given for 4hrs
- Formula to determine how much amount to be given
o Weight in kg multiply by 75 Amount 200- 450- 800-960 960-
450 800 1600
- Show how to prepare ORS solution
o 6tsp of sugar and half tsp of salt dissolved in 1L
of water
o After 4hrs
▪ Reassess and reclassify
▪ Select appropriate plan for treatment
▪ Begin feeding the child in the HC
▪ Give zinc supplements
- If the mother must leave before completing treatment
▪ Show her how to prepare the ORS at home
▪ Show her how much ORS to give her child to finish the 4-hour treatment at home
▪ Give her instruction on how to prepare salt and sugar solution for use at home
▪ Explain 4 rules of home treatment
PLAN C REHYDRATION
- Used for severe cases

- Give IV fluid immediately
o 100ml/kg LRS or NSS IF not available
o Reassess every 1-2hrs if not improving give fluids rapidly
o Also give ors 5ml/kg/hr as soon as child can drink
o Reassess the re-classify
- Refer urgently to the hospital for treatment
- If the child can drink provide the mother with ORS Solution and show her how to give frequent sips
during the trip
- If child cannot drink
o Start rehydration thru NGT: 20ml/kg/hr for 6hrs
o Reassess every 1-2 hrs
▪ If there is vomiting or increasing abdominal distention give more fluid slowly
▪ If hydration is not improving for 3hrs send for IV therapy
o After 6hrs reassess and reclassify
FINALS
NCMA 219 Ciprofloxacin
AGE OR GIVE 2 TIMES DAILY FOR 3
WEIGHT DAYS
100 MG 250 MG
TABLE TABLE
2-6 mos (3-5 ½ tab ¼ tab
kg)
6-12 mos (6- 1 tab ½ tab
9)
1-3 yrs (10- 1 ½ tab ½ tab
14 kg)
3-5 yrs (15- 2 tab 1 tab
19 kg)
Diarrhea for 14 days or more Severe persistent diarrhea ➢ Treat dehydration before referral unless
Dehydration present child has another severe classification
➢ Give vitamin A
➢ Refer to the hospital
Diarrhea for 14 days or more Persistent diarrhea ➢ Advise on feeding for child with persistent
Dehydration ABSENT diarrhea
➢ Give vitamin a
➢ Give multivitamins and minerals – include
zinc for 14d
➢ Follow up in 5 days
➢ Advise the mother when tot return
immediately
BLOOD IN THE STOOL DYSENTERY ➢ Give ciprofloxacin for 3 days
➢ Follow up in 2days
➢ Advise the mother when to return
immediately
FINALS
Signs of malaria
NCMA 219
- Stiff neck and runny nose
Sign of measles
FEVER: MALARIA - Generalized rash and
cough of runny or red
Decide malaria risk
eyes
Ask
- Does the child live in a malaria area?

- Has the child visited/travelled or stayed in a malaria risk for the past 4 weeks?
• If yes, obtain blood smear
Then ask:
- How long is the fever?

- If more than 7 days has the fever been present every day
- Has the child has measles within the last 3 mos?
Look and feel
- Stiff neck
- Runny nose
Look for sign of measles
- Generalized rash and cough or runny nose or red eyes

• Any general danger signs Very severe febrile ➢ First dose of quinine
• Stiff neck disease/malaria ➢ First dose of appropriate antibiotic
➢ Treat to prevent low blood sugar
➢ Give paracetamol if with fever (38.5)
➢ Send blood smear with the patient
➢ Refer urgently to the hospital
• Positive blood smear Malaria ➢ Oral antimalarial
➢ Paracetamol if with fever
➢ Advise the mother when to return immediately
➢ Follow up 2 days if fever persist
➢ If fever is present for more than 7 days refer to
assessment
• No general danger sign and no stiff Fever malaria unlikely ➢ Give paracetamol if with fever
neck ➢ Advise when to return immediately
• Blood smear negative ➢ Follow up in 2 days if fever persists
• Runny nose ➢ If fever is present everyday for 7days refer for
• Measles assessment
• Other cause of fever
FINALS
NCMA 219
DRUGS USED TO TREAT MALARIA

- For fever
PARACETAMOL
AGE OR WEIGHT TABLET 500 MG SYRUP 120 MG/5ML
2 MOS-3 YRS ( 4- <14KGS) ¼ 5 ML
3 YRS- 5 YRS (14 - <19 KGS) ½ 10 ML
- Antibiotics
o Give quinine then refer urgently to the hospital
o Referral not possible
▪ Give first dose of quinine
▪ Child should remain lying down for one hour
▪ Repeat quinine at 4 and 8hrs later then every 12 hrs until child can take oral
antimalarial. Do not give for more than 1 week
▪ If no malaria risk do not give to child less than 4 mos of age
FINALS
NCMA 219
FEVER: MEASLES
If the child has measle now or within the last 3 mos
Look:
- For mouth ulcers

- Pus draining from the eyes
- Clouding of cornea

• Any general danger signs or Severe complicated measles ➢ Give vitamin a
• Clouding of cornea or ➢ Give first dose of appropriate antibiotic
• Deep or extensive mouth ulcers ➢ Tetracycline ointment- for clouding of
cornea/pus
• Pus draining from the eye or Measles with eye or mouth ➢ Vitamin a
• Mouth ulcers complications ➢ Tetracycline- if with pus draining from the
eye
➢ Gentian violet- mouth ulcers
➢ Advise when to return immediately
• Measles now or withing the last 3 months measles ➢ Vitamin a
➢ Advise mother when to return
immediately
TETRACYCLINE
- Clean both eyes 3x daily

o Wash hands
o Use clean cloth and water to gently wipe away pus
- Appy tetracycline
o Ask the child to look up
o Small amount on the inside of lower lid
o Wash hands again
GENTIAN VIOLET
- For mouth ulcers

- Twice daily
o Wash hands
o Wash child mouth with a clean wrapped around the finger and wet with salt water
o Paint mouth with half strength gentian violet – 0.25% dilution
o Wash hands again
o Continue for 38hrs until ulcers have been cured
o Give paracetamol for pain relief
FINALS
NCMA 219
FEVER: DENGUE HEMORRHAGIC FEVER- DHF

Ask:
- Did the child had

o Bleeding from the nose or gums or in the vomitus or stools
o Black vomitus
o Black stools
o Persistent abdominal pain
o Persistent vomiting
Look and feel
- Bleeding from nose or gums

- Skin petechiae or red rashes in tourniquet test
- Cold and clammy extremities
- Slow capillary refill

• Any signs of bleeding Severe dengue hemorrhagic ➢ Plan b- vomiting, abd pain, + tourniquet
• Capillary refill for more than 3 secs fever ➢ Plan c- if with sign of bleeding
• Persistent abdominal pain ➢ Treat to prevent low blood sugar
• Persistent vomiting ➢ Refer urgently
• + tourniquet test ➢ Do not give aspiring
• No signs of severe DHF Fever: DHF unlikely ➢ Advise mother when to return immediately
➢ Follow up in 2 days if fever persist or child
➢ Show signs of bleeding- do not give aspirin
FINALS
NCMA 219
EAR PROBLEM
If yes
Ask:
- Is there ear pain?

- Is there ear discharge
- If yes for how long
Look and feel:
- Pus draining from the ear

- Feel for non-tender swelling behind the ear

• Tender swelling behind the ear Mastoiditis ➢ Give first dose of an appropriate antibiotic
➢ Give first dose of paracetamol for pain
• Pus is seen draining from the ear and Acute ear infection ➢ Give antibiotic for 5 days
discharge is reported for less than 14 days ➢ Give paracetamol for pain
• Ear pain ➢ Dry the ear by wicking
immediately
• Pus is seen draining from the ear and Chronic ear infection ➢ Dry the ear by wicking
discharge is reported for 14 days or more ➢ Instill quinolone otic drops for 2 weeks
immediately
• No ear pain and no pus seen draining no No ear infection ➢ No additional treatment
ear infection ➢ Advise mother when to return
DRY THE EAR BY WICKIN AND INSTILLATION OF QUINOLONE OTIC DROPS
- Dry the ear at least 3 times daily

o Roll clean absorbent cloth or soft strong tissue paper into a wick
o Place the wick in the child’s ear
o Remove the wick when the wet
o Replace the wick with a clean one and repeat steps until ear is dry
- Instill quinolone otic drops after wicking 2 to 3 drops three times daily for 2 weeks
FINALS
NCMA 219
MALNUTRITION
Look and feel
- Determine weight for age

- Look for edema of both feet
- Look for visible sever wasting
- For children 6 mos older check if measurement of the upper arm circumferential (muac)is less than
115 mm.

6 mos below: Severe malnutrition ➢ Treat the child to prevent low blood sugar
o Visible sever wasting ➢ Give vitamin a
o Edema of both fett ➢ Refer urgently to the hospital
6 mos below ➢
o Muach less than 115 mm
o Edema of both feet
o Visible severe wasting
Very low weight for age Very low weight ➢ Assess the child feeding and counsel
mother on feeding according to the
feeding recommendations and care for
development
➢ If feeing is a problem follow up in 5 days
➢ Give vitamin a
immediately
Not very low weight for age and no signs of Not very low weight ➢ Assess the child feeding and counsel
malnutrition mother on feeding according to the feeing
recommendation and care for
development
➢ If feeding is the problem follow up in 5
days
immediately
FINALS
NCMA 219
ANEMIA
Look and feel
- Look for palmar pallor

o Severe palmar pallor- white or yellow in color of the skin
o Some palmar pallor- pale skin

• Severe palmar pallor Severe anemia ➢ Refer urgently to the hospital
• Some palmar pallor Anemia ➢ Assess the child feeding and counsel
mother on feeding according to the
feeding recommendation and care for
development
➢ Give iron
➢ Give albendazole/mebendazole if child is 1
year or older and has not had a dose in the
previous 6 mos.
immediately
• No palmar pallor No anemia ➢ If the child is less than 2 years old Assess
the child feeding and counsel mother on
feeding according to the feeding
recommendation and care for
development
immediately

Ncma 219 Finals Complete

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FINALS

Alterations with Infectious, Inflammatory and Immunologic Responses

JUVENILE IDIOPATHIC ARTHRITIS

- stiffness, swelling, and loss of motion

- systemic arthritis -rheumatoid factor (RF)–negative polyarthritis - enthesitis-related arthritis

Course and Prognosis

- outcome of JIA is variable and unpredictable

- there are no definitive tests.

• There is no cure for JIA.

Nonsteroidal anti-inflammatory drugs (NSAIDs

- ibuprofen, naproxen, tolmetin, diclofenac, indomethacin, and meloxicam.

disease modifying antirheumatic drugs (DMARDs)

- methotrexate and sulfasalazine

NURSING CARE MANAGEMENT

- a thorough history and physical examination

- antihistamines, α-adrenergic decongestants, mast cell stabilizers, leukotriene modifiers and

Nursing Care Management

ATOPIC DERMATITIS (ECZEMA)

Nursing Care Management

- complex disorder involving biochemical, genetic, immunologic, environmental, infectious,

Therapeutic Management: General

- Nonpharmacologic therapy is aimed at the prevention and reduction of exposure to airborne

- categorized into two general classes:

Breathing Exercises and Physical Training

Therapeutic Management: Specific

Nursing Care Management

- Acute Asthma Care

Basic Concepts on Oncology

Pathologic and Related Clinical Manifestations

- history, physical manifestations

acute lymphoblastic leukemia DIAGNOSTIC EVALUATION

- Infiltrations of the bone marrow by non-functional leukemic cells (blast)

- involves the use of IV and intrathecal chemotherapeutic agents.

- vincristine, doxorubicin, prednisone (dexamethasone)

- Newer or more intensive doses of chemo drugs may be tried

- Brain or spinal fluid

ACUTE MYLELOUD LEUKEMIA

- Accounts for 20% of childhood leukemias

- Constitutional chromosomal abnormalities

- Same with ALL due to infiltrations of bone marrow by myeloblast

- Consolidation- HiDAC- high dose ara-c (for younger patients)

- Prepare the Family for Diagnostic and Therapeutic Procedures

HODKIN LYMPOMA NON-HODGKIN LYMPOMA

- Each stage is further subdivided into A, B, E, or S

- painless enlargement of lymph nodes

- history and physical examination

- chemotherapy and irradiation

Nursing Care Management

- depend on the anatomic site and extent of involvement.

- aggressive approach using irradiation and chemotherapy

- cyclophosphamide and intermediate- or high-dose methotrexate

- painless swelling or mass within the abdomen.

- history and physical examination

STAGING OF WILMS TUMOR

- Stage I—Tumor is limited to one kidney and completely resected.

- Combined treatment with surgery and chemotherapy with or without irradiation

Nursing Care Management

Support the Family

- Headache- most common symptoms of infratentorial brain tumors

o MRI of the spine and electroencephalography

- use of surgery, radiotherapy, and chemotherapy

Nursing Care Management

- Assess for Signs and Symptoms