Digestive System & Gastrointestinal

Disorder

OBJECTIVES
1. Explain important concepts of the
Gastrointestinal system
2. Describe the pathophysiology, clinical
manifestation, collaborative care, and
medical/surgical therapy of GI disorders
3. Plan nursing care for a child with a
gastrointestinal disorder
4. Implement nursing care for a child with a
gastrointestinal disorder
5. Analyze ways that nursing care of a THE DIGESTIVE SYSTEM
child with a gastrointestinal disorder can
be more family-centered Laboratory Studies And Diagnostic Tests
6. Integrate knowledge of gastrointestinal • Stool examination
disorders with nursing process to • Complete blood count
achieve quality child nursing care ➢ Hematocrit – 37% - 47%
➢ Hemoglobin – 12mg% - 16mg%
➢ RBC – 4.0 – 5.5/cu. mm
➢ WBC – 5 – 10 /cu. mm

Differential count
Neutrophils – 50 – 80%
Eosinophils – 0 – 5%
Monocytes – 2 – 10%
Lymphocytes – 25 – 50%
Platelet count – 140 – 400 10^3/cu

Laboratory Studies
• Abdominal ultrasound
• Computed tomography
• Upper GI Imaging
− Upper GI Series
− Small-bowel series
• Barium or Meglumine Diatrizoate
(Gastrografin) swallow
OVERVIEW OF ANATOMY AND • Barium Enema (Lower GI series)
PHYSIOLOGY OF THE GI SYSTEM • Upper GI endoscopic procedure
(Esophagogastroduodenoscopy)
• Fiber-optic Testing
• Lower GI endoscopic procedure
(Proctosigmoidoscopy, Colonoscopy)
• Gastric Analysis
 Gastroesophageal reflux disease (GERD ➢ Anticholinergic
[chalasia]) ➢ Beta-adrenergic blockers
➢ Calcium channel blockers
➢ Nitrates
➢ Theophylline
➢ Diazepam
➢ Tight, restrictive clothing
➢ Bending, straining
➢ Hiatal Hernia

− Is a neuromuscular disturbance

Cause: unknown Nursing Assessment

➢ Heartburn or substernal burning pain,
Causes exacerbated by bending, straining and
• relaxation of lower esophageal sphincter recumbent position
(LES) ➢ Forceful vomiting, possibly with
− decreased LES tone hematemesis
➢ Weight loss
− increased
➢ Aspiration and recurrent respiratory tract
• intra-abdominal pressure
infections
• increased gastric volume, or a ➢ Cyanotic and apneic episodes
combination ➢ Esophagitis and bleeding from repeated
irritation
Possible Complications: ➢ Melena
1. Aspiration Pneumonia ➢ Abdominal pain and a bitter taste
2. Esophageal stricture
Diagnostic Assessment
Factors Decreasing LES tone
• 24 hours pH monitoring
➢ Nicotine
• Esophagography
➢ Caffeine
➢ Chocolate • Esophagoscopy
➢ Fatty Foods
➢ Alcohol Nursing Management
➢ Peppermint, spearmint • Promote adequate hydration
➢ Levels of estrogen and progesterone
 • assess the amount, frequency, and
characteristics of vomitus Nursing care
• Assess the relationship between feeding • Risk for altered nutrition, less than body
and vomiting and the infant’s activity requirements related to regurgitation of
level. food with esophageal reflux
• Improve nutritional status through
feeding techniques 1. Monitor intake and output (urination)
− small frequent feedings and weight.
− Formula thickened 2. After the feeding, the infant should lie on
− burp the infant frequently the side or prone on a slanted surface
• Prevent reflux and respiratory 3. Use a sheepskin-like covering
complications
− upright position in an infant seat • Risk for altered nutrition, less than body
requirements related to regurgitation of
− Assess breath sounds before and after
food with esophageal reflux
feedings
4. Be certain parents understand how
Pharmacological Intervention
much cereal to mix with formula
• Administer prescribed medications,
5. Mothers who are breastfeeding may
including: Antacid and histamine
manually express breast milk and mix it
receptor antagonist (cimetidine,
with rice cereal for feedings.
• ranitidine)
6. Encourage them to feed the infant in the
• Omeprazole hospital after surgery and give care
• Optokinetic medication
(metoclopramide) Cleft Lip / Cleft Palate
Nursing Management
Cleft Lip /Cheiloschisis
• Provide child and family teaching
regarding feeding and positioning
• Provide postoperative care
• May require hospitalization and possibly
surgery
• Placement of a nonsurgical
percutaneous gastrojejunostomy tube
• Postoperative nursing responsibilities
include:
− preventing gastric distention
− Assess for flatulence, inability to vomit,
poor feeding habits, and choking on
solid foods

Nissin Fundoplication

Cleft Palate / Palatoschisis

 • nasal distortion
• may include unilateral or bilateral
involvement.

Cleft lip

• is a visible or palpable gap in uvula, soft

palate, hard palate
• incisive foramen with exposed nasal
cavities and associated nasal distortion
• partial or complete

Cleft Palate

Complications
Cause • Speech defects
➢ Hereditary • Dental and orthodental problems
➢ Environmental • Nasal defects
➢ Teratogenic effect • Alteration in hearing
• Shock, guilt and grief for the parents
Assessment • Increased risk of aspiration
• abdominal distention • URTI
• difficulty swallowing • Otitis media
• involves a notched upper lip border
Diagnostic Findings
Ultrasonography

Palatoplasty (cleft palate repair surgery)

Medical Management
Cheiloplasty (cleft lip repair surgery)
 Breck – feeder
Haberman feeder
Preoperative Nursing Care
Preoperative Nursing Care
1. Assess respiratory status continuously
during feedings
2. Feed infant in upright position
3. Feed slowly and burp the infant
frequently (ESSR)
4. Use alternate feeding devices such as
elongated nipple (Lamb’s nipple)
1. Assess degree of cleft and ability to
suck
2. Provide postoperative feeding
instructions
3. Encourage parents to verbalize fears,
concerns, negative emotions
4. Facilitate grief responses of shock,
denial, anger, and mourning
5. Encourage touching, holding, cuddling,
and bonding
6. Provide parents with pictures of other
children before and after surgical repair
7. Parents of children with a cleft palate
must be alert to the signs of infection;
they need to report pharyngeal infection
• Infant is kept on NPO status for at least
4 hours. Introduced to liquids after.
• Monitor for respiratory distress
• No oral temperatures
• Advance feedings as tolerated
• No straws, pacifiers, spoons, or fingers
in or around mouth for 7 to 10 days
• For cleft lip, a metal appliance or
adhesive strips may be used (Logan
Bar).
 • For cleft palate, liquids can be taken
from a cup; no straws are allowed; soft
food can be taken from side of spoon
• Clean lip from suture line out after
feedings and pm
• Apply antibacterial ointments as ordered
• Use elbow restraints
• No tooth brushing for I to 2 weeks
• Place infant in side-lying position on
unaffected side
• Monitor site for signs of infections
• Assess pain using appropriate tools
• Provide comfort measures such as
crying.
• Provide analgesics and sedatives on a
scheduled basis
• Provide age-appropriate activities for
diversion
Client and Family Teaching
1. Stress importance of follow-up care and
referral appointments
2. Make appropriate and early referrals for
speech and language disabilities
3. Encourage early speech attempts and
arrange for speech therapy
4. Encourage good dental hygiene and
orthodontic follow-up
Phenylketonuria
Because a child with PKU lacks the normally
functioning enzyme necessary to break down
phenylalanine (PHE), it accumulates in the
blood and body tissues.
This excess PHE can prevent normal brain
development and result in mental retardation.
Overview:
• a disease of metabolism inherited as an
autosomal recessive, trait.
• Absence of the liver enzyme
phenylalanine hydroxylase prevents
conversion of phenylalanine to tyrosine
(a precursor of epinephrine, thyroxin
and melanin)
• excessive phenylalanine can lead to
severe cognitive impairment
• phenylpyruvic acid spills into the urine
Nursing Assessment
1. body pigment fades and the child
become:
➢ very fair skinned
➢ blonde
➢ blue eyed
2. The child fails to meet average growth
standards
3. Many children develop an
accompanying seizure disorder.
4. The skin is prone to eczema (atopic
dermatitis).
5. Untreated, the child with PKU will have
an IQ that is generally below 20 –
motor-mental retardation
6. Recurrent convulsions
7. muscular hypertonicity and spasticity.
8. Mouse-like odor in urine and sweat
Diagnostic Test
➢ Recombinant DNA techniques
➢ Guthrie Test
Normal Findings
Phenylalanine level
− A serum level of > 4 mg/dl is strongly
suggestive of phenylketonuria
− Phenylalanine level of the blood stays
below 8 mg/dl
Phenylketonuria: Therapy
• Phenylalanine resitricted diet,
supplementation of tyrosine, essential
amino acids and trace elements.
Goals of the therapy:
• 0-10 years: phenylalanine values: 0.7-4
mg/dL
• 11-16 years: phenylalanine values: <15
mg/dL
• 16+ years: phenylalanine values: <20
mg/dL
• Pregnant mothers with PKU:
phenylalanine values < 7mg/dL
Prognosis: with immediate and efficient
treatment, normal development and
intelligence
Diagnostic Tests
Guthrie Test for PKU
Bacterial plate with newborn blood samples
Therapeutic Management
1. Placed on an extremely low
phenylalanine formula (Lofenalac)
2. A dietitian may recommend a small
amount of milk in the infant's diet every
day
Therapeutic Management
1. Parents of children with PKU need a
realistic prognosis of their child's
potential.
2. Parents need an opportunity to express
their feelings about the difficulty of
maintaining a young child on such a
restricted diet.
Hirschsprung's disease
(aganglionic megacolon)
− Congenital anomaly resulting from an
absence of ganglion cells in colon
Cause
• Familial
• Incidence is higher in children with
Down syndrome and genitourinary
abnormalities
• Rectosigmoid region is most commonly
affected
• Absence of autonomic parasympathetic
ganglion cells – myenteric and
submucosal plexus are absent
• Caused by an abnormal gene on
chromosome 10
Defecation Reflex
a Local reflexes
b Parasympathetic reflexes
Nursing Management
Clinical manifestations in newborns:
• Failure to pass meconium stools within
24 hours
• Liquid or ribbonlike stools
• Reluctant to ingest fluids
 • Abdominal distention and easily
palpable stool masses Monitor urine specific gravity
• Bile-stained emesis or fecal vomiting • monitor electrolytes
• assess hydration status
Clinical manifestations in infants:
• Failure to thrive Postoperative Nursing Care
• Constipation ➢ Prepare child for surgery and temporary
• Abdominal distention placement of colostomy
• Vomiting ➢ Administer antibiotics as ordered
• Episodic diarrhea ➢ Monitor VS
• measure abdominal girth
Clinical manifestations in toddlers: • assess surgical site for redness,
• Chronic constipation swelling, drainage after surgery
• Foul-smelling stools
• Abdominal distention
• Visible peristalsis
• Palpable fecal mass
• Malnourishment
• Signs of anemia and hypoproteinemia

Diagnostic Tests ➢ Assess stoma for color, bleeding,

• Rectal examination
• Rectal Biopsy
− Absence of ganglion cells
Nursing diagnoses:
1. Constipation r/t reduced bowel function
2. Altered nutrition, less than body
requirements r/t reduced bowel function
3. Risk for ineffective family coping,
compromised, r/t chronic illness in child
Therapeutic Management
• Temporary colostomy
Preoperative Nursing Care
Assess bowel function and characteristics of
stool;
• measure abdominal girth
• monitor child for vomiting and
respiratory
• distress
breakdown of surrounding skin
➢ Assess anal area after pull-through for
patency of any appliance that may be in
place, presence of stool, redness,
drainage
➢ Provide meticulous skin care, use
appropriately sized stoma supplies
➢ Notify physician of any fever, unusual
drainage, redness, or odor
➢ Keep child NPO until bowel sounds
return or flatus is passed
➢ maintain NG tube,
➢ administer IV fluids as ordered
➢ monitor daily weights
➢ begin diet with clear liquids and
progress as tolerated
➢ Assess pain using age-appropriate
scales
• provide comfort measures and involve
parents
• provide pain medications on regular
basis as ordered
• notify physician if pain is not managed
➢ Involve child in quiet, age-appropriate
activities for diversion
➢ Encourage parents to share feelings,
anxieties, and concerns about disorder
and post-surgical care
➢ Refer to support groups and make
appropriate referrals
 − Atrophy of the villi
Client and Family Teaching − Reduce absorption
1. Explain surgical repair and recovery − Chronic diarrhea
process
2. Encourage preschool and early school-
aged children to draw pictures, use
dolls, and play
3. Provide parents with instructions about
how to complete rectal irrigations and
allow time for return demonstration
4. Teach colostomy care in immediate
postoperative period and encourage
parents
5. Teach parents how to assess for
distention and obstruction and
importance of reporting these findings to Nursing Assessment
6. physician • symptoms typically appear within 3 to 6
7. Help the parents learn about a minimal months
residue diet • Frequent bulky, greasy, malodorous
stools with frothy appearance
2ns step repair
malnutrition; Abdominal distention,
1. Infants will return with a nasogastric vomiting, and anorexia
tube in place attached to low suction. • Growth retardation
2. Intravenous infusion
• deficiency of fat sol vitamins (ADEK)
3. Indwelling urinary catheter • Anemia, irritability, edema
• In a celiac crisis, severe diarrhea and
1. Observe for abdominal distention dehydration; electrolyte imbalances and
2. Assess bowel sounds and observe also metabolic acidosis
for passage of flatus and stools
3. As soon as peristalsis has returned, the
NGT may be removed, hen offered
small, frequent feedings of fluids

Celiac Disease
Overview
• a genetic GI malabsorption condition
• known as gluten-induced enteropathy
• inability to tolerate foods containing
gluten
• inability to fully digest gliadin and
glutenin or protein component

Cause:
• “unknown”
• Genetic predisposition
• possibly influenced by environmental
factors
• an immunologic abnormality

− Exposed to gluten
− Damage in Intestinal mucosa
Laboratory Studies and Diagnostic Tests
• Flat mucosal surface, absence or
atrophy of villi, and deep crypts visible
on biopsy of small intestine
• Steatorrhea on analysis of 72-hour
quantitative fecal fat study
• Presence of serum antigliadin antibody
(AGA) and reticulin antibody levels are
elevated
• Importance of lifelong compliance with
dietary modifications and follow-up
medical care
Intussusception
− Is the invagination of one portion of the
intestine into another
− occurs mostly in the ILEOCECAL
VALVE

Nursing Diagnosis
• Altered nutrition; less than body
requirements, related to malabsorption
of food

Therapeutic Management

Younger than 1 year old – idiopathic reasons

Older than age 1 year – lead cause

• Assess child's growth at each routine

visit using a standard growth chart
• Administer fluids for hydration; serum
electrolytes and serum osmolality
• Monitor I & 0, assess skin turgor,
mucous membranes, and urine specific
gravity
• Encourage participation in age-
appropriate activities
• Inform parents of organizations

Client and Family Teaching

• Parents need a great deal of nutritional
counseling when children are first
placed on a gluten-free diet
• Written and verbal instructions on
gluten-free diet
• Read labels of processed foods,
because most contain gluten as a filler
• Urgency of seeking medical care in the
event of celiac crisis
 Intussusceptions
Overview:
• occurs in the second half of the first year
• The point of the invagination is generally
the juncture of the distal ileum and
proximal colon.
• Classifications:
1. Ileocecal
2. Ileoileal
3. Colocolic

Causes:
• Meckel’s diverticulum

• Intraoperative appearance of ileocolic

intussusception due to Meckel
diverticulum.

• Polyps
 Intussusception
Obstruction
Edema
Venous and
arterial
obstruction
GI bleeding and
fluid loss
Ischemia
Necrosis
• Hypertrophy of Peyer’s patches Perforation
Sepsis

• Bowel tumors
Nursing Assessment
• Intermittent attacks (15 min.) of colicky
pain…
• Emesis containing bile or fecal material
• After approximately 12 hours, children
develop blood in stool, containing
mucus described as a "currant jelly"
appearance.
Nursing Assessment
• Distended and tender abdomen with a
palpable, sausage-shaped abdominal
mass
• If necrosis has occurred, children
generally have
• an elevated temperature,
• peritoneal irritation
• Increased WBC,
• and often a rapid pulse.
Laboratory Studies and Diagnostic Tests
• History - (duration, intensity, frequency,
description, associated manifestations)
• Sonogram (ULZ)
• Increased WBC
• Abdominal X ray, Ultrasound,
Computerized Tomography

This is an abdominal plain radiograph of a 14-

week-old patient with intussusception. Note the
nonspecific appearance of bowel obstruction
Transverse ultrasonographic view This ileocolic intussusception is observed using
barium contrast enema. Intussusception has
been reduced to the level of the proximal
transverse colon.

Therapeutic Management

Appearance of intussusception on CT scan.

A. Reduction by a water-soluble solution

B. Pneumatic insufflation

Surgery
− Manual Reduction
− Resection

This ileocolic intussusception is observed using

air-contrast enema. Intussusception has been
reduced to the level of the cecum.
 Bowel Resection

Manual Reduction
Nursing care
• Pain related to abnormal abdominal
peristalsis
1. Infants need to be held and rocked and
comforted

• Risk for fluid volume deficit related to

bowel obstruction
1. NPO status before surgery or • Diagnosis: palpable olive shaped, firm,
nonsurgical reduction movable mass, located above to the
2. Intravenous fluid therapy - Vomiting right of umbilicus (mid epigastrium),
3. If a nonsurgical reduction was after vomiting.
accomplished, infants are kept NPO for • Visible gastric peristaltic wave across
a few hours… abdomen.
4. Infants who have surgery will return with • Confirmed by USG (>> length, >>
NGT thickness of wall, << luminal diameter)
5. Once bowel sounds are present, oral
feedings will be started gradually. Pyloric Stenosis
• Visible peristalsis
• Risk for altered parenting related to • “Olive” shaped mass at right upper
infant's illness quadrant
1. Parents need to hold infants after
reduction or Complications:
2. postoperatively • Dehydration
3. Provide guidance and support as they • Alkalosis
hold the infant. • Hypopnea
4. When oral feeding is resumed, • Tetany
encourage the parents to participate
with this aspect of care Diagnostic Procedure:
• Ultrasound
• Risk for altered parenting related to • Endoscopy
infant's illness
1. Reassure them that this did not occur Medical Management
because of anything they did. Surgical Management
2. They need to hold and be with the child • Laparoscopic correction
as recovery occurs. (pyloromyotomy)
• Performed before electrolyte imbalance
Pyloric Stenosis • Oral feeding is withheld - NPO
Hypertrophic Pyloric Stenosis • IV fluids
Hypertonic pyloric stenosis results when the • IV calcium and potassium
circular area of muscle surrounding the pylorus
hypertrophies and obstructs gastric emptying.

Clinical Manifestations
• Begins at 4-6 weeks of age
• Projectile vomiting
• Sour but contains no bile
• No presenting illnesses
• Gastric peristaltic movement passing
from Left to Right across the abdomen
• Round and firm olive size lump
 Biliary Atresia

Causes:
Prenatal period
• Unknown
• Viruses
• Toxins
• Chemicals

Overview:
A progressive inflammatory process that
causes both intrahepatic and extrahepatic bile
duct fibrosis.

Nursing Assessment
1. Healthy - appearing infant at birth
 2. Jaundice occurs within 2 weeks to 2
months
3. Acholic stools: puttylike, clay-colored
stools
4. Abdominal distention and hepatomegaly
5. Increased bruising of the skin,
prolonged bleeding time
6. Intense itching
7. Tea-colored urine
8. Malnutrition and growth failure

Diagnostic tests
• Liver biopsy
• Ultrasound

Medical Management Therapeutic Management

• Kasai Procedure
Surgery – for temporarily correct
obstruction and supportive care
1. Weigh daily
2. Administer TPN with or without
intralipids as ordered
3. Administer fat-soluble vitamins A, D, E,
and K as ordered
4. Monitor stool pattern
5. Establish an open, caring relationship
with family
6. Refer parents to support groups

Client and Family Teaching

1. Instruct the parents in meticulous skin
care
2. Provide verbal and written information
regarding nutritional needs
3. Provide instructions on home
medication regimen and allow time for
return demonstration
4. Inform parents of the signs and
• Liver tranplatation symptoms for which to call the physician
5. If a transplant is performed, include
Post OP Patient detailed instruction on post-transplant
medication
 Neurologic Disorders
Prenatal Brain Development and Neural Tube Related Birth Defects
Organization

Formation of Neural Tube

• Three primordial tissues – 2 weeks
o endoderm
o mesoderm
o ectoderm

• Neural crest becomes peripheral

nervous system (PNS)
• Neural tube becomes central nervous
system (CNS)
• Somites become spinal vertebrae.
 Cerebrospinal fluid

Neurologic System
Nerve cell
NS continues to mature thru the 1st 12 years of
life

CSF
− 4 fld-filled ventricles lie within the brain
− Choroid plexus of pia mater – secretes
CSF for about 100 (neonates) to 500
(adults) milliliters per day Time span for replacement = 6 hours
− Colorless, alkaline fluid, with SG of Spec grav. = 1.004-1.008
1.004 to 1.008 Appearance = clear and colorless
− Traces with proteins, glucose, CHON = 15-45 mg/100 ml
lymphocytes and body salts Glucose = 60-80% of serum glucose
Cell count = 0-8/mm3
Blood Flow Inc. granulocyte = CNS infection
− Must be maintained to meet the Inc. lymphocyte = meningeal irritation
metabolic needs of the brain
− 45 – 50- millilitres per gram of brain Spinal Cord
tissue per minute (adult and older
children)
− 18-20 milliliter per gram (younger
children less)

Intracranial Pressure
− 0-12 millilitres in mercury (1-10 mmHg)
 Diagnostic Test
Diagnostic Procedure
1. Lumbar Testing
2. Ventricular Tap
3. X Ray Techniques
a Cerebral angiography (femoral artery-
extracranial artery)
b Myelography (spinal cord – CSF by
LP)
c CT scan/ MRI
4. Nuclear medicine Studies (Brain Scan,
PET scan) Headache is the most common side effects
5. Echoencephotograhy (ULZ)
6. Electroencephalograhy Ventricular Tap
− Should be done in a supine position
Lumbar Testing
during the test
− Insertion of a spinal needle through the
− Applied pressure dressing after the
L4 or L5 interspace into the lumbar
procedure and place in a Semi – fowlers
subarachnoid space to obtain CSF
position
− To diagnose for hemorrhage or
− Comfort
infarction in the CNS or obstruction of
CSF
X-ray Techniques
Cerebral angiography

Myelography – thru lumbar puncture

 Cerebral Function
Cranial Nerves
Cerebellar Function
Motor function
Sensory Functions
Posturing
Reflexes
Kernig's sign and Brudzinski’s sign

CT Scan and MRI

Neurological Assessment

Electroencephalogram/EEG

Glasgow Coma Scale Modified for Infants –

Berkowitz, C.D.
I. Eye Opening Points
a. Spontaneous 4
b. To command 3
c. With Pain 2
d. No response 1
II. Verbal Response
a. Coos and babbles 5
b. Irritable cry 4
c. Cries to pain 3
Neurological Assessment d. Moans to pain 2
Health History - Denver Developmental e. None 1
Screening III. Motor Response
Level of Consciousness (GCS) a. Normal spontaneous movement 6
Intracranial pressure b. withdraws to touch 5
Fontanels c. withdraws to pain 4
Developmental Milestone d. abnormal flexion 3
e. abnormal extension 2
Neurological exam f. None 1
Hydrocephalus • Non-communicating
− An increase in the amount of CSF in the
ventricles and subarachnoid space

Caused:
Increased production of CSF
Impaired absorption
Block in the flow of CSF
Communicating Hydrocephalus
An obstruction outside the ventricular
system causing decreased absorption of
CSF in the subarachnoid space
Adhesion from inflammation, such as
with meningitis or subarachnoid
hemorrhage
Over production of CSF
Defective absorption of CSF
Venous drainage insufficient

Two types:
• Communicating
 Compression of the subarachnoid space Meningomyelocele
by a mass such as tumor
Congenital abnormalities of the
subarachnoid space
High venous pressure within the sagittal
sinus
Head injury
Cerebral atrophy

Dandy-Walker Syndrome

Noncommunicating Hydrocephalus
Congenital abnormalities in the
ventricular system
CSF flow is blocked within the Arnold-Chiari Syndrome
ventricular system − Defect in the posterior fossa where
Mass lesions such as a tumor that there is herniation of the cerebellum,
compresses one of the structures of the medulla, pons and fourth ventricles into
VS the cervical canal through enlarged
Types: foramen magnum
a Aqeuductal Stenosis
b Meningomyelocele
c Dandy-Walker syndrome
d Arnold- Chiari malformation

Aqueductal Stenosis
 Treatment
Surgery
Shunt system (VP shunt / AV shunt)
• Ventricular catheter
• Unidirectional pressure valve and
pumping chamber
• Distal catheter

Nursing Management
• Preoperatively
− neck muscle are well supported
Hydrocephalus − sheepskin should be placed under the
Classification – Functional head
Obstructive Communicating − Position changed frequently
(Non-communicating) (Non-obstructive) − offer small frequent feedings with
Block proximal to the Block at the level of intermittent burping
arachnoid arachnoid
granulations granulations • Postoperatively
e.g., aqueduct e.g., Post meningitic 1. Flat position on the unoperated side –
stenosis avoid rapid reduction of CSF – post op
2. Head elevation if ICP increase
3. Monitor vs and neurologic checks
4. Measure head circumference
5. Monitor I and O
6. Meticulous skin care
7. Observed for signs of infection and
increased ICP (headache, loss of
appetite – toddlers)
8. Antidiuretic, antibiotic, anticonvulsant

Clinical Manifestations: Neural tube defect

• Infants − Failure of the neural tube to close during
• Toddler embryonic development
• Older children
Spina Bifida
Subdural Taps − A neural tube defect where there is an
CT / Brain scan incomplete closure of the vertebrae and
Lumbar Puncture neural tube
EEG
Etiology
Nursing Diagnosis: • Poor intake of folic acid
1. Altered tissue perfusion
• Exposure to teratogens
2. High risk for infection r/t shunt
3. Risk for impaired skin integrity
Recommended intake:
4. Risk for injury r/t increase intracranial
− 0.4 mgs of folic acid per day at least 1
pressure
month before conception
5. Interrupted family process r/t having a
seriously ill child
Types:
Anencephaly • The higher the deformity, the
− Absence of cranial vault with cerebral more neurological defects
hemispheres • Lower extremity may be
partially or completely
Microcephaly paralyzed
− In which brain growth is so slow that it • Bowel/bladder may or
falls more than 3 standard deviations may not be affected
below normal on growth charts • Flexion or extension
contractures
Encephalocele • Urinary tract infection
− protrusion of the brain and meninges • Orthopedic problems
into a fluid-filled sac through a skull • Scoliosis
defect

Spina bifida occulta

− Failure of the posterior vertebral arch to
fuse, 5th lumbar or 1st sacral vertebrae
− No herniation of the spinal cord

Diagnostic Tests:
Amniocentesis
Neural Tube Defect
Ultrasound (prenatal)
Transillumination
Spina bifida cystica MRI and CT scan
− defect in the closure of the posterior
vertebral arch
Nursing Diagnosis:
Types of anomalies: 1. High risk for infection
2. High risk for impaired skin integrity
3. Altered urinary elimination
4. Bowel incontinence/colonic constipation
5. Impaired physical immobility

Medical Management
Neurosurgery: Before Surgery
1. Place in prone position
2. With sterile dressing moistened with
normal saline
Spina bifida occulta 3. Keep in an isolette
Meningocele 4. Towel roll may be used
Myelomeningocele 5. Meticulous skin care
6. Egg crate mattress pad should be
Clinical Manifestations: placed
7. Neurological Assessment
 8. Provide tactile stimulation Cerebral Palsy
9. Infant should be placed prone on a − Chronic nonprogressive motor
pillow on the nurse lap dysfunction caused by damage to the
10. Infant should be fed with the head motor areas of the brain
turned to one side (PRONE)
11. Neurogenic bladder and bowel Etiology:
management Prenatal
12. Collaborate with physical therapy Birth
13. Medication therapy Perinatal
Childhood
Neurosurgery: After Surgery
1. Prone position for several days Etiologic Factors
2. Antibiotics should be given Prenatal
3. Watched for signs of systemic infection Genetic or chromosomal abnormalities
4. Bowel and Bladder dysfunction must be Brain malformation
noted Exposure to teratogens
5. Watched for CSF leakage Multiple fetuses
6. Skin integrity must be maintained Intrauterine infection
Ineffective placenta causing insufficient
Craniosynostosis nutrition and oxygen delivery to fetus
− Premature closing of the cranial sutures Birth
Preeclampsia
Complicated labor and delivery
Birth injury caused by direct head
trauma.
Asphyxia secondary to cord collapse or
strangulation.
PERINATAL
CNS infection or sepsis
Kernicterus (hyperbilirubinemia of the
newborn)
CHILDHOOD
Head Trauma
Clinical Manifestations: Meningitis
Increased ICP Toxic ingestion or inhalation
Papilledema
Blindness (untreated) Types:
1. Pyramidal or spastic type
Treatment: 2. Extrapyramidal type
Surgery
− Parallel craniotomy Clinical Manifestations
Patient is asked to wear helmet until the 1. Delayed gross motor development
facial bone grows 2. Abnormal head circumference
3. Abnormal posture
Nursing Management: 4. Abnormal reflexes
Monitor 5. Abnormal muscle performance and tone
− Vital signs
− Increased ICP ABNORMAL MOTOR PERFORMANCE
Very early referential unilateral hand use
− Infection
Abnormal and asymmetrical crawl
− Bleeding
Standing or walking on toes
 Uncoordinated or involuntary
movements
Poor sucking
Feeding difficulties
Persistent tongue thrust
ALTERATIONS OF MUSCLE TONE
Increased or decreased resistance to
passive movements
Opisthotonic posture (exaggerated
arching of back)
Feels stiff on handling or dressing
Difficulty in diapering
Rigid and unbending at the hip and knee
joints when pulled to sitting position (an
early sign)
ABNORMAL POSTURE
Maintains his higher than trunk in prone
position with legs and arms flexed or
drawn under the body
Scissoring and extension of legs, with
the feet plantar flexed in supine position
Persistent infantile resting and sleeping
posture
− Arms abducted at shoulders
− Elbows flexed
− Hands fisted
REFLEX ABNORMALITIES
Persistence of primitive infantile reflexes
− Obligatory tonic neck reflex at any age
− Nonpersistence beyond months of age
Persistence or hyperactivity of the Moro,
plantar, and palmar grasp reflexes
Hyperreflexia, ankle clonus, and stretch
reflexes elicited in many muscle groups
on fast passive movements
Associated disabilities
Subnormal learning and reasoning
(Mental retardation in about two thirds of
individuals)
Seizure behavioral and interpersonal
relationships
Sensory impairment (vision, hearing)
Warning signs
PHYSICAL SIGNS
Poor head control after 3 months of age
Stiff or rigid arms or legs
Pushing away or arching back
Floppy or limp body posture
Cannot sit u without support by months
Uses only one side of the body, or only
the arms to crawl
BEHAVIORAL SIGNS
Extreme irritability or crying
Failure to smile by 3 months
Feeding difficulties
− Persistent gagging or choking when fed
− After six months of age, tongue Pushes
soft food out of the mouth
Diagnosis
Definitive diagnosis is between 18
months to 2 years of age
Neurologic examination and history are
primary modes of diagnosis
Diagnostic Evaluation
SUPPLEMENTAL DIAGNOSTIC TESTS
Electroencephalography
Tomography
Screening for metabolic defects
Serum electrolytes values
Nursing Diagnoses:
1. Impaired Physical mobility
2. Self-care deficit
3. Altered nutrition: less than body
requirements
4. High risk for injury related to
neuromuscular, perceptual, or cognitive
impairments
5. Impaired verbal communication
6. Fatigue
Medical Management:
Technical aids: braces and walkers,
wheelchairs
Physical and speech therapy
Muscle relaxants (dantrolene (dantrium),
baclofen, methocarbamol (robaxin),
diazepam) or neurosurgery
− Rhizotomy
Anticonvulsant medication
Care of visual and auditory deficits
Dental care
Nursing Management
 1. Use pillows ad bolsters to support body
part
2. Protect bony prominences
3. High calorie diet
4. Assist with locomotion and
communication
5. Promote age-appropriate mental activity
6. Provide a safe environment
7. Provide adequate nutrition and rest
8. Collaborate with multidisciplinary team
for speech, nutrition, physical therapies
Family Teaching
Teach parents use of physical therapy
strategies
Child will learn self-care skills
Teach parents special feeding
techniques (gastrostomy tube) and use
of adaptive devices
Mental Retardation
− significantly sub-average general
intellectual functioning manifested
before age 18, with limited adaptive
skills in at least two or more areas of
functioning
− Is associated either with syndromes in
which genetic alterations or intracranial
lesions
Etiology:
Genetic
Prenatal
Perinatal
Postnatal
Classifications:
MILD
− 50-70 IQ – educable, live independently,
working in the community
MODERATE
− 35-49 IQ, obvious delays, most live in
supervised settings
SEVERE
− 20-34 IQ, cognitive challenge, focuses
on the basics of independent living
skills, like toileting, bathing, feeding,
simple communication
PROFOUND
− Less than 20 IQ, need a highly
structured setting with constant
monitoring and supervision.
Diagnostic
Thorough physical examination and
history
Routine developmental assessments
Standardized tests of intellectual and
adaptive functioning (Standford-Binet
Test)
Nursing Management
− Specialized educational and therapeutic
services
Down Syndrome
− A congenital condition characterized by
mental retardation
Chromosome 21 likely contains 200 to 300
genes that provide instructions for making
proteins. These proteins perform a variety of
different roles in the body. Down syndrome is a
chromosomal condition that is associated with
intellectual disability, a characteristic facial
appearance, and weak muscle tone
(hypotonia) in infancy.
Assessment Findings
Brushfield’s spot
Flat, broad forehead
Flat nose
Hypotonia
Mild to moderate mental retardation
Protruding tongue
Short stature with protruding hands
Fingers are short and thick, little finger is
often curve inward
Small head with slow brain growth
Upward slanting eyes
Epicanthal fold
 Ears may be low set
Management
Seizures shows an active tonic-clonic or
convulsive pattern which lasts for 15-20
seconds
EEG tracing usually normal
History of often other family members
having had similar seizures.

Prevention:
Acetaminophen
If 2nd seizure occurs
− Diazepam (Valium)

Therapeutic Management
Be cautious for potential seizure occur.
Monitor Vital signs, if fever is high do
TSB.
Put washcloth in the forehead, axillary,
and groin areas.
Advise them not to put the child in the
bathtub.
Applying alcohol or cold water is also
not advisable.

Nursing Interventions:
Provide activities and toys appropriate
for age
Set realistic, reachable goals
Provide stimulation and communicate at
a level appropriate to the child
Mainstream daily routines to promote
normally Meningitis and Encephalitis
Provide a safe environment Meningitis – Coverings of the Brain

Febrile Seizure
− Seizures associated with high fever (102
degree – 104-degree Fahrenheit or 38-
40 degree Celsius)
− Most common 5 months – 5 years
− Usually occur after immunizations

Causes of Fever
Infections (most common)
Cancer
Heat exhaustion
Side effects of certain medications What is meningitis?
Autoimmune disorders and diseases The brain and spinal cord are covered by 3
Overdressing (common with infants) connective tissue layers collectively called
the meninges which form the blood-brain
barrier.
- Pia mater (closest to the CNS)
- Arachnoid mater
- Dura mater (farthest from the CNS)
- Meningitis is defined as a disease
caused by the inflammation of the
meninges; these provide protective
functions to the central nervous system
(CDC, 2012).
- Cerebral spinal fluid that surrounds
the central nervous system becomes
infected, which causes the meningeal
inflammation.
Types of Meningitis & Their Causes
BACTERIAL MENINGITIS: commonly caused
by Streptococcus pneumonia
(pneumococcal) bacteria which causes ear
and sinus infections but can also be caused by
the Haemophilis influenza type B bacteria,
Listeria B and the meningococcal bacteria.
- Group B streptococcus and Escherichia
coli
VIRAL MENINGITIS: commonly caused by
enterovirus, but herpes simplex virus, and
viruses causing mumps, measles, rubella
and chicken pox can also cause viral
meningitis
FUNGAL MENINGIITIS: caused by a fungal
infection and can mimic bacterial
meningitis, but is uncommon
- can be spread through coughing,
sneezing, kissing, sharing eating
utensils and a toothbrush
or a cigarette
Viral Meningitis Key Facts
- Younger than 24 months-5 years old
- Peak incidence-winter time
- Living in a community setting
- Compromised immune system
Meningitis Now Survey:
- Viral Meningitis can affect anyone of any
age.
- Over 50% of sufferers experienced
difficulties at work or in education
- There are about 6,000 cases of viral
meningitis each year.
- Symptoms include severe headache,
neck stiffness, dislike of bright lights
nausea and vomiting, and confusion and
drowsiness.
- Viral meningitis is an infection that
causes inflammation of the membranes
that surround the brain and spinal cord.
- Viral meningitis can make people very
unwell is rarely life-threatening.
- Over 80% are not given any or enough
information during their recovery.
- 97% of sufferers experience after
effects, including exhaustion (78%),
headaches (70%) and memory loss
(50%).
Bacterial meningitis - Organisms
• Neonates
- Most caused by Group B Streptococci
- E coli, enterococci, Klebsiella,
Enterobacter, Samonella, Serratia,
Listeria
• Older infants and children
- Neisseria meningitidis, S. pneumoniae,
tuberculosis, H. influenza
Bacterial meningitis
- 3 – 8 month old at highest risk
- 66% of cases occur in children
Meningitis can strike quickly and kill within
hours so urgent medical attention is
essential.
Meningitis
 • Stiff neck or nuchal rigidity
• Meningismus (stiff neck +
Brudzinski + Kernig signs)

Normal Meningitis vs. Infected Meninges

Meningitis Baby Watch

Is your baby getting worse fast? Babies can
get ill very quickly, so check often.

Definitions
• Meningitis – inflammation of
the meninges
• Encephalitis – infection of the
brain parenchyma
• Meningoencephalitis – inflammation of brain
+
meninges
• Aseptic meningitis – inflammation of
meninges
with sterile CSF
- Tense or bulging soft spot
- High temperature but often absent in
babies in under 3 months
- Ver sleepy/staring expression/too sleepy
to wake up
- Breathing fast/difficulty breathing
- Extreme shivering
- Pin prick rash/marks or purple bruises
anywhere on the body
- Sometimes diarrhea
- Vomiting/refusing to feed
- Irritable when picked up, with a high
Symptoms of meningitis
pitched or moaning cry
• Fever
- Blotchy skin, getting paler or turning
• Altered consciousness,
irritability, photophobia blue
• Vomiting, poor appetite - A stiff body with jerky movements, or
• Seizures 20 - 30% else floppy and lifeless
• Bulging fontanel 30%
- Pain/irritability from muscle aches or
severe limb/joint pain Diagnostic Test
- Could hands and feet • Analysis of CSF obtained by
lumbar puncture
Not every baby gets all these symptoms. - Elevated WBC
Symptoms can appear in any order. - Elevated protein
- Decreased level of glucose
• Blood culture
• CT scan and MRI or Ultrasound

Bacterial meningitis – Clinical course

• Fever
• Malaise
• Vomiting
• Alteration in mental status
• Shock
• Disseminated intravascular coagulation
(DIC)
• Cerebral edema
• Vital signs
• Level of mentation

Increased intracranial pressure (ICP)

• Papilledema
• Cushing’s triad
• Bradycardia
• Hypertension
• Irregular respiration
• ICP monitor (not routine)
• Changes in pupils

Diagnosis – lumbar puncture

Intracranial Pressure
ICP = P cerebrum +P blood + P CSF
- Cerebrospinal fluid drawn from between The normal range for ICP varies with age
two vertebrae. Age group ICP
- Cerebrospinal fluid is collected. normal(mmHg)
Infant < 7.5
Child < 10
Contraindications:
Adult <15 (7.5 – 20 cm H2O)
- Respiratory distress (positioning)
- ICP reported to increase risk of
Meningitis - Treatment duration
herniation • Neonates: 14 – 21 days
- Cellulitis at area of tap • Gram negative meningitis: 21 days
- Bleeding disorder
• Pneumococcal, H flu: 10 days immunosuppressed cephalosporin +
• Meningococcal: 7 days patients vancomycin +
ampicillin
Table 1. Recommended Antibiotic Postneurosurgical Vancomycin +
Therapy for Patients with Possible meropenem
Bacterial Meningitis, and Their Most
Commonly Associated Organisms Meningitis - Acute complications
2.50 years: S. Vancomycin + 3rd- • Hydrocephalus
pneumoniae, N. generation • Subdural effusion or empyema ~30%
meningitidis cephalosporin • Stroke
>50 years: S. Vancomycin + 3rd • Abscess
pneumoniae, N. generation • Dural sinus thrombophlebitis
meningitidis, L. cephalosporin +
monocytogenes Ampicillin Bacterial meningitis - Outcomes
Basilar skull fracture: Vancomycin + 3rd • Neonates: ~20% mortality
S. pneumoniae, H. generation • Older infants and children:
influenzae, Group A cephalosporin • <10% mortality
beta hemolytic strep • 33% neurologic abnormalities at
Penetrating trauma: Vancomycin + discharge
S. aureus, Coagulase cefepime or • 11% abnormalities 5 years later
negative ceftazidime • Sensorineural hearing loss 2 - 29%
staphylococci (CNS),
gram-negative bacilli Management for Bacterial Meningitis
(GNB) (including • Antibiotics ASAP, even if Lumbar
Pseudomonas) Puncture not yet done
Postneurosurgery: Vancomycin + • Vanco + cephalosporin until some
GNB (including cefepime or identification known (8-10 days)
Pseudomonas), CNS, ceftazidime - CSF, Latex, exam
S.aureus • Corticosteroids (dexamethasone), osmotic
CSF shunt: CNS, S. Vancomycin + diuretic (mannitol)
aureus, GNB cefepime or - To reduce ICP and help prevent hearing
(including ceftazidime loss
Pseudomonas), • Isolate if bacterial x 24 hours, Universal
Propionibacterium Precautions (Respiratory)
acnes • Monitor for status changes
- Pupils, LOC, HR, BP, resp
Treatment: Bacterial meningitis - Seizures
Patient Population Empiric Treatment - Hemodynamics
Neonate Ampicillin plus - DIC, coagulopathy
cefotaxime or - Fluid, electrolyte issues
aminoglycoside
Healthy children and 3rd or 4th generation Medical Management
adults with cephalosporin + - Antibiotics that cross the blood=brain
community- acquired vancomycin
barrier into subarachnoid space
disease [+metronidazole if
➢ Penicillin antibiotics or one of the
otitis, mastoiditis,
sinusitis are cephalosporins
predisposing ➢ If resistant strains of bacteria
conditions] identified, vancomycin hydrochloride
>55 year or with 3rd – or 4th – alone or in combination with rifampin
chronic illness or generation may be used
 - Dexamethasone as adjunct therapy
➢ 5-20 minutes before the first dose of
antibiotics, and every 6 hours for the
next 6 days
- Fluid volume expanders to treat hock an
dehydration
- Phenytoin to treat the seizure
Nursing Diagnosis
• Pain related to meningeal irritation
• Risk for ineffective tissue perfusion (cerebral),
related
to increase ICP.
If recognized earlier and treatment is effective,
a child will recover with no sequelae.
Neurologic Sequelae:
1. Learning problems
2. Seizures
3. Hearing and cognitive challenges
4. Inability to concentrate urine
What is Encephalitis?
It is a medical condition where there is
inflammation of the brain. The commonest
cause of Encephalitis is viral infections.
Causes
- The exact cause of encephalitis is
unknown.
- - Usually caused by a virus or
sometimes even a bacterial infestation
as well as non infectious inflammatory
conditions may cause encephalitis.
- Few viruses that may be instrumental in
causing encephalitis includes-
1. Herpes simplex
2. Polio viruses
3. Mosquito – borne viruses
4. Tick – borne
5. Rabies
6. Childhood viruses
Viral invasion
- Enterovirus – most common
- May occur direct invasion of the CSF
during lumbar puncture
Encephalitis symptoms
- Headaches
- Neck stiffness
- Paralysis
- Very high fever
- Disorientation
- Reduced consciousness, perhaps coma
- Tremors and convulsions
- Muscle weakness or paralysis
- Signs of meningeal irritation (nuchal
rigidity, + Brudzinski neck sign and
kernig’s sign)
What? Encephalitis is an inflammation
(swelling and irritation) of the brain.
Whom? Most cases happen in children,
the elderly, and people with a weakened
immune system.
Symptoms? Symptoms include
headache, fever, stiff neck and vomiting.
Cases? More than 100 children died in
Indian village in the month of June 2019.
Diagnostic Evaluation
• History and physical assessment
• CSF evaluation shows
- Elevated leukocyte Count
- Elevated protein
- Glucose normal
• EEG shows widespread cerebral involvement
• Brain biopsy (temporal lobe) – identify the
virus
Lumbar Puncture
Step 7
CSF COLLECTION IN 3-4 TEST TUBES (2-
5ML EACH)
Tube 1 – Glucose Protein
Tube 2 – Gram Stain Culture
Tube 3 – Cell count
Tube 4 – for special tests
Therapeutic Management: Supportive
• Antipyretic treatment
• Vital signs check and monitor
• Mechanical ventilation
• Antiviral agent
- acyclovir (zovirax)
• Anticonvulsants
- Carbamazepine (Tegretal)
 - Phenobarbital
- Phenytoin (Dilantin)
• Steroids
- Dexamethasone and mannitol
Complications
- The long-term neurologic sequelae can
be grouped into 3 categories as follows:
➢ Hearing impairment
➢ Obstructive hydrocephalus
➢ Brain parenchymal damage: most
important feared complication of
bacterial meningitis. It could lead to
sensory and motor deficits, cerebral
palsy, learning disabilities, mental
retardation, cortical blindness, and
seizures
Ataxic
• irregularity in muscle action or coordination,
intention tremors
• wide based gait
•Unable to perform the finger-to-nose test
•May have intention tremors
To keep her balance the child with ataxia walks
bent forward with feet wide apart. She takes
irregular steps, like a sailor on a rough sea or
someone who is drunk.
Dyskinetic or Athetoid
• abnormal involuntary movement (constant
involuntary
movement), athetosis (slow, “worm like”,
writhing movements that usually involve the
neck, extremities, trunk, facial muscles, and
tongue), drools and speech is difficult to
understand, jerking (choreoid) during emotional
stress
Typical athetoid arm and hand movements
may be as a regular shake or as sudden
“spasms”. Uncontrolled movements are often
worse when the child is excited or tires to do
something.
Mixed
- Shows symptoms of both spasticity and
athetoid movements or ataxic and
athetoid
- This combination results in a severe
degree of physical impairment
Spastic CP
- Excessive tone in the voluntary muscles
that results in loss of upper motor
neurons
- May involve one or both sides
1. Hypertonic muscles (hypertonicity with
poor control of posture, balance, and
coordinated motion)
2. Abnormal clonus
3. Exaggeration of deep tendon reflexes
4. Abnormal reflex (positive Babinski
reflex, tonic neck reflex)
5. Arch their backs and extend their arms
and legs normally
6. Scissor gaits
7. Walk on their toes
- Muscles are rigid and jerky, scissoring,
abnormal clonus , walk on their toes
➢ When you try to stand the child the
legs often stiffen or cross like
scissors.
➢ Less commonly the head and
shoulders may stiffen forward…
➢ The child who learns to walk may do
so in a stiff, awkward position, with
the knees pulled together and bent.
Feet often turn in.
 BORH LEGS ONLY (PARAPLEGIC) or
with slight involvement elsewhere
(DIPLEGIC)
- Upper body usually normal or with very
minor signs
- Child may develop contractures of
ankles and feet.

BOTH ARMS AND BOTH LEGS

(QUADRIPLEGIC)
- When he walks, his arms, head, and
even his mouth may twist strangely.
- Children with all 4 limbs affected often
have such severe brain damage that
they never are able to walk.
- The knees press together.
- Legs and feet turned inward.
Astereognosis

ARM AND LEG ON ONE SIDE

(HEMOPLEGIC)
- Arm bent; hand spastic or floppy, often
of little use
- She walks on tiptoe or outside of foot on
affected side
- This side completely or almost normal
 MUSCULOSKELETAL DISORDER
• Developmental hip dysplasia
• Talipes deformities
• Duchenne syndrome
• Scoliosis, kyphosis, lordosis
NOTE:
Some defects can be diagnosed within birth or
after birth
Nurses must understand the principles of
therapy to help the families
What are the assessment in the DR?
- Ballard Scale (helps nurses know any
deviations on the client) (helps in assessing the
neuro and muscular maturity)
- APGAR
As the child grows, there might be deviations
Developmental Dysplasia of the Hip
− Describes a spectrum of disorders
related to abnormal development of the
hip that may occur at any time during
fetal life, infancy, or childhood
− Girls are affected more than boys
− Breech intrauterine position
They can occur anytime
From Congenital Hip Dysplasia to
Developmental Dysplasia of the Hip (change of
the term) because before they can just be seen
after the birth of the baby but now, it can occur
anytime.
Affects the race, ethnicity.
1 or 2 infants to 1000 live births
Positive family history
PATHOPHYSIOLOGY
The cause of DDH is unclear but is likely
multifactorial
Predisposing factors:
− Physiologic factors
Maternal and intrauterine positioning
− Mechanical factors
 Breech presentation, multiple fetus,
polyhydramnios, less amniotic fluid,
large infant child, extension and flexion
− Genetic factors
Category:
− Idiopathic
Infant is neurologically intact (no
problem with neurologic system)
− Teratologic
Involves neuromuscular defects
Post-natal positioning can predispose to DDH
Subluxation – incomplete dislocation of the hip;
there is flattening of the socket
Dislocation – femoral head loses contact;
maglisod of move ang tiil sa bata; the ball and
the socket does not meet
Clinical Manifestations
Infants
− Shortening of limb on affected side
(Galeazzi sign)
− Restricted abduction of hip on affected
side
− Unequal gluteal folds (best visualized
with infant prone)
− Positive Ortolani test (hip is reduced by
abduction)
− Positive Barlow test (hip is dislocated by
adduction
Older Infants and Children
− Affected leg appears shorter than the
other
− Telescoping or piston mobility of joint:
− Head of femur felt to move up and down
in buttock when extended thigh is
pushed first toward child’s head and
then pulled distally
− Trendelenburg sign:
− When child stands first on one foot and
then on the other (holding onto a chair,
rail, or someone’s hands) bearing
weight on affected hip, pelvis tilts
downward on normal side instead of
upward, as it would with normal stability
− Greater trochanter prominent and
appearing above a line from
anterosuperior iliac spine to tuberosity of
ischium
− Marked lordosis and waddling gait
(bilateral hip dislocation)
Barlow Test and Ortolani Test
- each hip must be examined separately
Barlow Test
- Thomas Barlow
- provocative maneuver used to reveal hip
instability
- face the baby and one hand will be stabilizing
the baby while the other hand will flex the
knees
- adduct (bring together the thigh, going inside)
by 10-30 degrees
Positive Barlow Test: if the hip will pop out of
the socket when performing the manuever; the
dislocation will be palpable

Ortolani test
- 1936 by Marino Ortolani
- place the baby in supine position
- position your medially near the groin crease
- use the opposite hand to abduct (away)
- palpable click or clang indicated a positive
Ortolani test

Galeazzi sign
- infants and older children
- allis sign or skyline test
- assess DDH
- hips flexed in 45 degrees and knees 90
degrees
- ankles are touching the buttocks
- unequal of the height is a positive Galeazzi
sign
Trendelenburg Sign
- Gluteal fold are uneven
- seen when assessing dysfunction of the hip
- the pelvis drops on the contralateral side
- let the child stand on one leg and you will see
the asymmetry of the hips (older children)
Must be performed by an experienced clinician.
Ultrasound and x-ray are only additional tests.
X-ray is useful in confirming the diagnosis with
6 months old and above children.
Therapeutic Management
- Periacetabular osteotomy
- The Pavlik harness is a soft splint. It usually
remains in place for approximately six to 12
weeks (or for as long as the doctor
recommends)
The harness will hold your baby’s legs in a
frog-like position
This is the best position to allow the pelvis
sockets to deepen around the thigh bone and
for the hip joint to stabilize

The treatment varies with the child’s age.

Pavlik – most used; 6-12 weeks or for as long
as the doctors will recommend it
The harness is worn 24 hours a day; Sponge
bath the kid only

Sometimes DDH is not detected after birth.

Infants must be assessed with DDH during the
first-year checkups (well-baby checkups)
Barlow and Ortolani Test - most reliable from
birth to 4 weeks of age

Casting – if dili madala sa harness

The cast is changed periodically Prenatal is very important – the position of the
(approximately, 3 months) child will be determined (Leopold’s maneuver)
Duration of the treatment depends on the
development. Three categories:
Recommended for 6-12 months children. 1. Positional clubfoot
Child in a traction – causes the legs to be fully
abducted

Nursing Care Management

- Skin care is an important aspect of the care of
an infant in a harness
- Parents are encouraged to hold the infant
with a harness and continue care and nurturing
activities
- Children in corrective devices need to be
involved in all typical age-appropriate activities

Instruct the mother to maintain and help the 2. Congenital clubfoot

goal of the treatment (goal: apply the device)

The adjustments must be done by the

healthcare provider.
Skin care – teach the mother if there are
presence of skin breakdown due to the
harness
Check 2-3 times a day for any presence of skin
irritations under the harness
Gently massage the skin once a day 3. Syndromic (or teratologic) clubfoot
Do not put powder or lotions because these
can harden and irritate the skin.
Place the diaper under not over.
As nurses, we must be available for the
parents.
Teach the parents how to clean the cast. It
must not be wet.

CLUBFOOT
− Clubfoot may occur as an isolated
deformity or in association with other
disorders or syndromes, such as
chromosomal abnormalities,
arthrogryposis, spina bifida
− Incidence: 1 per 1000 live births
− Boys affected twice as often as girls
− With a 1 in 10 chance that a parent with
clubfoot will have an affected offspring
− Precise cause is unknown From intrauterine crowning
Positional clubfoot – can be corrected
the foot is pointed downwards spontaneously or may require exercise or
the mother is encouraged to take folic (to casting; no bony abnormality
prevent neural tube defects) during pregnancy. Congenital clubfoot – Indio pathetic; has wide
range of rigidity and prognosis; true clubfoot;
require surgical intervention because there is a Only the doctor must do the adjustments.
bony abnormality
Syndromic – associated with other Nursing Care Management
abnormalities; more sever form of clubfoot; - Care is the same as for any child who has a
requires surgical correction; have high cast
incidence of recurrence; mildest and worst - Parent education and support are important
among the three
DUCHENNE MUSCULAR DYSTROPHY
Therapeutic Management (DMD)
Treatment of clubfoot involves three stages: - Symptom onset is in early childhood, usually
1. Correction of the deformity between ages 2 and 3
2. Maintenance of the correction until normal - Primarily affects boys, but in rare cases it can
muscle balance is regained affect girls
3. follow-up observations to avert possible
recurrence of the deformity Deliomi Benjamin Duchenne – 1860
Passed on by the mother
Recommended treatment is with the use of the The mother is the carrier (DMD carriers)
Ponseti method
Ponseti method – a serial casting (pasunod); SIGNS AND SYMPTOMS, WHICH
done shortly after birth TYPICALLY APPEAR IN EARLY
6-10 weeks CHILDHOOD, MIGHT INCLUDE:
Tenotomy – surgical procedure to release the - Frequent falls
ligaments; done at the end of the casting - Difficulty rising from a lying or sitting position
- Trouble running and jumping
- Waddling gait
- Walking on the toes
- Large calf muscles
Ponseti sandal/brace - Muscle pain and stiffness
- Learning disabilities

Children with Duchenne muscular dystrophy,

the most common form, may live to their late
teens or 20s

DUCHENNE’S MUSCULAR DYSTROPHY

- Progresses weakness and wasting of
muscles
- Onset: 3-5 years old
- Genetic: primary males

- History of motor development delay

To maintain the alignment of the foot and to
prevent recurrence of clubfoot.
Teach the mother how to apply the sandal and
how to remove it (during bathing of the child)
Infant must wear it 24 hours and only removed
when cleaning the child.
- Clumsiness
- Frequent falls
- Difficulty climbing stairs, running, and riding
tricycle
- Waddling gait
- Ambulation frequently impossible by age 12
- As breathing muscles become more affected,
life-threatening infections are common. This
usually leads to death by age 15-18 years
 Kyphosis – Can be seen as hump
Nursing considerations Lordosis – anterior curvature of the spine
- Fatigue
- Mobility TYPES OF SCOLIOSIS
- Frequent infections Healthy
- Psychological effects Thoracic scoliosis
- Maintain function Lumber Scoliosis
Thoraco-Lumbar Scoliosis
Combined Scoliosis

Sir William Richard Gowers – 1879

Climbing ___

Nursing Care management

Multi-disciplinary care is essential in the
management of DMD Scoliosis
- Range-of-motion and stretching exercises - Complex spinal deformity
- Exercises - most common spinal deformity
- Braces - classified by age
- Mobility aides/devices Caused by:
- Breathing assistance - Neuromuscular condition
Idiopathic - unknown cause
Treatment is lifetime. Identified during the pre-adolescents.

Scoliosis, Kyphosis, & Lordosis Scoliosis Radiographs

The Cobb Method of angle measurement
1. Identify the upper and lower end vertebrae
2. Draw lines extending along the vertebral
borders
3. Measure the Cobb Angle directly (a) or
geometrically (b)

Scoliosis - Lateral or S-shape curvature of the

spine
 Wilmington – custom made for the patient
Boston brace – standard brace
Asymmetry of the shoulder Milwaukee brace – involves neck support;
Pelvic obliquity helps the spine and promote correction of
Asymmetry of the ribs can be seen spine deformity
Scoliometer – to measure the truncal rotation Charleston – used during night time; limited
The head and hips are not aligned. movement is needed
The definitive diagnosis is also made by
radiographs (x-ray)
Operative Management
KYPHOSIS
- Kyphosis is the lateral
convex angulation in the
curvature of the thoracic
spine

Cause:
- Poor posture in
childhood, such as slouching, leaning back in
chairs and carrying heavy schoolbags, can
cause the ligaments and muscles that support
the vertebrae to stretch

LORDOSIS Nursing Care Management

- Is the inward curve of the lumbar spine (just - Nursing care to meet not only physical needs
above the buttocks) but also psychological needs associated with
- A small degree of lordosis is normal the diagnosis, surgery, postoperative recovery,
- Too much curving is called swayback and eventual rehabilitation
Cause: Halo traction that is screwed into your skull
- An imbalance between the muscles Treatment includes meeting the psychological
surrounding the pelvic bones needs.
- Weak muscles used to lift the leg forward (hip
flexors) combined with tight muscles used to
arch the back (back extension), can cause an
increased pelvic tilt, limiting movement of the
lower back

Therapeutic Management
 REPRODUCTIVE DISORDERS
Male Reproductive Organ

CRYPTORCHIDISM
- Failure of one or both testes to descend
from the abdominal cavity into the
scrotum

Caused:
- Unclear
- Caffeine intake during pregnancy
- Inadequate length of spermatic vessels

Assessment:
- Early detection is important

LAPAROSCOPY
- Surgical intervention

EPISPADIAS
- Urethral defect in which the opening is
in the dorsal surface of the penis

HYPOSPADIAS
Assessment:
- Chordee
- During the delivery of the fetus, look at
Therapeutic Management: the reproductive organ of the fetus
- Usually delayed for 6 to 12 months - Cryptorchidism
- Chorionic gonadotropin maybe given for
5 days
- ORCHIOPEXY (repair of the testes), if • Should not be circumcised
necessary • Meatotomy
- There are situations that the testes will • May have testosterone cream applied or
be delayed daily injections

HYPOSPADIAS Normal Penis – normal

- Is a urethral defect in which the urethral Hypospadias – urethra opens on underside of
opening is not at the end of the penis penis
but on te ventral (lower) aspect of the Severe Hypospadias – urethra opens at base
penis of scrotum and chordee pulls penis down
 ENURESIS
- Is involuntary passage of urine past the
age when a child should be expected to
have attained bladder control
- Occur at approximately 5-7 years old
- Bladder control – 2-3 years old for
daytime and 4 years old for nighttime
- Occurs in toddlers. Toddlers can already
control their bladder.
- Usually occurs 5-7 yrs old
Assessment:
- History -ask mother or SO
- Stresses in the family
- Uncomfortable school situation
- Engrossed in an interesting activity
- Ask the mother. Check how and when
she will toilet train the child
Diagnostic Tests:
- IVP, VCUG, or Ultrasound
- Clean-catch urine specimen
- Specific Gravity
- Protein and Glucose levels
- Intra Venous Pyelogram – done to
evaluate any abnormal condition of the
kidney and ureter (upper urinary tract)
- Voiding cystourethrogram (VCUG) –
evaluate and assess the problem in the
bladder and urethra (lower urinary tract)
- Both needs contrast medium to see
obstruction or problem. Inject the dye
and this will flow through the blood
vessels to the kidneys.
- Prior to the test, ask any allergic to the
dye (seafood). Contrast medium
contains iodine. Prior to the test, dapat
NPO ang patient.
- There should be a consent because it is
an invasive procedure.
- For VCUG, the bladder should be fully
distended. This is also to check the
presence of reflux (if mo balik ba ang ihi
sa ureter). Check for any presence of
stenosis or narrowing of the ureter.
- Instruct the patient that there will be
facial splashing. They need to drink a lot
of water to excrete the contrast medium.
- Urinalysis – a test that confirms Urinary
Tract Infection or high WBC or cloudy
urine or presence of bacteria
- Specific Gravity – 1010-1030
Therapeutic Management
- Limits fluid after dinner
- Caution parents of children with sickle
cell anemia
- Alarms bells that ring when children wet
at night
* Bladder stretching exercise
* Synthetic antidiuretic hormone
administered (ADH or Desmopressin)
* Bath in the morning is encouraged
- Happens because of stress or anxiety
- Happens because the child is very
engrossed to what they are playing.
- Be cautious with parents of children with
sickle cell anemia (crescent shape of
RBC). Patient’s blood is acidotic and
patient has dehydration. They must
maintain the fluid and perform other
options.
- Bladder stretching exercise – the doctor
will instruct the child to control their
bladder so that the bladder will stretch.
Until the child cannot control anymore
then she is okay to urinate.
- Synthetic antidiuretic hormone – inhibit
the function of the diuretic hormone
- Bath in the morning rather than in the
evening.
NEPHROBLASTOMA (WILM’s TUMOR)
- Is a type of childhood cancer that starts
in the kidneys
- It is the most common type of kidney
cancer in children
 - About 9 of 10 kidney cancers in children
are Wilm’s tumors Diagnostic Procedure:
- Cancer starts when cells in the body - Ct scan or Ultrasound
begin to grow out of control - Glomerular Filtration Rate or Bun
- Usual kidney cancer of children - Biopsy
- No abdominal palpation - To confirm the tumor, there must be
- Inspection, Auscultation, Percussion, biopsy (malignant or benign).
Palpation (kidney only) - Less than 60 – there is abnormal
- No abdominal palpation if suspected function of the kidney
with Wilm’s tumor
Complication:
Gross Pathology - Anemia
- Large tumor compressing the normal - Hypertension
renal parenchyma *the kidney abnormally secretes
- Intact fibrous capsule with prominent hydrogen ions. Eventually there is fluid
veins retention
- Yellowish color with heterogeneous - Small bowel obstruction from fibrotic
appearance -hemorrhagic/cystic areas scarring and hepatic damage from
radiation to the lesion
Wilm’s Tumor - Nephritis
- Is commonly seen in kids from ages 3 to - Sterility in girls
4 and tends to occur less frequently - Interstitial pneumonia
after the age of 5. The most common - Scoliosis
kidney cancer in children is Wilm’s (RADIATION EFFECT)
tumor

Signs and Symptoms

- Swelling in the abdomen
- Pain the abdomen
- Mass in the abdomen which can be felt
- Fever
- Hematuria or blood in the urine

*it occurs in association with congenital

anomalies

Symptoms:
- Abdominal pain
- Blood in the urine
- Fever
- Loss of appetite
If no therapy, metastatic spread by the
- Swelling in the abdomen. (Assessment:
bloodstream is most often to the:
Protuberant of the abdomen)
1. lungs
- Abdominal girth - measurement of the
2. regional lymphnodes
distance around the abdomen at a
3. liver
specific point
4. bone
- Hematuria – presence of blood in the
5. brain
urine (observed in the urinalysis)
- Wilm’s tumor is associated with patients
Criteria of the National Wilm’s tumor Study
with down syndrome
Group
 Stages Description ANORECTAL ANOMALIES (Imperforate
I Tumor confined to the Anus)
kidney and completely - Assess if the baby already passed the
removed surgically meconium stool before 24 hours.
II Tumor extending beyond
the kidney but completely Anorectal Anomalies
removed surgically - Failure of the membrane separating the
III Regional spread of rectum from the anus to absorb during
disease beyond the eight week of fetal life; anomalies range
kidney with residual from simple (imperforate anus only) to
abdominal diseases complex (genitourinary and pelvic
postoperatively organs involved); one of the most
IV Metastases to lungs, liver, common congenital malformations
bone, distant lymphndes - May include fistula from distal rectum to
or other distant sites perineum, urinary system, or
V Bilateral disease reproductive system
The other kidney is
already affected

Therapeutic Management
- Place a sign reading “No Abdominal
Palpation” over the child’s crib
- Surgical intervention: Nephrectomy
- Radiation Therapy
- Chemotherapy – may be given at
varying intervals as long as 15 months
* Dactinomycin
* Doxurubicin
* Vincristine
- A second surgical procedure after 2 to 3
months to remove the remaining tumor
- Place a sign in the patient’s door or - Recto bladder neck fistula (high)
bedside that there should be no
abdominal palpation. Also endorse to
other nurse
- Patients’ undergoing chemotherapy are
at risk for infection so the child should
be protected (wear masks). Avoid any
crowded areas. Place the child in an
isolated area.

Prognosis:
- Therapy for nephroblastoma is so
effective that about 90% of children who
had no metastatic spread at diagnosis
survive for at least 5 years
- There should be early diagnosis.
- Chemotherapy must be done prior to the
surgery.
Types: - If the stoma is located in the descending
1. Rectal atresia and stenosis part, the stool is solid.
2. Persistent Cloaca

Persistent Cloaca - There’s an opening in the

rectum but the bladder is connected to the
rectum.
Atresia – there is no opening but it is supposed
to be open
Fistula – there is an opening but it is supposed
to be close

Classification:
Males -
- Cutaneous (perineal fistula)
- Rectourethral fistula
*A. bulbar
B. Prostatic

- Recto-bladder neck fistula

- Imperforate anus without fistula
- Rectal atresia
Females
- Cutaneous (perineal fistula)
- Vestibular fistula
- Imperforate anus without fistula -
- Rectal atresia
- Cloaca
*short common channel Nursing Care:
*long common channel - Assessment
- Complex malformations - Nursing Diagnosis
1. Risk for disorganized infant behavior
Clinical findings: related to discomfort, need to restrict
- Failure to pass meconium stool oral intake,
2. Constipation related to obstruction of
- Abdominal distention
intestinal lumen
- Meconium on perineum via fistula
3. Compromised family coping related to
lack of knowledge about colostomy care
Therapeutic Interventions
- Immediate surgical correction unless
Implementation
fistula is present; possible colostomy
A. Preoperative Nursing Care
with multistage surgical repair
- Keep NPO; provide a pacifier; observe
- Either they will be doing anal opening or
for signs of dehydration and shock
colostomy
- Maintain nasogastric suction; monitor
- Colostomy – if there is a multistage
intake and output
surgical repair (daghang problema);
B. Postoperative Nursing Care: depends on
bring the colon in the surface
type of surgery performed
- Assessment with colostomy bag:
- Keep operative site clean and dry,
- If the stoma is located in the ascending
especially after passage of stool
part (right-side part), the stool is liquid
- Position on side rather than abdomen to
and loose.
prevent pulling legs up under chest
 - Care of colostomy: prevent excoriation
of skin by frequent cleansing and use of
a diaper held on by belly binder
- Instruct the parents about colostomy
care (include avoidance of tight diapers
and clothes around the abdomen)
Provide pacifier since the baby is ordered
NPO.
Gavad – providing food to the person
Lavad – they need to remove the undigested
food from the stomach
Measure the urine in the diaper (measure the
clean diaper then measure the used diaper
then minus it to the clean diaper).
Weigh the patient regularly to check if there is
a progress, to monitor if ni decrease ba ang
weight.
POSTOPERATIVELY
- Respiratory suppression – number one
assessment; oxygen saturation of the
baby; they may be at risk of bleeding
SEXUALLY TRANSMITTED DISEASES IN
TEENS (STD’s)
- Also known as STI’s (INFECTIONS)
- These are infections that are transmitted
by sexual contact
- Note that not all STD’s are curable
- You teens are at higher risk to obtain
STD’s, partly because you participate in
frequent sexual activity more with
multiple partners
- These infections that people catch come
from having oral, anal, or vaginal sex
- They can be transmitted that person’s
blood, semen, or vaginal fluids
- Skin-to-skin contact with a person who
has them also increases your chances
of obtaining one
- About 9.5 million adolescents and young
adults (ages 15-24) are diagnosed with
sexually transmitted diseases (STDs)
each year
- These Adolescents account for nearly
half of the 20 million new cases of
STD’s each year
- Four in 10 sexually active teen girls
have had an STD that can cause
infertility and even death
- STDs often have no obvious sign or
physical symptom, so regular
screenings are critical
- Also, though rates of HIV are very low
among adolescents, males make up
more than two-thirds of HIV diagnoses
among 13- to 19- year olds
LIST OF COMMON STD’S
- Bacterial Vaginosis (BV)
- Chlamydia
- Gonorrhea
- Viral Hepatitis
- Genital Herpes
- HIV/AIDS
- Human Papillomavirus (HPV)
- Pelvic Inflammatory Disease
- STDs and Infertility
- Syphilis
- Trichomoniasis
- Many other STDs
WHAT ARE THEY?
- Chlamydia -the most common bacterial
STD is found in 20 to 40 percent of
teens having sex outside of marriage.
Up to 40 percent of all girls between the
ages of 15 and 19 are infected – the
highest chlamydia infection rate of any
age group. Chlamydia often has no
overt symptoms, and if untreated can
cause sterility in both males and
females
- Human Papilloma Virus (HPV) -up to 15
percent of sexually active teenage girls
are infected with HPV. The majority of
those infected have a strain that has
been linked to cervical cancer
- Genital Warts -Viral growths that appear
on the external genital organs, genital
warts infect as may as a third of all
sexually active teenagers. No
permanent cure exists for these
growths, with at least 20 percent
recurring following removal. In females,
there is an association between genital
warts and cervical cancer
* Symptoms: 1. Raised, ilesh-colored
lumps or bumps
2. corrugated (cauliflower life)
appearance
 3. They appear anywhere on body 50 y/o and 17 78
- Herpes -this is a viral infection that, above
undiagnosed, can cause miscarriage or SEXUAL MALE FEMALE
stillbirth during pregnancy. There is no CONTACT
cure. Male-Female 50 32
Sex
Male-Male Sex 343 -
Sex with both 184 -
Male and
Female

HIV IN THE PHILIPPINES (MAY 2020)

- 78, 069 individuals have been
- Gonorrhea -a highly contagious diagnosed with HIV since 1984
bacterial infection affecting the penis in - 187 newly diagnosed cases in May
men and the vagina in women, 2020
gonorrhea, left untreated, can cause - Ages of newly diagnosed cases in May
sterility, arthritis, and heart trouble 2020 range from 13-55 yo (median age:
- Syphilis -A serious, highly contagious, 29 years old)
progressive bacterial disease that can - Among the new cases in May 2020, 179
affect all parts of the body -the brain, are Males, 8 are Females
bones, spinal cord, heart, and
reproductive organs
- AIDS -acquired immune deficiency
syndrome (AIDS) is a disease in which
the body’s natural defense system is
disabled, allowing other bacterial and
viral infections to become deadly

FACTS ABOUT STD’S

- Young people (age 15-24) have five
times the reported rate of chlamydia of
the total population, four times the rate
of gonorrhea and three times the rate of
syphilis
- These infections can spread all
throughout the body
Info: Risk Factors for HIV infection are
- In 2006, an estimated 5,259 young
people aged 13-24 in the 33 states - Being born to an HIV-positive mother
reporting to CDC were diagnosed with - Receiving a blood transfusion or blood
HIV/AIDS, representing about 14% of components
the persons diagnosed that year - Injection drug use
- Sexual contact with an infected partner
HIV AMONG MILLENEALS in which there is an exchange of semen
AGE APRIL TOTAL or vaginal fluids
2017 (Jan-Apr
2017) The most common methods of
transmission of HIV are:
Less than 15 yo 2 10
- Unprotected sex with an infected partner
15-24 y/o 190 1,020
- Sharing needles with infected person
25-34 y/0 323 1,653
35-49 y/o 97 529
Almost eliminated as risk factors for HIV
transmission are: SYPHILIS
- Transmission from infected - Primary Syphilis symptoms are
- Infection from blood chancres
- Secondary Syphilis is a rash, if any.
RISK FACTOR Usually from one to twelve months after
HIV can be transmitted by: the chancres appear, the rash will
- Sexual transmission appear
- Transmission by blood or blood - Latent Syphilis is irreversible damage to
products central nervous system and
- Occupational transmission cardiovascular system, and there are no
- Maternal-fetal/infant transmission signs or symptoms
Typically cannot be transmitted at
SIGNS AND SYMPTOMS this point but a mother can pass it to her
- Sores unborn child
- Unusual discharge - Tertiary Syphilis causes tissue and
- Itching or tingling in genital and anal organ damage 10-20 years after
areas beginning of Latent Stage
- Burning (especially with urination)
- Lumps or bumps (can be raised, reddish Stage Signs and Incubation
or dimpled) Symptoms Period
- Rash Primary Painless ulcer 3-6 weeks
- Redness (chancre), (even up
- Swelling in the genital and anal areas Regional to 3
- Sores can be a symptom whether they lymphadenopathy months)
hurt or not Secondary Red/brown rash on 4-10
- Discharge is a symptom only if it is palms of hands weeks
unusual or abnormal. (In men, any liquid and soles of feet,
other than urine or semen coming from Lymphadenopathy,
the penis is unusual. For a woman, White patches in
there’s normal, healthy vaginal the mouth, Fever,
discharge.) headache, fever,
sore throat,
GONORRHEA Feeling unusually
SIGNS AND SYMPTOMS tired (fatigue),
In Female: patches of hair
- Neisseria gonorrheae loss (alopecia)
- Abdominal pain or pain with intercourse Latent No symptoms Early: less
- Vaginal discharge and bleeding than one
In male: year
- Infected kidneys Late: more
- Urinary tract infection than one
- Burning sensation with urination year
- Inflammation of the penile Tertiary Even if no
- Swollen testicles symptoms, at this
- Discharge from the penis stage the nervous
system, brain,
Dyspareunia bones or heart are
- It is a condition where the person feels seriously affected
pain during intercourse
 - Apple cider vinegar
GENITAL HERPES - Ginger tea
- Indian gooseberry
- Cinnamon
- Hot compress
- Coriander powder
- Baking soda
- Garlic

CYSTITIS AND UTI PREVENTION

- Practice good hygiene
- Avoid irritating personal care products
- Take showers instead of baths
- Get plenty of sleep
- Eat a healthy diet
- Stay hydrated
SYMPTOMS OF HIV INFECTION
- Severe headaches
HOME REMEDIES FOOR UTI IN CHILDREN
- Swollen lymph nodes
- Pineapple
- Ulcers in the mouth
- Apple cider vinegar
- Enlargement of kidneys
- Lemon juice and sugar
- Body rash
- Consumption of water
- Nausea, vomiting, diarrhea
- Probiotics
- Joint pain
- Ginger tea
- Muscle aches
- Parsley and water
- Coconut oil
PREVENTIONS
- Amla and turmeric powder
• Abstinence
- The most effective way to prevent STDs PROTECTING YOUR SEXUAL HEALTH IS
is to abstain from sexual activity AS EASY AS (TALK, TEST, TREAT)
• Condoms
- The use of condoms is highly effective HOW TO SAY, “NO!”
in reducing chances of getting an STD You as a teen can learn this!
• Mutual Monogamy - What are some ways you can say no?
- Agreeing to be sexually active with only - How can you explain you’re not ready
one individual without causing anger in your partner?
• Vaccinations - What should you do if they don’t take
- Recommended to help fight against “No” as an answer?
HPV and hepatitis B PLEASE RESPECT MY CHOICE
• Limit the amount of sex partners I JUST CHOOSE NOT TO
- The more people you choose to have I’M NOT READY!
sex with will increase your chance of
receiving a Sexually Transmitted If you choose to have sex, know how to protect
Disease. yourself against STDs.

HOME REMEDIES FOR URINARY TRACT

INFECTION
- Yogurt
- Cucumber
- Drink lots of water
- Pineapple
 URINARY DISORDERS
Acute Glomerulonephritis VS Nephrotic
Syndrome

Note:
Nephron is the functioning unit of the kidney.
Pulmonary congestion – naglisod ginhawa
Note: If there is no or less water, ADH will
Check the intake and output especially fluids
automatically release water.
(IVF) of the baby.
Oliguria – less than 500 mL
Anatomy and Physiology
Take note the specific age
Urine – will only depends on fluid intake,
Adults (500-1000 mL)
kidney health and age
- Oliguria
Nephron Anatomy
- Anuria
- Polyuria
Note:
Anuria – 100 mL per day or no urine at all
Polyuria – excessive urination; patients having
high glucose level

Color: Amber Yellow

Appearance: clear
> increase protein – foamy appearance
pH: 4.608.0
Specific Gravity: 1.003-1.030
> Inc. – DHN
> Dec. – over DHN
Note: Protein: 0
Nephrons – basic unit of kidney; in charge; Ketones: 0
problems of the kidneys depend on the > Ketones are released after breakdown of
nephrons body protein – starvation
 5-10 mL (number of bacteria present in
the urine)
− Renal Biopsy
check if there’s Wilm’s tumor (any
kidney tumor)
− Creatinine Clearance Rate
Excessive creatine – there’s kidney
problem (more than .5 to 1.5)
Normal Creatine: 0.5 to 1.5 per dl
Too much creatine – acidic
− Blood Studies:
BUN = 6-20 mg/dl
Note: UREA = 10-40 mg/dl
Cloudy – urinary tract infection you can see creatine (end product of
Ketones will be positive if the patient has muscle use)
starvation for months − X-ray studies:
Glucose is very important. KUB
− Cytoscopy
Glucose: 0 visualize the internal part
> Glucose in urine – DM, pregnancy − CT Scan:
(Eclampsia) IVP – upper part
RBC: less than 1 or negative CPU – lower part
> Glomerulonephritis, UTI or trauma, leukemia − MRI
or blood dyscrasias they can see the injured part; smallest
WBC: less than 5 blood vessel
> Bacteria (UTI)
Casts: 0 Note:
Crystals: 0 Blood urea – presence of nitrogen in blood
> Uric acid, calcium oxalate, phosphate should be excreted in the form of urine
crystals or Sulphur Renal biopsy –
X-ray – check the structure of kidney, ureters,
and bladder

Cystoscopy

Note:
Hematopoietic - Capacity to destruct the RBC
Phosphate crystals – develop kidney stones

Diagnostic Tests
− Urinalysis
30 mL enough to get the sample
− Urine Culture
Renal Biopsy Definition
Nephrotic syndrome is a clinical complex
characterized by a number of renal and
extrarenal features, most prominent of which
are
> Proteinuria (in practice >3.0 to 3.5 gm/24hrs),
> Hypoalbuminemia,
> Edema
> Hypertension
> Hyperlipidemia,
> Lipid Uria and
> Hypercoagulability
Note: The dressing should be properly covered
Most common cause: Minimal change disease
with pressure (to avoid bleeding)
Secondary Diseases: Lupus, Diabetes, HF,
etc.
Nephrotic Syndrome
Note:
- is a type of kidney disorder characterizing a
Minimal change disease – most common
group of symptoms that causes the body to
cause
pass excess protein via urine, and lead to
Congenital disease – from pagkabata
absence of protein in the body and presence of
excess fat or cholesterol in your blood, and
Nephritic Syndrome VS Nephrotic
swelling in the feet and ankles interpreting that
Syndrome
the kidneys are not functioning properly.
Note:
More than 3.5 per dL na protein ang na loss sa
patient every day.
Hyperlipidemia – excess fat or cholesterol
- Glomerular membrane becomes permeable
to proteins.
- Leaking into the urine, and lacking in the
blood.

Signs: Note:
- Weight Gain Puffy face Protein is a large molecule
- Ascites Once the blood vessel is consecrated, the
- 4 cardinal signs: water will diffuse there. But there will be the
> Proteinuria lack of protein in the blood because the protein
> Hyperlipidemia is naapil sa pag-ihi
> Edema If the patient has no protein, there will be leak
> Hypoalbuminemia (mo transfer and fluid sa uban surfaces)
There will be decreased blood volume in the
* low salt diet blood vessels
* corticosteroids
* prevent infection Oliguria
- voiding scant amounts of urine
Note: - less than 500 ml/day or 30 ml an hour for an
Hyperlipidemia, Proteinuria, and adult
Hypoalbuminemia – present in Nephrotic
Syndrome but not in Glomerulonephritis Anuria
Weigh patient regularly (Dapat mo gamay ang - refers to a lack of urine production
bata; increase in pounds means fluid retention) - voiding less than 100 ml/day
- may result from low fluid intake, kidney
disease, severe heart failure, burns and shock
- usually accompanied by fear and heavy
respiration
Average Daily Urine Output by Age
variants, or changes in genes present at
birth.
• Membranous nephropathy (MN)
MN is an autoimmune disease that
causes immune proteins to build up in
the kidney’s glomerular basement. As a
result, the membrane becomes thick
and does not work properly, allowing too
much protein to pass into the urine.

Note:
Primary – common for kids
Idiopathetic – no known cause
Focal segmental – kuyaw; patient may have a
lifetime dialysis because of scarring
Membranous nephropathy – will become
Nephrotic Syndrome
scarred; glomerular part will be injured and
- is a type of kidney disorder characterizing a
eventually it will be damaged and will not be
group of symptoms that causes the body to
used.
pass excess protein via urine, and lead to
absence of protein in the body and presence of
excess fat or cholesterol in your blood and Pathophysiology
swelling in the feet and ankles interpreting that
the kidneys are not functioning properly
- kidney disease that affects a kidney’s filtering
system is the most common cause of nephrotic
syndrome in children. Other causes can
include diseases that affect other parts of the
body, infections, some medications, and
genetics.

What causes nephrotic syndrome in

children?
Primary Nephrotic Syndrome, Secondary and
Congenital

• Minimal Change Disease (MSD)

MSD is the most common cause of
nephrotic syndrome in young children.
The disease causes very little change to Nephrotic Syndrome
the glomeruli or nearby kidney tissue.
The changes in the kidney can only be
seen using an electron microscope,
which shows tiny details. Although the
cause of MCD is unknown, some health
care professionals think the immune
system may be involved.
• Focal segmental glomerulosclerosis
(FSGS)
This disease can cause some of the Note:
kidney’s glomeruli to become scarred. Your own immune system attacks your body
FSGS may be caused by genetic
Podocyte – gate control (para di mo gawas ang What is Glomerulonephritis?
dagko nga nutrients like protein) Is inflammation of the glomeruli, which are
Immunoglobin – one of the components of structures in your kidney that are made up of
antibodies; if the podocyte will flatter, the tiny blood vessels. If your glomeruli are
immunoglobulng will pass through. Thus, there damaged, your kidneys will stop working
will be a decrease level and patient have a risk properly and you can go into kidney failure
for infection because nawala iyang
immunoglobulin - Congested
- Inc waste in blood
Cause - Dec GFR, HPTN
Idiopathic - unknown - Abnormal appearance in urine
Associated with HODGKIN’S LYMPHOMA
- increased cytokines A GFR of 60 or higher is in the normal range.
A GFR below 60 may mean kidney disease. A
Diagnosis GFR of 15 or lower may mean kidney failure.
Tricky
Light Microscopy + H&E
- can’t see EFFACEMENT
- “Minimal Change”
Electron Microscopy
- Effacement of Foot Processes
Immunofluorescence
- negative

Note:
Tiny blood vessels – ma affected ang blood
vessels later on in the process of infection.
Thus. Inhibiting hematuria
There is congestion
There is osmotic pressure (decreased)
The fluids mo leak japon
RBC are solutes (large molecules); to prevent
too much concentration, there is fluid including
plasma (WBC and RBC); Glomerulonephritis is
Note: because of the streptococcus A beta hemolytic;
Yellow (podocyte) – gi attack sa immune Beta hemolytic destructs RBC (the reason mo
system leak ang dugo kuyog sa urine); thus, there will
be hematoria
Ultrafiltration Congestion occurs because the blood is limited
already (ang uban nga blood kay naa nas
urine). Thus, there is decrease osmotic
pressure (ni gamay ang water)
Too much water can cause hypertension
Normal GFR: 60 or higher (below 60 means
kidneys has a disease)
Below 15 GFR (check the function of the
kidney) – the kidney is not functioning anymore
(dialysis always)
Glomerulonephritis – too much blood in the
urine
 - Diabetes Mellitus
GLOMERULONEPHRITIS - Amyloidosis of the kidney
- Systemic Lupus Erythematosus
- Renal Vein thrombosis
(occur ages 2-5 years old)
Note:
Systemic Lupus Erythematosus – secondary

Initial Signs
Acute Glomerulonephritis
Note: - Hypertension
Proteinuria – ginagmay sa Glomerulonephritis - ASO “antistreptolysin” titer +
than Nephrotic syndrome - decreased GFR
Peripheral edema – there is kidney problem - swelling in face/eyes (periorbital
(kidney is not functioning well) swelling) – edema mild
General edema (nephrotic syndrome) - tea-colored urine
Peripheral edema with periorbital edema - recent strep infection
(acute glomerulonephritis) - elevated BUN and Creatinine
If patient have impetigo (skin infection) or (AZOTEMIA)
pharyngitis (throat infection) – this may be the - Proteinuria (mild)
main cause Nephrotic Syndrome
Proteinuria (>3.5 mg/dl)
- foamy, frothy urine and dark yellow
Hypoalbuminemia
- hyperlipidemia
- generalized edema (periorbital), in
dependent areas (sacrum, ankles, and
hands) and in the abdomen (ascites) (
decreased oncotic pressure in the
capillaries)
Note:
Antibodies will appear if there is presence of
streptococcus
Note: Nephrotic – orange color urine
Protein leakage will increase plasma volume Glomerulonephritis – cola color urine
Once the heart does not receive the exact
amount of blood, the kidneys will stimulate Edema
(specifically the angiotensin-aldosterone)
Too much sodium and water in the blood
vessel will cause hypertension

Contributing Factor:
Acute Glomerulonephritis
- Group A beta-hemolytic streptococcal
infection of the throat – occur 14 days
after infection
- Impetigo, Pharyngitis and Acute viral
infections
(occur ages 2-10 years old) Notes: Measure the edema
Nephrotic Syndrome
- Idiopathic – autoimmune corticosteroids
- Chronic glomerulonephritis
LATE SIGNS
Acute Glomerulonephritis
- Oliguria and anuria
- headache
- chills and fever
- weakness
- pallor
- anorexia, NV
- reduced visual acuity
- Ascites, pleural effusion, CHF
Nephrotic Syndrome Proteinuria and Hematuria
- Anorexia A normal capillary in a glomerulus keeps red
- Hypoalbuminemia – malaise or blood cells, white blood cells, and most
tiredness proteins in the blood and only lets watery fluid
- Irritability amenorrhea into the urine.
- hyperlipidemia A capillary in a diseased glomerulus lets
> xanthelasma protein into the urine (proteinuria) and red
> xanthomata blood cells into the urine (hematuria).
- breathlessness
> pulmonary edema
> pleural effusion
- Frothy urine appearance
Note:
Allow the patient to have bed rest

Nursing Diagnosis
Acute Glomerulonephritis
- Fluid Volume Excess r/t failure of
regulatory mechanism
Note: Too much lipid in the body
- Acute pain r/t effects of circulating toxins
and edema of renal capsule
Cardinal Signs
Acute Glomerulonephritis - Altered Nutrition less than body
requirements r/t anoxia and dietary
- gross hematuria
restrictions
- proteinuria – mild
Nephrotic Syndrome
- glomerulonephritis
- Fluid Volume Excess r/t depletion of
Nephrotic Syndrome
serum protein High Risk for infection r/t
- proteinuria – massive
decrease immune system response
- hypoalbuminemia
(from steroid therapy)
- Altered Nutrition less than body
requirements r/t anoxia, loss of protein
in urine.
Note:
Corticosteroids - Inhibits the function of the
immune system
 - Low sodium - for hypertension, edema
Screening Test and CHF
Acute Glomerulonephritis - Carbohydrates - for energy and reduce
- (+)Antistreptolysin-O titer protein catabolism
- Serum Urea Nitrogen - Limit potassium
- Creatinine Clearance Rate Nephrotic Syndrome
Nephrotic Syndrome - High protein – to prevent urinary
- Hypoalbuminemia - Low sodium – for severe edema
✓ <2.5 gm/dl
- Hyperlipidemia Best Position
✓ Cholesterol level >200 mg/dl Acute Glomerulonephritis
- Urinalysis - Bedrest during the acute phase until
✓ (+) Protein ->3.5 grams per day urine clears and BUN, creatinine and
✓ 3+ or 4+ dipstick Blood pressure return to normal
✓ Foamy, frothy urine and dark yellow Nephrotic Syndrome
Note: - Bedrest for a few days to promote
Deep stick – test of urine using strips diuresis and reduce and edema

Confirmatory Test Best Drug

Acute Glomerulonephritis Acute glomerulonephritis
Decrease Glomerular Filtration Rate - Penicillin for streptococcal organism
- (low urine output)- monitor Potassium - Azathioprine and Cyclophoshamide
level since it can't be excreted leading to Nephrotic Syndrome
hyperkalemia - Corticosteroids
Nephrotic Syndrome - Cyclophosphamide and Chlorambucil
- needle biopsy of the kidney - Furosemide
- angiotensin-converting enzyme (ACES)
Best Major Surgery inhibitors or angiotensin receptor
Acute Glomerulonephritis blockers (ARBS) to lower blood
Nephrectomy - if the kidney is abscessed or pressure and help reduce protein loss
completely destroyed - diuretics, or water pills, to reduce
Nephrotic Syndrome swelling by helping the kidneys remove
Nephrectomy - if the kidney is abscessed or extra fluid from the blood
completely destroyed - statins NIH external link to lower
cholesterol
- blood thin NIH external link to treat
blood clots
Note:
Furosemide – diuretics (weigh regularly and
monitor intake and output)
Statin – lower cholesterol levels

Nursing Alert
Acute Glomerulonephritis
Note: Partial Nephrectomy - Portion of the - Orbital edema which parents report
kidney is being removed worse in the morning
- Loss of appetite
Best Diet (Pre- or Post Operation) - Decreased output
Acute Glomerulonephritis - Dark-colored urine
- Low protein - for BUN - Streptococcal infection
Nephrotic Syndrome
- Weight gain
- Parent observation that the child's
clothes fit tightly
- Decreased urine output
- Pallor, fatigue

Nursing Management
Acute Glomerulonephritis
- Monitor BP (HPTN)
- Antihypertensive and diuretics
- Monitor Fluid status: I and O. check diet.
- Low UO, swelling
- Limiting Sodium and fluid restriction
- Relapse is not common but teach how
to monitor strep and available cultures
Nephrotic Syndrome
- Monitor fluid status and swelling
> diuretics, and IV albumin to help dec.
swelling)
- Risk for infection, esp. swollen areas.
> Corticosteroids or immune
suppressor-to decrease protein in urine
and relapse
- Assess for blood clots: DVT and
respiratory status
- Diet limiting sodium, fluids and fats
- Education on relapse risk
Note: Nephrotic – there is relapse

WHO NEEDS DIALYSIS?

(Check The Vowels)
A: Acid-Base Problems
E: Electrolyte Problems
I: Intoxications
O: Overload Of Fluids
U: Uremic Symptoms