Pediatric Nursing ( Part one ) second term

Family in uence - Morbidity and Mortality - Cultural :

MCQ and Matching
Toddler stage : MCQ and Matching
Development screening : MCQ

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Out lines
- Perspectives and evolution of pediatric nursing.
- Family influences on child health promotion.
- Human growth and development.
- Communicating with children and their families.

Learning Objectives
By the end of this part the nurse students should be able to:

- Describe perspectives and evolution of pediatric nursing.

- Discuss Family influences on child health promotion
- Describe Human growth and development.
- Discuss communicating with children and their families.

Perspectives of pediatric nursing.

Learning Objectives

By the end of this part the nurse students should be able to:

- Identify perspectives of pediatric nursing.

- Describe the functions and roles of the pediatric nurse in promoting health
of the children .
- Discuss the Philosophy of pediatric nursing care
- Describe the evolution of Pediatric Nursing in Relationship to Child Health.

Introduction to pediatric nursing

Pediatric is the study and care of children in health and sickness .

The ward pediatrics comes from Greek and means child cure .The doctor
who specializes in pediatric is called pediatrician and The nurse who caring for
diseased children it called pediatric nurse.

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Measurement of children's Heath Status :

Measuring a child's health status is not always a simple process. A traditional

method of measuring health is to examine mortality and morbidity data.

This information is collected and analyzed to provide an objective description of

nation's health.

Why Mortality & Morbidity Data

Provides rationale for planning and delivering care through:

Tells us the causes of death and illness.

High-risk age groups for disorders or hazards.

Driving force for funding → Advances in treatment and prevention.

Guides us in providing specific areas of health counseling.

The main indicators of children health status :

Infant mortality rate (IMR).

Child mortality.

Immunization rates.

Mortality

Is the number of individuals who have died in specific period.

This statistic is presented as rates per 1,000 and is calculated from a sample of
death certificates.

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Neonatal Mortality Rate

NMR (Neonatal mortality is the number of infant deaths occurring in the first 28
days of life per 1,000 live births.

First cause of death <1 yr: congenital anomalies

LBW major determinant of neonatal death & major indicator of infant health
and mortality.

Other risk factors: maternal age, maternal education, short or long gestation.

So prenatal care most important, early identification of risk factors, and

early intervention .

Infant Mortality Rate

IMR (Infant Mortality Rate) is the number of infant death during the first year of
life per 1,000 live births.

Leading causes of death are:

Birth defects, preterm births, maternal complications, SIDS, injuries

Low Birth Weight: Health Risk?

Low birth weight (LBW) is defined by the World Health Organization as a birth
weight of a infant of 2,499 g or less, regardless of gestational age. Normal weight
at term delivery is 2500–4200 g (5 pounds 8 ounces – 9 pounds 4 ounces).

LBW babies are at risk for:

Impaired health.

Developmental delay.

Neurosensory deficits.

Cognitive delays and school and behavioral difficulties.

The most common major neurologic abnormality seen in these infants is cerebral
palsy, which increases with decreasing birth weight.

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Childhood Mortality Rate

Is the number of death in children over 1 year of age per 1,000 live births

Common causes of death of children , Infectious diseases, Pneumonia and other

lower respiratory diseases, Preterm births and neonatal disorders, and Diarrheal
diseases.

Specific groups have increased morbidity- homeless children, children living in

poverty, children of LBW, children with chronic illness, children in day care
centers.

Childhood Mortality :

Developmental stage & environment determine prevalence & type of injury.

Unintentional injuries are the leading cause of death for all children over 1 year of
age .

Morbidity

Refers to having a disease or a symptom of disease, or to the amount of disease

within a population.

Is the measure of prevalence of a specific illness in a population at a particular

time. It presented in rates per 1,000 population.

The most important aspect of morbidity is:

the degree of disability it produces, which is identified in children as the number of

days missed from school or confined to bed.

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Childhood Morbidity

The leading causes are acute & chronic illness or disability.

Risk factors:

Poverty.

Homelessness.

Children of LBW.

Chronic illness .

Children in day care.

For children 1 to 4 and 5 to 9 years of age, respiratory diseases are the major cause
of hospitalization and accounted for 39% and 24% of their discharges,
respectively.

Role of the pediatric nurse related to mortality and morbidity:

The goal is to rise awareness and provide guidance and counseling to prevent
unnecessary illnesses and deaths in children.

The nurse's role in relation to morbidity and mortality in children involves:

educating the family and community regarding the usual causes of deaths.

the types of childhood illnesses, and the symptoms that require health care.

Healthy People 2020 Leading Health Indicators:

Physical Activity

Overweight and obesity

Substance and Tobacco Abuse

Responsible Sexual Behavior

Mental Health

Injury and Violence

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Environmental Quality

Immunization

Access to Health Care

Adolescent Health

Diabetes

Early interventions for children with disabilities

Growth & Development

Growth and development

Learning objectives
By end the of this cession the nurse student can be able to :

1.Define growth and development .

2.Discuss concept of growth and development

3.List principles of the growth and development.

4.Identify characteristics of physical growth

5.Describe stages of development

6.List factors affecting growth and development .

7. Recognize how to assess development according to age

8. Recognize how to measure weight ,height ,and head circumference and

plotted in growth chart

9. Recognize the developmental tasks for different age groups in connection with
related biological and psychosocial concept.

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Family influences on child
health promotion
Family influences on child health promotion
• To understand health promotion, it is important
to develop a definition of health. The World
Health Organization (WHO) defines health as a
state of complete physical, mental, and social
well-being and not merely the absence of disease
and infirmity (WHO, 2016). Health in this
expanded view is dynamic, changing, and
unfolding; it is the realization of a state of
actualization or potential (Pender, Murdaugh, &
Parsons, 2015).
 Health promotion
Health promotion refers to activities that increase well- being and
enhance wellness or health (Pender, Murdaugh, & Parsons, 2015).
These activities lead to actualization of positive health potential for
all individuals, including those with chronic or acute conditions, as
well as persons whose social experiences puts them at risk for poor
health.
Examples include providing information and resources in order to:
• Enhance good nutrition at each developmental stage
• Integrate physical activity into the child’s daily events
• Provide adequate housing
• Promote oral health
• Foster positive personality development
 The child as member of family
• Children they live and are cared for in the context of a
family structure. Families are responsible for meeting
children’s physical and emotional needs to enable
them to grow and become healthy, mature, and ethical
adults. To achieve those goals, adult family members
are expected to provide children with such things as
clothing, food, medical and dental needs, moral
guidance, and love. However, the way those needs are
provided is not universal. Indeed, families are diverse.
 Family as social unit
• The arrival of a baby alters forever the primary social
unit—a family—in which all members influence and
are influenced by each other. Each subsequent child
joining that family continues the process of reshaping
the individual members and the family unit. Nursing
care of children demands a solid understanding of
normal patterns of growth and development—
physical, psychological, social, and intellectual
(cognitive)—and an awareness of the many factors
that influence those patterns.
 Family function
• The family’s primary purpose is to ensure survival of
the unit and its individual members and to continue the
society and its knowledge, customs, values, and beliefs.
It establishes a primary connection with a group
responsible for a person until that person becomes
independent.
• Although family structure varies among different
cultures, its functions are similar.
• For each family member, the family functions to
provide sustenance and support in the five areas of
wholeness: physical, emotional, intellectual, social, and
spiritual.
 Physical needs
• The family is responsible for meeting each
member’s basic needs for food, clothing,
shelter, and protection from harm, including
illness.
• The family determines which needs have
priority and what resources will be used to meet
those needs. Sometimes families need help
obtaining the proper resources.
 Emotional support
• The process of parental attachment to a child
begins before birth and continues throughout
life. This process is enhanced when early
interaction is encouraged between the new
parents and the newborn.
• Research studies continue to support the
importance of early parent–child relationships to
emotional adjustment in later life. As little as a
few hours may constitute a critical period in the
emotional bond between parent and child.
 Intellectual stimulation
• Many experts suggest that parents read to their unborn
children and play music to provide early stimulation. It
is unknown when the fetus can actually hear, but it is
clear that the newborn recognizes and is comforted by
his or her parents’ voices. The need for intellectual
development continues throughout life. The small infant
needs to have input through the five senses to develop
optimally. Many parents buy brightly colored toys and
play frequently with their infants to facilitate this
stimulation. Talking and reading to the infant and small
child is another way parents fulfill this function
 Socialization
• Within the family, a child learns the rules of the society
and the culture in which the family lives: its language,
values, ethics, and acceptable behaviors. This process,
called socialization, is accomplished by training,
education, and role modeling. The family teaches
children acceptable ways of meeting physical needs,
such as eating and elimination, and certain skills, such as
dressing oneself. The family educates children about
relationships with other people inside and outside the
family. Children learn what is permitted and approved
within their society and what is forbidden
 Family Structures
• Children’s family experiences are as
diverse as the types of families that exist.
Nurses must be understanding and
accepting of each type of family to
minimize the need for explanations by
either the parents or child and to minimize
each family’s stressors.
The major types of family structures
A. Traditional family
• Mother, father, and one or more children.
B. Nontraditional family.
• Single parent:
– either mother or father with one or more children.
• Adoptive family.
• Traditional or single parent family.
• One or more children is adopted.
• Adopted children may or may not be of the same ethnicity or race
as the parent(s) or siblings.
• Blended family.
– One or both parents are single, divorced, or widowed.
– Children from former relationships live together.
 CONTINU
• Multigenerational family.
– Traditional or single parent family with one or more
children.
– Grandparents of one or both parents live in the same
household.
• Grandparent-led family.
– Because of death, incarceration, or other reason, the
parents are not able to care for the children.
– Grandparents assume the responsibility of
parenthood.
• Communal family.
– Many family units living together
 Parent-Child Relationships
• The relationships between parents and
children, as well as parents’ disciplinary
practices, are grounded in the cultural
practices of the family. Parenting is not
learned in a classroom, rather one learns
to parent from watching the behaviors of
one’s parents.
 Family factors that influence child bearing and
child rearing
Family size
The smaller the family, the more time there is for
individual attention to each child. Children in small
families, often spend more time with adults and therefore
relate better with adults than with peers so children tend to
be more advanced in language development and
intellectual achievement. A large family emphasizes the
group more than the child. Less time is available for
parental attention to each child. There is greater
interdependence among these children and less dependence
on the parents.
 Sibling older and gender
• Firstborn children command a great deal of
attention from parents and grandparents and also
are affected by their parents’ inexperience.
• Gender identity in relation to siblings also
affects a child’s development. Girls raised with
older brothers tend to have more male-
associated interests than do girls raised with
older sisters. Boys raised with older brothers
tend to be more aggressive than are boys with
older sisters.
 Parental behavior
• Some mothers work because they are the
family’s only source of income, others because
the family’s economic status demands a second
income, and still others because the woman’s
career is highly valued. More than half of all
children between ages 3 and 5 years spend part
of their day being cared for by someone other
than their parents.
• Many factors contribute to the trend for families to spend less
time together. Both parents may work; the children participate
in many school activities; family members watch television,
rather than talking together at mealtime, or eat fast food or
individual meals without sitting down together as a family; and
there is an emphasis on the acquisition of material goods,
rather than the development of relationships. All these factors
contribute to a breakdown in family communication, and they
are typical of many families. Their impact on today’s children,
the parents of tomorrow, is unknown.
 Divorce
• Children may go through many emotions when a
divorce occurs. Feelings of grief, anger, rejection, and
self-worthlessness are common. These emotions may
follow the children for years, even into adulthood, even
though children may understand the reason for the
divorce. In addition, the parents, either custodial or
noncustodial, may try to influence the child’s thinking
about the other parent, placing the child in an emotional
trap. If the noncustodial parent does not keep in regular
contact with the child, feelings of rejection may be
overwhelming. The child often desperately wants a sign
of that parent’s continuing love.
 Culture
• A family’s culture is defined by the values, principles, and
convictions espoused by the family members. The culture of
the family guides many decisions and practices as well as
dietary preferences, financial priorities, and other choices
made within the family.
• One of the most important factors that influence cultural
beliefs is religion.
• Some of the more important issues guided by a culture that
impact pediatric nursing care are birth practices;
developmental rites of passage, such as ritual circumcision,
and dietary preference.
THE TODDLER STAGE

Toddler stage is between 1 to 3 years of age (12-36 months). During this period,
growth slows considerably.

Physical growth:

Is a time of slowed growth and rapid development. Each years the toddler
gains 2.25 to 4.50 kg and about 7.60 cm.

Continued eruption of teeth particularly the molars which is help the toddler
learn to chew food.

1 year to adult head increases 10 cm only.

During toddler years, chest circumference continues to increase in size and

exceeds head circumference.

Anterior fontanel closes between 12 – 18 months of age.

Teething:

By 2 years primary dentition of 16 teeth and 20 teeth by 30 months (2 ½

years).

Abdomen:

It is protruded and toddler appears “ pot-bellied” because of the immature

abdominal musculature.

SENSES:

• Toddlers have full binocular vision at 20/40 acuity.

• Senses of smell, hearing, touch, becomes increasingly well developed.

• Taste:

• a. Is well developed, and toddlers become very discriminating in relation to

their food choices. They clearly declare which foods they like and which
they do not.

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Calculating toddler’s weight

Weight = Age in years x 2 + 8

Wt of 2 years old child = 2 x 2 + 8= 12 kg

PHYSIOLOGICAL GROWTH

Pulse: 80-130 bpm (Average 110 /min)

Respiration: 20 – 30 cpm

Blood pressure: 80/50 – 112/80

MOTOR DEVELOPMENT

15th months
Gross motor

- Walks alone.

- Creeps upstairs.

-Assumes standing position without support.

Fine motor

- Builds tower of 2- 3 blocks.

- Open boxes.

- Holds a cup with all fingers grasped about it.

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 18th months
Gross motor

Pulls and pushes toys

- Jumps in place with both feet.

-Throws ball overhand without falling

Fine motor

- Removes simple clothes, e.g. shoes.

-Transfers objects hand-to-hand at well.

-Imitates a vertical line

24th Months
Gross motor

Runs well.

-Goes up and down stairs alone with two feet on each step.

Fine motor

- Builds a tower of 6 to 7 blocks.

- Holds cup with one hand.

- Open the door by turning doorknob.

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 30th months
Gross motor

- Jumps with both feet.

-Takes a few steps on tiptoe.

-Stands on one foot alone momentarily.

Fine motor

- Builds a tower of 8 blocks.

-Drinks without assistance

- Good hand-finger coordination, therefore, holds crayon with fingers rather than
fist

Psychosocial development

Toddler is very social beings but still egocentric.

Develop Autonomy vs shame and doubt

Develop “sense of autonomy” i.e. “I can do it my self.”

Doubt and shame arise when children are made to feel small and self-
conscious, when their choices are disastrous, when others shame them.

Psychosocial development

Imitations of people are more advanced, e.g. in clothes, in cleaning the house.

> Notice sex differences and know own sex.

Extremely curious becomes a communicative social being parallel play

Sense of power from saying “no” and “mine”.

The favorable outcomes are self-control and willpower.

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LANGUAGE DEVELOPMENT

15th months: Says 4 to 6 words (mainly names).

18th months: Says 10 words or more.

24th months: vocabulary of almost 300 words.

30th months: Talks constantly.

-Uses plurals.

-Gives first and last name.

EMOTIONAL DEVELOPMENT

Less fear of strangers, but he develops separation anxiety (anxiety develop when
he is separated from the caregivers- mother).

Temper – tantrums as means of anger expression.

Afraid from falling, loss of support, loud voices and strange places and people.

Parent education:

a. Parents should be encouraged to incorporate learning into play, daily

conversation, and everyday activities, for example: “You are wearing a red shirt
today.”

When providing toddlers with explanations, parents as well as health-care

providers should use understandable language, for example:

i. “The doctor is going to take a picture of your insides,” rather than “You are
going to have an x-ray.”

Moral development:

a. Toddlers believe that actions are only wrong if they are punished. Similarly,
they believe that actions are good if they are not punished or if they are
rewarded.

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Parent education:

a. It is important for parents to begin to use appropriate means of limit setting and

discipline in preparation for later, more sophisticated stages of moral development.

Routine checkups:

At age 15 months of age is the time for booster immunization.

Assess growth and development, oral hygiene, toilet training, daily health care, the
family care giver –toddler relationship.

Communication with the toddler on his level.

The child should receive current immunization.

Nutrition during toddler stage:

The toddler needs foods from the major food groups each day.

Daily nutritional needs for toddler including caloric requirements and the

appropriate number of serving perday as follow:

Fruit 1- 1.5 cups.

Vegetables 1-1.5 cups.

Dairy 2-2.5 cups

Grains 3-5 oz

Protein 2-4oz

Eating problems :

Commonly appear between the ages of 1 to 3 years. These problems occur for a
number of reasons such as:

- The child's growth rate has slowed, therefore he or she may want and need
less food than before. So family caregivers need to know that this is normal.

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 - The child's strong drive for independence and autonomy compels an
assertion of will to prove his or her individuality.

- The child's appetite varies according to the kind of foods offer

Guidance to parents:

Serve small frequent mail according to the like and dislike because they have
physiological anorexia.

Provide balanced diet

Do not use food as reward .

Do not force the child to eat.

Encourage independence

Iron deficiency anemia is a possible problem, so they should increase food

contained iron.

DENTAL HEALTH

o Toddler must eat an adequate, low cryogenic diet and practice daily oral
hygiene.

o Parents should be instructed about types of food that can be served to the
child. They also need to train toddlers to use tooth brush after eating &at bed
time.

Dental care guideline:

Brush twice daily with parents help.

First visit to dentist as soon as all primary teeth have erupted .

Limit concentrated sweets.

Do not give a child bottle contain juice or milk on bed time.

Provide diet consist calcium, phosphorus and appropriate vitamins.

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Elimination: Toilet Practice

Learning bowel and bladder control is one of the major tasks of toddlerhood and is
depend on the physiological and cognitive factors (readiness) as well as parents
positive attitude and patient.

Voluntary control of the anal and urethral sphincters occur at about 18-24mon.

Children may be able to communicate that they are wet or need to urinate or
defecate.

Parent guidance:

1. The child must be sit on the potty for 5-10min.

2. The parents can place on the toilet training at regular intervals such as (when
the child wakes up at morning, after naps, before meals, and at bed time).

3. Restrict fluids before bed time also help in bladder training.

Red Flags in toddler development

No quadruped crawling; cannot pull to stand; stiff legs.

No imitative play after 18 months.

Hand dominance before 18 months.

No first word (besides “mama”/“dada”) by 18 months.

Has 10–12 episodes of otitis media.

No two-word sentences by age 2 years.

Very clingy to mother at 24 months.

Incorrect pronoun use.

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Play during toddler period (Parallel)

Purpose:

To help the child make transition from solitary to cooperative play ,to
stimulate motor development , the child plays alongside other children but
not with them .

The toys should be:

-Simple because attention span is still very short ,and change of toys occur
at frequent interval .

-Allow muscle coordination and provide attention.

-Safety is important, there are danger of :

.Breaking a toy through exploration and ingesting small pieces .

.Ingesting lead from lead –based paint toy .

Suggested toys:

-Push and pull toy ,jumping toy.

-Cuddly toy and large dolls.

-Large crayons, car and trucks.

Others:

-He likes coloring books and hard board

-Games like to throw and retrieve objects

-He likes to hear the same story over and over ,to hear stories about
animals

-Sings to self

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Accident Prevention:

Toddlers are explorers who require constant supervision in a controlled

environment to encourage autonomy and prevent injury.

When supervision is inadequate or the environment is unsafe, tragedy often results;

accidents are the leading cause of death for children between the ages 1-4 years

Common causes of accidents for this group

Motor vehicle

Drowning

Burns

Poisoning

Reinforcing family teaching can help minimize the risk for accident and injury.

Accidents prevention for this group

Motor vehicle accidents:

The number of Motor vehicle deaths in this age group is more than three times
greater than the number of deaths caused by burn or drowning.

Prevention:

Proper use of restrain.

Adults must be responsible for teaching the child that seat belt are required for safe
car travel and that he or she must be securely fastened in the car seat before the car
start.

(for more details refer to family teaching tips in page 537 in your maternal and
pedia nursing book)

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Drowning prevention:

Although drowning of young of young children is associated with bathtubs, the

increased number of home swimming pools added significantly to the number of
accidental drowning.

For prevention must not leave a mobile infant or toddler unattended, even for a
moment.

Even small amount of water, may be enough to drown a small child.

Burns prevention

Burn accidents occur often as scalds from immersions and spills and from
exposure to un-insulated electrical wires or live extension cord plugs.

Children are also burned while playing with matches or while unattended in a
home where a fire breaks out.

(for more details refer to family teaching tips ,preventing burns in page 538 in your
maternal and pedia nursing book)

Preventing Poisoning

The curious toddler wants to touch and taste everything.

Left unsupervised, the toddler may sample cosmetics, personal care products,
household cleaners, prescription or over-the counter drugs, kerosene, gasoline,
peeling lead-based paint chips or dust particles.

Poisoning is still the most common medical emergency in children with the highest
incidence beteewn the ages of 1 and 4 years.

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The following medications are most commonly involved in cases of childhood
poisoning:

Acetaminophen.

Salicylates (aspirin).

Laxatives.

Sedative.

Analgesics, such as ibuprofen, opiods.

Antihistamines.

Cough/ Cold medicines.

Birth control pills.

(for more details refer to family teaching tips ,preventing poisoning in page 538 in
your maternal and pedia nursing book)

Preschool Growth and development

Is the period from 4 to 5 years ages.

Physical development:

In the preschool includes:

- A slowed growth rate

- Changes in the dentition

- Visual development

- Skeletal growth changes especially in the feet and legs.

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(Oral presentation )

School-Age Growth, development, and Health Promotion

Adolescent Growth, development, and Health Promotion

DEVELOPMENTAL SCREENING

The American academy of pediatric recommended that all children be

screened for developmental delays and disabilities during regular well child
doctor visit at :

9 month

18 month

24-30 month

Additional screening might be needed if a child is at risk for developmental

problems due to preterm, low birth weight or other reasons

Parents are usually are the first to pick up signs of possible developmental
delay, and any concern the parents have about their child development
should always be taken seriously .

Developmental delay:

Occurs in up to 15% of children under 5 years this include delays in :

Speech and language development

Motor development

Social development

Cognitive development

It has been estimated that only about half of children with developmental problems
are detected before they begin school.

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Guidelines for developmental screening:

Screening instrument should be reliable, cultural relevant and used only for
specific purpose

Multiple sources of information should be use

Should be done only by trained personals

Screening should be on recurrent and periodic basis

Family members should be part of process

DEVELOPMENTAL SCREENING TOOLS

1. Chronologic Age – assessment of developmental tasks related to birth date.

2. Brazelton Neonatal Behavioral Assessment Scale – This tool assesses the

following:

Newborn behavior during the first month of age.

Documents individual differences among babies.

Determines how environment shapes the behavior differences among babies.

Determines how environment shapes the behavior of babies and how

neonates shapes the environment.

Emotional and cognitive development.

DEVELOPMENTAL SCREENING TOOLS

3. Bayley Scale of Infant Development

this tool is used in evaluating children between 6 and 30 months of age to

assess the baby’s progress in areas like motor development, postural
development, attention spans to objects and humans, perception, language,
object manipulation, understanding commands, and problem solving.

score is converted to raw score to an estimated mental age.

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4. The Denver Developmental Screening Tests

provides a developmental profile of the individual child in four areas:

personal-social, fine motor-adaptive, language and gross motor skills. It does
not measure intelligence.

DEVELOPMENTAL SCREENING TOOLS

5. Mental Age

assess cognitive or intellectual development or IQ (intelligent quotient).

mental age is tested using standardized intelligence tests using toys and
language based on mental rather than chronologic age.

should be conducted twice at two different sessions before a reliable

assessment can be obtained.

The End

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 PEDIATRIC NURSING NUR 363 II
Second term 2020-2021
NURSING CARE OF HOSPITALIZED CHILD

1
LEARNING OBJECTIVES
By the end of the course the student should be able to:
Establish a plan of care for the different children disorders.
Assess & diagnose health needs of children and families.

MCQ,Matching
Nursing management of children with respiratory disorders
Learning Objectives:
At the end of the unit, the student will be able to:
1. Describe the assessment signs and symptoms seen in children with respiratory
difficulties.
2. Discuss the nursing management of the common upper and lower respiratory
system.
Introduction
Respiratory conditions are the most common cause of hospitalization in children
between 1 and 17 years of age when numbers for pneumonia and asthma are
combine. Some respiratory conditions are chronic and have a significant impact
on the child’s growth and development. However, most respiratory problems in
children produce mild symptoms, last a short time, and can be manage at home.
Anatomy and physiology
The respiratory tract consists of upper and lower airway structures. Upper airway
structures begin with the oronasopharynx, the passageway connecting the nasal
airway to the trachea. Because the oral area is a shared passageway to the
esophagus as well as the pharynx and larynx, inflammation in the area can impact
swallowing as well as breathing. The pharynx and upper trachea, which contains
the glottis or vocal cords and epiglottis of the larynx, have an impact on speech as
well as breathing.

2
UPPER RESPIRATORY TRACT INFECTIONS ACUTE VIRAL NASOPHARYNGITIS

ACUTE VIRAL NASOPHARYNGITIS

Acute viral nasopharyngitis (AVN) is referred to as the common cold and may be
caused by a number of viruses such as Rhinovirus Respiratory syncytial virus (RSV)
Influenza virus Para-influenza virus
Signs and Symptoms
Symptoms are more severe in infants than in children.
The most prevalent symptom is fever along with Irritability.
Restlessness.
Decreased appetite.
Decreased activity.
Nasal stuffiness and discharge.
Muscular aches.
Cough.
Occasionally fever may recur or the child might experience otitis media
The diagnosis& Treatment
Diagnosis for AVN is usually made on the child’s history and physical exam.
Affected children usually have a normal WBC count.
Treatment:
There is no specific treatment for AVN. Children are usually treated at home.
Antipyretics are prescribe for mild fever and discomfort. Decongestants may be
prescribed for children and infants >6 months of age.

3
Nursing Intervention
A thorough nursing assessment is essential.
Education and support to the caregiver
Provide nursing care and teach family members to :
• Assess hydration.
• Note color of nasal drainage, duration of fever.
• Monitor for the presence of respiratory distress or complications from a more
severe condition:
- Wheezing or shortness of breath Respiratory rate >50 to 60 breaths/minute for
infant, listlessness or irritability and crying Persistent cough >2 days Refusing food
or drink Poor sleeping pattern
Preventing Influenza Infection
Yearly vaccination against influenza is recommended
for high-risk groups. Children who are 6 months or older
considered high risk are those who:
Have chronic heart or lung conditions
Have sickle cell anemia or other hemoglobinopathy
Are under medical care for diabetes, chronic renal disease, or immune deficiency

4
 TONSILLITIS AND PHARYNGITIS
Tonsillitis and pharyngitis are common viral infections in children; however, 20%
of acute tonsillitis and pharyngitis are caused by group A b-hemolytic streptococci
(GABHS) and can lead to significant health problems.
Signs and Symptoms
Sore throat.
Difficulty swallowing.
Fever.
Most manifestations are by inflammation.
As the palatine tonsils enlarge with edema, they may meet midline of the throat
and cause the child to have difficulty swallowing and breathing. Mouth breathing
leads to offensive mouth odor. Persistent cough.
Children with GABHS may experience :• Headache • Abdominal pain • Nausea •
Vomiting • Diarrhea
Diagnosis & Treatment
Throat cultures positive for GABHS infection antibiotic treatment.
Treatment of viral tonsillitis and pharyngitis is symptomatic.
Warm saline gargles.
Analgesics and antipyretics.
If left untreated, GABHS infections can lead to:
• Otitis media • Suppurative infections of surrounding tissues

5
 Otitis media
Is the inflammation of the middle ear. may be the result of upper respiratory tract
infection. 40% to 50% of the infection are viral the bacterial cases 50% caused by
streptococcus pneumonia.
Infants are more prone to ear infections because the Eustachian tube is shorter,
wider, and straighter than older children.
Because babies lie flat for long periods, microorganisms have easy access from
the Eustachian tube to the middle ear.
Common Causes
Eustachian tube dysfunction
Previous URI causes mucous membranes of the Eustachian tube to become
edematous and blocks tube.
Enlarged adenoids , Allergic rhinitis

Types of otitis media:

1- Suppurative or purulent otitis media
It is most commonly caused by S.pneumonia and H.influenza.
2- Nonsuppurative otitis media with effusion:
The cause is unknown and is the most common cause of hearing loss in children.
Signs and symptoms of otitis media
1. Ear pain
2. Irritability
3. Sucking or chewing has tendency to increase the pain
4. High fever up to 40c
5. Vomiting and diarrhea
6. Ear discharge

6
How the nurse suspect an earache in infant?
The infant who:
Rubs the ear frequently or pull it.
Rolling the head from side to side
Pus may be drain from the ear
Complications of otitis media
Hearing loss
Mastoiditis
Chronic otitis media
Meningitis
Nursing Management for OM
Nursing objectives:
Relieving pain
Facilitating drainage when possible
Preventing complications or recurrence
Educating the family in care of the child
Educate regarding prevention
Providing emotional support to the child and family
Antibiotics for 10 days ( amoxicillin is the drug of choice)
Pain relive and fever by analgesics and antipyretic
Warm and cold compress may be applied to ear
If the ear is draining the outer canal can be cleaned with sterile water
Children should be fed in upright position and should not put on bed with a
bottle.

7
 Croup (spasmodic laryngitis)
Croup is a general term applied to a complex syndrome that ranges from
infections of the larynx . This is a serious obstructive inflammatory process and
requires immediate attention.
Occur in children b/w 1-3 years, the attack may be proceed the runny nose,
hoarseness during evening.
Signs & Symptoms
Croup
Viral
Usual age range: 1-3 yrs
Fever
Hoarseness
Resonant cough
Stridor (inspiratory)
Risk for significant narrowing airway with inflammation
Humidity for treatment
Treatment
The major objective for treatment is medical management of the infectious
process and maintaining an airway for adequate respiratory exchange. Children
with mild croup without stridor are managed at home. High humidity with cool
mist provides relief in most cases. Fluids are essentials for recovery. If the child is
unable to take fluids, intravenous fluid therapy is initiated.
Nursing Interventions
Observation and accurate of assessment of the respiratory status.
Noninvasive cardiac, respiratory, and blood gas monitoring.
Ensure intubation equipment is immediately accessible to the patient.

8
Keep the child comfortable.
Allow the parent or caregiver to lie next to the child in the mist tent to lessen
anxiety.

Epiglottitis
Epiglottitis is a serious and frightening disease for the child and family. It is
important to act quickly but calmly and provide support without increasing
anxiety.
The child is allowed to remain the position that provides the most comfort and
security, and parents are reassured .
Signs& Symptom
Bacterial
Usual age range 3-7 yrs
High fever
Rapidly progressive course
Dysphagia
Drooling
Dysphonia
Distressed inspiratory efforts
Antibiotics needed
Diagnosis & Treatment
Chest films
WBC with differential count
Treatment:
Intensive observation by experience personnel. Endotracheal intubation.
Tracheostomy.

9
All invasive procedures should be performed in the operating room or areas
equipped to initiate immediate intubation.
Antibiotic therapy.
Nursing Interventions
Reassure the child and family to reduce anxiety.
Avoid assessment of the oral cavity with a tongue blade.
Allow the child to remain in the caregiver’s lap and in the position that is most
Comfortable.

Pneumonia
Definition
Pneumonia is a pulmonary infection with inflammation that develops after
someone inhales airborne pathogens or aspirates pathogens in secretions from
the upper respiratory or gastrointestinal tract.
Classification
- bacterial
- viral
- fungal
Depending on the patient's clinical and X-ray findings, pneumonia is further
classified as lobar pneumonia (affecting one or more lobes), bronchopneumonia
(affecting the terminal bronchial tree, distal airways, and alveoli), or inflammation
of the interstitial space.
Clinical manifestations
Fever
Cough (note type and whether productive or not)
Increased respiratory rate

10
 Childhood Asthma

Asthma is a chronic inflammatory disorder of the airways. It is characterized by

chronic inflammation, bronchoconstriction, and bronchial hyper-responsiveness.
Asthma is the most common chronic respiratory illness in the childhood
population.
Most common chronic disease of childhood , primary cause of school absences.
It is also the leading cause of emergency department visit, and hospital admission.

12
Triggers of Asthma
Allergens such as foods ,perfumes , dust mites and animal dander.
Respiratory Infections mainly viral infection.
Cold air
Nose and Sinus problems
Drugs and Food Additives
Cigarette smoke
Exercise
Emotional Stress
Family history
Clinical manifestations
Expiratory wheezing
Chronic cough
Dyspnea (shortness of breath or difficulty in breathing)
Nonproductive cough
Tachypnea
Chest pain
Irritability
Restlessness
Use of accessory muscles
Orthopnea (an increase in difficulty breathing when students are lying down)

13
Asthma Diagnostic Studies
Detailed history and physical examination are of primary importance in diagnosis
Pulmonary function tests
Peak flow monitoring
Chest x-ray
Oxygen saturation monitoring can help determine the severity of episode.
ABGs
Blood levels of eosinophil
Complications
Asthma may cause a number of complications, including:
•Severe asthma attacks that require emergency treatment or hospital care
•Permanent narrowing of the airways (bronchial tubes)
•Missed school days or getting behind in school
•Poor sleep and fatigue
•Symptoms that interfere with play, sports or other activities
Treatment and nursing care
The goal of treatment is to appropriately manage the condition so the child can
maintain optimal life style and development.
The treatment is focused on:
- Reducing episodes
- Minimizing the inflammatory process
- Decreasing the number of hospitalization
- Avoiding precipitating factors
- Facilitating normal growth and development.

14
Treatment and nursing care
Eliminate the allergic factor
Medications are classified into two categories:
- Long term medication (controllers)
- Short term medication (relievers )
Preferred route of administration is inhalation via nebulizer or metered dose
inhaler.
Acute exacerbations of asthma treated with nebulized albuterol every 20 minute
for 1 hour with oxygen.
On admission:
- Place the child in a high fowler's position
- Oxygen is given with nasal prongs, hood or mask.
- Nebulized albuterol is continued either continuously or intermittently.
- IV fluid
- Intravenous steroids are administered to control the inflammatory process
- Before discharge the treatment is change to oral medication.
Children and their families must be taught to recognize:
The symptoms that leads to an acute attack so they can be treated as early as
possible.
Asthma triggers.
Medication administration
How to use a peak flow meter

15
Asthma Drug Therapy
Bronchodilators ( -adrenergic agonist e.g salbutamol
Useful in preventing bronchospasm precipitated by exercise and other stimuli
Overuse may cause rebound bronchospasm
Too frequent use indicates poor asthma control and may mask severity
Anti inflammatory drugs
Corticosteroids (e.g., beclomethasone, hydrocortizone, predinsolone, fluctisone))
Suppress inflammatory response
Inhaled form is used in long-term control
Systemic form to control exacerbations and manage persistent asthma
Health Promotion
Teach patient to identify and avoid known triggers
Use dust covers
Use of scarves or masks for cold air
Avoid aspirin or NSAID
Prompt diagnosis and treatment of upper respiratory infections and sinusitis may
prevent exacerbation
Fluid intake of 2 to 3L every day
Adequate nutrition
Adequate sleep
Take -adrenergic agonist 10 to 20 minutes prior to exercising

16
Peak Flow meter
Peak Flow Results
A peak flow meter is a portable device that measures air flow, or peak expiratory
flow rate (PEFR).
Green zone
Usually 80-100% of personal best
Remain on medications
Peak Flow Results
Yellow zone
Usually 50-80% of personal best
Indicates caution
Something is triggering asthma
Red zone
50% or less of personal best
Indicates serious problem
Definitive action must be taken with health care provider
Interpreting Peak Expiratory Flow Rates
Green: (80-100% of personal best) signals all clear and asthma is under
reasonably good control
Yellow (50-79% of personal best) signals caution; asthma not well controlled; call
dr. if child stays in this zone
Red (below 50% of personal best) signals a medical alert. Severe airway narrowing
is occurring; short acting bronchodilator is indicated

17
 Pediatric Respiratory Disorder Requiring Surgery
Tonsillectomy
Are surgical removal of tonsillar structure, this is the part of lymphoid
tissue, it is the first line of defense against respiratory infections .
Peak incidence in children is 3-6 years
Is the most frequently performed surgical procedures in the children.
Indications for Tonsillectomy
Recurrent or persistent tonsillitis with documented streptococcal infection four
times in 1 year.
Enlargement that interferes with breathing (Obstructive Sleep Apnea).
Marked hypertrophy of tonsils, which distorts speech, causes swallowing
difficulties, and causes subsequent weight loss.
Tonsillar malignancy.
-Contraindications to Surgery:
Bleeding or coagulation disorders.
Uncontrolled systemic disorders (.e.g. diabetes, rheumatic fever, cardiac or renal
diseases).
Child younger than 4 years , unless life-threatening situation.
Presence of upper respiratory infection in child or the person who given care for
child.
Repeated chest infection.
-Complications:
If untreated lead to:
Obstructive sleep apnea in the child result in pulmonary hypertension.
Failure to thrive .
Respiratory failure

18
 Attention deficit disorders.
Cardiac arrhythmias.
Chronic otitis media may result in hearing loss, mastoiditis, and meningitis.
Complications of surgery include:
Hemorrhage .
Reactions to anesthesia .
Bacteremia.+
-Nursing management:
Pre operative:
1. Preoperative investigation (bleeding &clotting time is very important
because prolonged bleeding and clotting time is indication for delayed
surgery.
2. Assure that the child is well hydrated before NPO Start.
3. Antibiotic as order.
4. Reassure parents that complication rates is low and that recovery is usually
swift.
5. Prepare the child specifically for what expect post-operatively, using
technique appropriate to the child's developmental level
Post operative:
Assist the child in maintaining a patent air way by drainage secretions and
preventing aspiration of vomiting, by place the child prone or semi prone with
head turned to side while still under the effect of anesthesia, then allow the child
to assume comfort position when alert.
Remind the child not to cough unless necessary.
Provide ice collar to neck .(remove ice collar if the child becomes restless).
Assess for evidence of bleeding (frequent swallowing, pallor, restlessness,
increase pulse rate……).

19
Provide cool liquid not thick or red 1-2hrs after full recovery from anesthesia,
continue for 12-24hrs.
Administer analgesic and antibiotic as order.

20
 MCQ, Matching

Nursing Management for child with hemolytic disorders

LEARNING OBJECTIVE
At the end of the unit, the student will be able to:
1. Describe the assessment signs and symptoms seen in children with blood
disorders.
2. Recognize common blood disorders in children.
Introduction:
A hematological disorder in a child can have various causes, including injury,
nutritional deficit, genetic disorder, infection, congenital problem, or any number
of blood-related conditions
Hematopoiesis
(blood-formation)
Blood is composed of two parts:
1- The fluid portion called plasma.
The solutes in the plasma include albumin, electrolytes, proteins, clotting factors,
fibrinogen, globulins, and circulating antibodies.
2- The cellular portion.
cellular portion consists of the formed elements (red blood cells [RBCs], white
blood cells [WBCs], and platelets).
function of the RBCs : transport hemoglobin that carries oxygen from the lungs to
the tissues life span of a normal RBC is approximately120 days
Leukocytes (WBCs) are mobile units of the body’s protective system. Most
leukocytes migrate to areas of serious inflammation and provide a rapid defense
against any foreign agent.

21
Differences between child and adult hematological systems
In infants and young children all of the bone contains red marrow .
At the end of adolescence, only the ribs, sternum, vertebrae, and pelvis continue
to produce blood cells. The remainder of the bone marrow becomes yellow from
deposition of fat.
Common Hematological conditions
Several conditions can occur in children. Some of these are acute in nature and
with proper care can be easily managed.
Others can be life threatening or cause a chronic illness that can permanently
impact on lifestyle of the child and his or her family.
Signs of blood disorders:
There are some weighty clinical signs that directly show on blood disorders. They
are:
Hemorrage (bleeding);
Hematoma;
Enlargement of lymph nodes;
Pallor;
Ossalgia (pain in bones).
Other complaints:
Often headaches,
Dizziness
decreases attention span,
hyperthermia,
Apathy,
Shortness of breath,
Easy fatigability.

22
 Common Hematological Conditions
ANEMIA
One of the most common hematological conditions of infancy and childhood is
anemia
Anemia exists when the hemoglobin content is less than required to meet the
oxygen demands of the body
Normal hemoglobin (Hgb) (g/dL) lab values for children are:
Newborn: 12.7–18.6
2 Months: 9.0–14.0
2 Years: 10.5–12.7
6–12 Years: 11.2–14.8
12–18 Years: 10.7–15.7
Causes of anemia:
Decreased Production of RBCs:
Iron Deficiency Anemia
Aplastic Anemia
Increased Destruction of RBCs:
Hemolytic Anemia
Sickle Cell Anemia
Thalassemia
Blood loss:
Hemorrhagic Anemia

23
Classification of anemias:
Morphologic (describe the size of RBCs):
(1) normocytic,( normal RBC size)
(2) microcytic,( small RBC size)
(3) macrocytic. (large RBC size)
Anemia. Assessment
Take health history:
Careful diet history to identify any deficiencies.
Observe for manifestations of anemia:
Muscle weakness
Easy fatigability:
frequent resting,
shortness of breath,
poor sucking (infants)
Manifestations of anemia
Pale skin, mucous membranes, lips, nail beds, and conjunctiva
Waxy pallor seen in severe anemia
Capillary refill – no change color
Rapid heart beat
CNS manifestations:
Headache
Dizziness
irritability
decreases attention span

24
Apathy
Depression.
Manifestations of severe anemia
Loss of skin elasticity
Thinning and early greying of the hair
Abdominal pain,
nausea,
vomiting,
anorexia
Low-grade fever
Nursing management
Based on the etiology , to effectively replaced of the RBCs the underlying causes
must be identified.
For the mild anemia the nurse can provide supportive care through diet and
vitamin supplement.
Moderate to severe anemia RBCs transfusion to restore blood volume.
The family must be made aware of the clinical signs and symptoms indicate
anemia
Nurse can teach the family that alterations in daily activities may be necessary
such as quit play, allowing period of rest, and diet high iron.

25
 Sickle-cell anemia

Sickle cell anemia is autosomal recessive genetic defect disease in which the body
produces abnormally shaped red blood cells.

26
The cells are shaped like a crescent or sickle. They don't last as long as normal,
round red blood cells (shortened RBC life span), weakened RBCs, hemolysis which
leads to anemia.
The sickle cells also get stuck in blood vessels, clump together blocking blood
flow. This can cause pain and organ damage crises.
Sickling caused by decreases in blood oxygen may be triggered by dehydration,
infection, physical or emotional stress or exposure to cold.
The primary defect in this genetic disease is that the globulin chain in normal
hemoglobin A (Hb A) is partially or completely replaced by hemoglobin S (Hb S).
Hemoglobin S has a substitute of the amino acid valine for glutamine which is
more sensitive to the changes in the oxygen concentration in the blood.
When the child has large amount of hemoglobin S and a decrease in the oxygen
levels, these abnormal hemoglobin clump together within the cell and change the
sickle shape.
SICKLE CELL ANEMIA – Manifestations:
Take health history, especially regarding any evidence of sickling crisis and history
of the disease in family members.
General signs:
Growth retardation
Chronic anemia
Delayed sexual maturation
Marked susceptibility to sepsis
Other signs and symptoms
weakness; anorexia; joint, back, and abdominal pain; fever; and vomiting.
Chronic leg ulcers are common in adolescents and adults and are thought to be
the result of thrombosis and decreased peripheral circulation.

27
Sickle cell crises
It is the painful episodes of the disease, it recur periodically throughout
childhood, however they tend to decrease with age.
Precipitating factors:
Hypoxia From:
high altitude, hypoventilation, and
vasoconstriction due to hypothermia
Excessive exercise
Types of crisis
Vaso-occlusive:
Pain in area(s) of involvement
Signs of ischemia:
Extremities: painful swelling (“hand-foot” syndrome), painful joints
Abdomen: severe pain resembling acute surgical condition
Cerebrum: stroke, visual disturbances
Liver: obstructive jaundice, hepatic coma
Kidney: hematuria
Acute chest syndrome:
Pulmonary infracts
Signs:
-chest pain
-cough
-hypoxia
-fever
-tachypnea
28
Splenic sequestration
Life threatening—death can occur within hours, commonly preceded by acute
febrile illness.
Blood pools in the spleen
Signs
Profound anemia, enlarge spleen , irritability , dyspnea, tachycardia, hypotension
hypovolemia, and shock.
Diagnostic evaluation
For screening purposes:
the Sickle-dex is commonly used. If the test is positive, hemoglobin
electrophoresis is necessary to distinguish between those children with the trait
and those with the disease.
Sickling test (sickle cell slide preparation): place a drop of blood on a slide and
cover it with a sealed cover slip to produce de-oxygenation. Eventually sickling of
the red blood cell occurs.
Medical Management
Treatment
During the crisis, the use of oxygen, the maintenance of good hydration,
correction of acidosis by electrolyte replacement, rest and Pain management
Aggressive treatment of infection
Possible prophylactic antibiotics from 2 mos-5 yrs
Monitor reticulocyte count regularly to evaluate bone marrow function
Blood transfusion, if given early in crisis, may reduce ischemia
Rx—Hydroxyurea (Cytotoxic) decreases production of abnormal blood cells and
decreases pain
Folic acid, - Penicillin tabs as prophylactic
Pain killer during the acute crisis and morphine is drug of choice.

29
Nursing Management
Should focus on encouraging rest, hydration, pain control and adequate
oxygenation.
Increase fluid intake (orally or intravenously ).
Pain control can pharmacological and nonpharmacological method.
Monitor respiratory status and oxygenation.
If abnormal findings are detected the nurse must immediately inform the medical
team so treatment can begin.
The nurse must remember that pneumonia and pulmonary infarcts occur.
Educate the family about chronic disease care.
Monitor child’s growth—watch for failure to thrive
Careful multi-system assessment
Assess pain
Observe for presence of inflammation or possible infection
Carefully monitor for signs of shock
Keep the child well hydrated during the school day
Case Study
A is a 16years old boy with a history of sickle cell disease admission to the hospital
for pain crisis and blood transfusion . Today , in the emergency room the child
complains of pain in his chest and fever .During the physical assessment the
nurse notes that his lung are congested and that has moist. cough. His oxygen
saturation is 86% on room air.
Questions
In addition to respiratory status what are the other crisis this child can have?
What are the nursing intervention according to the child findings?
What information will the nurse teach the parent regarding their child?

30
Avoid aspirin
In case of need for surgery should be carried out under cover of replacement
therapy
Provide appropriate activity to lessen the chance of trauma.
Select safe toys

MCQ,Matching

Nursing of children with Acquired heart disease

Nursing Management of children with Rheumatic Fever

Rheumatic Fever
Is a chronic disease of childhood affecting the connective tissue of the heart,
joints, lungs and brain.
Is precipitated by streptococcal infection such as strep throat, tonsillitis or
pharyngitis, which may be undiagnosed or untreated.
Presentation
Acute rheumatic fever (RF) is a systemic disease. Thus, patients may present with
a large variety of symptoms and complaints.
History of sore throat 1-5 weeks prior to onset is present in 70% of older children
and young adults. Only 20% of younger children can recall sore throat.
Other symptoms on presentation may include fever, rash, headache, weight loss,
epistaxis, fatigue, malaise, diaphoresis, and pallor.
Patients also may have chest pain with orthopnea or abdominal pain and
vomiting.
Finally, history may reveal symptoms more specific to rheumatic fever.

33
Major diagnostic criteria
Carditis-clinical and/or subclinical (echo)
Polyarthritis (mono-arthritis or poly-arthralgia are adequate to achieve a major
diagnostic criteria in Moderate/High-risk populations; for poly-arthralgia exclusion
of other more likely causes is also required)
Chorea
Subcutaneous nodules
Erythema marginatum
Minor diagnostic criteria
Fever ≥38.5o C (≥38o C to achieve a minor diagnostic criteria in Moderate/High-risk
populations)
Polyarthralgia (Monoarthralgia is adequate to achieve a minor diagnostic criteria
in Moderate/High-risk populations)
Prolonged PR interval for age on electrocardiography
Elevated peak erythrocyte sedimentation rate during acute illness ≥60 mm/h
and/or C-reactive protein ≥3.0 mg/dl
Major clinical manifestations
Arthritis
Polyarthritis is the most common symptom and is frequently the earliest
manifestation of acute rheumatic fever (70-75%).
Characteristically, the arthritis begins in the large joints of the lower extremities
(ie, knees, ankles) and migrates to other large joints in the lower or upper
extremities (ie, elbows, wrists).
Affected joints are painful, swollen, warm, erythematous, and limited in their
range of motion. The pain is out of proportion to clinical findings.
The arthritis reaches maximum severity in 12-24 hours and persists for 2-6 days
(rarely more than 4 wk).

34
The arthritis responds rapidly to aspirin, which decreases symptoms in affected
joints and prevents further migration of the arthritis.
Polyarthritis is more common and more severe in teenagers and young adults
than in younger children.
Carditis
Pancarditis is the most serious complication and the second most common
complication of rheumatic fever (50%).
In advanced cases, patients may experience of dyspnea, mild-to-moderate chest
discomfort, pleuritic chest pain, edema, cough, or orthopnea.
Upon physical examination, carditis is most commonly revealed by a new murmur
and tachycardia . The murmurs of acute rheumatic fever are from valve
regurgitation, and the murmurs of chronic rheumatic fever are from valve
stenosis.
Congestive heart failure (CHF) may develop secondary to severe valve
insufficiency or myocarditis
Diagnostic Evaluation
Throat culture for group A beta-hemolytic streptococci and blood sample for titter
of streptococcal antibodies ( antistreptolysin O, or ASO titer) to support evidence
of recent streptococcal infection.
Complete blood count, ESR, and C-reactive protein for changes described above.
Baseline ECG and echocardiogram may be done to evaluate valve function.
Chest x-ray for cardiomegaly or heart failure.
Pharmacologic Interventions
Antibiotics to treat streptococcal infection – generally I.M. penicillin or
erythromycin in penicillin allergy.
Corticosteroids for patients with carditis complicated by heart failure to prevent
permanent cardiac damage.

35
Salicylates or nonsteroidals for patients with arthritis (but not while on high-dose
corticosteroids because of risk of GI bleeding) and antipyretics to control fever,
after diagnosis has been established.
Phenobarbital, diazepam if chorea is present.
Prophylactic antibiotics for at least 5 years after ARF.
Nursing intervention
Monitor temperature frequently, and patient’s response to antipyretics.
Monitor the patient’s pulse frequently, especially after activity to determine
degree of cardiac compensation.
Auscultate the hear periodically for development of new heart murmur or
pericardial or pleural friction rub.
Observe for adverse effects of salicylate or nonsteroidal anti-inflammatory drug
(NSAID) therapy, such as stomach upset, tinnitus, headache, GI bleeding, and
altered mental status.
Explain the need to rest (usually prescribed for 4 to 12 weeks, depending on the
severity of the disease and health care provider’s preference) and assure the
patient that bed rest will be imposed no longer than necessary.
Monitor the patient’s response to long-term activity restriction.
Restrict sodium and fluids and obtain daily weights as indicated.
Administer medications punctually and at regular intervals to achieve constant
therapeutic blood levels.
Assist the patient to resume activity very gradually once asymptomatic at rest and
indicators of acute inflammation have become normal.
Provide comfort measures. - Provide safe, supportive environment for the child
with chorea. - Observe for the disappearance or any major or minor
manifestations of the disease and report signs of increased rheumatic activity as
salicylates or steroids are being tampered.
Encourage continuous prophylactic antimicrobial therapy to prevent recurrence.

36
 MCQ,Matching
NURSING CARE OF CHILDREN WITH GASTROINTESTINAL DISORDERS
Learning objectives:
By the end of this unit, the student nurse will be able to:
Define the common gastrointestinal disorders.
Mention the etiology and causative organisms of these disorders.
Design the nursing process to different gastrointestinal disorders.
Provide health education to parents regarding the management and prevention
of common gastrointestinal disorders.

INTRODUCTION
Focuses on most common gastrointestinal disorders such as,thrush stomatitis
,vomiting, colic, constipation, diarrhea and dehydration, major nursing
diagnostic and nursing intervention related to recognition and management of
the child.

Stomatitis
Definition:
Inflammation of the mucous membrane of the mouth. It may be due to local
lesion in the mouth or a feature of a systemic disease e.g. measles.
Causes of stomatitis:
Infection:
Viruses: measles, primary herpes simplex, coxsackie A.
Bacteria: streptococcus, diphtheria.
Fungus: monilia coral thrush.
Eruption stomatitis: associated with eruption of teeth.
Traumatic: cheek biters.
Local reactions: due to sensitivity to contact substances from toys and foods.
37
Immunological impairment: in leukemias.
Drugs and poisons: phenytoin, salicylates, corrosives.
Types of Stomatitis:
Catarrhal stomatitis.
Herpetic stomatitis.
Thrush stomatitis.
Thrush stomatitis:
Definition
It is a "fungus infection" of the skin and mucous membrane of the mouth
characterized by white patches, resembling milk curds.
Etiology
Candida infection is due to inadequate sterilization of bottles or from mother's
breast of the attendant's hand. Newborns are infected during passage in birth
canal.
Assessment:
Mouth contains white patches, which resembles milk curds (it is difficult to
remove and if removed bleeding occurs). Also there discomfort during feeding.
Nursing management:
Treatment should be continued for one week after recovery prevent recurrence.
Cleanliness and sterilization of the feeding bottles.
The infant's mouth is gently painted three times daily with 1% solution of gentian
violet.
This may be combined with nystatine, 100.000 units by month, 3 – 4 times daily.
Mother's nipple and areola painted with nystatine ointment between meals.

38
Diarrhea Disorders
Definition:
It is defined as "An increase in the fluidity, volume and number of stools relative
to the usual habits of each individual".
Factors promoting the transmission of enteric pathogens:
Failure to breast – feed exclusively for the 1st 4 – 6 months.
Using infant feeding bottles (easily contaminated).
Inappropriate storing of cooked food.
Using drinking water contaminated with bacteria.
Poor personal hygienically
Failing to wash hands.
Young age (highest incidence in the age group 6 – 12 months).
Malnutrition.
Measles in the previous 4 weeks.
Immunodeficiency.
Season:
Bacterial diarrheas are more frequent in summer.
Rotavirus is more frequent in winter but occur throughout year.

Types of diarrhea:
Acute Watery Diarrhea: (80% of cases)
This refers to diarrhea that begins suddenly; it persists for 3 - 4 days then
gradually improves over another 4 - 5 days. It is usually self-limited (lasts less than
14 days) and involves the passage of frequent loose or watery stool without
visible blood.

39
Dysentery: (5 – 10% of cases)
This is diarrhea with visible fresh blood in the stools. Its sequelae include
anorexia and damage to the intestinal mucosa.
Persistent Diarrhea: (10% of cases)
Post infectious diarrhea that begins actually and lasts at least 14) days. Persistent
diarrhea is not chronic diarrhea which is recurrent or long- lasting due to non-
infectious causes. (e.g. metabolic disorders).
Dangers of diarrhea :
Dehydration, which might lead to death if not properly, treated.
Malnutrition: diarrhea is worse in child with malnutrition and can make it worst
because:
Nutrition is lost from the body in diarrhea.
Mothers may not feed their children during the episode or even for some days
after the diarrhea improves.
N.B. The life span of intestinal mucosal cells is 3-5 days. New normal cells will
replace the destroyed cells damaged by toxins, within this period. This is why
diarrhea is usually a self-limited disease of 3-5 days duration.
Seriousness of diarrheal disorders during infancy :
Their higher needs for water exchange to meet their high metabolism.
Greater susceptibility of infants to infection .
Their smaller metabolic reserves of water and electrolytes.
Therefore, with limited intake and /or extra loss of fluid during diarrhea, acute
dehydration usually occurs
Causes of diarrhea:
1- Enteropahtogenic: (infectious diarrhea)
Viruses (rotavirus) (15 – 25% of cases).
Bacteria (E.Coli 10 – 20% of cases), (shigell 5 – 15% of cases).

40
Protozoa (cryptosporidium 5-15% of cases).
Other less common pathogens include (Giardia - doudenaris, Entamoeba
histoloticày andsalomnella).
2- Dietary :
A-Formula feeding problems:
Contaminated feeding bottles.
Overfeeding.
Over concentrated formula.
Excess sugar or fat in formula.
B-Weaning food problems:
Introduction of food, which is not suitable for the age.
Unripe fruits.
Introduction of new food.
Improperly cooked diet.
Malnutrition .
3- Some parenteral infections:
Pneumonia and otitis media may be accompanied by diarrhea. It may actually be
due to an associated intestinal infection.
Communicable diseases (e.g. measles) diarrhea occurs due to immunological
impairment.
4- Miscellaneous:
Emotional tension & Irritable colon.
Antibiotic
5- Malabsorption:
Cystic fibrosis, celiac disease.

41
Nursing management of diarrhea
Nursing Assessment:
It includes taking the child's history, measuring weight and temperature and
Assessing the degree of dehydration.
1- History:
Child characteristics (age and sex) and socioeconomic background (home
environment, income, education, occupation, beliefs .... etc).
Duration of the episode.
Frequency and consistency of stool.
Presence or absence of mucus, pus or blood in stool.
Patient's ability to drink and or presence of thirst.
Presence of vomiting, fever or other problems (cough, otitis media).
Last time urine passed.
Feeding practices before and during illness.
Treatment during this episode (ORS, drugs).
Vaccination taken especially measles vaccine.
2- Assessment of the degree of dehydration:
Assessment of the degree of dehydration is based on 4 signs which are the most
important to be detected
Prevention of diarrhea:
1- Promotion of breast-feeding
2- Improved weaning practices
3- Proper use of water for hygiene and drinking:
4- Personal hygiene
5- Safe disposal of stools of young children

42
 Dehydration
Introduction:
Is a condition that can occur with excess loss of water and other body fluids.
Dehydration results from decreased intake, increased output .
Causes of dehydration
Gastroenteritis (diarrhoea and vomiting)
Mouth ulcers, stomatitis, pharyngitis, tonsillitis: pain may severely limit oral
intake
Diabetic ketoacidosis (DKA)
Febrile illness: fever causes increased insensible fluid losses
Burns: fluid losses may be extreme and require aggressive fluid management
Heat stroke
ASSESSMENT
Loss of body weight:
o Mild dehydration: 5-6% loss of body weight.
o Moderate: 7-10% loss of body weight.
o Severe: over 10% loss of body weight.
Assessment of skin fold (Skin turgor ):
Skin turgor is assessed by pinching the skin of the abdomen or thigh longitudinally
between the thumb and the bent forefinger
- Normal: skin fold retracts immediately.
- Mild or moderate dehydration: slow; skin fold visible for less than 2 seconds.
- Severe dehydration: very slow; skin fold visible for longer than 2 seconds.

43
Other features of dehydration include:
dry mucous membranes,
reduced tears and
decreased urine output.

Clinical features of mild-to-moderate dehydration; 2 or more of the following

signs:
Restlessness or irritability.
Sunken eyes (also ask the parent)
Thirsty and drinks eagerly
Skin turgor

44
Clinical features of severe dehydration; 2 or more of the following signs:
Abnormally sleepy or lethargic.
Very sunken eyes.
Drinking poorly or not at all
Skin turgor
Additional signs of severe dehydration include :
circulatory collapse (e.g. weak rapid pulse, cool or blue extremities,
hypotension),
rapid breathing,
sunken anterior fontanels

45
Sunken eyes

Very Sunken eyes

46
Signs and symptoms of dehydration

47
CLINICAL ASSESSMENT OF DEHYDRATION

Mild Moderate Severe

Weight loss Up to 5% 6-10% More than 10%

Appearance Active, alert Irritable, alert, thirsty Lethargic, looks sick

Capillary filling Normal Slightly delayed Delayed

(compared to your own)

Pulse Normal Fast, low volume Very fast, thready

Respiration Normal Fast Fast and deep

Blood pressure Normal Normal or low Very low

Orthostatic hypotension

Mucous memb. Moist Dry Parched

Tears Present Less than expected Absent

Eyes Normal Normal Sunken

Pinched skin Springs back Tents briefly Prolonged tenting

Fontanel (infant sitting) Normal Sunken slightly Sunken significantly

Urine flow Normal Reduced Severely reduced

48
When we talk of 5% dehydration, it means that the child has lost an amount of
fluid equal to 5% of the body weight. So,
- A 10 kg child who is 5% dehydrated will weigh 9.5 kg.
A 10 kg child who is 10% dehydrated will weigh 9 kg.
A 5 kg child who is 10% dehydrated will weigh 4.5 kg.
- The child's current (dehydrated) weight can be used for calculation of
dehydration and maintenance fluids. After all, clinical assessment of dehydration,
and therefore the volume needed for correction, is approximate!

Dehydration management
Address emergent :
airway, breathing, and circulatory problems first.
Obtain intravenous access.
Give a 20 mL/kg isotonic fluid bolus (Ringer lactate or normal saline) to children
with severe dehydration with shock
Mild dehydration management
Encouraged to continue an age-appropriate diet and adequate intake of oral
fluids.
Oral rehydration solution (ORS) should be used.
Children should be given sips of ORS (5 mL or 1 teaspoon) every 2 minutes.
As an estimate for the amount of fluid to replace, the goal should be to drink 10
mL/kg body weight for each watery stool and estimate volume of emesis for each
episode of vomiting.
Arrange outpatient follow-up evaluation within 48 hours.
Instructions to return sooner if symptoms worsen.

49
Moderate dehydration management
Children with moderate dehydration may require inpatient treatment.
Oral Rehydration Solution, child should receive approximately 50-100 mL/kg body
weight over 2-4 hours, starting with 5 mL every 5 minutes.
Children in whom ORS fails should be given a bolus (20 mL/kg) of isotonic fluid
intravenously.
Fluid Maintenance
Body Wt Fluid per day
0 – 10 kg 100 ml/kg
11 -20 kg 50 ml/kg
More than20 kg 20ml/kg
e.g. a child of 25kg with dehydration
First 10 kg = 1000 ml
Second 10 kg = 500 ml
Remaining 5 kg = 100 ml
Total = 1600 ml/ day
i.e. per hr = 67 ml/ hr
ORAL REHYDRATION SOLUTION (ORS)
ORS components
WHO/UNICEF
Na = 90 mmol/l
k = 20 mmlo/l
cl = 80 mmol/l
glucose = 111mmol/l
Osmol = 311 mmol/l

50
Hypo-osmolar ORS
It is preferred in severely malnourished (marasmic) child as the standard (old)
WHO ORS may cause hypernatremia
WHO vs. Hypo-osmolar ORS
WHO/UNICEF Hypo-osmolar
Na = 90 mmol/l Na = 60 mmol/l
k = 20 mmlo/l k = 20 mmlo/l
cl = 80 mmol/l cl = 50 mmol/l
glucose = 111mmol/l glucose = 84 mmol/l
Osmol = 311 mmol/l Osmol = 224 mmol/l

51
 Celiac Disease
Also known as celiac sprue and gluten-sensitive enteropathy.
Is a genetic disease that results in the inability to digest gluten.
This is a permanent disorder that affects about 1 in 1000 live birth.
Gluten is a protein found in wheat, barley, rye and oats.
Gluten breaks down into gliadin in the small intestine.
Signs and symptoms
In celiac disease the gliadin cannot be digested and damage to intestinal mucosal
cells occurs.
Malabsorption
Failure to thrive
Chronic diarrhea
Abdominal distention
Muscle wasting
Anorexia
Irritability
Stools are foul-smelling and fatty in appearance because of the malabsorption
Diagnosis
A serum anti-gliadin antibody (AGA) test
A small bowel biopsy
Nursing management
All gluten is to be removed from the child diet .
Foods containing wheat , barley rye and oats should not be eaten by the child
Rice ,corn ,and soy are safe to eat if no gluten has been added to them.

52
Consult a dietitian to design a gluten free diet.
Symptoms may be relieved in as early as 1 week after introducing a gluten –free
diet.
Vitamin supplementation.

Pediatric Gastrointestinal Disorders Requiring Surgery

Cleft Lip and Palate
Congenital anomalies resulting in structural facial malformation. Can occur
unilateral or bilateral. Either type can occur with or without a cleft of the hard or
soft palate.
Cleft lip with or without cleft palate occur more frequently in boy and associated
cleft palate is more frequently in girls.
Occurs between 5-8 weeks of fetal life .
-Diagnosis:
1. Cleft lip.
a. Clinical appearance that may be noted prenatally via ultrasound or at birth.
2. Cleft palate.
a. May be seen visually when the child’s mouth is opened with good light source.
b. Even when the palate appears intact visually, both the hard and soft palates
must be assessed carefully with a gloved finger.
-Clinical Manifestations:
Physical appearance
- Incompletely formed lip .
- Opening in roof of the mouth felt by the examiner's finger on the palate.
53
Nursing management
Maintain adequate nutrition because cleft lip and palate present feeding
difficulties.
Breast feeding may be interrupted for a period time based on the need for
surgical repair.
Bottle feeding is usually initiated with a special nipple to help prevent aspiration.
Fed in upright position to decrease the incidence of regurgitation.
Surgical repair of cleft lip is typically done at 3 month of age and cleft palates are
usually repaired before 18 months.
Some clefts require more than one surgical procedure
Parent must be supported by having all treatments, feeding methods
Emotional support is needed

Hirschsprung’s Disease (often called

megacolon)

55
Incidence.
1. Hirschsprung’s disease is more common in boys
than in girls.
B. Etiology.
1. Cause is usually unknown, although it does occur in relation with some genetic
syndromes (e.g.Down syndrome)..
• The defect begins in the internal anal sphincter and extends proximally for
a variable length of gut.

Pathophysiology.
1. Congenital absence of enervation to the rectum and/or lower intestine.
2. Signs and symptoms.
a. Delayed expulsion of meconium and/or recurring constipation early in infancy.
b. Ribbon-like or pellet-like stools.
c. Failure to thrive.
d. Distended abdomen.
TYPES
1. Congenital : This type is the commonest one .
Etiology of the disease is still unknown. But Genetic factors are now identified.
%00 of cases have familial history, especially those with long segment disease.
2. Acquired :
Degeneration of the ganglions may occur due to:
-Vascular causes like after pullthrough procedure due to ischemia & tension.
- Non vascular causes like
56
Trypanosoma (chaga's disease).
Vit B1 def.
Chronic infection ( TB.).
ASSOCIATED ANOMALIES
HD is usually a solitary anomaly in a full term, otherwise healthy infant
Associated anomalies do occur in nearly 20% of cases
urogenital system (11%)
cardiovascular system (6%)
gastrointestinal system (6%), with 8% having various other malformations
Prematurity is reported in as many as 10% of those children with HD
Trisomy 21 occurs in approximately 5% of cases
Diagnosis
1. Highly suspicious if ultrasound shows enlarged upper colon with absence of
feces in distal colon and rectum.
2. Definitive diagnosis is made from a biopsy of the affected colon showing
absence of nerve fibers.
Rectal biopsy :
Rectal biopsy is the definitive diagnostic test and demonstrates absence of
ganglion cells, nerve hypertrophy and stains indicating increased
acetylcholinesterase activity.
suction mucosal biopsy (at different levels ). Can be done without anesthesia
full thickness biopsy is done under general anesthesia.
UltraSonography: for associated anomalies.
Management :
Manegement of HD differs according to the presentation form and clinical
situation of the patients:

57
Acute I.O. : if the patient presents with acute intestinal obstruction in the early
life the management will be
resuscitation ,
NGT , NPO
IVF ,
Antibiotics ,
Rectal tube,irrigations .

Treatment
1. One-step surgical repair: removal of the affected colon and the
anastomosis of the healthy colon to the anus, or, if needed:
2.Two-stage repair with:
a. First procedure: creation of a temporary colostomy.
b. Second procedure: Once the child has reached an adequate size and age (6-12
months; 20 pounds or more), removal of the colostomy and a formal pull-through
procedure is done the anastomosis of the healthy colon to the anus.
(for the nursing care refere to pediatric
Nursing considerations
Preoperative.
a. Risk for Imbalanced Nutrition/Imbalanced Fluid Volume.
i. Carefully monitor the child’s hydration status, including:
(1) Calculating the percentage of weight loss.
(2) Assessing for additional physiological signs of dehydration, including low
urinary output, poor skin turgor, absence of tears, and altered vital signs and,if
the child is an infant, assessing for a sunken anterior fontanel.

58
ii. Monitor I & O.
iii. Monitor biologic growth.
iv. Monitor laboratory data, including serum electrolytes.
b. Constipation.
i. Administer saline edemas to clear.
ii. After enemas, keep NPO until surgery.
c. Risk for Infection.
i. Antibiotic administration (usually per rectum) to decrease bacterial levels in the
bowel.
Postoperative.
a. Risk for Infection/Risk for Impaired Skin Integrity.
i. Monitor vital signs.
ii. Monitor laboratory data, including CBC and serum electrolytes.
iii. Provide stoma care, if needed.
iv. Refer the family to a stoma therapist, if indicated.
b. Imbalanced Nutrition: Less than Body Requirements/Risk for Imbalanced Fluid
Volume.
i. Keep NPO with N/G tube until peristalsis is present.
ii. Maintain IV therapy, as prescribed.
iii. Monitor hydration status and I & O.
For more details about nursing consideration referred to your pedia book
(pediatric nursing contents review)

59
 Appendicitis in children

Definition
Appendicitis is inflammation of the appendix.
When the appendix becomes inflamed or infected, rupture may occur within a
matter of hours, leading to peritonitis and sepsis.
The mean age in the pediatric population is 6-10 years.
Appendicitis is rare in the neonate, and the diagnosis in this age group is typically
made after perforation.
Younger children have a higher rate of perforation, with reported rates of 50-85%.
Perforated appendicitis.

60
Risk Factors
Obstruction by fecalith or foreign bodies, bacteria or toxins.
Low fiber diet
High intake of refined carbohydrates
Signs and Symptoms/ Assessment
Pain in the periumbilical area that descends to the right lower quadrant.
Central abdominal pain moving to right iliac fossa
Rebound tenderness and abdominal rigidity
Low-grade fever
Elevated white blood cell count
Anorexia, nausea, and vomiting
Child in side-lying position, with abdominal guarding and legs flexed
Constipation or diarrhea

Diagnostic Evaluation
Diagnosis is based on a complete physical examination and laboratory and
radiologic tests.
Leukocyte count greater than 10,000/mm 3, neutrophil count greater than 75%;
abdominal radiographs, ultrasound studies, and CT scans may reveal right lower
quadrant density or localized distention of the bowel.
Medical Management
An appendectomy (surgical removal of the appendix) is the preferred method of
management for acute appendicitis if the inflammation is localized. An open
appendectomy is completed with a transverse right lower quadrant incision.
A laparoscopic appendectomy may be used in females of childbearing age, those
in whom the diagnosis is in question, and for obese patients.

61
If the appendix has ruptured and there is evidence of peritonitis or an abscess,
conservative treatment consisting of antibiotics and intravenous (IV) fluids is
given 6 to 8 hours prior to an appendectomy.
Generally, an appendectomy is performed within 24 to 48 hours after the onset of
symptoms under either general or spinal anesthesia. Preoperative management
includes IV hydration, antipyretics, antibiotics, and, after definitive diagnosis,
analgesics.
LAPAROSCOPIC APPENDECTOMY

The major complication is perforation of the appendix, which can lead to

peritonitis or an abscess.
Perforation generally occurs 24 hours after onset of pain, symptoms include fever
(37.7°C [100° F] or greater), toxic appearance, and continued pain and
tenderness.
Pharmacologic Intervention
Crystalloid intravenous fluids an isotonic solutions such as normal saline solution
or lactated Ringer’s solution 000–500 mL/hr of IV, depending on volume state of
the child, is used to replaces fluids and electrolytes lost through fever and
vomiting; replacement continues until urine output is 1 cc/kg of body weight and
electrolytes are replaced.

62
Antibiotics (broad-spectrum antibiotic coverage) to control local and systemic
infection and reduces the incidence of postoperative wound infection
Other Drugs: Analgesics.
Nursing Intervention
Preoperative interventions
Maintain NPO status.
Administer fluids intravenously to prevent dehydration.
Monitor for changes in level of pain.
Monitor for signs of ruptured appendix and peritonitis
Position right-side lying or low to semi fowler position to promote comfort.
Monitor bowel sounds.
Apply ice packs to abdomen every hour for 20-30 minutes as prescribed.
Administer antibiotics as prescribed
Avoid the application of heat in the abdomen.
Avoid laxatives or enema.
Postoperative interventions
Monitor temperature for signs of infection.
Assess incision for signs of infection such as redness, swelling and pain.
Maintain NPO status until bowel function has returned.
Advance diet gradually or as tolerated or as prescribed when bowel sound return.
If ruptured of appendix occurred, expect a Penros drain to be inserted, or the
incision maybe left to heal inside out.
Expect that drainage from the Penros drain maybe profuse for the first 2 hours.

63
Documentation Guidelines
Location, intensity, frequency, and duration of pain
Response to pain medication, ice applications, and position changes
Patient’s ability to ambulate and tolerate food
Appearance of abdominal incision (color, temperature, intactness, drainage)
Discharge and Home Healthcare Guidelines
MEDICATIONS.
Be sure the child and his caregiver's understands any pain medication
prescribed, including doses, route, action, and side effects. Make certain the child
understands that he or she should avoid operating a motor vehicle while taking
such medication.
Discharge and Home Healthcare Guidelines
INCISION
Sutures are generally removed in the physician’s office in 5 to 7 days. Explain the
need to keep the surgical wound clean and dry. Teach the patient to observe the
wound and report to the physician any increased swelling, redness, drainage,
odor, or separation of the wound edges. Also instruct the patient to notify the
doctor if a fever develops. The patient needs to know these may be symptoms of
wound infection. Explain that the patient should avoid heavy lifting and should
question the physician about when lifting can be resumed.
COMPLICATIONS.
Instruct the patient that a possible complication of appendicitis is peritonitis.
Discuss with the patient symptoms that indicate peritonitis, including sharp
abdominal pains, fever, nausea and vomiting, and increased pulse and respiration.
The patient must know to seek medical attention immediately should these
symptoms occur.
NUTRITION.
Instruct the patient that diet can be advanced to her or his normal food pattern as
long as no gastrointestinal distress is experienced.
64
 Short answer,MCQ,Matching
Pediatric Patients and Emergencies
Learning objectives
Define the common emergency condition in pediatric population.
Mention the etiology of this condition.
Provide health education to parents regarding the management and prevention
of common emergency condition.
Introduction
Accidental injury is the number one cause of illness and death of children. In fact,
over 9 million children are seen in emergency departments each year after such
incidences as accidental or intentional consumption of poisons, traffic accidents,
so children may need immediate intervention because of a disease process.
The nurse must be prepared to intervene if he or she should be a witness to a
child in immediate need of care.
Pediatric basic life support is very important to pediatric nurse to have.
Emergency Triage
• Emergency triage is to “pick or sort”.
• Goals of triage:
• Rapidly identify seriously injured.
• Prioritize all patients using the emergency department.
• Initiate therapeutic measures.
Triage Classification
Resuscitation
Emergent- needs to be seen within 10 minutes
Urgent – need to be seen within 30 to 60 minutes
Semi-urgent – need to be seen within 1to 2 hours
Non-urgent – need to be seen within 2 to 3 hours
65
Anatomic Differences in children
Total blood volume is smaller – small blood loss may led to hypovolemia and
impaired profusion
Lose body heat more easily
Bones are more flexible
Less fat surrounding organs
Could be much internal damage with little external visible trauma
Airway Differences
• Larger tongue relative to the mouth
• Less well-developed rings of cartilage in the trachea
• Head tilt-chin lift may occlude the airway.
Breathing Differences
Infants breathe faster than children or adults.
Infants use the diaphragm when they breathe.
Respiratory arrest is more common in pediatrics
Circulation Differences
The heart rate increases for illness and injury
Pale, extremities, decreased cap refill are early signs of perfusion problems
Tachycardia and delayed capillary refill are early signs of shock
Decreased blood pressure is late sign of shock
Focused Physical Assessment
Airway
Breathing
Circulation
Disability
66
 Exposure
Test and Procedures
Complete Blood Count with differential
Blood glucose
Blood grouping and cross match
Serum electrolytes
Radiographs: chest, abdomen, bones
Computed tomography – CT scan

Obstructed Airway
It is common for children to experience an obstructed airway. Children, who
already have narrow tracheas, frequently move and play while eating snacks and
insert objects into their mouths that should not be placed there. Because it is
essential that the airway be patent for gas exchange to take place, immediate
intervention is needed.
Incidence:
1. Most commonly seen in children under 5 years of age (greater than 90% of
cases).
Etiology:
1. Objects that frequently lead to an obstructed airway in children are:
a. Liquids, especially common choking item in infants.
b. Food items (e.g., carrots, hot dogs, hard candies, grapes).
c. Play items (e.g., uninflated balloons, small toys).
d. Everyday items (e.g., coins, buttons).

67
Pathophysiology.
1. Children who are choking on objects usually present with sudden upper
respiratory difficulty without any other symptoms.
2. When a mild obstruction is present, the airway is not completely occluded, and
air exchange is occurring.
a. Signs and symptoms.
i. The child may begin to cough violently and/or appear to gag, but the child is
able to cough effectively enough to be able to expel the object himself or herself.
3. When a moderate or severe obstruction is present, little to no gas exchange is
taking place.
a. Signs and symptoms.
i. The conscious child will appear frightened and panicky with:
(1) Inspiratory stridor and ineffective cough.
(2) May wrap his or her hands around his or her own throat to indicate the
presence of an obstruction .
Diagnosis
1. Clinical history and picture are most common.
2. X-ray, CT, MRI.
Treatment
1. Prevention.
a. Because many obstructions are caused by items that are unsafe for young
children to eat, to play with, or have access to, the majority of airway
obstructions are preventable.
a. Mild obstruction
Unless the obstruction should worsen, emotional support should be provided
while the child coughs up the obstruction.

68
b. Moderate to severe obstructions
i. In infants.
(1) Back blows and chest compressions.
ii. In children over 1 year of age.
(1) Heimlich maneuver, if the child is conscious.
(2) CPR, if the child is unconscious.
c. The child may require bronchoscopy or laryngoscopy for removal of the object.
Nursing considerations
a. Parents must be educated regarding safety precautions to take in order to
prevent airway obstructions.
b. b. Parents should be strongly encouraged to become certified in CPR and
other first aid skills.
c. a. The nurse must perform emergency interventions, as needed.

Febrile Seizure

69
Febrile seizures are the most common seizure disorder in childhood, affecting 2 -
5% of children between the ages of 6 months and 5 years
Causes
Caused by the increase in the core body temperature greater than 38o C
Threshold of temperature which may
trigger seizures is unique to each individual
Can occur within the first 24 hours of an illness
• Can be the first sign of illness in 25 - 50% of patients

Febrile Seizure: Characteristics

• Occurrence: between 6 months to 5 years of age
• May be either simple or complex type seizure
• Seizure accompanied by fever (before, during or after)
• WITHOUT ANY
Central nervous system infection
Metabolic disturbance
Febrile Seizure: Two Types
Simple Febrile
6 months – 5 years of age
Febrile before, during or after seizure
Includes all of the following
• Seizure lasting less than 15 minutes
• Generalized seizure
• Occurs once in a 24-hour period

70
Complex Febrile
6 months – 5 years of age
Febrile before, during or after seizure
One or more of the following
• Prolonged (lasting more than 15 minutes)
• Focal seizure
• Occurs more than once in 24 hours

Emergency Department Assessment

Full History
• Obtain seizure history :
• When did the seizure occur?
• How long was the seizure and what did it look like?
• How was the child acting immediately before the seizure?
• History of previous seizures (child and family)?
• History of developmental delay/recent loss of milestones?
Continue assessment
• Does the child have a current illness/fever?
• Any indications of trauma or abuse
• Immunization history?
• List current medications
• Include any antipyretics given (time and dose)

71
Febrile Seizure: Management
Based on
• Keep air way patent by positioning the child
• Stop convulsion (rectal diazepam (0.5 mg/kg) or intranasal (0.2 mg/kg) are
effective and can be given at home for a seizure lasting longer than 5
minutes
• Reduce fever (fever management)
• Identify the cause ( investigations)
Simple Febrile Seizure:
ED Ongoing Management
Reassess temperature
Consider giving antipyretic
if not previously administered
Treat appropriately
Simple Febrile Seizure: Family Education
Instruct parent/caregivers to prevent injury during a seizure:
• Position child while seizing in a side-lying position
• Protect head from injury
• Loosen tight clothing about the neck
• Prevent injury from falls
• Do not place anything in the child’s mouth
Simple Febrile Seizure:
Prior to discharge home:
Educate regarding use of:
• Thermometer
• Fever management
72
 • Antipyretics dose
Identify a Primary Care Provider for follow-up appointment and stress
importance of follow-up
Provide developmentally appropriate explanation of event for child and
family members

Severe dehydration management

Address emergent:
airway, breathing, and circulatory problems first.
Obtain intravenous access.
Give a 20 mL/kg isotonic fluid bolus (Ringer lactate or normal saline) to children
with severe dehydration with shock
Children with severe dehydration should receive intravenous isotonic fluid
boluses (20-60 mL/kg).
In children with difficult peripheral access, perform intraosseous or central access
promptly.
Fluid boluses (normal saline for these initial boluses) should be repeated until
vital signs, perfusion, and capillary refill have normalized.
Check a bedside glucose level for child who appear lethargic .
Treat hypoglycemia promptly if present. The appropriate dose is (2.5 mL/kg of
10% dextrose or 1 mL/kg of 25% dextrose IV)
Reassessment of glucose level after administration of dextrose
Severe dehydration management
Once vital sign abnormalities are corrected, initiate maintenance fluid therapy
plus additional fluid to make up for any continued losses. Daily requirements for
maintenance fluids can be approximated as follows:
If the patient weighs less than 10 kg, give 100 mL/kg/day

73
If the patient weighs less than 20 kg, give 1000 mL/d plus 50 mL/kg/d for each
kilogram between 10 and 20 kg
If the patient weighs more than 20 kg, give 1500 mL/d, plus 20 mL/kg/d for each
kilogram over 20 kg
Divide the total by 24 to obtain the hourly rate
Daily fluid requirements may be met using dextrose 5% in half-normal saline
solution.
The emergency physician also should consider daily sodium and potassium
requirements as follows:
Sodium 2-3 mEq/kg/d
Potassium 2-3 mEq/kg/d
Add potassium to fluids when the patient has documented hypokalemia. For all
other children, avoid adding potassium to fluids until the child has demonstrated
adequate urine output.

Poisonings
Because the toddles are naturally curious and particularly mobile, they prone to
accessing places and items that are dangerous.
Poisoning incidents are a particular risk for children at this developmental level.
Emergency care:
Steps in emergency unit:
Assess any signs of impending or current respiratory or cardiac distress (ABCs)
Cardiorespiratory support if needed
Removal of toxins with the use of emesis with:
Syrup of ipecac
Gastric lavage

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 Short answer,MCQ
GENITO-URINARY DISORDERS IN CHILDREN

Common disorders
Urinary tract infection (UTI)
Nephrotic syndrome
Acute Post-Streptococcal Glomerulonephritis (APSGN)
Vesicoureteral reflux
Hypospadias

Urinary Tract Infection

Definition
UTI is the presence of bacteria in the urine
Infection usually occur at the upper urinary tract or at the lower urinary tract
Incidence
Common age of onset for UTI is 2-6 years
Girl>Boy - Female has shorter urethra
Uncircumcised male prone to develop UTI
Causes
Causative organisms – E. Coli
Route of entry -bacteria ascending from the area outside of the urethra.
Vesico-ureteral reflux
Poor perineal hygiene - fecal organisms are the most common infecting organisms
due to the proximity of the rectum to the urethra.
Short female urethra

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Types
Urethritis – infection of the urethra
Cystitis – an infection in the bladder that has moved up from the urethra
Pyelonephritis – a urinary infection of the kidney as a result of an infection in the
urinary tract
Signs & Symptoms of UTI in babies
Unexplained fever (febrile fits)
Abdominal pain
Poor growth \Weight loss (failure to weight gain)
Foul-smelling urine
Poor feeding
Vomiting
Irritability

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Signs & Symptoms of UTI in older children
Urinary frequency/urgency
Dysuria
Foul-smelling urine
Cloudy urine
Incontinence during day and/or night
Increased irritability
Nausea and vomiting
Low abdominal or flank pain
Fever and chills
Fatigue
Small amount of urine while micturating despite feeling of urgency
Signs of serious infections
Central pyrexia but peripherally cold
Pale, grey mottled skin
Quiet and lethargic child
Poor tone
Tachycardic and hypertensive

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Diagnostic investigation

Obtaining a urine specimen:-

- Urine bag
- Clean catch urine
-Mid-stream urine
- Catheterisation
- Supra-pubic aspiration-draining the bladder by inserting a sterile needle
through the skin above the pubic arch and into the bladder.
Ultrasound
Plain x-ray
Micturating Cystourethrogram (MCUG)
Nursing management
Obtain urine specimen before antibiotics started, sent for ME/CS
Blood tests
Strict I/O chart
Monitor vital signs esp. body temperature

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 Administer antibiotics as prescribed (5 days course)
Administer anti-pyretic drugs to reduce fever and pain
Advised to take plenty of fluids to prevent dehydration and to flush the
urinary tract
If the child is unable (vomiting) or refuse to take fluids, administer IV fluids
as prescribed
Nursing Diagnosis
1. Altered body temperature due to increased temperature related to urinary
tract infection.
2. Alteration in urination (frequency, pain, burning, dribbling and enuresis)
related to infection.
3. Pain related to inflammatory changes in the urinary tract.
4. Lack of knowledge about UTI and health prevention
Health teaching to prevent UTI
Ensure the child to pass urine regularly (every 2-3 hours) and take the time to
completely empty the bladder.
Avoid holding urine for prolonged period of time.
Perineal hygiene - wipe from front to back.
Avoid tight fitting clothing or diapers; wear cotton panties.
Encourage fluid intake.

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 Nephrotic Syndrome
Is alteration of glomerular membrane permeability with massive proteinuria,
hypoalbuminaemia, hyperlipidaemia and oedema
Causes
It occurs when the filters in the kidney leak an excessive amount of protein. The
level of protein in the blood ↓ and this allows fluid to leak across the blood
vessels into the tissues – causing oedema
Nephrotic syndrome are caused by changes in the immune system
For unknown reason, the glomerular membrane, usually impermeable to large
proteins becomes permeable.
Protein, especially albumin, leaks through the membrane and is lost in the urine.
Plasma proteins decrease as proteinuria increase.
Incidence
1 : 50 000 children
Males > females
Common age of onset is between 2 to 6 years, but can occur at any age
Clinical manifestations
Oedema
- initially noted in the
periorbital area
- ascites
- intense scrotal oedema
- pitting oedema
↑ weight
↓ urine output

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Proteinuria
Fatigue
Irritable and depression
Severe recurrent infections
Anorexia
Wasting of skeletal muscles
Diagnostic investigations
Urinalysis
- protein 3+ - 4+ on dipstick
- haematuria may be absent or microscopic
Blood test
- total serum protein – low
- serum albumin – low
- cholesterol and lipoproteins – high
Renal function test – often normal
Blood pressure – often normal but 25% hypertension
Renal biopsy

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Nursing Management
Admission to ward
Explain to parents nature of illness
U +E, Creat., Serum lipid, C&S, LFT, serum albumin
For CXR and Echo
Daily urine dipstick for protein, ME and C&S – every morning
Daily BP, weight and abdominal girth
Nursing Management…con’t
Administration of IV albumin
Start on steroid therapy – prednisolone given at a dose of 2mg/kg/day divided
into 2-3 doses. This regimen is continued until remission is achieved
Remission is achieved when the urine is 0 or trace for protein for 5 to 7
consecutive days
Administer prophylactic antibiotics to reduce infections
Start on diuretic therapy – frusemide (lasix)
Dietary restriction – provide ↑ protein, high carbohydrate, ↑ potassium diet &
no salt diet
Strict I/O chart
Provide careful skin care
Good hygiene

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 Short answer,MCQ,Matching

Nursing care of child with a problem that interferes with

physical mobility
Juvenile Idiopathic Arthritis (Juvenile rheumatoid arthritis (JRA))
A term used for a group of idiopathic chronic autoimmune inflammatory diseases
affecting joints and connective tissues in children
JRA is the most common pediatric connective tissue disease with arthritis being
the principal manifestation.
Appear in two peak age levels 1-3 years and 8-10 years.
Clinical manifestations
Joint inflammation if untreated leads to changes in joint cartilage , ligament and
eventually causing complete immobility.
Systemic onset
Fever (usually high)
Rash
Arthralgia/myalgia
Arthritis
Fatigue/malaise
Lymphadenopathy
Hepatosplenomegaly
Possible signs of carditis

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Poly-articular onset
Arthritis in many joints (five or more)
most particularly the joints of the knees, wrists, ankles, and proximal
interphalangeal joints of the fingers.
often neck and joints are affected.
Low-grade fever
Olig-articular onset
Arthritis in a few joints (less than 4)
most particularly joints of the knees and ankles.
Diagnosis of Juvenile Idiopathic Arthritis
American College of Rheumatology diagnostic criteria
Onset before 16 years of age
Arthritis of at least 6 weeks’ duration (objectively observed)
Exclusion of other conditions such as other rheumatic diseases
There are no specific laboratory tests for JRA.
Laboratory data:
elevated erythrocyte sedimentation rate (ESR),
elevated C-reactive protein (CRP),
elevated white blood count,
decreased hemoglobin, and increased platelet count.
Rheumatoid factor (RF) are positive in a proportion of children with arthritis
X rays can demonstrate characteristic changes such as:
soft tissue swelling and joint effusion.
bony erosions and narrowing of the joint spaces
Subluxations and malalignment
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Treatment of Juvenile Idiopathic Arthritis
Multidisciplinary approach
Medications
Physical and occupational therapy
Nutritional considerations
Family teaching
Drug therapy
The first group of drugs prescribed for juvenile rheumatoid arthritis are the
nonsteroidal anti-inflammatory drugs (NSAIDs), namely ibuprofen.
If this regime is not successful other drug regimes maybe needed.
The second group of drugs used are the slow acting antirheumatic drugs
(SAARDs) and include gold, D-penicillamine and hydroxychloroquine.
Other drugs include cytotoxic agents but are only used for those children with
severe form of the disease and who have not responded to the above drugs.
Other anti-inflammatory drugs include the corticosteroids. The use of cytotoxic
and corticosteroid drugs are limited because of the long term effects.
Any of the above drug regimes need careful monitoring because of potentially
severe side effects.
Physical Therapy
Physiotherapy and occupational therapy are aimed at the preservation of joint
function and the prevention of deformity of joints. Each of these therapists have
specific aims.
Physiotherapy :
- focuses on the strengthening of muscles,
- mobilizing of joints and
- correcting and preventing deformity.

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Occupational therapy :
- involves general mobility and the performance of daily living activities.
- Splinting and positioning are recommended because deformity and pain
may be reduced. In addition, there needs to be a balance between rest and
activity. Surgery in young children is questionable but joint replacement
has proven helpful in older children who are fully grown
Long term care of the child and family with arthritis
Because of the chronic nature of the disease and its characteristic remission and
exacerbation cycle, the child may have difficulties in relation to physical,
psychological, emotional and social development. Many children experience
nutrition related problems due to the disease process itself because of treatment
involved with the disease.
Schooling may be affected and the child may become dependent on the family
unit. Consequently, the role of the nurse as part of the multidisciplinary team is to
help the child and family to adapt to the disease and the restrictions it causes.
Education, counselling, guidance and support are important aspects of the long
term care of the child with arthritis.
Nursing Management
The most important steps in diagnosing JRA are the medical history and physical
exam.
Medical history. Assess for the duration of symptoms, onset, affected joints, pain
description, changes in physical activity, general health, history of arthritis,
previous illness, and other symptoms associated with JRA.
Physical exam. Assess the vital signs, auscultate the heart and lung, palpate the
abdomen, and examine the skin.
Nursing care needs to be related to certain goals, which include:
- the management of systematic manifestations,
- the relief of pain, the reduction of joint inflammation,
- the performance of activities of living,
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 - and knowledge of the treatment, interventions
- and prognosis of the disease process.
Nursing Interventions
The nursing intervention appropriate for a child with JRA are:
Physical therapy. Physical therapy includes exercise, application of splints, and
heat.
Activity. Stress to the caregivers the importance of encouraging the child to
perform activities of daily living to maintain function and independence.
Pain relief. Recommend or provide firm mattress or bed board, small pillow;
elevate linens with bed cradle as needed; and suggest patient assume position of
comfort while in bed or sitting in chair.
Emotional support. Encourage verbalization about concerns of disease process,
future expectations; give positive reinforcement for accomplishments; and
acknowledge and accept feelings of grief, hostility, dependency.
Health education. Review disease process, prognosis, and future expectations;
discuss patient’s and family role in management of disease process through
nutrition, medication, and balanced program of exercise and rest; and assist in
planning a realistic and integrated schedule of activity, rest, personal care, drug
administration, physical therapy, and stress management.

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 Short answer,MCQ
Diseases of the Nervous System in Children
Meningitis
Haemophilus influenzae meningitis:
leading cause of bacterial meningitis in children under 5 years of age. It occurs
most frequently in children from 1 month up to 4 years with a peak at 6 to 9
months.
The infection usually spreads from somewhere in the respiratory tract to the
bloodstream and then to the meninges (the membranes that cover the brain). At
the meninges, the bacteria produce infection and inflammation causing serious
illness and sometimes death
Symptoms
Irritability, poor feeding in infants
Fever (in young infants the temperature may actually be below normal)
Severe headache (older children)
Nausea and vomiting
Stiff neck or pain in neck when flexed
Pain in back when neck is flexed fore ward and chin brought toward chest (older
children)
Photophobia
Complications
Roughly 20% of patients may experience some hearing loss.
Some patients will have brain damage, which can include seizures, mental
retardation, hydrocephalus ("water on the brain"), learning disorders,
abnormalities in speech and language development, and behavioral problems

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Meningococcal Menigitis:
infection caused by the bacterium Neisseria meningitidis that causes
inflammation of the membranes covering the brain and spinal cord.
The death rate ranges from 5% to 15%, with young children .
Symptoms:
Rash, pinpoint red spots (petechiae)
Complications :
Brain damage , Shock ,Increased spinal fluid pressure ,Myocarditis (inflammation
of the heart) , Hydrocephalitis (blockage of spinal fluid in brain) , Deafness and
Mental retardation
Pneumococcal meningitis:
Streptococcus pneumoniae is the most common cause of meningitis in adults, and
the second most common cause of meningitis in children older than 6 years old.
Prevention
Early treatment of pneumonia and ear infections caused by pneumococcus may
decrease the risk of meningitis. There are also two effective vaccines on the
market to prevent pneumococcus infection.The current recommendations are for
people at high risk for pneumonia, children, and everyone over the age of 55 to
be vaccinated.
Treatment
Antibiotic therapy should be started as soon as possible. Ceftriaxone is one of the
most commonly used antibiotics. If antibiotic resistance is suspected, vancomycin
or rifampin are used.
Prognosis
With early treatment, the outcome is better. However, 20% of people who
contract this disease will die of it and 50% have serious long-term complications

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 Nursing care of a child with Cerebral Palsy

What Is Cerebral Palsy?

The word “cerebral” refers to the brain’s cerebrum, which is the part of the brain
that regulates motor function. “Palsy” describes the paralysis of voluntary
movement in certain parts of the body.
Cerebral palsy (commonly referred to as CP) affects normal movement in
different parts of the body and has many degrees of severity.

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Etiology of Cerebral Palsy
Brain injury to the fetus
Brain injury during birth
Brain injury after birth
Prenatal Causes Cerebral Palsy
Maternal infections
Trauma
Metabolic disturbance

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Rh incompatibility
Malnutrition
Hemorrhage
Anoxia during the prenatal period (lack of oxygen)
Birth Trauma Causes Cerebral Palsy
Shaken baby syndrome
Anoxia during birth
Hemorrhage
Mechanical injury
Complications associated with premature or late-term deliveries
Trauma to brain from delivery with forceps
Postpartum Causes Cerebral Palsy
Shaken baby syndrome (SBS)
Meningitis
Neonatal jaundice
Complications of low-birth weight
Infections
Trauma
Exposure to toxic substances
Risk Factors for Developing CP
Infants born prematurely are at a higher risk of developing cerebral palsy
because of the complications that arise in these births, such as bleeding in
the brain.
Estimates show that 10 to 30 percent of people with cerebral palsy were
born prematurely.

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Some additional risk factors include:
.Abnormal deliveries, such as a breech birth (feet first)
.Maternal diabetes or high blood pressure
.Poor maternal health
Types of Cerebral Palsy
The 4 main types are:
• 1-Spastic (70% of cases) — The most common type of cerebral palsy is
known as spastic cerebral palsy. This is caused by damage to the brain’s
motor cortex. Typical symptoms include stiff, exaggerated movements.
• 2-Dyskinetic (10%) — This type is caused by injury to the brain’s basal
ganglia, which controls balance and coordination. Children with dys-kinetic
CP often exhibit involuntary tremors and movement.
• 3-Ataxic (10%) — Ataxic cerebral palsy is characterized by lack of
coordination and balance. This is caused by damage to the cerebellum,
which is the part of the brain that connects to the spine.
• 4-Mixed (10%) — Some cases of cerebral palsy are classified as Mixed. This
occurs when an individual exhibits symptoms of more than one type of CP.

Cerebral Palsy Diagnosed.

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Clinical Examination and Medical History:
Patient presentation symptoms are usually noticeable by the
time the child reaches 18 months of age
Imaging:
Magnetic resonance imaging (MRI)
Computed tomography scan (CT)
Electroencephalogram (EEG)
Cranial ultrasound

When are Children Diagnosed with Cerebral Palsy?

The signs of cerebral palsy usually appear in the first few months of life, but many
children are not diagnosed until age 2 or later. In general, early signs of cerebral
palsy include: Developmental delays. The child is slow to reach milestones such
as rolling over, sitting, crawling, and walking.

Treatment for Cerebral Palsy

Manage Symptoms
Treatment is guided based upon the child’s symptoms and diagnostic data. It is
highly supportive, as there is no cure for irreversible brain damage. However,
Botox injection may be used to improve function. Botox injections decrease pain
from spasticity and improve overall motor status by decreasing rigidity. Symptom
management is focused on:
Relieving pain , and discomfort,
Preventing skin breakdown.

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Goals of Treatment
Manage symptoms
Promote function
Prevent complications
Potential Nursing Diagnoses for Cerebral Palsy
Ineffective breathing patterns
Infective coping patterns
Failure to thrive
Risk for injury
Risk for a cute or chronic pain
Risk for impaired skin integrity
Knowledge deficit related to disease and management .
Potential Nursing Interventions
Breathing: administer mucolytic as ordered. Teach the child to perform breathing
exercises if developmentally able
Pain assessment and management
Parents are often most in tune to the subtle changes in the child’s behavior and
often provide the best resource for pain assessment
Safety: provide a safe and therapeutic environment for the child
Skin: assess skin for signs of breakdown
Growth: monitor height and weight, calculate body mass index, provide for
dietary interventions, as needed
Knowledge: provide for patient and family education. Teach the caregiver how to
perform tasks and foster independence in the child by promoting the acquisition
of new skills .

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Coping: facilitate referrals to specialists, community resources, and
credible online sources of information for the family

For more details about children nursing care referred to your Maternal &
Pediatric book –Hatfield and other supported documents in blackboard

Thank you

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