overview of child health

7/30/2019 Overview of Child Health

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Overview of Child Health Nursing

Child Health Nursing

Focuses on protecting children from illness and injury Assists children to obtain optimal levels of wellness

Primary roles of the Pediatric Nurse

Care provider Educator Advocate

Pediatric Health Statistics

Infant Mortalityo Number of deaths per 1000 live births during 1styear of life.o Infant mortality rate is an indicator of how healthy the nation is.o This rate is used to compare national health care to previous

years and to other countries.o There has been a great decrease in the number of deaths over

the past century. In 1997, 6.9 per 100 live births.

Childhood Mortality

For children older than one year, death rates have always been lessthan those for infants.

In later adolescence, there is a sharp rise in deaths.

Injuries; the leading killer in childhood

Injuries cause more death and disabilities in children than anydiseases.

Some examples include:o Motor vehicle accidents are the leading cause of death in

children over 1 year of age.o Majority of deaths are due to no use of seatbelts.


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Drowning is 2nd leading cause of death in boys 1-14; both sexes 15-24years old. Drowning is the 3rd leading cause of death for girls 1-14.

Burns are the 2nd leading cause of death from injury in girls and the 3rd

in boys from 1-14 years old.

Childhood Morbidity (Illness)

An illness or injury that limits activity, requires medical attention orhospitalization, or results in a chronic condition.

Examples:o Congenital heart defectso Asthmao Cerebral Palsyo Cystic Fibrosis

Concerned with helping to decrease these statistics as children miss

school and other activities when ill.

Advanced Practice roles for nurses in Child health nursing

Family nurse practitioner Neonatal nurse practitioner Pediatric nurse practitioner Nurse midwife

Growth and Development

Growth : used to show an increase inphysical size or a significantchange.

Includes:o Heighto Weighto Head circumference

Development : Used to denote an increase in skill or ability to finction. Measured by:

o Observing child do specific taskso Parents description of childs abilityo Using standardized testing (Denver II screening test)

Principles of Growth and development


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G & D is a continuous process from birth to deatho Rate of growth varies at different times

G & D proceeds in an orderly mannero Growth from smaller to largero Development: from sitting to crawling to walking

Different children pass through the predictable stages at different rates All body systems do not develop at the same time. CNS, Cardiac develops quickly. Lungs are typically the last to develop.

Development is Cephalicaudal, which is the 3rd principle of G & D. Headto toe.

Development goes fromproximal to distal, which is the 4th

principle.

Example: Development proceeds from gross to refined. A child cannot learn tasks until the nervous system is ready. Neonatal reflexes must be lost before development can proceed.

Factors that influence growth and development

Genetics Gender Health Intelligence

Temperament

Inborn in all of us A way of reacting to the world around us

Reaction Patterns:

Activity levelo Level of activity differs widely among children

Rhythmicityo Have a regular rhythm is physiologic terms

Approach


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o Childs response to a new situation Adaptability

o Is the child able to adapt to new situations? Intensity of reaction Distractibility Attention span and persistence Mood quality

Categories of temperament

The Easy Childo Easy to care for if they have predictable rhythmicity, approach

and easily adapt to new situations, have a mild to moderateintensity of reaction, and an overall positive mood quality.

o 40-50% of children fall into this category

The Difficult childo Children are difficult if irregular in habits, have negative mood

quality, and withdraw from new situationso 10% of children fit this image.

Slow to warm up childo Describes children who are overall fairly inactive, respond only

mildly, adapt slowly to new situations, and have a generalnegative mood.

o 15% of children display this pattern.

Other factors that impact growth and development

Environment Socioeconomic level Parent-child relationship Position of birth in the family Health Nutrition As a child normally develops somewhat predictably in growth and

physical development, he also matures emotionally, intellectually, andspiritually along certain paths.

Review:

Eriksons theory of Psychosocial development Piagets theory of cognitive development Kohlbergs theory of Moral development


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Assessment of the Child

Basic Principles

Know norms; child vs. adult A & P variations are farthest from adult norms at birth

o Most of these variations mature quickly in the first yearo By 5-7 years of age, body is that of a Small adult; however, a

child is not a miniature adult and should not be treated as such. As a child normally develops somewhat predictably in growth and

physical development, he also matures emotionally, intellectually, andspiritually along certain paths.

Try to see the childs world and body through his/her mind. If you do

this, you will connect with the child.

Approach to exam

Always think of where the child is developmentally. Approach must be individualized Usually the child will be frightened and anxious. May lack verbal skills

to express fear or ask for information. Use both hands on child when possible comforting touch.

o Place left hand on shoulder while auscultating the heart.o Move unhesitatingly, firmly, and gracefully.o Talk pleasantly and reassuringly.

Instructions to the child:o Use a directive voiceo Have specific instructionso Do not ask, but instead tell a child

Example: Say Roll over on your belly rather than Willyou roll over on your belly?

Physical Exam

Can take place almost anywhereo On parents lapo On the flooro Examiners lap


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Conducting the exam

Perform the least distressing procedures first and the most distressinglast.

o Heart and lungs; have the child lie down.o Abdomen, throat, and ears (throat and ears are the worst)o Genitalia and rectum

Physical exam technique

Inspectiono Observe before you touch

Auscultationo Use diaphragm of stethoscope for high pitched sounds (bowel

sounds)

o Use bell of stethoscope to help localize sounds for infant Palpation

o Use pads of fingers to determine tenderness and pulsationso Use palmar surface of fingers to determine masses and organ

enlargemento Observe reaction to palpation rather than to ask if it hurts (dont

suggest that it does) Percussion

o A more advanced technique usually done by physicians andadvanced practice nurses.

The general survey

Vital signs General appearance Mental status Body measurements

Vital signs

Temperatureo Body temperature in infants is less constant than in adultso Use ax/tympanic for children less than 4 years of ageo Values are the same as in adults

Axillary: hold childs arm firmly Tympanic:

o Less than 3 years of age


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Insert gently into ear Pull down on ear

o Over 3 years of age Pull up on ear

Rectal temperatureo Most hospitals are done only with doctors order, or there is a

standing order.o Lubricate tip wello Insert 1 inch

Pulseo Apical is besto May use femoral arteries, brachial arterieso Radials only in older children (at least 2 years old)

Respirationso The younger the child, the more abdominal breathingo Observe the abdomen instead of the chest in infants and small

childreno

May need to auscultate the chest or put the stethoscope in frontof the mouth and nose. Oxygen saturations Blood pressure

o Wide enough to over 75% of the upper armo Narrow cuff elevates reading, wide cuff lowers readingo In infants less than 1 year:

Thigh BP = arm BPo Older than 1 year:

Systolic in thigh is 10-40 mm Hg higher than in arm Diastolic is same in thigh and arm

o If BP in thigh is less than in arm:

Cardiac anomaly or decreased circulation to extremities Be sure to use correct size cuff Use the same extremities, the same size cuff, and same

position whenever possible when trending values for anindividual patient.

o Diastolic BP Diastolic pressure reaches about 55 mm Hg at one

year of age Gradually increases to 70 throughout childhood

o The most common cause of hypertension in children are: Anxiety (increases BP in children) Renal disease (78%)

Coarctation of the aorta (2%)

General appearance

To form a general impression of childs health and well-being To pin-point specific areas that may require more detailed assessment


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Initial observations

Degree of illness or wellness Mood State of nutrition Speech, cry, facial expression, posture Apparent chronological and emotional age Respiratory pattern Parent and child interaction

Parent and child interaction

Amount of separation tolerated

Displays of affection Response to discipline Look for signs of:

o Anxious parentso Disengaged parentso Stressed familieso Possible abusive parents (no separation anxiety when removed

from parent, or over-affectionate)

Child cries or clings to parent

Ignore the child temporarily Engage the parents in conversation, then place a small game, toy, or

your stethoscope within reach of the child while continuing yourdiscussion

Mental status

Is the child alert?

Able to respond to questions easily? Assess appropriateness of behavior Assess memory

Assessing Growth/Body measurements


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Height, weight, head circumferenceimportant indicators of growth Measured and plotted on standard growth charts These charts are used to determine if the baby/childs growth is falling

within the accepted percentile for age

Length

Birth to 36 monthso Fully extend the body by:

Holding the head midline Grasping the knees together gently Pushing down on the knees until the legs are fully

extended and flat against the table.o Hold pencil at right angle to the table and mark the head and

toes (which are pointed toward the ceiling)

Height

Childs back is to the wall, with heels, buttocks, and back of theshoulders touching the wall and the medial melleoli touching ifpossible.

Check for bending of the knees, slumping of the shoulders, or raisingthe heels of the feet

Weight

Birth to 36 months, weigh nude Older children with panties and light gown Balance (or zero) scale prior to weighing

Head circumference

Measure at greatest circumference Slightly above the eyebrows and pinna of the ears

o Around the occipital prominence at the back of the skullo Compare to 36 months

Denver Developmental


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The standard for measuring the attainment of developmentalmilestones throughout infancy and childhood.

Designed for birth to 6 years Includes screening for:

o Personal social skillso Fine motor adaptiveo Languageo Gross motor

Denver screening for articulation and eyes

Example of DDST for One year of age:

Personal/Socialo Drink from a cup, imitate activities, play ball with examiner,

indicate wants, play pat-a-cake

Fine motor/adaptiveo Scribbles, puts block in cup

Languageo Dada/Mama specific, one word

Gross motoro Stands alone

More on DDST:

Only a measure of developmental attainmentnot a measure ofintelligence

Not a highly specific testo Most normal children score as normal

Not very sensitiveo Many children with mild developmental delays also score normal

Only a screening test Other more sophisticated tests are available if delay is suspected even

when DDST is normal.

Heart Murmurs

50% of all children develop an innocent heart murmur at some pointduring childhood. It is usually not something to be overly concernedabout unless there are other symptoms. Must be determines if murmuris normal; therefore always report when one is heard.


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Abdomen

Protuberant abdomen is typical in most children until adolescence. If child is ticklish on palpation, hold his/her hand over yours to reduce

apprehension and increase relaxation of the abdominal musculature.

Neuromuscular

If possible, watch the child standing upright. Have them walk, stoop,and touch their toes

Checking for scoliosis.

More tidbits:

Always think of childs development when assessing Know the BP and pulse variations When there is an abnormal finding ALWAYS gather more data Weight is a huge concern for children. Many medications are weight

dependent. The Denver Developmental is not very precise; its more of a screening

tool As it says, the Denver Developmental is only developmentalnot a

cognitive or an IQ test. For breath sounds:

o Encourage the child to blow out your light, in your pen light or

flashlight. This will almost always produce full inspiration.

Care for the Hospitalized child

General communication guidelines

Pay attention to infants and younger children through play or byoccasionally directing questions or remarks to them.

Include older children as active participants. With children of all ages, the nonverbal components of the message

conveys the most. Communicate at the childs level

o Developmentally and physically


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Communication Guidelines

Allow children time to feel comfortable Avoid sudden or rapid movements, extended eye contact, or other

gestures that may be seen as threatening. Talk to the parent if the child is initially shy Communicate through puppets, dolls, or stuffed animals before

questioning a young child directly. Give older children the opportunity to talk without the parents present Speak in a quiet, unhurried, and confident voice. Speak clearly, be specific, and use simple words and short sentences. Be honest with children Offer a choice only when one exists. Allow them to express their concerns and fears Use a variety of communication techniques; if one technique doesnt

work, try another.

Infant

One month to one year old Eriksons developmental task: Trust vs. Mistrust

o Task: Attachment to the mothero Resolution of crisis: Trust in persons; faith and hope about the

environment and future.o Unsuccessful resolution of crisis: General difficulties relating to

persons effectively; suspicion; trust-fear conflict, fear of thefuture.

Infant: communication

Forms first social relationships Communicates needs and feelings through nonverbal behaviors and

vocalizationso Smile and coo when contento

Cry when distressedhunger, pain, body restraint, loneliness Respond to adults nonverbal behaviors

o Become quiet when cuddled, patted, or receive other forms ofgentle, physical contact.

o Get comfort from the sound of voiceusually respond to anygentle firm handling until they reach the age of stranger anxiety(5-8 months).


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Infant: Stressors of Hospitalization

Separation anxiety Stranger anxiety Painful, invasive procedures Immobilization

Separation Anxiety

Occurs as early as 4 months old; infants face shows disapproval asprimary caregiver walks away.

Three stages of separation anxiety:o Protest

Cries loudly; rejects attempt to be comforted by anyonebut the caregiver

o Despair Crying stops and depression is evident Much less active Uninterested in food or play Withdraws from others

o Detachment (denial) Shows increased interests in surroundings Interacts with strangers or familiar caregivers Forms new but superficial relationships Appears happy Detachment usually occurs after prolonged separation

from parents; rarely seem in hospitalized children.

Behaviors represent a superficial adjustment to loss. Interventions for separation anxiety:

o Encourage parents to room-in with infanto Involve parents in childs care whenever possibleo Keep parent in infants line of visiono If parent is unable to be with infant, place familiar object with

infant (stuffed toy, etc.)o Support sibling and grandparent visitation

Stranger anxiety

Occurs as early as 5 months Usually peaks at 8 months Behaviors exhibited by infant:

o Crieso Screamso Searches for parent with eyeso Clings to parent


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o Avoids and rejects contact with strangers Interventions for stranger anxiety:

o Holding out hands and asking the child to come will usuallynot work. If infant must be handled, better to pick up firmlywithout gestures.

o Observe position in which parents hold infant and imitate this.o Hold infants where they can see their parentso Are usually more at ease upright than horizontal.

Fear of proceduresinterventions

During procedure, use sensorysoothing measures (Stroking skin,talking softly, giving pacifier)

Cuddle and hug after stressful procedure or encourage parent to do soif present.

Older infants may associate objects, places, or persons with priorpainful experiences and will cry and resist at the sight of them

o Keep frightful objects out of viewo Perform painful procedures in separate room, not in crib,o Use non-intrusive procedures whenever possible.

Immobilization

Infants explore life through activity and mobility. If taken away:o Feel helplesso May have difficulty with language skillso May have problems mastering developmental taskso Problems with motor skillso Immobility impacts development.

Immobilization interventions:o Play therapyo Transport infant outside of room by wagon of by carryingo Spend time interacting with infanto Encourage caregivers to do the same

Toddler

Ages one to three years old Eriksons developmental task:Autonomy vs. shame and doubt.

o Task: Gaining some basic control over self and environmento Resolution of Crisis: Sense of self-control and adequacy; will

power


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o Unsuccessful resolution of crisis: Independence-fear conflict;severe feelings of self-doubt.

Developing a sense of autonomy He wants to make choices and like the word No! Is egocentric Focus communication on toddler

o Toddler not interested in the experiences of others

Stressors of hospitalization

Separation anxiety Loss of control Painful, invasive procedures Bodily injury Fear of dark

Separation anxiety

Verbally attack stranger (Go away!) May physically attack stranger (kicks, bites, hits) Tries to escape to find parent Tries to physically force parent to stay (clings) May have temper tantrums or refuse care Behaviors may last from hours to days

Separation anxietyinterventions

Childs reaction to separationo Toddler might ignore parent.

Other strategies are same as for infant. Feels more secure with familiar item Allow them to touch and examine articles that will come into contact

with them Be direct and concrete

They interpret words literally.

Loss of control

Very threatening to the toddler Many hospital situations decrease amount of control a child feels


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Loss of control occurs due to:o Restriction or limitation of movemento Altered routines and rituals

Eating Toileting Sleeping Bathing Play

o When routines are disrupted, problems can occur in these areas Interventions

o Promote freedom of movement Encourage parent-child contact Transport in carriage, wheelchair, carts, etc. Maintain childs routine Encourage as much independence as possible (allow child

to wear clothes from home, etc.)

Bodily Injury/Invasive procedures

Concept of body very poor Intrusive procedures (examining ears) create much anxiety React with intense emotional upset and physical resistance Interventions:

o Tell child its ok to yell, cry, or do whatever is needed duringprocedure

o Explain procedure in relation to childs senseso Ignore temper tantrumso Use distraction techniques (Sing song with a child)

Fear of the dark

Keep night light on in room at all times Encourage parents to room-in with child

Preschool

3-6 years of age Eriksons developmental task: Initiative vs. Guilt

o Task: Becoming purposeful and directiveo Resolution of Crisis: ability to initiate ones own activities; sense

of purpose.o Unsuccessful resolution of crisis: aggression-fear conflict; sense

of inadequacy or guilt


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Developing a sense of initiative Preschooler is:

o Egocentrico Has increased language skillso Concept of time and frustration tolerance is limitedo Illness and hospitalization may be viewed aspunishment

Fears of hospitalization

Separation anxiety and fear of abandonment Loss of control Bodily injury Painful, invasive procedures Fears of the dark, ghosts, monsters

Separation anxiety- preschooler

Tolerate separation better than toddlers; may develop substitute trustin other significant adults

However, they may show other behaviors:o Refuse to eato Have difficulty sleepingo Cry quietly for parentso Constantly ask when parent will be visitingo May express anger

Interventions:o Have parents bring in familiar articles from homepictures/radioo If child has attachment to special item, have it brought ino Same strategies for toddlers

Loss of control

Egocentric and magical thinking; perception of actual events are morefrightening

o Typical fantasy: Illness is a punishment for their misdeeds Purely verbal instructions do not help them, have them practice on doll

or toy.

Bodily injury


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Differentiate poorly between themselves and outside world. Fear of mutilation Take things literally Stick for blood Fear if when given a shot, when needle is removed, their insides will

leak everywhere (put a band aid in place).

Interventions:

Point out on drawing, doll, or child where procedure is performed Emphasize that no other body part will be involved Use non-intrusive procedures when possible Apply adhesive bandage over puncture site Encourage parental presence Allow child to wear underpants with gown Explain unfamiliar situations, especially noise or lights

Involve child in care whenever possible (hold equipment, removedressing)

Praise child for helping and attempting to cooperate Never shame child for lack of cooperation

School age child

6-12 years old

Eriksons developmental task: Industry vs. Inferiorityo Task: developing social, physical, and school skillso Resolution of Crisis: competence, ability to learn and worko Unsuccessful resolution of crisis: Sense of inferiority; difficulty

learning and working Developing a sense of industry and concrete thought Has increased language skill

o Interest in acquiring knowledgeo Improved concept of timeo Increased self-controlo Developing relationships with peers; peers are very important at

this stage.

Usually will want explanations and reasons for why things are beingdone Want to know more about procedures, activities, and objects Have a greater concern for privacy and body integrity Usually easier to communicate with than previous age groups

o Concrete thinkers; no abstract thought


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Separation anxiety Loss of control Bodily injury Painful, invasive procedures Fear ofdeath

Separation anxiety

Younger school age children miss their parents more than olderchildren

Middle/late react more to separation from peers and usual activitieso May feel lonely, bored, isolated, depressed due to separation,

not the illness.

o May try to be brave and strong.o May be irritable with parents

Interventionso Make environment as home-like as possible

Continue school lessons Have friends visit or call on phone Decorate walls with cards

Bodily injury

Less concerned with pain, more concerned about disability or death Take very active interest in their health Request facts

Invasive procedures

Want to know about a procedure (will it hurt? Whats it for?) Tolerate intrusive procedures well By age 9 or 10 should less fright to pain

Adolescent

Ages 12-20 years

Eriksons developmental task: Identity vs. Role confusion


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o Task: developing sense of identityo Resolution of Crisis: sense of personal identityo Unsuccessful resolution of crisis: confusion about who one is;

identity submerged in relationships or group memberships Developing a sense of identity and abstract thought Fluctuate between child and adult thinking and behavior

o Need to express their feelings, for some this comes easily, forothers it does not.

o Major sources of concern for this age group are attitudes andfeelings toward sex, substance abuse, relationships withparents, peer-group acceptance, and developing a sense ofidentity.


Loss of control Altered body image, disfigurement

o Do not want to look different Separation from peer group Loss of control

o Anything that interferes with sense of independenceo Patient role fosters dependencyo May withdraw, be uncooperative, angry, frustrated.

Altered body imageo Very relevant at this stageo Any change that makes them different from peers is seen as a

major tragedyo Insecure with their bodies due to the many changeso May react with know it all attitude (but may be afraid, deep

down)o Privacy is very importantmay need to give them some time

alone.

Cystic Fibrosis

Epidemiology

Affects approximately 30,000 children and adults in the US today or 1in 2500 live births

Occurs most commonly in whites, rarely in blacks and Asians


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More than 10 million Americans (1 in 31 or 3.3%) are symptom freecarriers of the defective CF gene

Survival

In 1955, few children with CF lived to attend elementary school. Today,the median age of survival is 32 years.

In this decade, many CF survive into their 40s.

Etiology

An inherited (genetic) disease CF is an autosomal-recessive disease (this means an individual must

inherit 2 defective CF genes, one from each parent) The defective gene in CF occurs in Chromosome 7 The gene causes the dysfunction of the exocrine glands

What are exocrine glands?

Glands that secrete things such as:o Lungso Pancreaso Sweat glandso Salivary glandso Digestive glands

Pathophysiology

CF causes the body to produce an abnormally thick, sticky mucuswhich:

o Clogs the lungs and leads to life-threatening lung infections;o Obstructs the pancreas, preventing enzymes from reaching the

intestine to help break down and digest food Primary symptoms:

o Thick, sticky mucuso Salty taste on skin

Marked electrolyte changes in sweat glandso Chloride in sweat is 2-5X above normal


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Lung involvement

Thick tenacious mucus polls in the bronchial tree and obstructsbronchioles

Results in:o Bronchiectasis : Chronic dilation of the bronchi. Involves a

chronic cough that produces mucopurulent sputum. Over timeresults in destruction of the bronchial walls.

o Pneumonia : Staph Aureus, pseudomonas, and H. Influenzae Symptoms over time include:

o Clubbing of fingers Clubbing is related to lack of tissue perfusion

Symptoms over time:

Easily fatigued Physical growth stunted Chest may become enlarged from over inflation of alveoli because air

cannot be pushed past the thick mucus on expiration (barrel chested) Increased carbon dioxide in blood (hypercapnia and/or chronic

acidosis)

Pancreas involvement

Thick secretions mix with pancreatic enzymes and block the pancreatic

duct. Therefore:

o Essential pancreatic enzymes cannot flow into the duodenum toaid with digestion (lipase, trypsin, and amylase)

o Fats, proteins, and some sugars cannot be digestedareexcreted in stools:

o Stools (The 4 Fs in CF) Frothy (bulky/large) Foul smelling (comparable to a cats stool) Fat containing greasy Steatorrhea Floaters

Clogged ducts causes back pressure on the acinar cells (they make theenzymes)

The cell lining of pancreas is damaged Over time the acinar cells atrophy and no longer produce the enzymes

Symptoms related to Pancreatic Involvement


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Protuberant abdomen because bulk of stool is setting in the intestines Signs of malnutritiononly benefit from 50% of food taken in Fat soluble vitamins are not absorbed A, D, E, K In infants, thick, sticky stools (meconium) which may cause intestinal

obstructiono One of the first signs of CF in infants

Sweat gland involvement

The structure of the sweat glands is not changed, however: Level of chloride to sodium in the perspiration is increased 2 5 times

above normal Some parents report they knew their newborn had the disease because

when they kissed their child they could taste such strong salt in theirperspiration

How is CF diagnosed?

By the history (cough, stool, abdomen, hx. of pneumonia) The abnormal concentration of chloride in sweat The absence of pancreatic enzymes in duodenum (can be tested

through NG tube) Pulmonary involvement

Common complaints that bring these patient to the doctor

Newborn that loses 5-10% of weight after birth but does not gain itback

Feeding problemskids are always hungry because of their poordigestive function

Frequent respiratory infections Cough

Diagnostic tests

A sweat test is a test for the chloride content of sweat Infants may not be tested until 6-8 weeks of age. (they dont sweat a

great deal)o Normal concentration of Chloride in sweat is 20 mEq/Lo A level of 50-60 mEq/L suggests CFtest is repeated


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o A level >60 mEq/L = CF Duodenal analysis of secretions for detection of pancreatic enzymes Stool analysis: for fat content (although appearance may be enough) Pulmonary testingchest x-rays or PFTs

Therapeutic management

Maintain respiratory functiono Keep bronchial secretions as moist as possible to facilitate

drainage: Moistened oxygen: Oxygen is supplied to children by

mask, prongs, ventilators, or neubulizers, and rarely bytent

Aerosol therapy- 3-4 times/day via neubulizer to provideantibiotics and bronchodilators

o Never give cough syrups or codeine Aggressive chest physiotherapy- usually needed 3-4 times a day Activity- need frequent position changes, especially when in bed. Helps

facilitate drainage of various lobes, as well as prevent skin breakdown. Respiratory hygiene: frequent mouth care, toothbrushing and good-

tasting mouthwash. Need frequent check-ups and current immunizations/vaccines Adequate rest and comfort

o Dyspnea can lead to exhaustiono Need periods of rest during the day:

Rest period before meals so not too tired to eat Rest periods before chest physiotherapy

Promote optimal nutritiono Pancreatic enzyme supplements with meals and snacks

Pancreatic enzyme: Cotazym or pancrease Comes in large capsule which can be opened and

dissolved in a tsp. of food Children usually begin to gain weight, and stools decrease

in size and foul odor.o High calorie, high protein, moderate fat dieto Multivitamins and E, others when deficient.

During hot months, extra salt may be added to food to replace thatwhich is lost through perspiration

Keep room temp at 72 degrees and have water available at all times.

Parents need to supervise kids playing outdoors to preventoverheating.

Keep well hydrated all of the time!

Complications


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Infertility in males related to blocking of vas deferens from tenaciousseminal fluid

Infertility in females related to tenacious cervical secretions that blocksperm penetration

Rectal prolapse in infants from straining to pass hard stool. Loss ofblood supply to prolapsed rectal mucosa can occur if not replaced

promptly and properly. Hypercapnia/respiratory acidosis from inability to adequately exhale

carbon dioxide Exhaustion, slow growth patterns Skin irritation in diaper area from stool that is irritating due to acidic

nature of stools Socialization and peer acceptance difficulties Cor Pulmonale (right sided heart failure) from increased respiratory

resistance Anemia and bruising Frequent respiratory infections and compromised immunity

Portal hypertension related to obstruction of bile ducts

area of biliaryfibrosis biliary cirrhosis Pneumothorax related to rupture of pulmonary blebs

Parental involvement

Parents assume a great deal of responsibility when taking care of a CFchild.

o Need to encourage a balance of work, the child, and the rest ofthe family

o Encourage involvement of support groupo Requires extensive involvement of the discharge planner

Nursing Diagnoses

Ineffective airway clearance r/t thick mucus in the lungs Ineffective breathing pattern r/t thick tracheobronchial secretions and

airway obstruction High risk for infection r/t presence of mucus secretions conductive to

bacterial growth Altered nutrition: Less than body requirements r/t inability to digest

nutrients Fear/Anxiety (parent or child) r/t prognosis and effect of illness on

growth and development Knowledge Deficit (parent or child)


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Summary

CF is an inherited genetic disorder Causes the exocrine glands to produce thick secretions Primary body organs involved are lungs and pancreas. Prone to respiratory infections r/t mucus. Digestion problems r/tpancreatic enzymes. Treatment centers around control and management. No cure for the

disease.

Eriksons Stages

Infant

One month to one year old Eriksons developmental task: Trust vs. Mistrust

o Task: Attachment to the mothero Resolution of crisis: Trust in persons; faith and hope about the

environment and future.o Unsuccessful resolution of crisis: General difficulties relating to

persons effectively; suspicion; trust-fear conflict, fear of thefuture.

o Developmental tasks: Learning to eat solid foods

Toddler

Ages one to three years old Eriksons developmental task:Autonomy vs. shame and doubt.

o Task: Gaining some basic control over self and environmento Resolution of Crisis: Sense of self-control and adequacy; will

powero Unsuccessful resolution of crisis: Independence-fear conflict;

severe feelings of self-doubt.o Developmental tasks:

Learning to walk Learning to use fine muscles Toilet training Learning to communicate

Preschool


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3-6 years of age Eriksons developmental task: Initiative vs. Guilt

o Task: Becoming purposeful and directiveo Resolution of Crisis: ability to initiate ones own activities; sense

of purpose.o Unsuccessful resolution of crisis: aggression-fear conflict; sense

of inadequacy or guilto Developmental tasks:

Independence of self-care Learning sexual role identity Forming reality concepts Internalizing concepts of right and wrong Learning to identify with family members and others.

School age child

6-12 years old

Eriksons developmental task: Industry vs. Inferiorityo Task: developing social, physical, and school skillso Resolution of Crisis: competence, ability to learn and worko Unsuccessful resolution of crisis: Sense of inferiority; difficulty

learning and workingo Developmental tasks:

Acquiring game skills Learning to relate positively with peers Building a wholesome self-concept

Refining communication skills

Adolescent

Ages 12-20 years

Eriksons developmental task: Identity vs. Role confusiono Task: developing sense of identityo Resolution of Crisis: sense of personal identityo

Unsuccessful resolution of crisis: confusion about who one is;identity submerged in relationships or group membershipso Developmental tasks:

Forming peer relationships Responding to an appropriate sexual role Attaining emotional independence Achieving a sense of economic independence


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Cardiac defects in children

Alteration in Fluid-gas transport

Cardiac Defects in children:

Divided into two major groups:o Congenital cardiac defectso Acquired heart disease

Congenital Heart Disease

Anatomic abnormality present at birth; the heart has not developed asit should in utero.

Thus, the heart is unable to adjust to life outside of mom Results in abnormal cardiac function

Acquired Cardiac disease

Abnormalities that occur after birtho Can occur by selfo Can occur with other congenital heart defectso Example; Rheumatic disease is the 2nd largest cause of cardiac

problems in children over 5)

Both congenital and acquired heart disorders can lead to heartfailure

Assessment of cardiac function

Historyo History of heart disease in the familyo Contact with known teratogens, such as rubella during

pregnancyo Presence of chromosomal abnormalities (Downs)


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o Poor weight gain and/or feeding behavioro Exercise intolerance and/or fatigue during feedso Sweating during feedingo Frequent respiratory infectionso Respiratory difficulties, such as tachypnea, dyspnea, and

shortness of breath.o Recent streptococcal infection (may lead to valve damage)

Physical examo Begins with observation of general appearance, then the

specificso Use general assessment techniques but look specifically for the

following:o Inspection:

Nutritional state: failure to thrive or poor weight gain Skin color: cyanosis and pallor Chest deformities- enlarged heart Unusual pulsations of neck veins seen in some patients

Respiratory pattern- tachypnea, dyspnea, presense ofexpiratory grunt Clubbing of fingers (now rarely seen in children d/t

advances in surgical techniques)o Palpation

Quality and symmetry of pulseso Auscultation

Heart rate and rhythm Presence of murmurs

o Height and weighto Position of comfort

Remember, squatting/fetal positions are often

comfortable for a child with a CHD. Tests of cardiac function

o Electrocardiography Records electricitygenerated by the beating heart Painless but scary, child must be still

o Exercise stress test Monitoring of heart rate, BP, ECG, and oxygen

consumption at rest and during exercise on a tread mill orbicycle

o Chest x-ray Shows accurate picture of heart size and contour; size of

the heart chambers

Used more as a screening toolo Echocardiography

Ultrasound (high frequency sound waves produce animage of heart structures)

The primary diagnostic test for heart disease.


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Cardiac catherization

Radiopaque catheter is inserted through peripheral blood vessel intoheart

o Contrast material is injected and films taken (calledangiography)

Reasons for performing:o Diagnose specific heart diseaseo Measure pressures and O2 satso Visualize heart structureso Determine blood flow patterns

Preparation for Cardiac cath

Although done frequently, there are some risks. Typical reactions

include:o Acute hemorrhage from entry site (usually femoral artery)o Low grade fever (reaction to contrast media)o Nauseao Vomitingo Loss of pulse in the catheterized extremityo Transient dysrhythmias (d/t ventricular irritability)

Done on an outpatient basis NPO for 2-4 hours before Older children should see the cath lab before procedure Accurate height and weight (for medications) Most children are sedated to decrease anxiety

Post catheterization care

Are usually on a cardiac monitor and pulse oximeter for the first fewhours of recovery.

Know the baseline pulse/BP before the procedure to compare Most important nursing responsibility is observation of the following for

signs of complications:o Pulses, especially below the catheterization site, for equality and

symmetry (pulse just distal to site may be weaker for the firstfew hours but gradually increase in strength.

Observations of:


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Temperature and color of the affected extremity. Coolness or blanchingmay indicate arterial obstruction.

Vital signs are taken every 15 minutes. Special emphasis on heart rate.Must take for one full minute.

Assess blood pressure, especially for hypotension.o Hypotension could indicate:

Hemorrhage Too much medication Dehydration

Dressing, for evidence of bleeding. Fluid intake, both IV and oral, to ensure adequate hydration.

o Remember sensible and insensible fluid loss (breathing tooquick!).

Hypoglycemia, especially in infants.

Interventions

Child must keep extremity straight 4-6 hours after venouscatheterization and 6-8 hours for arterial cath.

Childs diet can be resumed as soon as tolerating sips of clear liquid Keep site clean and dry Encourage child to void.

Congenital heart disease

Incidence: 4-10 per 1000 live births The major cause of death in the first year of life

o Other than prematurity/low birth weight More than 35 well recognized defects Statistics improving due to more surgeries/treatments that help

prevent death.

Etiology

Not known in 90% of cases Factors associated:

o Maternal rubella during pregnancyo Maternal alcoholismo Maternal age over 40o Maternal insulin-dependent diabetes

More likely to have other defects such as Down syndrome.


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Circulatory changes at birth

In order to understand the pathophysiology of cardiac defects, it isimportant to understand fetal circulation and the changes that occur atbirth.

Review of prenatal circulation- 3 essential structures

Ductus venosus (DV): opening between umbilical vein and inferior venacava.

o The ductus venosus is a vessel that allows blood to bypass thefetus's liver. It carries blood with oxygen and nutrients from theumbilical cord straight to the right side (right atrium) of the

fetus's heart. The ductus venosus closes shortly after birth,when the umbilical cord is cut and blood flowing between themother and fetus stops.

Foramen ovale: opening between the right and left atriumbypassesfetal lungs.

o The foramen ovale is an opening in the wall that separates theupper right and left heart chambers (atria). This opening allowsblood to flow to the left side of the heart without going to thelungs. Before birth, the foramen ovale is kept open by thepressure of blood that passes through it. When the baby takesthe first breath, blood begins to flow through the lungs, and theforamen ovale closes

Ductus arteriosis (DA): Opening between pulmonary artery anddescending aorta; allows fetal blood to bypass the lungs.

o There is still very little blood getting into the fetal lungsjustenough to help it grow in utero, even though they are collapseduntil birth.

Purpose of these structures

Allow most of blood to bypass the liver and lungs.

Fetal circulation

Oxygenated blood from placenta to ductus venosus inferior vena

cava right atrium. Blood then shunts over to the left atrium through the foramen ovale.

Then over to the left ventricle aorta head/extremities.


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The unoxygenated blood returns to the right atrium via the superior

vena cava flows into the right ventricle exits thought thepulmonary artery (which is connected to the aorta).

Most of this blood shunts through the ductus arteriosis into descendingaorta, and back into the placenta.

Birth changes

Infant cries, lungs expand Ductus arteriosis closes as resistance decreases though the pulmonary

vasculature (infants now need to use their own lungs) Clamping cord causes ductus venosus to clot (infant needs to use own

liver)

Venous return from lungs causes increase in left atrium pressure. Increased left atrium pressure causes left to right blood flow through

patent foramen ovale (which is a bad thingwe no longer want tobypass the lungs)

The foramen ovale is a one way valve so it closes permanently.

Birth changes, summary

Ductus venosuso Clots to form ligamentus teres

Foramen ovaleo Closes to form interatrial septum

Ductus arteriosiso Closes to form ligamentum arteriosus

Altered hemodynamics

Important to remember pressure gradients as blood will always flow (orshunt) from an area of higher to lower pressure.

Heart defects cause a change in the direction of this normal flow ofblood; create symptoms, especially those associated with congestiveheart failure.

Congenital heart defects


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Usual causeheart structure fails to progress beyond earlier Was once classified as Cyanotic and Acyanotic New classifications below

Classification of Congenital heart disease

Increase in pulmonary blood flow Decrease in pulmonary blood flow Obstruction to blood flow from ventricles Mixed blood flow

Defects with increased pulmonary blood flow

Ventricular septal defecto Hole between the ventricles

Atrial septal defecto Hole between the atrias

Patent Ductus Arteriosis (PDA)o Allows blood to flow from higher pressure aorta to the lower

pressure pulmonary artery, causing a left to right shunt. Atrialventricular septal defect

o Most likely to be a low artrial and a high ventricular defect.

More blood to the lungs than needed. These defects allow blood to flow from area of higher pressure (left

side of the heart), to area of lower pressure (right side of the heart). This creates increased blood volume on the right side of the heart

which increases pulmonary blood flow. Usually results in CHF.

o Pulmonary hypertension and cor pulmonae are frequentdisorders associated with this.

Defects causing Decreased pulmonary blood flow

Tetralogy of the Falloto Pulmonic Stenosis: Narrowing of the pulmonary artery or valveo Ventricular septal defect


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o Overriding of the aorta: position of the aorta is not correct. Bloodmay be shunted from both ventricles.

o Hypertrophy of the right ventricle Clinical symptoms:

O2 sats below 80% Clubbing of fingers and toes Polycythemia (increased hct) Anoxia aeb: dizziness & convulsions Squatting Stunted growth

Tricupsid Atresiao Extremely serious.o Tricupsid valve is completely closed.o No blood flow from the right atrium to the right ventricleo Blood passes through patent foramen ovale into the left atrium

and through a ventricular septal defect to the right ventricle andout to the lungs.

Defects causing obstruction to blood flow from ventricles

Coarctation of the aortao A segment of the aorta is too narrow, near the insertion of the

ductus arterious.o High blood pressure developso Left ventricle is enlargedo Oxygenated blood to the body is reduced.

Pulmonary stenosiso Narrowing of the pulmonary artery or pulmonary valve just distal

(under/below) to the valve.o Eventually causes right ventricular enlargement (hypertrophy)

Aortic stenosiso Narrowing of the aortic valveo Prevents blood from passing freely from left ventricle unto aorta.o Causes left ventricular hypertrophy from increased pressure in

the left ventricle.

Mixed blood flow

Cardiac anomalies that involve the mixing of blood from thepulmonaryand systemic circulation in the heart chambers.

Results in deoxygenation of systemic blood flow. Cyanosis is not always visible.


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Mixed blood flow involves:

Transpositions of the Great Arterieso Aorta arises from the right ventricle instead of the lefto Pulmonary artery arises from the left ventricleo Blood enters the heart from the vena cava.

o Goes to the right atrium to the right ventricle then goes outthe aorta to the body completely deoxygenated.

o Very incompatible with lifeo Surgery indicated

Total Anomalous Pulmonary Venous Returno Pulmonary veins return to the right atrium or the superior vena

cava instead of to the left atrium as they normally would. (Theoxygenated blood keeps going back into the lungs)

o Blood must be shunted across a patent foramen ovale or ductusarteriosus in order to reach the systemic circulation.

Truncus Arteriosus

o One major artery or trunk arises from the left and rightventricles in place of a separate aorta and pulmonary artery.

o Usually accompanied by a VSD.o Restructure common trunk to create two separate vessels (2

separate trunks) Hypoplastic left heart syndrome

o Left ventricle of the heart is non-functional.o Unable to effectively pump blood into the systemic circulation.o Right ventricle enlarges as it tries to do all of the work.o Transplant or the 3 Staged Norwood procedures performed.

Two principle clinical consequences of defects

Heart failure Hypoxemia

Heart Failure

Results when myocardium of heart cannot circulate and pump enough

blood to supply oxygen and nutrients to body cells Blood pools in the heart or in pulmonary or venous systems To increase cardiac output, the heart compensates in several ways:

o Muscle fibers lengthen, causing ventricles to increase andhandle more blood with each stroke (ventricular hypertrophy).

o Heart rate can also increase Eventually the heart can no longer compensateblood pools, unable to

be pushed forward effectively.


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First signs of CHF

Tachycardia, at rest and on slight exertion Tachypnea Scalp sweating, especially in infants Fatigue and irritability Sudden weight gain Respiratory distress

Implementation in CHF

Reduce workload of the heart:o Decrease extra fluid (diuretics)

o Strengthen cardiac function (digoxin)o Decrease afterload with vasodilators

Afterload is the amount of force needed for left ventricleto push blood through the body.

Decrease cardiac demandso Allow for uninterrupted sleep periodso Small frequent feedings or gavage

The more food in the stomach, the more cardiac work it isto digest.

Reduce respiratory distresso Count respirations carefullyo Humidified O2o Semi or high Fowlers

Hypoxemia

Color is not a great indicator SaO2 of 80-85%-- Saturation of Oxygen (arterial blood/Hemoglobin) Polycythemia (increase of the RBCs d/t chronically low oxygen

saturations) Clubbing

Squatting to increase venous return Hypercyanotic spells

Surgical intervention

Early intervention prior to hypoxic episodes preferred


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Mortality rates vary from 2% to 25% Surgery should be done in major centers

Alteration in Nutrition and Elimination

Overview of function of GI system

Responsible for taking in and processing nutrients for all parts of thebody.

Any problems can quickly affect other systems of the body In children, can affect overall health, growth, and development

Overview of nutrition

Infantso First 6 months can live off of breast milk or commercially

prepared formula with iron addedo May need to have Fluoride added if not already in the water.

Cows milk is not recommended until 1 year of age d/t allergies First year is one of rapid growth

o High proteino High calories

A little about obesityo A baby who is overweight by the age of one will usually struggle

with weight as an adult.

Introducing solid foods

5-6 months: iron-fortified infant cereal mixed with breast milk, orangejuice, or formula.

7 months: vegetables 8 months: fruit 9 months: meat 10 months: egg yolk

Toddler Nutrition


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Appetite is usually smaller than infant because they are growing at aless rapid rate

Tend to play with their food Want to feed themselves. Do not want to be fed. May also choose the same foods over and over.

Preschooler and Nutrition

Still not very big eaters at this age Parents should attempt to make meal times a pleasant experience for

children.

School age children and nutrition

Good appetites Should begin the day with breakfast Usually hungry after school

Adolescents and nutrition

Growing so fast that they may always feel hungry May tend to eat faddish foods or those not very nutritious. May rebel against a parents wishes for them to eat good food This is a time when binging and unhealthy dieting may occur (even

with athletes) Tend to not eat enough iron, calcium, and zinc

Physiological differences: Adults vs. Children

Internal distribution of watero Fluid is a greater fraction of their total body weight as compared

to adults

Infants: 75-80% TBW 2 years: 60% TBW Amounts stay approximately the same through later

childhood and adult lifeo Body water is also distributed differently in infants than older

children. Infants have more interstitial fluids


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Extracellular fluid compartment in infants includes 35-45% body water

Insensible water losso Loss of fluid through lungs and skino Insensible water losses per unit of body weight are higher for an

infant and younger child than an adult. Total body surface is largerin infants/children

Body surface is the percentage of skin compared tototal body weight.

Infants have more skin for their size. The more skin,the more fluid loss through skin

Infants and children have rapid respiratory rate andmetabolic rate

o All of these factors contribute to greater fluid loss throughevaporation.

o In addition, treatments or other conditions may increase fluidoutput

Activity, fever, diarrhea, vomiting Kidney function

o During the first 2 years, kidneys are not mature Do not excrete waste products efficiently Difficulty concentrating or diluting urine Sodium regulation mechanisms are not mature

o Nurses want to make sure that kidneys are working beforeadding potassium to I.V. fluids.

Other imbalanceso Children are also more readily susceptible to imbalances in:

Serum glucose Calcium

Potassium

Glucose

Infants and children haveo Higher glucose needs due to high metabolic rateo Low glycogen storeso Hypoglycemia a threat under periods of stress

Calcium

Infants and children have:o Regulation of calcium less exact in infant than in older child or

adulto When stressed, more growth hormone (GH) is secreted

GH increases result in increased calcium deposits in bone


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Infant unable to keep up with these increased demands Hypocalcemia results.

Potassium

Potassium concentration easily affected by decreased intake orintestinal illnesses (diarrhea)

Decreased K can lead to cardiac arrhythmias K must fall below 3 mEq/L before symptoms show

Critical!

Any condition that interferes with normal water and

electrolyte intake or causes excessive losses will produce amore rapid depletion of fluid and electrolyte stores in theinfant and child than it will in the adult.

Example:

Adults, when they do not eat for a day due to GI upset, and whosekidneys are normal, will have 14% less body fluid by the end of the day

Infants who do not eat for a day, and whose kidney function is normal,will be 40% short of fluid by the end of the day!

Urine output norms

Infants: 2-3ml/kg/hr Toddlers/preschoolers 2ml/kg/hr School age: 1-2ml/kg/hr Adolescents: 0.5-1ml/kg/hr

Physical assessment

Skino Color indicates the state of perfusiono As extracellular fluid volume decreases (as with dehydration),

peripheral circulation decreases.o Note the following:


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Warmth Skin color: from pink to pale as peripheral circulation

decreases (cyanosis is a late sign) Hands will get cold before core temperature Cap refill increases


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o Weight The single most important variable to follow in

planning treatment of fluid imbalanceso Intake and output

Record all intake Output usually a decrease in urine output and an

increase in specific gravity (the higher the specificgravity, the more dehydrated the person is).

Every hour is documentedo Output

Weigh diapers 1 gm = 1 ml document all stools, vomiting, wound drainage,

perspirationo Behavioral assessment

Changes seen with fluid volume deficit usually include: Anorexia Drawn, flaccid expressions Decreased levels of activity Increased seeking of comfort and attention

Diarrhea

Increase in stool frequency and content of water Caused by abnormal intestinal water and electrolyte transport More water in the intestines

Acute diarrhea

Major cause of infant mortality in developing countries Most cases caused by infectious agents, viral or bacterial, and

parasites Chronic diarrhea is more likely related to malabsorption or

inflammatory cause

Infectious causes of acute diarrhea

Viruseso Rotavirus is responsible for 50% of hospital admissions for

dehydration and diarrhea Also a nosocomial infection

Bacteriao Salmonella


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o Campylobacter (ingested by contaminated food)o Clostridium difficile (C-Diff)

Food poisoning

Staphylococcus Clostridium perfringens Clostridium botulinum

Parasites

Giardia lamblia Cryptosporidium

Etiology

Spread by contaminated food or water Also from person to person More common in crowded conditions, such as day care centers and

schools Infants immune system plays a role (the younger the infant, the less

developed the immune system).

Assessment of mild diarrhea

Fever of 101-102 degrees F may be present Anorexia Irritable Appear unwell Episodes of diarrhea consist of 2-10 stools per day Mucous membranes are dry Pulse rapid

Skin feels warm Skin turgor is not yet decreased at this time Urine output usually normal Skin color is pale

Therapeutic management of mild diarrhea


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Is not serious at this stagechildren can be treated at home Rest the GI tract for at least one hour; then offer water or oral

hydration solutions such as pedialye.o Approximately 1 tablespoon every 15 minutes x 4o Then 2 tablespoons every hour x 4o If retained, give small sips of fluid; avoid giving large amounts of

fluid. Give in small doseso Do not give OTC drugs such as Imodium or Kaopectate

because theyre too strong for little tummieso Depended on developmental age of child; instruct on good

handwashing technique.

Severe diarrhea

May result from mild or may appear on its own

Temp: 103-104F Pulse and respirations are weak and rapid Skin is pale and cool Infants may appear apprehensive, listless, lethargic (appears as a

hypovolemic state) Obvious signs of dehydration

o Depressed fontanelo Poor skin turgoro Sunken eyes

Bowel movement every few minutes Stool is liquid green, may be mixed with mucus and blood (because the

intestines are inflamed and irritated) Stool may be passed with explosive force Urine output scanty and concentrated Lab findings:

o Increased hematocrit, hemoglobin, serum protein levelso Falsely high because the percentage is low

Loss of 2.5-5% of body weight- mild dehydration Severe diarrhea can cause of loss of 5-15% of body weight quickly Any infant who has lost more than 10% if body weight requires

immediate treatment

Therapeutic measures

Assessment of the fluid and electrolyte imbalance Rehydration Maintenance of fluid therapy Reintroduction of adequate diet Antimicrobial agents if necessary


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Nursing considerations: assessment

Observe general appearance and behavior Assess for dehydration

o Decreased urine outputo Decrease in weighto Dry mucous membraneso Poor skin turgoro Sunken fontanel in infant

More severe dehydrationo Increase in pulseo Increase in respirationso Decreased blood pressureo Prolonged cap refill timeo All signs of impending hypovolemic shock

o Also assess for septic shock

Nursing goals

Urine output is more than 1ml/kg/hr Bowel movements are formed and fewer than 4 per day Stool tests negative Blood pH more than 7 (to prevent metabolic acidosis) Specific gravity < 1.030

Malabsorption syndromes

Celiac Disease Short bowel syndrome

Celiac Disease

Sensitivity or immunological response to the gluten factor of protein When gluten is ingested, a autoimmune response destroys part of the

small intestine mucosal Body is unable to properly digest food and absorb nutrients, especially

fats As a result, these children develop:

o Steatorrhea (bulky, foul-smelling, fatty stools)o Deficiency of fat-soluble vitamins (A, D, E, K)


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o Protuberant abdomeno Rickets (disease in bone formation) due to a loss of vitamin Do Hypoprothrombinemia may occur due to loss of vitamin K (need

Vitamin K to make prothrombin in the liver)o May also have iron deficiency anemia and low albumin (blood

carrier molecule that helps maintain blood volume and blood

pressure) levels.

Assessment of Celiac disease:

These children may be anorexic and irritable A typical celiac baby:

o Would be fit and well until after the ingestion of gluten-containing solids (usually between 6 and 18 months of age)

o Then the baby would develop pale, bulky, offensive smelling

stools (steatorrhea), become miserable and lethargic They gradually fall behind other children in their age in height and

weight Appear skinny with spindly extremities and wasted buttocks Face, however, may be plump and well-appearing

Diagnosis of Celiac disease:

History Clinical symptoms Serum analysis of antibodies against gluten Biopsy of intestinal mucosa (too determine degree of inflammation) Stool may be collected for fat content analysis Children are also put on a gluten-free diet and observedresponse to

this diet is usually very dramatic Continue children on a gluten-free diet for life Need to take water-soluble forms of vitamins A and D May also need to take iron and folate to correct anemia

Gluten is not found in rice or corn.

Celiac crisis:

Can occur when any child with celiac disease develops an infection Usually experiences acute vomiting and diarrhea


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o Cause electrolyte and fluid imbalances

Short Bowel syndrome and its causes

A decrease in the amount ofabsorptive surface Caused by congenital malformations such as gastroschisis (infant born

with some or all of intestinal contents outside of body; loses absorptivesurface), or intestinal atresia.

May be seen in children with intestinal ischemia due to malroation(twisting of intestines), intussusception (the slipping of one part of anintestine into another part just below it; ensheathed), and volvulus(infection which makes bowel obsolete).

Occasionally seen in patients with chronic irritable bowel disease (IBD). Necrotizing entercolitis in preemies (tissue death in bowels due to

colonization/infection and/or inflammatory changes).

Care of the infant/child with Short bowel syndrome:

Parenteral nutrition Enteric feedings if tolerated Monitor for vitamin and mineral deficiencies

Mortality-related complications of SBS

Sepsis Liver and biliary tract infections associated with TPN-causes cholestasis

o Seen in children under 4 years of ageo Leads to liver failure

Obstructive disorders

Hypertrophic pyloric stenosis

Intussusception

Pyloric stenosis

Pyloric sphincter is the opening between the lower portion of thestomach and the beginning portion of the intestine (duodenum).


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If there is hypertrophy (increase in size) or hyperplasia (excessiveproliferation of normal cells in normal tissue) of the muscle surroundingthe sphincter, there will be problems with the stomach emptyingcalled pyloric stenosis.

At 4-6 weeks of age, infants begin to vomit with feeds Vomiting grows increasingly forceful until it is projectile; can project up

to 3-4 feet (this is the most common symptom) Occurs most frequently in first born white males

o 1:150 maleso 1:750 females

Cause is unknown, but is probably inherited Vomitus usually smells sour (because of increased gastric acid)

Diagnosis of pyloric stenosis

Made primarily from history When the parent says their infant is vomiting, we need to find out:

o What is the duration, intensity, frequency, description of vomituso Is the infant ill in any other way?o Many infants show signs of dehydration at the time of diagnosis.

A definite diagnosis is made by watching the infant drink; there isusually an olive-sized mass in the right upper quadrant which becomesmore prominent with drinking the water (seen on the outside of thebody).

May also confirm with ultrasound

Therapeutic management of pyloric stenosis

Surgical correction: pyloromyotomyo Muscle of pylorus is split allowing for a larger lumeno Is usually done laparoscophyo Prognosis is excellent

Nursing care postoperatively for pyloric stenosis:

Feedings usually begun 4-6 hours post-op with 1 tsp (5 ml) of 5%glucose in saline hourly by bottle for four feeds

If no vomiting, 2 tablespoons given hourly for the next four feeds Next, half-strength formula is given every 4 hours By 24 to 48 hours, infants are taking their full formula diet or being

breastfed. Usually discharged after 48 hours. Do not give more fluid than ordered; risks for breaking open the newly

operated areas.


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IV fluids decreased as oral amount increases Infants need to be bubbled/burped well after each feeding to decrease

swelling; we dont want air or gas to be in tummies Lay them on their side, preferably right side, to aid the flow of

fluid through the pylorus via gravity Monitor daily weights Usually no vomiting occurs after the surgery. If it does, report

immediately! Feeding regimen may need to be adjusted. Some infants experience diarrhea due to the rapid functioning of

pyloric sphincter Elevate the head of the bed Monitor intake and output carefully; weigh all diapers

Nursing care for the pyloric sphincter incision

Care of the operative site:o Observe for any drainage or signs of inflammationo Care of incision as dictated by hospital policyo Keep diaper folded low to prevent contamination of incisiono Change diapers frequently

Intussusception

Invagination of one portion of the intestine to another (telescoping is agood synonym for it)

Generally occurs at 6-12 months Typically idiopathic in patients under 12 months May be related to another disorder in patients over 12 months.

Treatment of intussusception:

Surgery Reduction by fluid/air/barium (done in radiology)

Motility disorders

Hirschsprungs disease (once known as Congenital Aganglionicmegacolon)

GERD (low esophageal and gastric mobility)


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Hirschsprungs Disease (Congenital Aganglionic megacolon)

Absence of ganglionic innervation to a portion of the bowel Peristalsis does not occur in non-innervated bowel areas Patients have chronic constipation or ribbon-like stools

Treatment of Hirschsprungs disease

Surgery to remove the agangilionic colon segment May be done in 2 stages, with a temporary colostomy for 6-8 months

to allow bowel to rest.

Meckels Diverticulum

In embryonic life, the intestine is attached for the umbilicus by a duct This duct becomes a ligament near term In 2-3% of infants, this duct remains open as a pouch off of the ileum

Problems associated with Meckels diverticulum

Some gastric mucosa (which secretes acidic fluids) may be displaced This may allow acidic, irritating secretions to flow into the intestine This irritates the bowel, leading to ulceration and bleeding Appendicitis symptoms Can serve as a lead point causing intussusception (from weakened

area) A fibrous band extending from the diverticulum to the umbilicus can

act as a constricting band around the bowel

Treatment of Meckels diverticulum

The diverticulum (pouch) is surgically resected.

Structural defects

Cleft lip and palate


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Esophageal atresia Tracheoesophageal fistula

Cleft lip and palate

Cleft lip occurs when there is a failure of the fusion of the maxillary andmedian nasal processes.

Cleft palate occurs when there is a failure of the fusion of the palatalprocess (roof of the mouth)

Associated Nursing Diagnoses for Cleft lip and palate

Risk for fluid volume deficit

Risk for altered nutrition; less than body requirements Risk for aspiration

Treatment for cleft lip and palate

Special nipples before surgery and while recovering Cleft lip surgery is usually done between birth and 10 months of age Cleft palate repairs are done at 18-24 months, so that anatomic

changes in the palate contour are complete. Recovery is usually excellent Remember, these are typically stages surgeries

Tracheoesophageal Fistula and Esophageal atresia

Failure of the esophagus to develop normally, will end in a blind pouchor connect directly into the trachea instead of being a discretepassage.

These defects may occur separately or in combination About half of the infants with TEF or EA also have associated

anomalies, especially congenital heart disease and anorectalmalformations.

Clinical manifestations of TEF and EA

Excessive salivation (drooling)


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A newborn with drooling that is accompanied with choking, coughing,and sneezing, especially when fed.

Fluid returns through the nose and mouth Infant becomes cyanotic and may stop breathing Most are corrected with one surgery or two or more staged surgeries.

Alteration in Activity and Mobility

Why study this topic?

Quest for mastery at every stage of development is related tomobility.

Infant:

Speech, language, and overall development require sensorimotoractivity.

Toddler

Explore and imitate behaviors, a must for autonomy.

Preschooler

To express initiative, requires vigorous activity.

School-age

Strongly influenced by physical achievement and competition

Adolescent

Relies on mobility to achieve independence.


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Effects of Immobility:

Affects all body systems in some way. Major physical consequences that impact children are:

o Significant loss of muscle strength, endurance, and muscle mass(atrophy)

o Bone demineralization leading to osteoporosiso Loss of joint mobility and contractures.

Other effects:o Metabolism

Decreased metabolic rateo Cardiovascular system

Pooling of blood in extremities Postural hypotension Blood clots

Dependent edemao Respiratory system

Decreased chest expansion Can lead to increased secretions,pneumonia

o GI system Constipation

o Urinary system Difficulty voiding UTIs (d/t retention and urinary stasis)

o Integumentary Decreased circulation and increased pressure can lead to

ulcers.

o Behavioral changes in Immobilized children: Restlessness Lack of concentration Depression Regression Egocentrism Decreased communication Feel isolated May become angry, aggressive or quiet and passive

Effects of Immobility and the family:

Financial strain Siblings may feel ignored Guilt Caregiver becomes worn out


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Common Musculoskeletal problems

Traumatic injuryo Soft tissue injuries to the muscles, ligaments, and tendons are

common in children.o In young children they occur from mishaps during play.o For older children and adolescents, they occur during sports.

Soft Tissue Injuries

Contusions (bruise)o Damage to soft tissue, subcutaneous structures, and muscleso Injured area is ecchymotic (black and blue discoloration) due to

blood leaking into tissues; swollen and painful. Cannot tell how long ago injury occurred by the bruise.

o Immediate treatment is application of cold.

Sprainso Occur when trauma to a joint is so severe that a ligament is

partially or completely torn or stretched. Usually involvesdamage to blood vessels, muscles, tendons, and nerves.

o Child may describe a snap, pop, or tearing.

Therapeutic management of soft tissue injuries

The first 6-12 hours is the most critical for almost all soft tissueinjuries.

Basic principles include RICE or ICESo R.I.C.E.: Rest, ice, compression, elevationo I.C.E.S.: Ice, compression, elevation, support

Ice immediately; do not apply for more than 30 minuteso Reverse effects: vasodilation occurs

Elevate the extremity above heart level. Torn ligaments, especially those in the knee, are usually made

immobile with a cast or splint for 3-4 weeks. Passive leg exercises, gradually increased to active leg exercises,

begun as soon as sufficient healing has occurred.

Fractures


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Common injury at any age but more likely to occur in children andolder adults

Usually due to traumatic incidents at home, school, in a motor vehicle,or associated with recreational activities

Rarely occur in infants unless there is an underlying hematologydisorder

Toddlers- be suspicious of fractures at various stages of healing School-age childrenusually due to bicycle-automobile or skateboard

injuries Adolescents: bikes, motorcycles, sports

Common Fracture sites:

Forearm: falling on the outstretched hand. Clavicle fractures are common

Hip fractures are rare Auto/pedestrianfrom 4 to 7 years of age

o Triad of injury: Level of the bumper, fractured femur Hood of the automobile, injury to childs truck Contralateral (Originating in or affecting the opposite side

of the body) head injury due to impact

Types of fractures in children

Bends : Deformity without breaking (think of a young, green stick thatwont break, but it bends)

Buckle fractures : Compression of the porous bone, raised or buldgingprojection at site. (not broken all the way through)

Greenstick fracture : incomplete fracture, bone is angulated beyondlimits of bend.

Complete fracture : Divides bone fragments

Complete fractures

Transverse : straight up and downo Crosswise, at right angles to the long axis of the boneo Oblique : Slanting but straight, between a horizontal and

perpendicular direction (diagonal).o Spiral: slanting and circular, twisting along the bone shafto Comminuted : broken into pieces (crushed).


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Fractures, continued

Closed or simple Open or compound (protruding through the skin)

Growth plate or Epiphseal injuries

Weakest part of long bones Frequent site of damage Fracture may be through degenerating cartilage cells, without damage

to growth Other fractures of the epiphysis may cause growth problems such as

shortening of the limb

Associated problems with fractures in general

Muscles contract and spasm Bones are pulled out of alignment Severe hemorrhage in tissues, especially with femur fractures Vascular injuries

o Femur fracture may cause injury to sciatic nerveo Bone marrow is high vascularized

5 Ps of Ischemia

Pain Pallor Pulselessness Paresthesia Paralysis

Nursing actions for fractures

Support the injured limb; splint, DO NOT MOVE OR STRAIGHTEN OUTTHE BONE.

Ask the child to point to where it hurts Ask the child to wiggle fingers or toes Check distal pulses Get historical information from someone who witnessed the injury if

possible.


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Diagnostic Evaluation

History may be lacking!o Young children cannot tello Older children may not tell the truth in fear of repercussions

Radiography is the most useful tool

Therapeutic management of fractures

Reduction : regain alignment and length; setting bone. Immobilization : retains alignment and length Restore function Prevent further injury

Bone healing and remodeling

Rapid in childreno Due to thickened periosteum (the fibrous membrane that forms

the covering of bones).o Generous blood supply from bone marrow

New bone cells are formed in immense numbers almost immediatelyafter the injuryimmediate treatment is detrimental

Examples of healing times for femoral shaft in different age groups:o Neonatal period: 2-3 weekso Early childhood: 4 weekso Later childhood: 6-8 weekso Adolescents: 8-12 weekso The general rule of thumb is that the younger the child is; the

quicker the bones heal.

Delays in healing

Gaps between fragments delays or prevent healing Prompt healing with end-to-end apposition (two normally contiguous

parts)o Though, may cause bony overgrowth and greater length of

extremity Angulated deformity may remodel in young children. Careful reduction

and follow-up to prevent permanent disability.


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Fracture complications

Circulatory impairment Nerve compression syndromes Non-union Pulmonary emboli (fat, blood, and air)

Circulatory impairmentvery important

Absence of pulse, discoloration, swelling, pain Report immediatelyto practitioner Take steps to improve circulation (take action!)

o Loosen ace wrap

Most common lawsuits against nurses

Compartment syndrome

Typically caused by blunt trauma Pressure rises within this space with tight dressings or casts,

hemorrhage, trauma, burns, and injury Most common symptoms

o First sign: Pain out of proportion to injuryo Second sign: Tenseness on palpationo Third sign: motor weakness

Non-union fractures

Failure of bone fragments to unite Failure to unite due to any of the following:

o Separation of bone fragments at fracture siteo Hematoma (swelling of comprising a mass of extravasated

blood, usually clotted, caused by a break in a blood vessel)

o Extra tissue between bone fragmentso Necrosis of bone tissues or infectiono Interruption of blood supply

Bone grafting may be required

Pulmonary Emboli


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Blood, air, or fat (fat tends to occur faster) May not occur for 6-8 weeks after injury Fat emboli, first 24 hours usually in adolescents Signs and symptoms:

o Dyspneao Chest paino Onset of sudden pain

Nursing interventionso First: Elevate the heado Second: Administer oxygeno Notify physician immediately

Cast care

Risk for altered peripheral tissue perfusion related to pressure from

cast Expected outcomes:

o No pain or numbness in extremityo Distal nail beds blanches and refills in less than 3 secondso Pedal pulses palpableo Area surrounding case is warm and pink

Interventions:o Keep extremity elevatedo Check circulation every 15 minutes during the first hour, every

hour for 24 hours, then every 4 hours thereaftero Assess for numbness or tingling (children under 6 or 7 may not

be able to express this)o Edema that does not improve with elevation should be reportedo Assess for the 5 Psif any of these symptoms are present,

requires immediate attention! Can lead to permanent paralysis of extremity.

Risk for impaired tissue integrity related to pressure from casto Edges of cast are usually covered by a fold of stockineto If no stockinet, adhesive tape strips are applied to prevent skin

irritation (petaling)o If the cast is surrounding the genital area, or there is any chance

of cast coming into contact with stool or urine, need to coverwith plastic. Prevention is very important as once urine haspenetrated a cast, there is no way to remove it.

Can clean cast with a damp cloth when soiled with food Knowledge deficit related to cast care

o Instruct parents/child on how to care for casto Instruct on 5 Ps

Casting complications


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Continued swelling could cause cast to become a tourniquet.o This is why we wait a day or two to cast

Parents should receive verbal and written instructions Teach neuro/circulation checks to parents (5 Ps) Document parents response to teaching. Always have parents re-

demonstrate

Cast removal

Most casts in place to 6-8 weeks Removed with electric cast cutter Skin usually looks macerated and dirty, a good bath will remove dirt.

o Atrophy will resolve in its own Once healing takes place, the extremity is as strong as beforebut

children will usually favor the extremity. Allow them to regain full use

on their own time schedule.

Scoliosis

Lateral (sideways) curvature of the spine May involve all or only a portion of the spinal column Functional scoliosis (in response to another condition)

o Occurs as a compensatory mechanismo Usually due to unequal leg lengthso Created a pelvic tilt that is C-shapedo Must correct the initial problem

A lift placed in one shoe Remind the child to maintain good posture (walking with

book on head 3 x daily for 10 minutes) Sit-ups and push-ups are good exercises

Structural scoliosis Permanent curvature of the spine with damage to the vertebrae Spine has an S-shaped appearance

Usually there is a family history 5x more common in girls than boys Usually peaks between 8-15 years (school age) Diagnosis is made on physical exam by having the child bend forward X-rays confirm diagnosis Therapeutic management:

o If spinal curve is less than 20 degrees, no therapy except closeobservation until the child reaches 18 years of age)


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o If greater than 20 degrees, may use braces, traction, surgery, orcombination.

Nursing care of the immobilized child: Goals and interventions

Goal One : Increase physical mobility related to mechanical restrictions,physical disability

o Transport child by gurney, stroller, wagon, bed, WC from room toplay room, lobby, or other area as allowed

o Change position of bed in roomo Out of bed in chair, wagon, etc. as allowed

Goal Two : Assist child to maintain optimal autonomyo Provide mobilizing devices (crutches, WC)o Assist with acquiring specialized equipmento Instruct in use of equipment

Encourage activities that require mobilization Allow as much freedom as possible and encourage normal activities Encourage child to participate in own care Allow child to make choices

High Risk for Impaired Skin integrity

Goal: Maintain skin integrityo Place child on pressure-reducing mattresso Change position frequently, unless contraindicatedo Protect pressure points with proper positioning and cushioningo Inspect skin surfaces for signs of breakdowno Eliminate mechanical factures that cause frictiono Good skin careo Gently massage skin area until contraindicated

High risk for injury

Child will experience no physical injury

o Teach correct use of devices (child and parent)o Assist with moving and/or ambulatingo Remove hazards from environmento Modify environment as neededo Keep call button within reacho Keep siderails up at all timeso Help child use bathroom or commode if possible


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o Implement safety measures appropriate to childsdevelopmental stage

o Diversional activities

Muscular Dystrophies

The largest group of muscle disorders of childhood

Three types:

Congenital myotonic dystrophyo Begins in uteroo Newborn may already have significant myotonia (muscle

weakness)o Usually die before one year of age due to respiratory failure

Assessory muscles for respiration fail

Facioscapulohumeral Muscular dystrophy

Begins after 10 years of age Facial weakness is the predominant symptom Very slow progression of symptoms Less disability than the other types Normal lifespan is possible.

Pseudohypertrophic Muscular Dystrophy/ Duchennes Disease

Most common form of MD Symptoms usually appear by age 3 years

Occurs only in boys Late in meeting motor milestones Muscle weakness gradually becomes more pronounced Usually wheelchair-dependent by adolescence Heart and respiratory failure may occur by early adulthood


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Cerebral Palsy

Cerebral Palsy

A group of non-progressive disorders of upper motor neuronimpairment that result in motor dysfunction.

Can happen before, during, or after birth Occurs 2:1000 births Most common permanent disability of childhood

Incidence and Causes of CP

Most frequently associated with brain anoxia that leads to cell

destructiono Symptoms can range from very mild to quite severe, depending

on the extent of brain damage Also can be caused by:

o Kernicterus (a form of jaundice from hyerbilirubinemia; stainingof the brain with bilirubin)

o Meningitis (viral is the most common) Occurs most frequently in very low weight infants (born prematurely),

or those small for their age.o Their lungs haven

overview of child health

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