Fatemeh Sahrapour
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Nursing 4532: Child & Family
ROUNDING GUIDELINES FOR DOSAGE & MEDICATION CALCULATIONS OBJECTIVES
1. To achieve maximum accuracy in administration of oral and parenteral medications and fluids.
2.To calculate an accurate measurable dose for administration.
Guiding Principles:
1. When calculating dosages, accuracy is maximized by rounding only once, at the end of the dosage calculation.
2. When rounding numbers 0.5 and above, round up. Numbers 0.49 and below round down.
3. Do not leave trailing zeros (E.g. 0.4000 is incorrect, should be 0.4)
4. Always place a zero before a decimal point (E.g. 0.23)
5. In the classroom, including all exams, use these rounding guidelines unless otherwise specified by course faculty
Measurable Dose for Administration:
• Liquid oral medications and parenteral medications:
a. If the volume is greater than 1 ml (milliliter), Round to the tenths place. (E.g. 0.1)
b. If the volume is less than 1 ml (milliliter), Round to the hundredths place. (E.g. 0.12); c. For oral liquids in
household measurements, round to the nearest whole number. (E.g. 2.75 tsp = 3 tsp); use appropriate
measuring device.
• Tablets:
a. Tablets are administered to the nearest whole or half tablet (if scored). (E.g. 2.6 tablets = 2.5 tablets; or 2.8
tablets = 3 tablets)
• Weights (pounds, Kilograms, grams, milligrams, etc.):
a. All weights should be carried to the thousandth and rounded to the hundredth; (E.g. 77.272 kg = 77.27kg;
1.885 mg = 1.89 mg)
b. Weights in pounds and ounces rounded to nearest whole ounce.
c. (E.g. 8 lb. 12.44 ounces = 8 lb. 12 ounces; 8 lb 12.45 ounces = 8 lb. 12 ounces)
• Calculating Maintenance IV flow rates: All IV flow rates are rounded to the whole number when calculating drip rate
by drop factor. (See exceptions below for specialty units or populations)
a. Drops per minute: Round to the whole number. (E.g.: 20.77 drops = 21 drops)
• Pediatric, Critical Care, Specialty Units
a. Dose of the weight-based medication to be infused:
1. Pediatrics: For most of pediatrics, the weight is carried out to the thousandths (0.001) and rounded to the
one hundredths (0.01) when charting in kg.
2. Obstetrics: In the NICU with the premature infants, the weight is in grams so would round to the one
thousandths if charted in kg.
3. Adults: Dose of medication (example: mcq/kg/min) should be rounded to the nearest one hundredth (e.g.
12.21mcg/kg/min)
b. Infusion rate of IV medication
1. Pediatrics: As a general rule, round to the nearest tenth, but there may be exceptions in NICU, PICU,
and CVICU. (Check first with your faculty, staff nurse, and pharmacy depending on the medication)
2. Obstetrics: Typically no rounding, but if needed can round to the one-hundredths place (5.01)
3. Adults: Infusion rate of medication (mL/hr) should be rounded to the nearest tenth (5.1); there are
multiple exceptions depending on the medication, see pharmacy directions for correct administration.
4. Rounding rules for infusion medication doses/rates may vary depending on the specific medication
CLASS ORIENTATION
- Work/function of child is to play and grow
- Medical-surgical nursing content targeted to 0-18 years old
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Fatemeh Sahrapour
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Reading the book is very important!
Anything you turn in must be in APA format
1st Rule of pediatrics, always keep the baby safety!
2nd Rule of pediatrics, you can’t force a child to do anything!
3rd Rule of pediatrics, everything is a game!
Take medication dosages out to one thousands if that’s how the medicine comes. Ex: Digoxin comes in 0.125/ml or
0.25/ml, so that’s what you carry out your answer to
MODULE: PEDIATRIC SKILLS LAB I
Required Readings for lab I & II:
Ht/Wt/VS
Physical Assessment
Scoliosis
Acanthosis Nigricans
Meds
IV Therapy
Hearing and Vision
General Hygiene, Safety Specimen
Collection
Feeding
Elimination
O2 Therapy & Trach Care
Calculations
Perry: 791-802
See module topic: Physical Asmt for readings
Perry: 1556-1557 and School Screenings handout
School Screening handout- in prefab review link
Perry: 1155-1171
Perry: 1171-1177
Perry: 806-811 and School Screening handout
Perry: 1140-1150
Perry: 1151-1155
Perry: 1183-1190
Perry: 1190-1192
Perry: 1177-1183
Review Pediatric drug calculation book from prior classes
Medication Admin
Oxygen Therapy
Hearing/Vision
2013 ATI: 68-74
2013 ATI: 148-160
2013 ATI: 137-146
Other Resources
Elsevier Evolve web site for the book
Children’s Growth
Accuracy is Critical
Weighing the Child
Growth Charts
•Used to compare children in same age group
•Several chart variations
–Girls 0-36 months
–Girls 2yrs. to 20 yrs.
–Boys 0-36 months
–Boys 2 yrs. to 20 yrs.
•Percentiles use to
–Rank individual growth
–Indicate percentage of reference population that individual equals or exceeds
–Determine risk and need for further assessment
•<5th percentile
•>95th percentile
Adjusted Age
•Adjust up to 1 year of age
•Term baby is 37 weeks
•Example:
•2 month checkup. Baby born on Dec, 21, 2013 at 29 weeks
6
•Today is March 6, 2014 = 2014 3
= 2013 12 21
•DOB
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•Subtract to get 2 months and 15 days as actual age
•Subtract the premature time of 8 weeks or 2 months
•Baby is 15 days adjusted – Plot this
•Expect to see a 2 week old baby, not a 2 month old
BMI Measurement
•Recently a change to complement growth charts
•BMI for age curves
•BMI for age used to identify upper end of distribution
–>85th percentile = risk for overweight
–>95th percentile = overweight
–<5th percentile = long term malnutrition, delayed maturation, chronic illness or genetic disorders
•BMI = (wt in pounds ÷ht in inches ÷ ht in inches) x 703
•BMI = (wt in kg ÷ht in cm ÷ ht in cm) x 10,000
Questionable Growth
•Children whose height and weight percentiles are widely disparate
–Height in 10th percentile and weight in 90th percentile esp. with high skin fold thickness
•Children who fail to show expected growth rates in ht and wt
•Children who show sudden increase or decrease in previously steady growth pattern
Skills Review: Safety and Swaddling of Infant
Swaddling Techniques
• Swaddling is the art of snugly wrapping a baby in a blanket for warmth and security. It can keep your baby from
being disturbed by her own startle reflex, and it can help her stay warm and toasty for the first few days of life until
her internal thermostat kicks in. It may even help to calm your baby.
• Be sure you know how to do it correctly. Improper swaddling by tightly wrapping your baby's legs straight down
may loosen the joints and damage the soft cartilage of the hip sockets, leading to hip dysplasia.
• To prevent hip dysplasia when you swaddle, be sure there's enough room at the bottom of the blanket so that your
baby can bend her legs up and out from her body.
• Once the baby is about a month old you might want to stop swaddling her while she's awake, as it can interfere
with mobility and development in older babies.
• “You want to be able to get at least two or three fingers between the baby’s chest and the swaddle
Different Ways to Hold an Infant
• The most common way to carry an infant is the cradle
hold. Place the baby’s head in the bed of your elbow and
use your arm to support the body.
• Place baby’s head over your shoulder, and use one hand
to support the head, and the other to support the body.
• Hold the infant like a football with the head in your hand
and her body under your arm; the feet will be pointed
toward your elbow.
• Once a baby is able to hold up his or her head, you can carry the infant on your hip.
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• Avoid holding the baby around the ribs. This could cause pressure resulting in a fracture.
• When putting down a baby, make sure to support the head until it touches the mattress or car seat.
Safe Ways to Hold an Infant Toddler
• Picking up an infant or toddler:
• If the baby is lying on his or her back, slide one hand under the neck and your other hand under the lower back.
• Lean close to the baby and lift him or her as a whole bundle, keeping the head a little higher than the rest of the
body.
• If the baby is lying on his or her stomach, roll the baby over onto the back and then follow the instructions
above.
• When holding an infant, always make sure you are supporting the head, neck, and back.
• If someone is handing you a baby, lean close to the person and collect the baby in a tight bundle.
• Pick up a toddler by grasping under the arms or around the body.
Preventing Nursemaid Elbow and Other Lifting Injuries
• The best prevention for nursemaid’s elbow is to be careful how a child is lifted and handled.
• Avoid pulling a child by the wrists or hands, and do not swing the child by the arms.
• When picking up a young child, grasp the toddler under the arms or around the body.
• Infants and toddlers rely on adults for their care and growth. A big part of that care and nurturing is carrying infants.
Knowing how to properly pick up and carry an infant or toddler given the child’s size, muscle structure and
age is important to handling them safely.
• Infants and toddlers can develop “nursemaid’s elbow” if they are picked up the wrong way. It is a common condition
that happens when a bone in the forearm slips out of place from where it normally attached to the elbow. It occurs
when a child is pulled too hard by the hand or wrist, picked up by one arm, or lifted in the air by the arms.
Nursemaid’s elbow generally affects children under five.
• Newborns are especially delicate because their necks are not very strong, and their heads are very big compared
to the rest of their body. Because of this, infants are particularly at risk for shaken baby syndrome. Shaking can
cause bleeding in the brain and even death. Never pick up or touch an infant if you are feeling angry or
frustrated.
Transporting an Infant
• Never carry patient to another area (x-ray, ultrasound)
• Always transport patient in crib isolette or bed
• You can have mom get in wheelchair while holding infant and escort them to procedure.
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Breast Feeding
• Provides essential nutrients for the infant
• Provides passive immunity
• Research has shown that breastfed babies are sick less and have a higher IQ
• It is portable, inexpensive, just the right temperature, and facilitates mother/baby bonding, very easily digestible
• Mothers may pump breast milk for infants needing tube feedings
Bottle Feeding
• Cow’s milk based formula is 20kcal/ounce and is usually iron-fortified
• liquid “ready to feed”
• powder that needs to be reconstituted
• concentrated liquid
• Soy-based formula
• used for infants that are cow’s milk or lactose intolerant
• 20 kcal/ounce
• powder, liquid, or concentrated
• recommended for infants with galactosemia
• Casein or Whey-hydrolysate formulas
• AR formulas or Sensitive RS – for infants with GERD
• Isomil DF – for infants with diarrhea
• Gentlease – for infants with upset stomach, colic, gas
• Neosure – for premature infants
• We can always increase calories/oz by adding more powder per oz or adding certain oils and fortifiers – this give a
higher calorie content while giving a smaller amount of fluid – great for premature babies, delayed gastric emptying
Formula Preparation
• Formula may be administered at room temperature and kept at the bedside
• Some babies prefer warm formula – warm it for 10-15 minutes in a cup of warm water prior to feeding
• Formula preparation following instructions – 1 scoop of powder per 2 oz of water
• If preparing powder formula in the hospital, prepare with sterile water
• Sterilization for conditions such as well water or sanitary concerns
• Sterilization for 20 to 25 minutes by boiling water if parents have well water
• May be fed at room temperature or warmed—never heat in microwave! May heat in a bottle warmer or in a cup of
warm water
• Remember that formula should be considered a medication – giving a baby the wrong formula could be very
dangerous
Feeding Techniques
• Infant should be in a semi-upright position
• Bottle should never be propped
• Bottle held so fluid fills the nipple
• Should be burped several times during feeding
• If baby is sleepy or falls asleep, gently rub the baby’s head, pull off the blanket, rub the bottom of their feet, switch
positions to keep awake
• In newborns – they have temperature instability so be sure to keep them wrapped during feedings
Bottles and Nipples
• Preemie nipples
• Graduate feeders
• Habberman nipples
• cleft palate feeder
• nipple can be trimmed to fit palate
Diapers and Urine Collection Techniques
• Important to know size/brand of patient diaper
• Skin allergies?
• U-bags
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Cotton Balls
Straight Catheterization
Clean Catch
Urine Screening for Glucose, Ketones, Protein, Blood, pH, and Specific Gravity
For males, place the entire penis in the bag and attach the adhesive to the skin.
For females, place the bag over the labia.
Weighing Infants, Toddlers, and Children
• Make sure scale is covered with clean blanket or disposable paper.
• Make sure scale is zeroed with the above!!
• Make sure infant is naked for most accurate weight.
• Older children weighed in underpants/gown
• Try to use same scale and same time of day if possible.
• Prevent falls: Never leave infants/child’s side while they are on scale.
Measuring the Pediatric Population
• Make sure head is midline, line of vision parallel to floor, shoulders touching, buttocks touching, heels touching and
together. Length board with 2 people assisting is most accurate!
• OFC: head circumference: use paper tape measure around the occipitofrontal circumference (the widest diameter)
of the newborn’s head, positioning it above the ears and just above the eyebrows. Adjust the tape measure at the
occipital bone to obtain the largest measurement, and read the tape in centimeters at the zero mark.
• Crown-to-heel recumbent length infant/child placed in lying position on infant scale, crib, or bed.
• Tricks to the trade: you can have helper assist with lying infant flat… you mark on paper/sheet infants crown and
helper marks the heel (toes flexed). Give infant back to caregiver and use measuring tape to measure your
markings!
• Stadiometer, paper tape, measuring tape may be used for the standing child.
Papoose Board
Circumcision Board
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Safe Crib Protocol
• Always raise side rails up and make sure they are in locked position when leaving your patients side.
• Make sure you do not leave any medication syringes, caps, needles in patients crib. (you would be surprised at
what we find)
• Make sure you teach family not to leave extra blankets, stuffed animals, or bottles in the crib.
• Watch IV tubing, O2 tubing carefully because they can strangle infant.
Safe Sleep Environment
Code Pink- Infant and Pediatric Security
• Code Pink - A code pink overhead page will alert staff in the hospital that there has been a potential child
abduction. Examples of actions which may be suspicious for child abduction:
a. Observation of a child struggling or appearing to be restrained.
b. A person in the hospital without proper identification.
c. Any person who might be seen trying to avoid contact with a Public Safety Officer stationed at an entrance.
d. d. Anyone who appears to be carrying an unusual bag or container which could harbor a small child or infant.
• TYPICAL ABDUCTOR
• Almost all abductions of infants that take place in hospitals have characteristics that are typical.
• Character profile of a typical infant abductor:
• Female, age 15-44, often overweight.
• Most likely emotionally immature and compulsive.
• Frequently has lost a baby or incapable of having one.
• Often married or cohabiting; companion's desire for a child may be the motivation for the abduction.
• Considers the baby her own once the abduction occurs.
• Typically does not harm the baby.
• Usually lives in the community where the abduction takes place.
• INITIAL RESPONSE
• Staff fulfill a crucial role when a child is abducted from a hospital. The quick response and immediate action of
these health care professionals can make a critical difference in the successful recovery of that child.
• In the event of a child abduction or attempted child abduction many actions will be accomplished
simultaneously…follow your hospital protocol!
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Skills Review: Feeding 1 NG (nasogastric), OG (orogastric), Tube Insertion/Removal
ALERT
Do not use an NG or an OG tube in a child with a suspected basilar skull fracture or maxillofacial trauma because of
the risk of inadvertent placement of the tube in the brain by way of the cribriform plate or ethmoid bone.
The child must have a mobile cervical spine in order to position the head for insertion.
1.
2.
3.
4.
5.
6.
Perform hand hygiene and don gloves.
Verify the correct child using two identifiers per institution policy.
Review the child's history for trauma, nasal or palate deformity, epistaxis, gastric fundoplication, gastric or
esophageal surgery, esophageal malformations or injuries, and pyloric malformations.
Assess the upper respiratory tract, oxygenation, ventilation, and patency of the nares.
Assess the desire of family members to be present during the procedure.
Have suction available per institution policy.
NG or OG Tube Insertion
1. Ensure that the child's vital signs and indicators of adequate oxygenation and ventilation are monitored.
2. Position the child in the supine position. The head of the bed may be flat or (preferably) elevated as the child's
condition permits. If indicated, enlist a second person to help keep the child immobile during the procedure
and/or encourage parental presence for support.
3. Estimate the depth of tube insertion by measuring the tube from the tip of the nose to the earlobe, then from
the earlobe to the midpoint between the xiphoid and the umbilicus. Mark this point on the tube with a marker
or small piece of tape.
4. Lubricate the distal tip of the tube with a water-soluble lubricant.
5. Gently but steadily thread the tube through either the mouth or one of the nares to the previously identified
mark. Avoid extending the head backward. If a cervical spine injury is present, do not flex the child's head. If
passage is difficult or if choking, coughing, cyanosis, or decreased oxygen saturation occur, STOP, remove
the tube and reattempt placement at a different angle.
a. For nasal placement: Insert the tube into a patent nostril, aiming posterior and parallel to the nasal septum.
When the tube touches the pharynx, flex the child's head forward and, if the child is cooperative, ask the
child to swallow. Advance the tube as the child swallows. Infants may be offered a pacifier.
b. For oral placement: Position the end of the tube downward and insert the tube into the oral cavity over the
tongue. Aim the tube back and down toward the pharynx. When the tube touches the pharynx, flex the head
forward. If the child is cooperative, ask the child to take sips of water through a straw while the tube is
advanced.
6. Obtain an abdominal radiograph for confirmation of correct tube placement. Do not rely on the auscultation
method to confirm tube placement.
7. Stabilize the tube by taping it securely to the face. Avoid taping the tube to the naris.
8. Ensure that the previously marked place on the tube is visible where the tube exits the mouth or naris.
NG or OG Tube Removal
1. If applicable, turn off suction or continuous feeding.
2. Position the child in the supine position. Elevate the head of the bed as tolerated by the child. If indicated,
enlist a second person to help keep the child immobile during the procedure and/or encourage parental
presence for support.
3. Gently remove tape from under the lip or cheek. Consider the use of skin adhesive remover to assist in the
removal of tape.
4. Occlude the tube by pinching it closed, bending it, and holding it with the thumb and index finger. Pull the tube
out of the mouth or nose using a swift, consistent motion.
Completing the Procedure
1. Monitor the child's tolerance of NG or OG tube placement.
2. Monitor proper tube placement.
3. Monitor the insertion site of the tube.
4. Assess, treat, and reassess pain according to institution standard.
5. Discard supplies, remove gloves, and perform hand hygiene.
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Document the procedure in the child's record.
Skills Review: Feeding 2 Enteral Nutrition: Administration
ALERT
To prevent enteral tubing connection errors, trace the tube from the child to the point of origin before connecting for
an enteral feeding.
Medication and enteral formulas may interact, reducing the effectiveness of the medication and nutrient stability.
1.
2.
3.
4.
Perform hand hygiene before patient contact.
Verify the correct child using two identifiers per organization policy.
Review the child's history for cardiac, hepatic, renal, and pulmonary disease.
Review the child's history for conditions that affect GI absorption, metabolic rate and fluid status, food
allergies, and enteropathy.
5. Review the child's current medications.
6. Assess anthropometric measurements, including weight, length or height, head circumference, body mass
index (children 2 years of age or older), and skin folds. Plot these values on the appropriate growth chart for
the child's age and gender.
7. Assess GI tract function, including abdominal examination results and function.
8. As appropriate, assess oral feeding behaviors, including the ability to tolerate oral stimulation.
9. Assess fluid balance, caloric needs, and enteral formula goals with a dietitian if available.
10. Ensure that the proper placement of an orogastric, nasogastric, gastrostomy tube, gastrojejunostomy tube, or
postpyloric feeding tube is verified.
11. Verify the practitioner's order for enteral feedings, ensuring that the order includes the type of formula, the
volume to be delivered, the rate or duration of infusion, the route, and the frequency of feedings.
12. Perform hand hygiene and don gloves.
13. Verify the confirmation of the feeding tube placement.
14. For gastric feedings, elevate the head of bed at least 30 to 45 degrees. If the child must be supine, monitor
closely for aspiration; consider using a postpyloric feeding tube.
15. Close the clamp on the enteral feeding bag, and pour up to 4 hours of room-temperature formula or breast
milk into the bag. If a syringe is used for continuous enteral feedings, draw up to 4 hours of room-temperature
formula or breast milk.
16. Place the bag on the IV pole and prime the tubing, purging the system of air. If a pump is used, load the
administration set into the enteral feeding pump. If a syringe is used for continuous enteral feedings, attach
the distal end of the syringe to the feeding tubing, prime the tubing with formula, and purge the system of air.
Load the syringe into the infusion pump.
17. Label the enteral feeding bag and administration set with the child's name, type of formula, the amount of
formula, delivery site, and the date and time it is prepared and started.
18. Flush the feeding tube with water. Flush the tube with the lowest volume to clear the tube. To reduce
excessive free water use, limit volumes of flush to 1 to 3 ml in neonatal patients and 3 to 5 ml in children.
19. Connect the feeding bag set to the distal end of the feeding tube.
20. Begin the infusion. Offer infants a pacifier to satisfy oral needs.
a. For continuous feedings by way of a feeding pump, set the prescribed infusion flow rate for continuous
feeding and start the infusion.
b. For bolus feedings by way of syringe method, remove the plunger from a 30-ml or 60-ml syringe. Attach the
syringe to the distal end of the feeding tube. Pour the enteral formula into the syringe and administer it
slowly by means of gravity. Consider using a feeding bag for bolus gravity feedings, depending on the
volume of feeding administered.
21. Assess, treat, and reassess pain according to organization standard.
22. Remove gloves and perform hand hygiene.
23. Document the procedure in the child's record.
Skills Review: Feeding 3 Tube Care: Gastrostomy and Gastro-Jejunostomy Tube Care
ALERT
GTs and GJTs are indicated for children with a functional GI tract who are unable to swallow adequate oral nutrition,
have gastric reflux, are at risk for aspiration, or need supplemental feeding therapy for an extended length of time.
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1.
2.
3.
4.
Perform hand hygiene and don gloves.
Verify the correct patient using two identifiers per institution policy.
Assess for signs of gastric distention and assess for any GI symptoms, including vomiting.
Remove old dressing and tube stabilizer (if present). Check for skin redness, rash, edema, drainage, and
excess granulation tissue. If leaking is present, assess the tube for proper size, balloon functioning, tube
stability, and proper tube position. Refer to the manufacturer's recommendations regarding the amount of
water the balloon should have for proper stabilization.
5. Clean the skin around the tube site with soap and water. Dry the skin completely. Do not use antibiotic
ointments or hydrogen peroxide at the tube site.
6. Consider application of a skin barrier cream or ointment (e.g., petrolatum, zinc-based) if the site is leaking or
red.
7. Apply a foam dressing or one split gauze, if drainage is present.
8. Flush tubing.
A. GT: Flush with 5 to 10 ml of tap water after medications and with feedings. For children with fluid restrictions
or for infants, 1 to 5 ml is typically adequate.
B. GJT: Flush jejunal port every 4 hours with the lowest volume needed to clear the tube, and flush the gastric
port after use.
9. Vent gastric port when ordered.
A. GT: Vent via syringe or Y tubing (Farrell valve) for at least 30 minutes after feedings.
B. Low-profile device: Vent via appropriate decompression or feed set tube for at least 30 minutes after
feedings.
C. GJT: Vent via gastric port with gravity drainage. Do not use continuous or high intermittent suction.
10. Monitor the site for redness, rash, blisters, pain, odor, site drainage, or granulation tissue.
11. Cleanse the site with soap and water and dry once daily and when needed. Avoid the use of hydrogen
peroxide, alcohol, or Betadine.
12. Rotate GT "button" in a circle one to two times with care daily. GJTs should not be rotated.
13. Monitor the GT/GJ for leakage of formula around the site.
14. Apply cream or ointment, as indicated. To protect the skin, apply a barrier zinc-based or petroleum-based
cream, ointment, or nonalcohol skin preparation solution. For fungal rash, apply antifungal powder, cream, or
ointment.
15. For moderate to large drainage or leakage, consider application of a fenestrated foam dressing or ostomy
pouch.
16. For granulation tissue, consider application of silver nitrate or a steroid cream to granulation tissue as ordered
until resolved.
17. Flush before and after medications and formula administration.
18. GT: Check gastric residual volume only if ordered by the practitioner.
19. Discard supplies, remove gloves, and perform hand hygiene.
20. Document the procedure in the child's record.
Skills Review: Feeding 4 Enteral Feeding- Neonate
ALERT
The Joint Commission and the Institute for Safe Medication Practices recommend the use of enteral-only syringes
and tubing when delivering enteral feedings. The inadvertent connection of an enteral feeding to a venous or arterial
line results in death. Always trace the tubing from the neonate to the device before connecting any new device and
label any pump delivering feedings as enteral.
1.
2.
3.
4.
5.
6.
7.
Perform hand hygiene before patient contact.
Verify the correct neonate using two identifiers per institution policy.
Determine the family's understanding of the reasons for and risks and benefits of enteral nutrition
administration via a feeding tube.
Assess the neonate's clinical picture (stable vital signs, unlabored respirations, appropriate responses to
stimuli) to confirm readiness for enteral feedings.
Assess the neonate's history for contraindications to enteral nutrition.
Review the current anthropometric measurements, including admission weight, length or height, head
circumference, skin folds (if available), and plots of these values on appropriate age and gender charts.
Review the neonate's medications.
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8. Assess GI tract function.
9. Assess fluid balance to determine enteral nutrition requirements.
10. Prepare the appropriate amount of room-temperature formula or breast milk in an appropriate-size oral
syringe and label it.
a. For intermittent feedings, use the ordered amount.
b. For continuous feedings, use up to 4 hours' worth of the feeding.
11. Immediately before every feeding, monitor oxygen and ventilation indices. Notify the practitioner if the neonate
shows changes in the work of breathing (changes in respiratory rate and effort and lung sounds), blood gas
values, or oxygenation.
12. Perform hand hygiene and don gloves.
13. Verify the prescribing practitioner's order. Ensure the order includes the type of enteral feeding (formula or
breast milk), the volume, and the frequency of feedings.
14. Place the neonate on a cardiac respiratory monitor during the tube feeding. Immediately stop the feeding
infusion in the event of apnea or bradycardia. Assess the neonate for adequate respirations and heart rate
and evaluate the need for resuscitation. If the neonate recovers quickly, resume the feeding slowly after a
brief pause and observe the neonate carefully. If apnea or bradycardia continues or recurs, stop the feeding.
Check the airway for patency by clearing the mouth and then nose with suction. Notify the practitioner.
15. Verify tube placement.
16. Check for any residual gastric contents by gently aspirating stomach contents.
a. Use additional syringes as necessary to obtain the full amount of stomach contents.
b. If attempts to obtain an aspirate are unsuccessful (no air or residual), use a larger syringe to decrease the
pressure created by the plunger. Consider repositioning the neonate to move the tube tip away from the
stomach wall.
c. Return the gastric residual and subtract that amount from the volume of the feeding, as appropriate. A
partially digested aspirate of less than half of the previous feeding or a 1-hour volume of continuous infusion
is typically considered normal in the absence of illness. If the gastric residual is bloody or has the
appearance of coffee grounds, is green or bright yellow or has the appearance of fecal matter, or contains
thick mucus, do not refeed it. Notify the practitioner immediately if the gastric aspirate contains bile or blood
or has the appearance of coffee grounds.
17. Determine the need for an indwelling feeding tube or an intermittently placed feeding tube. Ensure that an
indwelling feeding tube is secured to the neonate's face. Change the adhesive dressing if necessary.
18. Note the centimeter marking at the lips for OG tubes or the nares for NG tubes.
19. Assess the neonate's abdomen for distention, discoloration, and loops of bowel before every bolus or
intermittent feeding or every 4 to 8 hours with a continuous infusion. Include abdominal girth in the
assessment by measuring around the neonate's abdomen over the umbilicus. Notify the practitioner
immediately of persistent distention, pain with palpation, discoloration, and visible loops of bowel.
20. Position the neonate for the feeding.
21. Match the two patient identifiers on the breast milk container to the neonate's identification band. Scan
barcoded labels to match the neonate's identification bar code or have a qualified individual verify that the two
patient identifiers on the container match the two patient identifiers on the neonate's identification band.
22. Add medications to the formula or breast milk (if needed) at the beginning of the feeding, after checking for
compatibility.
23. If medication is needed, ensure the six rights of medication safety: right medication, right dose, right time, right
route, right patient, and right documentation before adding medication to the feeding.
24. Label the feeding bag and administration set or oral syringe with the date and time prepared, type of formula
or breast milk, and amount.
25. Initiate the enteral feeding as ordered.
Bolus Feeding by Gravity Via Oral Syringe Method
1. Attach the syringe to the distal end of the feeding tube.
2. Remove the plunger from the oral syringe.
3. Allow the room-temperature enteral formula or breast milk in the syringe to run in slowly by gravity. If the flow
does not begin spontaneously, gently push the feeding, using the syringe plunger to establish flow.
4. Position the syringe about 20 cm (8 inches) above the neonate's abdomen to allow the feeding to run in
slowly, ideally during the course of 30 minutes.
Intermittent or Continuous Tube Feeding Via Syringe Pump
1. Attach the feeding extension tubing to the syringe and prime to expel air.
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2.
3.
Place the syringe on the pump.
Program the syringe pump.
a. For intermittent feeding, enter the ordered volume and infusion time.
b. For continuous feeding, enter the hourly rate.
4. Connect the tubing to the distal end of the indwelling feeding tube.
5. Begin the infusion.
Intermittent or Continuous Tube Feeding Via Feeding Pump
1. Close the clamp on the enteral feeding bag and pour the appropriate amount of room-temperature formula or
breast milk into the bag.
a. For intermittent feedings, use the ordered amount.
b. For continuous feedings, use up to 4 hours' worth of feeding.
2. Hang the feeding bag on the IV pole and prime the tubing to purge the system of air.
3. Load the administration set into the enteral feeding pump.
4. Program the pump.
a. For intermittent feeding, enter the ordered volume and infusion time.
b. For continuous feeding, enter the hourly rate.
5. Connect the tubing to the distal end of the indwelling feeding tube.
6. Begin the infusion.
Bolus, Intermittent, or Continuous Tube Feeding
1. Give the neonate a pacifier to satisfy oral needs.
2. When the feeding is complete, clear the feeding tube with a small amount of air. Maintain the neonate's
elevated position for 30 minutes.
3. Discard supplies, remove gloves, and perform hand hygiene.
4. Document the procedure in the neonate's record.
Skills Review: School Screenings
HEARING AND VISION SCREENING
INTRODUCTION:
The 68th Texas Legislature passed the Special Senses and Communication Disorders Act of 1983, Chapter 36 Texas
Health and Safety Code. One purpose of the legislation is to identify those children in need of professional vision and
hearing examinations. As a part of comprehensive preschool and school health programming, vision and hearing
screening is aimed at detecting problems which could limit the child’s educational opportunities.
Vision Screening Overview:
To carry out the vision screening requirements of the law, rules were adopted stating that all children enrolling for the
first time in any public, private, parochial, or denominational preschool or school in Texas shall have undergone an
eye examination by a licensed eye care specialist (an ophthalmologist or an optometrist) or a Texas Department of
Health approved vision screening test. At the present time, the youngest children required to be screened are 4-yearolds. Target groups currently required to be screened annually include: 4-year-olds, any first time entrant into a Texas
child care facility or school, and children in kindergarten, first, third, fifth, and seventh grades.
Normally by age 3-4 months, a child has achieved the neuromotor ability to fixate on one visual field with both eyes
simultaneously. One of the most important tests for binocularity is alignment of the eyes to detect strabismus.
In strabismus, one eye deviates from the point of fixation. If the malalignment is constant, the weak eye becomes lazy
and eventually the brain suppresses the image produced by that eye. If strabismus is not detected and corrected by
age 4-6 years, a type of blindness called amblyopia may result.
The two tests used to assess alignment are the corneal light reflex test and the cover-uncover test. The corneal light
reflex test is conducted by shining a flashlight directly into the eyes of the child from a distance of about 16 inches.
The screener observes where the light falls within each pupil. If the light falls off center in one eye, the eyes are
malaligned.
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Terms for describing the types of strabismus are:
1.
2.
3.
4.
esotropia or esophoria – inward deviation of the eye.
exotropia or exophoria – outward deviation of the eye.
phoria – malalignment that is not obvious until fusion is disrupted.
tropia – constant or intermittent malalignment of the eyes. More severe and more likely to result in amblyopia
than phoria.
In the cover test, one eye is covered and the movement of the uncovered eye is observed while the child gazes on a
near (33 cm or 13 in) or distant (50 cm or 20 in) object. If the uncovered eye does not move, it is aligned. If the
uncovered eye moves, a malalignment is present because when the stronger eye is temporarily covered, the weaker
eye attempts to fixate on the object.
In the uncover test, occlusion is shifted back and forth from one eye to the other eye and movement of the
uncovered eye is observed while the child is fixating at a point in front of the child. If normal alignment is present,
shifting the cover from one eye to the other eye will not cause movement of the covered eye. If malalignment is
present, the covered eye will move from its position to a straight position when uncovered. This test takes more
practice than the other cover test because the occluder must be moved back and forth quickly and accurately in order
to see the eye move. Since deviations can occur at different ranges, particularly in the case of phorias, it is important
to perform the cover test at both near and far distances.
Visual acuity in preschoolers is assessed by using the H:O:T:V test at a distance of 10 feet. The child matches the
letters on a large card to the one the screener points to.
Hearing Screening Overview:
Hearing is tested using pure tone audiometry. Pure-tones are caused by the simple harmonic motion of a vibrating
body. The tone that is produced by this vibrating body is pure or an unmixed tone. These pure-tones can be used to
test a person’s ability to hear. Two physical attributes are used to describe a pure tone. They are frequency and
intensity, and each pure tone can be measured for these two attributes.
The frequency of a pure-tone is the number of times a vibration occurs in a second and is perceived by a person as
the “pitch” of a sound. The pitch tells a person how high or low sounding the pure tone is. An example of a highfrequency tone would be the annoying high-pitched sound of a mosquito or a fire siren, whereas, low frequency tones
would include the hum of a typewriter or the sound of a tuba.
Because frequency is a physical attribute, it can be measured. Frequency is measured in units called Hertz,
abbreviated Hz. The lower the number of the Hertz, the lower the pitch of the pure tone. The higher the number, the
higher the frequency. For example, on a piano keyboard, middle C is about 256 Hz. The frequency range of normal
human hearing is from about 20 Hz to 20000 Hz but normal human speech only contains sounds ranging from 125
Hz to 8000 Hz. Since basic hearing screening is aimed at detecting those who may have problems hearing sound in
the important speech range, frequencies from 250 Hz to 6000 Hz are the ones usually tested in the screening
process.
The other physical attribute used to describe a pure tone is intensity. The intensity is the loudness or softness of a
tone. The intensity is measured in units called decibels, which is abbreviated dB. An average young listener, with no
history of ear trauma or disease, is noted as being able to hear at 0 dB hearing level (HL). This is the intensity or
loudness level at which a young, healthy ear can detect tones. There are some people who can even hear at an
intensity lower than 0 dB HL.
The useable range of intensity in normal listeners is from 9 dB HL to 120 dB HL. These numbers indicated loudness
levels as faint as rustling leaves or as loud as a jack hammer. It should be noted that a tone measured at 120 dB HL
in intensity is perceived as uncomfortably loud. This is the threshold of discomfort and will not be tolerated except for
brief periods of time by normal listeners.
The hearing screening is called sweep-check screening. It is intended to screen many children in a relatively short
period of time in an attempt to identify those who may have a hearing problem. The frequencies screened are 1000,
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Fatemeh Sahrapour
2000, and 4000 Hz at 25 decibels (dB). Each child is tested with the right ear and then the left. The order of
frequencies for testing is 1000, 2000, and 4000 Hz.
Vision Screening:
The material covered in this handout is excerpted from the 2003 vision screening manual developed and published
by the Texas Department of Health. The components of an effective vision screening program are:
1.
2.
3.
4.
5.
identification of a possible problem.
referral to an eye care specialist (ophthalmologist or optometrist) for diagnostic evaluation.
treatment when appropriate.
educational consideration of relevant condition.
tracking and follow-up of all referrals for statistical evolution of program’s effectiveness.
Vision screening for 4 year-old children includes assessment of visual acuity and screening for muscle balance
problems, which includes the Hirschberg corneal light reflex test and the cover-uncover test. Screenings for visual
acuity are also conducted for any first time entrant into a Texas child care facility or school when the child is at least 4
years of age and also children in kindergarten, first, third, fifth, seventh, and ninth grades.
The three charts used for vision screening for distance acuity are:
1.
2.
3.
the Snellen alphabet or letter chart which is appropriate for children 7 years and older.
the Snellen tumbling “E” chart for 5 and 6 year-old children.
the H:O:T:V chart for children 4 and 5 years old.
The process and the team discussed in this handout are for the screening of preschool children and the use of the
H:O:T:V chart.
Materials:
H:O:T:V chart
Response panel
Flash cards
Children’s sunglasses (2 pairs)
Cover or window cards
Materials:
Steel measuring tape
Masking tape
Occluders
Plain brown or butcher paper
Pointers
Lamp(s) on a flexible stand
Small table and chair
Vision screening forms (2 types)
The environment:
Quiet area
Room at least 12 feet long
Uncluttered, unpatterned wall
Normal light without glares or shadows on eye chart. In darker locations or cloudy days,
use one or 2 goose neck lamps approximately 3 feet from the chart.
Set up:
Position the chart on the wall with the 20/40 line at the eye level of the average child to be
screened. Consider whether the child will be sitting or standing. This will be approximately
36 - 42 inches for standing children and 30 - 36 inches for children who are sitting in a
small chair.
Start 4 years olds and younger at the 20/50 line. Start 5 year olds and older at the 20/40 line.
- 4 years and younger, passing is 40/40
- 4 years and older, passing is 20/30
- Must have 4 items right in a line to pass line
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- It’s not until adulthood that perfect vision is considered 20/20
Measure 10 feet from the chart to place where the child is to sit. Mark that spot with masking tape. Place the back of
the chair on the marked spot.
Place a small table in front of the chair with the response panel in easy reach of the seated child.
Position and assign each team member.
Passing/Failing the Screening:
Passing Acuities
Reading more than one-half of the symbols/letters on a line is passing the line. “The 20/40 line is passing for children
4 years and younger and have less than a 2 line difference between passing acuities of each eye. The 20/30 line is
passing for children 5 years and older” (Texas Department of Health, 2003, p. 43).
Failing Acuities
Children who read at the 20/50 line or worse in either eye or 20/20 in one eye and 20/40 in the other eye and are 4
years or younger have failed the screening.
Children 5 years or older who read at the 20/40 or worse in either eye have failed the screening. (Texas Department
of Health, 2003).
Children who fail the initial screening are to be re-screened in 2 or 3 weeks. When a child fails the second screen, it is
the responsibility of the screener to notify the parents and complete a referral form to an optometrist or
ophthalmologist.
Hearing Screening: Pure-tone Sweep-Check Screening
The material covered in this handout is excerpted from the 2002 hearing screening manual developed and published
by the Texas Department of Health. The purpose of the sweep-check screening is to screen many children in a
relatively short period of time, in an attempt to identify those who may have a hearing problem and those who
apparently do not. Frequencies to be screened are 1000, 2000, and 4000 HZ at an intensity of 25 dB HL. This
screening intensity is just outside the upper limit of normal hearing. With normal sensitivity beyond this level, a child
might have difficulty hearing conversation speech in a classroom situation. In noisy settings, where all the sweepcheck frequencies cannot be heard at 25 dB HL, screening should be suspended rather than set the HL dial at a level
higher than 25 dB.
Each child is tested individually in as quiet a setting as possible, although they may be conditioned as a group. The
child is instructed to respond, generally by raising his/her hand for each test tone given at a set intensity of 25 dB HL.
Specific instructions may be worded something like this: “You will hear tones through these earphones. Some of the
tones will be low-pitched and some will be high-pitched. Every time you hear the tone, raise your hand. When the
tone goes away, lower your hand”. When the screener is sure that the child understands the instructions, place the
earphones securely on the head and begin testing. The screening results are to be recorded on a form. (Texas
Department of Health, 2002).
Sweep-check testing procedures:
Set the output selector switch to the right ear, which is the ear that is screened first.
Set the HL dial on the 25 dB and leave it there for the entire sweep-check screening test.
Set the frequency selector on 1000 Hz, which is the frequency where screening is begun.
Present the tone for 1 to 2 seconds.
Record the child’s response on the screening form - a plus mark “+” for each frequency heard, and a minus “-” for any
tone with no indicated response.
Present the 2000 Hz tone, then the 4000 Hz tone in the right ear; record each result on the screening form.
Keep the HL dial at 25 dB, but change the output selector switch to the left ear.
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Repeat the test procedure for the left ear using the same sequence of tone presentations: 1000, 2000, and 4000 Hz.
Record those results on the screening form.
Note:
In sweep-check screening, the HL dial is always kept at the 25 dB setting. This is the highest intensity level permitted
for the screening. An HL setting above 25 dB increases the possibility that children with mild conductive hearing
losses will pass the sweep-check screening and thus not be identified as needing referral and possible treatment. If
the nose level in the testing room does not permit screening at a 25 dB HL level, then screening should be
discontinued.
Since most children are aware of the purpose of a hearing screening, care must be taken to be sure that each child
being tested is responding only to the tone being presented and not to cues that the screener might be inadvertently
giving.
Extended recheck-Starting at 40 dB and going down by 10 dB until no response is obtained or until 20 dB is reached
and then up by 5 dB until a response is obtained. The frequencies to be evaluated are 1 000, 2000 and 4000 Hertz
(Hz). (Texas Department of Health, 2002).
Precautions to be observed:
Do not let the child watch the operation of the audiometer’s presentation controls.
Do not look at the child when the tone is presented (use peripheral vision to observe the child).
Do not present the tone when there is a noise which would interfere with the child’s hearing the tone.
Do not give any clues as to when the tone is presented. Control eye, head, arm, or other body movement, reflections,
shadows, etc.
Do not establish a rhythm in tone presentations. Vary the time intervals between the tones. (Texas Department of
Health, 2002).
Passing/Failing Hearing Screening:
“Children failing to respond to one (of the three) frequencies in either ear should be rescreened with another Sweep
Check within 3 – 4 weeks” (Texas Department of Health, 2002, p. 49).
SCOLIOSIS SCREENING
The child is stood directly in front of the nurse, feet slightly apart, toes pointed and equal. The nurse observes his
shoulders and spine. The child is asked to bend over and touch his/her fingers close to the floor while the nurse
observes the spine, and shoulders for a curvature or difference in shoulder heights. If a difference is detected, a
second person is asked to assess. The nurse places her/his hands on the pelvis of the child as they bend over again.
The information is reported to the nurse as negative for curve or unequal shoulder heights detected.
ACANTHOSIS NIGRICANS SCREENING
The State of Texas has mandated screening students for acanthosis nigricans because of the rise in the number of
children with Type 2 Diabetes. A hyperkeratinization of the skin has been associated with insulin resistance, increase
in blood pressure and increased risk of developing Type 2 Diabetes. The hyperkeratinization serves as a marker for
development of Type 2 Diabetes.
Children at high risk for development of Type 2 diabetes are from the following ethnic groups; Native American,
Hispanic and African Americans. The children are overweight and have someone in the family who has Type 2
Diabetes.
Students in 3rd, 5th and 7th grades are to be screened annually and referred to a physician in the case of a positive
screen which includes a blood pressure in the 90% or greater for age of the child. A child who has a positive screen
will also receive a BMI assessment.
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The acanthosis nigricans skin pigmentation is often seen on the back of the neck. This makes this screening a
combination with scoliosis screening a quick and easy assessment. The appearance of the skin is light brown-black,
velvety, rough or thickened areas on the skin. The size of the discoloration is how the condition is graded.
Grade 1 is a line
Grade 2 is line that is 1-2 cm wide
Grade 3 measures 2-3 cm wide
Grade 4 measures greater than 3 cm wide.
Process:
1. Observe the back of the child’s neck.
2. If discoloration is observed, have the child sit down.
3. Obtain blood pressure; record on referral form.
4. Wait 5 minutes to measure blood pressure again. Record on form.
5. Record ht and wt. Calculate and record BMI.
6. Complete referral form.
7. Explain to child as age appropriate.
MODULE: PEDIATRIC SKILLS LAB II
Skills Review: Pediatric Medication Administration/IM Injection/IV Starts
Lab Prep Sheet
Medication Administration:
* Weight based dosing in Pediatrics; usually mg/kg/dose or day
•
Important to know your drug including safe dosage, possible side effects, signs of overdose, and what to
expect the drug to “do”.
•
Always double check all medication calculations.
•
Growth and maturation alter the capacity to metabolize and excrete drugs. Particularly important in
newborns/premature infants with their immature liver.
•
Always use two identifiers before administering any med. Your ID band is your identifier, if it is not present, a
replacement should be made before giving the med.
•
Oral route: preferred, solids not recommended due to aspiration. Use plastic medication measuring cups or
syringes for accurate dosing. Syringes are preferred! If a drug is ordered in a teaspoon – use standards. 1
tsp. = 5 ml. 1 Tbsp. = 15 ml. Droppers are very inaccurate.
o If giving tablets or pills – should be crushed, however make sure the drug can be crushed!
o When giving PO, important to prevent aspiration, particularly if child is crying. Place in seated or semireclining position in lap. Place syringe along side of tongue and give in small amounts allowing for the
child to swallow. NEVER add to formula because infant/child may refuse unless the med is due before
a feeding, this may be a method that can work for you. Older children can be taught to use the syringe.
Infants can suck medications from a nipple, but be aware that residual may be left behind. Never mix in
sippy cups or any other large amount of liquid. Use a “chaser” after the med is given.
o If the child refuses (and don’t ask them if yes or no they would like their medicine) – give the child an ice
pop to numb the mouth, give a “chaser” after the drug, if there is nausea give a carbonated beverage
before/after medication, pharmacists can add “flavorings” to medications
*HELPFUL HINTS
— Explain to the child what you are doing and that the medication will make them feel better. Sometimes a
simple explanation may help to alleviate the child's fears.
— Ask the caregiver how the child normally takes their medications.
—If the child is old enough offer them the option of taking PO meds through an oral syringe or medicine cup.
— Find out if the med can be crushed or given with food. To open his mouth, play a game with him. Who can
open the mouth the biggest?
— Give them a job to do – use conversation as distraction, have a fun toy on your stethoscope for them to play with,
let them have the penlight to play with, etc.
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*Intramuscular Injection:
- Newborns: General considerations: 25 gauge, 5/8-7/8 inch needle. Preferred site is vastus lateralis.
Dorsogluteal muscle is small, not developed and too close to the sciatic nerve. Deltoid also does not have enough
“meat”. Important to stabilize the infant’s leg and insert needle to the hub at 90 degree angle. Site is cleansed
appropriately (per hospital policy). Withdraw quickly and place pressure on the site to help alleviate the pain.
Comfort infant at end of procedure. Recent EBP (2012) states we do not need to aspirate on vaccines,
immunizations, heparin and insulin, nor do we need an air bubble. Common medications given at delivery
of the newborn:
1. Vitamin K IM (Vitamin K deficiency bleeding of the newborn)
2. Hepatitis vaccination – consent required
3. Hepatitis B immune globulin (HIBG) if mother is a chronic carrier or status unknown. Consent not required.
•
Must be given within 12 hours of birth
•
Inject in different legs, and not is same sites
- Infants 2 months and above
•
•
•
Needle length – must be sufficient to penetrate the subQ tissue so that the medication is deposited into the
muscle, smaller diameter needles cause less pain but larger diameters are often needed due to the
medication viscosity. General guideline to start with is 1” needle, 25 gauge.
General considerations: Do not repeatedly use the same site (risk of fibrosis with muscular contracture). Be
careful when using glass ampules – make sure you use a filtered needle! Children are unpredictable – have
extra help to hold them down! Use pain control as appropriate (e.g. Emla, 24% sucrose, developmental
considerations (e.g. swaddling, buzzy bee, game/movie distractors). Do it quick! Don’t ever show the
needle to the child.
Site determination: 1 ml is usually maximum amount administered in a single site for older infants/small
children. Remember – the larger amount of med to be given, the larger the muscle is needed!
o Preferred site for infants – vastus lateralis. Large, well developed muscle that can handle larger
quantities of fluid (0.5 ml in infants and 2.0 ml in child). Easily accessible. More painful than deltoid or
gluteal site. Sciatic nerve damage can occur if long needle is injected posteriorly/medially in small limb.
Thrombosis of femoral artery can occur from injection in mid-thigh area.
o Acceptable site for children over one year of age– ventrogluteal. Palpate to find greater trochanter and
posterior iliac crest. Place palm of hand over greater trochanter, index finger over anterior superior iliac
tubercle and middle finger along the crest of ileum posteriorly as far as possible. Inject into center of V
formed by fingers. 22-25 gauge, 1 inch needle. Insert needle perpendicular to site but angle slightly
to iliac crest. Site free of nerves and vascular structures. Easily identified. Not as much subQ fat so
less chance of placing medication into the subQ space. Can handle large quantities of fluid (as above
for vastus lateralis). Easily accessible and less painful than vastus lateralis. Remember -- Using this
site can be traumatic for preschool and younger school-aged children who are anxious about their
“private parts” being seen and hurt.
- Toddlers (12 months) – preferred site thigh (one inch), deltoid (5/8 inch). Gauge dependent on medication.
o
Deltoid: locate acromion process, inject only into upper third of muscle that begins about two finger
widths below acromion. 22-25 gauge. ½ - 1 inch needle. Fast absorption rates, easily accessible,
less pain/fewer side effects from vaccines than vastus lateralis. Small muscle mass though and there
could be possible damage to radial nerve and axillary nerve.
- Children (3-18 years) – Deltoid – 22-25 gauge, 5/8 – 1 inch. Important to consider body mass!
•
SubQ: 26-30 gauge needles. Change needles often (e.g. after drawing up med from bottle) to make sure
the needle is sharp and inserts easily. Insert at a 45 degree angle. Inject small volumes (up to 0.5 ml).
Common sites include upper arm, abdomen, and anterior thigh.
- How to give an IM shot:
1.
2.
3.
4.
Use safety precautions (e.g. EMR and two patient identifiers) and at all drug rights!
Pain medication as ordered, ex. 24% sucrose, EMLA cream, or use developmental, non-invasive procedures
Prepare medicine and determine site of injection.
Administer medication:
a. Have help available for restraint, explain briefly what is being done, use a new, sharp needle, don’t let
child stand – may faint.
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- Straddle position: infant/child faces mom, limbs on either side of mom’s legs and she bear hugs child.
- Comfortable restraint infants and toddler – parent holds child on lap and places one of the child’s arm
around the mother’s back (like a hug) and is held by that parents arm. The other arm is controlled by
the parents arm and hand. Both legs are anchored with the child’s feet held between the parent’s
thighs and controlled by the other arm. For older children, they can sit on the lap or stand and parent’s
arms embrace the child during process and child’s legs are held firmly between parent’s legs. Or child
lies down on table and parent lies over legs and other distracts by talking…..
- Infant – try breastfeeding/pacifier sucking
b. Have med at room temp
c. Prep skin per hospital policy and allow to dry (don’t blow or wave your hands!)
d. Grasp muscle firmly between thumb and fingers to stabilize the muscle.
5.
Decrease pain perception – distract child, give them something to concentrate on, etc.
6.
Insert needle quickly – use a new needle if you drew up meds from a rubber stoppered bottle. Use a gentle
dart like motion – remember skin is like “butter” in children!
7.
Be careful not to track any medication through the superficial tissues. The use of air bubbles in the syringe
is no longer supported by the evidence.
8.
Aspirate for blood dependent on the medication you are giving. If you find blood, remove syringe from site,
change needle and try again. No blood, inject. Remember do not aspirate for immunizations, insulin,
heparin or vaccines
9.
Remove needle quickly! Hold gauze firmly against skin near needle when removing to avoid pulling on
tissue. Apply firm pressure to site and massage (unless contraindicated)
10. Place an adhesive bandage on the site (it is always a good idea to ask the parents about this
beforehand….some kids don’t like these or may be sensitive/allergic), praise child, let them express their
feelings and give them a sticker. Everything is better with a sticker – doesn’t matter how old you are!
Remember to open your bandaid when you are preparing your medication so you can put it on immediately.
11. Discard syringe, uncapped needled. Document as appropriate.
*Restraints in Pediatric Population:
Remember a restraint is any method (physical or mechanical) that restricts a person’s movement, physical activity or
normal access to his/her body.
•
Two types – behavioral (risk of patient harming self) and non-behavioral (medical-surgical restraints).
•
Alternative approach – therapeutic holding which is the use of a secure and comfortable holding position
with the caregiver or parent for less than 30 minutes.
o Burrito Wrap swaddling
o Arm/leg/elbow restraints (no’s-no’s)
o Papoose board – NO for injections!!!!!
o Parent holding child with child facing parent leaving extremity exposed
o Have child cross arms over chest and lean over them
o Have someone lean over legs (no pressure on joints)
o Side lying position for LP’s for children, can use sitting position for infants
Skills Review: Peripheral IV Insertion for Pediatric Patient
Why are IVs more challenging in the pediatric population?
• Small children and infants have smaller peripheral veins
• They may have more subcutaneous fat
• Prone to vasoconstriction
• They are much less likely to remain motionless and cooperative during a painful procedure than adults
What IV gauge should I use for a pediatric patient?
• Depends on patients age, size
• Reason for therapy
• Always start with the smallest size possible to do the job.
• Remember the bigger the catheter size, the smaller the diameter of the needle.
• Bigger gauge PIVs may be needed if large volumes of fluid are needed quickly or if the consistency of the
fluid is thick!
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What supplies will I need?
• Emla (topical numbing cream)
• PIV at least(2)
• IV start kit ( has tape,alcohol,tegaderm, tourniquet and T-connector)
• NS flushes (5-10 cc pre-filled syringes)
• Extra tape
• IV site protector
• Elbow immobilizers (no-no’s)
Where should I place an IV in a pediatric patient?
Where should I place a PIV in a pediatric patient?
• Start distal to proximal
• Look at both sides first before selecting vein
• Think about the child’s age/developmental level!
• Are they mobile?
• Which hand is there dominant hand?
• Do they like to text or play video games? This requires using hands, bending of arms!
• School age children like choices!!!
• Try to avoid using big veins in the middle arm if you suspect your patient may need long term IV antibiotics
because these are the preferred sites for PICC lines.
How to make the placement of an IV a little less traumatic?
• Utilize Child life specialist to prepare child according to age/developmental level.
• Utilize distraction techniques: TV, videos games, Cell phones, IPADS
• Most of the time, unfortunately, no matter what you do to prepare that child for PIV placement, they will not be
cooperative.
How to hold a patient properly while placing a PIV?
• Call in the troops
• The holder is just as important as the person placing the PIV
• Kids have super strength, make sure you have plenty of help.
• Utilize papoose boards
• Swaddle the infant and child with blanket or sheet.
• Have all equipment ready to go!! Be prepared.
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Skills Review: Pediatric IV Care
IV Meds/IV Maintenance Lab STUDENT HANDOUT: Lab Prep
•
Why? Route used for giving drugs to children who have poor absorption as a result of diarrhea,
dehydration or peripheral vascular collapse, or who need a high serum concentration of a drugs, resistant
infections that require parenteral medication over an extended time, need for continuous pain relief or who
require emergency treatment.
•
IV sites –
o
How to choose: infant, toddler, child, adolescent: consider developmental, cognitive and mobility
needs. Always insert IV catheter following the direction of the vein.
Infant: hand, foot, scalp (if no other site available up to 9 months of age)
▪
Toddler: if walking, avoid feet
▪
Child: keep in mind mobility and “handedness”, superficial veins of forearm
▪
Adolescent: keep in mind “handedness”, superficial veins of forearm, let them help chose
▪
which vein to use
Be careful with the use of tourniquet on children with fragile skin – make sure if using
▪
rubber bands as tourniquet to place piece of tape on the band for easy and quick removal
•
How to restrain baby and child when inserting, assistance needed
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Papoose board (only if absolutely necessary)
Hold on to joints to prevent bending of arms/legs
Parental involvement
Infant: parents to be present, may help hold or comfort infant
Child: may need several helpers to stabilize
Adolescent: explain each step before doing it
▪
How to prep for iv insertion
o
Lay out all equipment prior to bringing child in and make sure line is primed prior to attempting IV
insertion
o
Depending on age, prepare child for procedure
o
Equipment needed: IV bag, tubing, opsite, IV start kit, catheters of different sizes, tape (already
cut), cotton balls, paper or plastic cup (for covering IV site), several syringes of normal saline,
alligator clip, tourniquet, lab drawing equipment if needed
o
Do not allow child, especially young child, to see needles
o
Obtain order for pain management as required (e.g. 24% sucrose, Emla cream). Use distractors
as appropriate
▪
Mother or caretaker –
o
Parental concerns: deciding to have parents present or not present
o
Set boundaries with parents
o
Implications re: parents present and not present
o
Explain procedure prior to starting
o
Explain to parent why shaving of head is necessary if scalp IV is indicated
o
Explain parent’s role during IV start (comfort, help holding, distract, etc)
▪
Securing the IV site – allowing for site inspection but yet decreasing risk for pulling it out
o
Infant: use of cotton balls and IV site covering, show how to tape cup to allow for inspection but
also safety (no longer recommended due to risk of injury), use of IV houses to guard site, use of
arm boards, backing on tape to prevent skin breakdown (e.g. cotton ball “fibers” backing against
the tape so it doesn’t stick to skin)
o
Toddler/Young Child: may need to cover IV site area with sock and tape to prevent child from
pulling at it
▪
Safety concerns of child with IV
o
Site protection
o
No scissors around lines
o
Have tape already cut
o
Do not encircle extremity with tape
o
Have people holding who are strong enough to stabilize patient
o
Always trace IV tubing to pump/bag at beginning and ending of shift, identify all lines with
medications running through them, particularly vasopressors
▪
Use of extensions
o
May be helpful for older child if longer lines needed for mobility
o
Beware of fall risk with extensions
o
Use extensions in toddlers to tape IV site down gown in the back to decrease lines exposed (risk
of fall, toddlers pull lines, etc)
▪
Line priming
o
Decrease air bubbles to decrease risk of embolism
o
Prime line prior to IV insertion
o
Prime piggybacks lines, TPN, lipids, syringe lines on pumps
o
Always trace lines to pumps and IV tubing
o
Ensure that there are no bubbles in tubing by “flicking” bubbles out of lines and draining any air
out of line when priming
▪
IV pump
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Used in pediatrics to give specific dose of medication over a specific amount of time
Risk of overdose in pediatrics is high; set pump volume let for 1-2 hours at a time or per hospital
policy
Pump ensures more accurate dosing and controls timing of infusion
▪
Assessment of IV site –
o
Assess every 2 hours or hospital protocol
o
Assess for kinks in lines, positioning interference such as bent joints (e.g. elbows), is there an ID
bracelet where the ID is placed,
o
Flushing the IV site for patency – good or no blood return is not indicative of whether an IV is
patent in a small infant. Is there resistance to flushing? When flushed, is there edema, redness or
streaking along the vein?
o
Assess for erythema, swelling, pain, phlebitis, infiltration
o
Nighttime assessment – use of flashlight or penlight so as not to disturb sleep but still mandatory
assessment every 2 hours
Notify parent prior to sleep that assessment needs to be done every 2 hours
▪
o
Infiltration vs. extravasation – infiltration is in relation to a nonvesicant solution while extravasation
speaks to vesicant solutions being inadvertently administered into surrounding tissues. A vesicant
solution can cause tissue injury and may require the use of a treatment agent. Actions:
immediately stop the infusion, elevate the extremity, and notify the practitioner, initiate and
treatment as ordered. Thoroughly document and institute any incident reports as hospital policy
dictates.
▪
Dressing change –
o
Change dressing if soiled (know hospital protocol for IV site changing – every 3 days, once a
week, etc.). Do not occlude site with dressing, use of transparent dressing and cleaning agents
(e.g. alcohol vs. chlorhexidine)
▪
IV flush, saline or heplock
o
Flush with normal saline if patent IV
o
If order calls for heplock, may use 1-3cc heparin lock solution after saline flush depending on
child’s age and healthcare provider order.
o
Be sure to check heparin units as there are 2 different dosages (remember overdose of Dennis
Quaid’s twins on heparin due to nurse error)
▪
IV meds – priming of tubing, flushing, labeling syringes always including saline flushes, etc., cleaning of
access ports
o
Prime tubing prior to IV insertion
o
Prime IV lines, piggybacks, blood product lines
o
Flush with NS and/or heparin prior to administering anything via IV – if IV is infiltrated and
medication goes through line, can be very painful and dangerous to the tissues
o
ALWAYS label syringes with type of fluid, date and time it was drawn up, and your initials
o
If there is a syringe from a previous shift, discard
o
If there is a syringe not labeled, DO NOT USE
o
Change IV fluid bag every 24 hours even if there are still fluids in the bag
o
Change IV tubing every 24-96 hours depending on hospital protocol
o
Clean all ports with alcohol and/or chlorhexidine per hospital protocol (if hospital still uses
betadine, check for iodine allergies)
o
Always be sure to calculate IV fluid rate and volume prior to administering – if the rate is too high
for weight, notify physician
▪
Troubleshooting –
o
Backup of blood in the tubing – flush with normal saline, ensure nothing is clamped
o
IV occlusion – check for clamps, IV infiltration, occlusion of line due to the way it is taped, check to
see if arm is bent at area of IV infusion, check pump
o
Air in line – disconnect from patient and prime line if primary fluids until air is out of line
o
IV won’t flush – may be small clot at end of catheter so flush with normal saline, if that fails, flush
with heparin in pulsating motion to dislodge clot. Also check placement of IV – if arm is bent, tape
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is too tight, paper or plastic cup is too tight and occluding line – do everything you can to save the
IV and save the child another stick
▪
Intraosseous access: used when IV can’t be started. IO space includes spongy interior of bone’s
epiphyses and medullary cavity of the diaphysis.
o
Space contains tiny blood vessels the rapidly absorb fluids/meds and can transport to central
circulation.
o
IO unlikely to collapse in response to shock, trauma, or dehydrations (unless bone is
compromised)
o
Manual insertion devices- inset hollow steel needle which has a removable trocar to prevent from
being plugged. PUSH AND TWIST needle through the periosteum. Done in younger patients –
bones still soft. Difficult on adolescents and adults due bone calcification.
o
Spring loaded mechanisms – generated enough force to drive a sharpened needle into the
medullary cavity
o
Power drive to drill the needle into the IO space with a rotation motion
o
Preferred placement site is medial proximal tibia, 1-2 cm below the tibial tuberosity. Other – distal
femur, humeral head.
o
Supported by AHA AAP – rapid, safe, effective. PALS teaches.
o
Must have competencies, only if IV can’t be obtained, concern regarding morbidity and mortality.
o
Complications: Rare. Do not attempt on a broken bone. Do not attempt on bone in which IO
access was recently attempted (24-48 hours) Extravasation can result from movement or
accidental dislodgement of the needle or repeated IO attempts. Monitor for compartment
syndrome. Have to use an IV pressure bag or pump with IO because of the arterial pressure in
the IO space, constantly monitor site. Risk of infection.
o
Remove IO needle within 24 hours of insertion to avoid osteomyelitis
o
Pain – typically no more than a needle stick. However fluid infusion is often painful. Use 2%
lidocaine injected slowly through IO device.
Blood Cultures/Mosby’s Skills (UTMB Website/Nursing Service)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Always collect blood cultures first to reduce the risk of contamination
Only obtain with medical order/needs to be clinically indicated.
Crucial is to keep the blood culture free of contamination (contamination rates: catheter drawn – 11%,
venipuncture = 3%)
Explain procedure to the child in a manner consistent with developmental stage and provide atraumatic
care.
Children are afraid of losing their blood – they tie to the concept as a threat to their lives. Explain that blood
is continually produced by them and that they have new blood every day in their body. Use an adhesive
bandage so that they won’t worry that the blood will leak through the puncture site.
Use a treatment/procedure room as required. Keep their “room” a safe place.
Only use restraints as a last alternative for the combative child.
Ensure that an age-appropriate site is used for venous access – scalp, antecubital fossal, saphenous and
hand veins.
Application of a topical anesthetic may be ordered to reduce pain in infants and young children.
Allow the child to sit in an upright position to help them feel a sense of control if appropriate.
Make sure to use diversional activities to minimize anxiety.
Procedure
1.
Procedure – perform hand hygiene
2.
Verify patient with two identifiers per hospital policy.
3.
Ensure privacy
4.
Organize supplies on bedside table and work at a comfortable height.
5.
Position patient appropriately.
6.
Locate appropriate site and use tourniquet as needed.
7.
Perform hand hygiene and put on gloves.
8.
Clean bottle tops with an alcohol swab.
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Clean the site by scrubbing with chlorhexidine based antiseptic and allow to AIR dry for 60 seconds (or per
manufacturer policy). Do not repalpate site! Use alcohol (or betadine per policy) for infants less than 2
months of age or per hospital policy.
Collect appropriate amount of blood per hospital policy (1 ml for infants, 1 ml per age of child to 10 mls).
Can pull back from newly started IV line or use butterfly/vacutainer. DO NOT OVERFILL BOTTLES, can
affect results.
If using tourniquet – release tourniquet. Apply 2x2 gauze over the puncture site, do not apply pressure and
remove needle. Apply pressure until bleeding stops and use a Band-Aid (check with parents regarding any
allergies to adhesives),
Report hematomas at venipuncture site, continued bleeding, infection at site, dizziness/fainting.
Make sure to document date and time of venipuncture, samples obtained, location of stick, education and
notification of results.
Skills Review: Chest Tube Care
Objectives
• Discuss why chest tubes are needed
• Describe the principles utilized when caring for a pediatric patient with a chest tube
• Discuss how chest tubes are placed
• Nursing responsibilities in caring for a child with a chest tube
• Summarize the requirements for documentation of a patient with a chest tube
• Identify the age appropriate care needs of children with chest tubes
• Evaluate trouble shooting techniques in regards to certain scenarios
• Discuss when to notify the physician
Various Types of Chest Tube Drainage Systems Dry or Water Seal Suction
• Various types of CT drainage systems, setup and maintain/change out according to manufacturers
recommendations and hospital policy. Good link from Atrium for Chest tube setup/maintenance. (highlight hyperlink
and right click to select open hyperlink) Good to show in conference if you have capability.
• Atrium Oasis Dry Suction Drain: Most commonly used in Pediatrics on the left
• Atrium Ocean Water Seal Drain on the right
Why are chest tubes placed?
• To evacuate air from the patients chest cavity or mediastinum.
• Pneumothorax caused from injury or chest/lung surgery
• To evacuate fluid from the patients chest cavity or mediastinum:
• Blood- hemothorax, pus- empyema
• Chylothorax- white, lymphatic fluid leaking from the pleural cavity
• Pleural effusion-too much fluid in pleural space caused from Heart failure, infection (pneumonia, TB), tumors
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• To prevent drained air and fluid from returning to patient.
• To restore negative pressure in the pleural space to re-expand the lung.
Four Major Principles in the Nursing Care of a Patient with a Chest Tube
• Monitor and assess the patients breathing, gas exchange, skin integrity, chest drainage output and pain
• Maintain a closed drainage system
• Promote lung re-expansion
• Prevent complications and intervene appropriately
• Complications include infection, accidental tube disconnection/removal
How are Chest Tubes Placed?
• Chest tubes are placed sterilely by a Physician, PA or NP in the operating room
• Or in emergent situations may be placed in patient’s room under sterile conditions.
• The physician will order the size of chest tube catheter, type of chest tube drainage device, CT to be placed to wall
suction and how much suction, or CT to be placed to gravity (which means placing the CT drainage device on floor
with no suction connected) , pre-sedation and narcotics.
The Nurse’s Responsibility in Assisting the Physician in Placing CT
• Educating/preparing child/family for procedure
• Making sure consent signed and understood
• Gathering supplies/medications according to physicians orders
• Making sure ambu-bag, mask, suction regulator, suction canister and suction tubing set up
• Opening up chest tube drainage system sterilely for physician placement
• Monitoring patient’s V/S and pain level during procedure
Once Chest Tube in Place
• Physician will attach sterile tubing from CT drainage system directly to the end of chest tube coming out of patient.
• Incision site will be dressed securely with an occlusive dressing.
• The nurse will then attach suction tubing from suction canister to the chest tube drainage system and apply the
desired suction or place to gravity per physician orders.
• Chest x-ray will be done immediately and at-least every day to evaluate effectiveness of therapy.
• Start at the lowest suction possible to produce gentile bubbling…not rapid, billing spaghetti bubbling
When Caring for a Patient with a Chest Tube the Nurse and Nursing Student Should Focus on:
• Assessing patient’s breath sounds, HR, BP, temperature, respiratory rate and rhythm and O2 saturation.
• Chest tube drainage (amount, color, consistency)
• Chest tube site (sutures intact, skin site clean, dry, intact, no subcutaneous air or drainage noted)
• Chest tube dressing remains clean, dry, intact
• Patients comfort level
• Stripping CTs is no longer a recommended practice, may lead to significant increase in intra-thoracic pressure.
• Keep suction container on floor below chest level (especially w/water seal) secure with tape so it doesn’t fall over.
• Water in water seal chamber should be at 2cm (replace according to manufactures recommendations)
• Mark level of drainage in chamber at least once per shift with sharpie and record as output on flow-sheet.
• Sometimes blood clots may form in the chest tube drainage tubing….nurses use to strip or milk these tubings to
remove the clot! No longer recommended, if occurs usually done by surgeon at bedside.
Assessing for the Presence of an Air Leak
• Checking for air leaks is a continual process
• Instruct patient to cough and observe the water seal chamber for the presence of bubbling
• Ask the patient to place thumb in mouth and blow out while you assess the water seal chamber.
• Does the bubbling fluctuate with inspiration or expiration or both?
• Is the bubbling continuous?
• Check connections, reinforce dressing and notify MD if continuous bubbling continues
• Bubbling in the water seal chamber is normal if CT was placed to evacuate pneumothorax and will stop once
pneumo. resolved.
Exchanging Drainage Systems:
• If full, the nurse will not empty the container and re-use; they will throw entire system away in a red biohazard bag.
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Order the appropriate CT drainage system for the patient according to physician orders.
Make sure to always have extra drainage system available.
Follow hospital and product policy for exchanging out the drainage system.
Refer to video for further instructions regarding Atrium CT drainage devices.
Highlight link, right click to open hyperlink..would be good video to show in pre/post conference
Promoting Lung Re-expansion:
• Encourage…
• Coughing & deep breathing exercises
• Incentive spirometry
• blowing bubbles/cotton balls
• Ambulation with portable suction device
• Frequent position changes
Documentation:
• Patient & Family Education
• Cardiopulmonary & VS assessment (o2 sat)
• Amount of suction or tidaling
• Type & amount of drainage
• Presence or absence of air leak
• Pt's tolerance to chest tube (i.e. pain, anxiety)
• Any changes in patient's condition related to changes in therapy
• Nursing Interventions (IS, walking, coughing, pain relief measures)
What if…
• If CT pulls/falls out:
• Immediately apply pressure at site
• Apply dressing with vaseline gauze, 4x4s, & occlusive tape
• Notify M.D.
• Watch for signs of pneumothorax
• Obtain CXR
• In case of CT disconnection:
• Clean tubing with alcohol swab
• Reconnect immediately
• Monitor for air leak
• Assure all connections are secure
• Notify MD
• Monitor patient
Notify Physician
• If there are any changes in the quantity or quality of chest tube drainage
• Drainage greater than 3/ml/kg/hr for more than 3 consecutive hours or 5 to 10ml/kg in any 1 hour is excessive.
Notify physician immediately.
• Changes in vital signs, Sp02
• Increase in pain/anxiety level
• Patients states they are having difficulty breathing!!
• If drainage was serous now sang.
• If drainage was minimal then suddenly excessive
Age Appropriate Care
• Before procedure:
• Consult Child Life
• Teach utilizing medical play
• Utilize dolls/models/pictures prior to procedure
• After procedure:
• Encourage age appropriate play in room : drawing, coloring, board games, video games
• Always encourage family involvement
• Patients who are ambulant post operatively will have fewer complications and shorter lengths of stay.
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Fatemeh Sahrapour
• If a patient is on strict bed rest or is an infant, regular changes in position should be encouraged to promote
drainage, unless clinical condition prevents doing so
Make Sure…
• Drainage system placed
securely on floor
• Drainage system placed
below patients chest
Mark output with sharpie directly on
device with time and initials.
Base of CT drainage system
should be taped to floor to
prevent tipping/knocking over
• Do not let dangel from side rails, always secure device to floor to prevent knocking over, always use sharpie to
mark output then time and initial!
Skills Review: Care of Child with a Trach
Tracheostomy Care Lab Video:
Indications for tracheostomy –
• Short-Term
o Trauma
o Burns
o Foreign body obstruction
o Severe anaphylaxis
o Infection such as epiglottitis or croup
o Tracheomalacia
• Long-term
o Chronic lung conditions (BPD), long term oxygen therapy
o Tumors such as cystic hygroma (congenital mass in neck)
o Subglottic stenosis
o Syndromes such as Treacher Collins (chromosomal defect that affects the head and neck causing
craniofacial abnormalities)
o Neuromuscular disease that paralyzes respiratory muscles
o Fracture of cervical vertebrae with spinal cord injury
Equipment
• Plastic tube
• Outer canula: remains in place
• Inner canula: removed for cleaning, inserted if going home with trach or if excess secretions are present
o Pedi shileys do not have an inner canula
• Obturator: guides the direction of the outer canula
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Cuffed: seals the opening of the trachea closed tight to fit, prevents air leak and aspiration, permits
mechanical ventilation
o Always deflate before feeding!
Uncuffed: what is mostly seen on units, preferable because it does not cause damage to the tracheal wall
Fenestrated: tubes that have a hole in the canula to permit speaking
o Not recommended in children because granulation tissue can obstruct the opening
Emergency bedside equipment must be checked by nurse at beginning of shift
o Obturator
o Suction
o Oxygen
o Extra trach of same size and 1 size smaller
Tracheostomy Care
• Goals of tracheostomy care for nurses
o Maintain patent airway
o Maintain skin integrity
o Prevent infection
o Prevent tube dislodgement
• Suctioning: According to the American Thoracic Society :
1. Suctioning should be done on the basis of clinical assessment.
2. In children with no evidence of secretions, a minimum of suctioning, at morning and bedtime, to
check for patency of the tube is recommended.
o Need for suction if:
▪ Rattling mucous sounds from the trach
▪ Increased respiratory rate
▪ Visible mucous in trach
▪ Dry raspy breathing or whistling noise from trach
▪ Signs of respiratory distress: increased heart rate, increased RR, increased BP, cyanosis
(severe)
▪ How to suction: You may hear different methods of determining suction catheter size
• One-half the internal diameter of the tracheostomy tube
• A popular formula to use when choosing catheter size is:
o Size of trach tube (mm) x 3 divided by 2
o So…if the patient has a size 4.0 pedi shiley trach:
▪ 4(3) = 12. Divide 12/2 = catheter size 6
o The American Thoracic Society recommends using the largest size catheter that will fit
inside the tracheostomy tube because a large-bore tube will remove secretions more
quickly and efficiently than the previously recommended smaller tube size thus
decreasing the patient’s risk of developing atelectasis.
• Explain the procedure to the patient - wash hands, put on gloves. Put on apron and fluid
shield mask if necessary for standard (universal) precautions). Turn on suction apparatus
and test that vacuum pressure is appropriate for patient
o 40-60mmHg for preemies
o 60mmHg for infants
o 80-100 mmHg for larger children
• Open / expose only the vacuum control segment of the suction catheter and attach to the
suction tubing.
• Stable children with a tracheostomy and no additional respiratory support such as
ventilator, CPAP or high levels of supplemental oxygen typically do not receive
hyperoxygenation or hyperventilation prior to suctioning according to the American
Thoracic Society because administering an artificial breath before suctioning could push/
force secretions down the trachea and the more distal airways.
• Put on disposable sterile gloves over the non-sterile gloves and withdraw the sterile
catheter from the protective sleeve.
• Maintaining sterility, insert the suction catheter while applying suction, and remove catheter
while applying suction (According to the American Thoracic Society) to prevent those
secretions visible in the tube or hub from being forced into the more distal parts of the
airway.
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Check hospital protocol for length of suctioning, but in general, the rule is never to extend
the suction catheter past the carina because it can cause tracheal damage
o 3 types of suction:
▪ Shallow: just beyond the opening hub of the trach, if visible secretions
▪ Pre-measured suctioning: suctioning the length of the obturator is
recommended for all routine suctioning according to the American Thoracic
Society.
▪ Deep suctioning: suctioning until resistance is met, then pull back
• This has been the practice for some time for nurses, but research has
proven that it can cause tracheal damage, so reserve deep suctioning
only for emergencies or if advised to do so by the physician
Place finger over suction hole when pulling out, do “twirling” motion or rotate the catheter
between the fingers and the thumb so that the catheter is more easily inserted and moves
the side holes of the catheter in a helix or spiral staircase motion, thereby suctioning
secretions off all the areas of the tracheostomy tube wall.
No more than 3 passes recommended per treatment. Let child rest for 30-60 seconds
between suctions.
Hyperoxygenate with 3-4 breaths of 100% oxygen after suctioning depending on patients
end tidal CO2 measurement and oxygen saturations.
On completing procedure, ensure patient comfort, discard of equipment as per hospital
policy, wash hands and document procedure in the patient’s notes.
Trach site care: wound care and change dressing
o Wash hands.
o Talk with parents to determine how involved they want to be (stay or leave)
▪ Every time you do anything with the trach, it is a learning opportunity for parents, so encourage parents
to be involved as much as possible
o Wearing unsterile gloves, remove and dispose of the soiled dressing.
o Wash hands. Put on sterile gloves.
o First, remove and clean the inner cannula using sterile pipe cleaners and normal saline. Dry. Reinsert. (If no
inner canula, disregard this step)
o Secondly, clean the stoma site using gauze and normal saline (or solution per hospital protocol). Some
hospitals use hydrogen peroxide with sterile water. Pat dry. Apply lyofoam / keyhole dressing if necessary.
o Lastly, if ties are soiled and need changing, have a second nurse hold the tracheostomy tube securely in
place, remove and replace tracheostomy ties. (Leave 1 finger space between ties and the patient’s neck.)
o REMEMBER: always keep one hand on the trach to avoid dislodging
o Assess the site for redness, irritation, tiny little bumps (could be yeast), bleeding, excoriation, foul-smelling
discharge, dryness
▪ Tiny little red bumps – usually yeast, Nystatin powder will be ordered
▪ Skin breakdown – apply an emollient cream, keep area dry and clean
▪ Excoriation – may use Nystatin or other antibacterial to prevent infection
▪ Dryness – may apply emollient cream such as Aquaphor, Vaseline, or Eucerin
o Ensure patient comfort.
o Discard of used equipment as per hospital policy.
o Wash Hands.
o Document procedure in the patient’s notes.
Changing the trach: once per month (at least) or as needed: According to the American Thoracic Society there is no
consensus regarding the frequency of tracheostomy tube changes. The most common frequency of tracheostomy
tube changes is weekly; refer to manufactures’ recommendations and/or hospital policy.
▪ Indications for changing trach include:
• buildup of mucous or secretions
• obstruction of tube
• dirty or soiled tube
• size no longer appropriate for patient,
• or at least every 29 days (for Shileys)
o Sterile technique
o Have all emergency equipment at bedside prior to beginning procedure
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Have 1-2 persons to assist
Lay child semi-flat with roll under neck to provide a good working area
Have all supplies out including sterile kit for cleaning and a trach a size smaller than the child usually wears
in case swelling occurs while trach is out
Make sure patient is well-suctioned prior to procedure
Have another nurse hyperoxygenate with 100% O2 for 3-4 breaths prior to pulling out trach
Put on sterile gloves
Pull old trach out with soiled or “dirty” hand
Place new, sterile trach in with “sterile” hand
Hyperoxygenate with ambu bag with 100% oxygen for 3-4 breaths
Monitor vital signs for respiratory distress, especially SpO2
Do proper cleaning or disposing of old trach
TROUBLESHOOTING:
Trach Dislodgement • DO NOT PANIC! As a prudent nurse, you already have an extra trach at the bedside.
• According to the American Thoracic Society tube obstruction is the most common cause of severe
respiratory distress in children with a tracheostomy and must be treated as a emergency: when in doubt,
change the tracheostomy tube out!
• Place the new trach in the stoma and hyperoxygenate with the ambu bag and 100% O2. Monitor vital signs,
especially SpO2.
• If the trach of the same size does not fit in the stoma (usually due to swelling or angle of insertion), the
prudent nurse will have a trach 1 size smaller, so place the smaller trach in the stoma, hold it in place,
hyperoxygenate, and hit the call button for the help of another nurse.
• Continue to monitor vital signs including heart rate, blood pressure, SpO2, and generally visualize the patient
for cyanosis, pallor, etc.
Low SpO2 –
• If you see on a monitor the patient has an SpO2 of 0 or a very low SpO2, PLEASE look at your patient
before panicking.
• It is common for patients to have leads that are incorrectly placed or have been pulled off. ALWAYS assess
your patient first! You don’t want to call a code or bag a patient when they are active and playing but simply
have pulled off a lead for the monitor.
****It is common for toddlers to pull out their trachs or to put food in it when they are self-feeding. Please monitor
these patients closely, especially during meals!*** Another culprit is the caps from PO medications – always count
your syringes and caps before leaving the room!
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MODULE: GROWTH AND DEVELOPMENT OF CHILDREN
Part I: Infant, Toddler, and Preschool Child
Readings:
General Growth and Development
Perry: 750-764
Infant Growth and Development
Perry: 864-882
Injury Prevention
Perry: 899-905
Infant Skin Disorders
Perry: 1511-1516
Nutrition
Perry: 882 - 886
Promotion of Infant
ATI 2013: 23-32
Toddler Growth and Development
Perry: 922-951
Preschool Growth and Development
Perry: 952-964
Maltreatment
Perry: 973-980
Autism
Perry: 1104-1107
Promotion of Toddler, Preschooler
ATI 2013: 33-49
Random Information:
Infant Nutrition - this is a period of rapid growth for the child. The correct nutrition is part of that growth. The
presentation and slides above might help clarify what some of the various infant formulas are used for. As nurses, this
is a key concept in caring for our patients and families.
Drowning - It is important to note that drowning is the leading cause of death in children ages 1-4 years and it is the
second leading cause of death in children ages 1-14 years. The American Academy of Pediatrics (AAP) has long held
the position that children ages 1-3 years should not have formal swim lessons because they are not developmentally
ready for such a task. Infant Swim is changing that and in the year 2000 the AAP began to reverse its position. Watch
the following 3-part video series to learn more about infant water safety.
GROWTH AND DEVELOPMENT OF THE INFANT AND FAMILY CENTERED CARE
Neonates- birth to 1 month of age
Infancy Period- 1 month to 12 months
* The infancy period is one of rapid motor, cognitive and social development
* Infant establishes a basic trust in the world, starts with forming a bond with caregiver
Psychosocial Development of the Infant
* Erikson: Trust vs. Mistrust (Phase 1: birth to 1 year of age)
o Infants acquire a sense of trust of self, of others and of the world
o Infants “trust” that their feeding, comfort, stimulation and caring needs will be met
o They must overcome a sense of mistrust…during this first year, the major emphasis is on parent’s
nurturing ability, in sense of visual contact and touch. Through positive nurturing child will develop trust,
optimism, confidence, and security. If needs aren’t met, child will develop mistrust of world, feeling of insecurity.
o The trust acquired in infancy provides the foundation for all succeeding phases
Cognitive Development of the Infant
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* Piaget’s Sensory Motor Phase: (Birth to 24 months of age)
o Primitive reflexes are replaced by voluntary actions
o Infants separate themselves from other objects in environment and discriminate persons
o Object permanence (objects that leave visual field still exist) develops between 9-10 months of age
Infant Physical Development
* Infant are unique, no two are alike
* Infants grow in their own unique way
* Growth sequence is predictable; the exact timing is not…this is why it’s important to use the growth charts. Because
growth is a continuous but uneven process, the most reliable evaluation lies in comparing growth measurements over
time.
Infant Physical Development: Weight
* From birth to one year of age physical growth is rapid
* In 6 months the infant DOUBLES their birth weight gaining 5-7 ounces weekly
* By 1 year of age an infant’s birth weight TRIPLES, for an average of 9.75 kg or x 2.2= 21.5 lbs
* The average weight for an newborn is 7-8 lbs.
* weigh the child naked and always remain by the side of scale
Infant Physical Development: Height
* Height increases 1 inch monthly for 6 months
* The average height at 6 months is 25 ½ inches or x 2.54 = 65 cm
* The average height at 1 year is 29 inches or x 2.54 = 74 cm
Infant Physical Development: Head Growth
* Head growth is also rapid in infancy
* OFC: measures the widest part of the head, just above the ears and eyebrows
* OFC = Occipital Frontal Circumference or head circumference increases 1.5 cm monthly for first 6 months, then 0.5
cm monthly from 6-12 months
* The average head size or OFC is 43 cm or / by 2.54 = 17 inches at 6 months and 46 cm or / by 2.54 = 18 inches
* In the hospital we measure OFC routinely in infants and children up to the age of 3 years, and also in children
greater than 3 years that have hydrocephalus or increased ICP (intracranial pressure).
Infant Physical Development: FOC
* Closure of the cranial sutures occurs with:
* Posterior fontanel closing first by 6-8 weeks of age
* Anterior fontanel closing by 12-18 months of age with average age being 14 months
* Premature closure (before the skull is fully formed) of fontanels is called craniosynostosis and inhibits a
perpendicular growth of skull and head is distorted, but the brain growth is normal.
* Important to notify physician if fontanels are sunken or bulging out, this is abnormal
Infant Fontanelle’s
* Anterior Fontanelle is diamond shaped
* Posterior Fontanelle is triangle shaped
* When we document healthy fontanelles, we write:
* anterior and posterior fontanelles are soft and flat
and open/closed
* If fontanelle is depressed or sunken in, the baby is
dehydrated
* If fontanelle is bulging, the baby could be bleeding in
skull, could have fluid accumulation/overload from
hydrocephalus, or an infection like meningitis
Growth charts
* Several chart variations
* CDC recommends health care providers in the United
States use the World Health Organizations growth
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charts from birth to 2 years of age
* For children 2 years to 20 years living the US, CDC recommends using the CDC growth charts
* If a child is 3 months old and in the 40%tile for weight, means that 40% of 3 month old boys weigh the same as or
less than your patient does and that 60% weigh more than he does. The higher the %ile number the bigger your
patient is compared to other babies the same age.
First Six Months: Nutrition for the Infant
* Human milk:
o Is the most desirable complete diet for the infant during the first 6 months
o It provides passive immunity to the infant: During the last three months of pregnancy, antibodies from the
mother are passed to her unborn baby through the placenta.This type of immunity is called passive immunity,
because the baby has been given antibodies rather than making them itself. Antibodies are special proteins that the
immune system produces to help protect the body against bacteria and viruses. Last a few weeks to months.Last
longer if baby breast fed.
o Easily digested
o Optimum nutritional source. There is evidence that proves breastfeeding for greater than 6 moths can have a
significant healthy impact on child even as they grow into adulthood.
American Academy of Pediatrics and Nutrition…recommends:
* Exclusive breastfeeding for about 6 months
* Then, continued breastfeeding for 1 year (at least) or longer as complementary foods are introduced
* Prevents diseases into adulthood
* Donor breast milk has become increasingly popular over the past few years. they have a process of pasteurizing
the milk to make sure it’s safe for the other babies. then milk is cultured to make sure it’s free from bacteria. Then
frozen and shipped to hospitals.
* All infants (including those exclusively breastfed) should receive an oral vitamin D supplementation of 400 Units/day
beginning at hospital discharge
* After 4 months, if the infant is exclusively breastfed, they will need iron supplementation (1 mg/kg/day) until ironcontaining complimentary foods are introduced
NURSING ALERT!!!
* NO warming up of expressed breast milk or formula in the microwave. It can cause severe burns in baby’s mouth
and destroys the antibodies and vitamins
* To thaw frozen milk instruct parents to place in refrigerator over night to defrost or place container under a lukewarm
water bath
* In the NICU you will see formula warmers used. But the ready formulas are served at room temperature and don’t
need to be heated. But if it’s from the refrigerator warm it up in lukewarm water.
Nutrition and the Infant
* Formula:
o An acceptable alternative to breastfeeding is commercial iron-fortified formula
o Like human milk it supplies all the needed nutrients for the first 6 months
The 3 Major Classes of Infant Formulas:
* Milk-based: which are prepared from cow milk with added vegetable oils, vitamins, minerals, and iron. These are
suitable for most healthy, full-term infants and should be the feeding choice when breastfeeding isn’t used or is
stopped before the age of 1 year.
* Soy-based formulas: which are made from soy protein with added vegetable oils and corn syrup and/or sucrose.
These are suitable for infants who are lactose intolerant and those who are allergic to milk-based formulas or the
casein protein in cow’s milk
* Special formulas for low-birth-weight (LBW) infants
o Low-sodium formulas
o “Predigested" protein formulas: who can’t break down casein or whey that are in milk-based formulas
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Fatemeh Sahrapour
o Ready made formulas used in hospitals. They are convenient. You don’t have to add anything to or warm them.
Differences Between
Formulas:
> It is very important that
the family knows which
one they’re using and
that they’re using it
appropriately! So
educate families.
NURSING ALERT!!!
> Neither formula or breast milk should be warmed in a microwave oven because this may cause oral burns
o The amount of formula per feeding and the number of feedings per day vary among infants
o In general the number of feedings decrease from six at 1 month of age to four to five at 6 months. But regardless of
the number of feedings, the total amount of formula ingested per day is 32 ounces.
• The estimate of how many ounces/day an infant should have depends the baby’s weight, age, and if they’ve taken
solid foods yet. But one rule of thumb we use is that: infants under 6 months who haven’t started solid foods should
be taking at least 2-2.5 ounces of formula/lbs of body weight/day. Babies eat about 3-4 ounces every 3-4 hours.
Introduction of Solid Foods
* There are a lot of discrepancies as to when we should start introducing sold foods to infants.
* The addition of solid foods before 4-6 months of age is not recommended
* Developmentally, an infant’s digestive tract is not ready for solid foods
> Signs of readiness include:
o Infant can sit in high chair and hold his head up
o Infant can open his mouth when food comes his way
o Infant can move food from a spoon into his throat and swallow appropriately
* Iron fortified infant cereal is generally introduced first because of its high iron content
* These include: rice, barley, oatmeal and high-protein cereals
* Rice cereal is usually suggested first because of its easy digestibility and low allergenic potential
* Honey should be avoided in the first 12 months due to risk of botulism. This occurs when the botulism spores are
ingested by baby. The bacteria will grow in the intestines and make toxins in gut that will make them very sick.
* Commercially prepared baby foods are the most common type of food served to infants in the United States
* A common sequence is to introduce strained fruits, followed by vegetables, and then meats
* Because the first introduction of food is a new experience, spoon feeding should be attempted after ingestion of
some breastmilk.
* One food item is introduced at intervals of 4 to 7 days to allow for identification of food allergies
* New foods are fed in small amount from 1 teaspoon to a few tablespoons
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* As the amount of solid food increases, the quantity of milk is decreased to less than 1 liter daily to prevent
overfeeding
Gross Motor Development of the Infant
* At 1 month infant has marked head lag and can turn head from side to side when prone. This is why it’s important to
hold they head because it is heavy and they don’t have control over it yet.
* At 3 months of age infant can hold head up with slight head lag
* At 4 months infants head lag almost gone and can roll from their back to their side. It is important that we put them
to sleep to their back. They can roll to their side and we have to be aware of them rolling on to their belly and
being at risk for SIDS. Also, if the fontanel is still open after 3-4 months of age, this is a developmental red flag,
and patient should be evaluated!!
* Between 4-6 months head control is well established. This is when you can hold them on your hip.
* At 5 months infant can roll from abdomen to back
* At 6 months infant can sit in high chair (because they have good head control) and roll from back to abdomen
o Infant who displays head lag at 6 months should have a developmental and neurologic evaluation. This is a
developmental red flag!!
* By age 7 months the infant can sit leaning forward on hands and bears weight on legs
* By 9 months of age infant creeps on hand and knees and pulls self to standing position
* By 10 months infant can change from prone to sitting
* It’s important to note when the children are standing, creeping, or crawling, because we want to avoid putting IVs in
their feet so we don’t restrict them from doing what they want to do.
* 11 months infant can cruise while holding furniture
* 12-14 months infant can stand alone and walks with one hand held
* Most infants take their first independent step by first birthday, and should be walking independently by 14 months.
o An infant who does not pull to stand by 11-12 months should be evaluated for possible developmental dysplasia of
the hip. This is another developmental red flag!!!
Fine Motor Development of the Infant
* Fine motor behavior includes using the hands and fingers to grasp an object
* Grasping occurs between the first 2-3 months as a reflex and gradually becomes voluntary
* Gradually the palmer grasp (using the whole hand) is replaced by the pincer grasp (using the thumb & index finger)
* 3 months the infant will hold a rattle if placed in their hand, they will not reach for it
* 4 months the infant plays with hands and can carry objects to mouth. So it’s very important to remove small objects
within the infant’s reach that can possess a choking hazard.
* 5 months the infant is able to voluntary grasp objects
* 6 months the infant can hold a bottle, grasp their feet and pull them to mouth, and feed themselves a cracker
* 7 months the infant can transfer objects from one hand to another, use one hand for grasping and hold a cube in
each hand simultaneously
* 8-9 months the infant uses a crude pincer grasp, bangs blocks, explores movable parts of toys
* 10 months the infant can pick up a raisin and other finger foods. They can deliberately let go of an object and let will
offer it to someone
* 11 months-12 months places objects into a container and removes them
At 2 months of age…
* Developmentally:
o Social smile in response to various stimuli
o Follows to midline
o Vocalizes along with using facial and body expressions, distinct from crying
o When prone, lifts head to 45 degrees. So it’s important to give them tummy time so their muscles can develop
* Physically:
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o Skin- infant acne may continue until 3 months of age, cradle cap, eczema common
o Head- posterior fontanelle should be closed by 2 months
o Eyes- unequal movements (eye-crossing) common
o Neck- holds head 45 degrees when prone. If they are lying on back make sure to position head from side to side so
they don’t get plagiocephaly (aka flat head syndrome, is a misshapen skull) or baldness on that spot
* Neurologically:
o Grasping reflex present when infant immediately closes fingers when object placed in hand. Usually gone by 3-4
months
o Moro reflex or “startle reflex” present when infant’s arms extend and abduct followed by flexion and adduction.
Usually gone by 3-6 months
o Stepping reflex present when you hold infant upright and touch foot to flat surface, they begin to step. Usually gone
by 2-4 months
o Sucking reflex present when the infants soft palate, lip, mouth, cheek or chin is stimulated or stroked, and then the
infant will automatically begin to suck. Usually gone by 4-6 months
o Rooting reflex is present when the infants cheek is stroked, the baby will turn head in the direction of the stimulus,
mouth open and ready to suckle. Usually gone by 4 months
At 4 months of age…
* Developmentally:
o Sit with support
o Rolls from back to side
o Has almost no head lag when pulled to sit
o Grasp objects with both hands
o Regards hands
o Hands together
o Laughs
o Bears weight on legs when held up
* Physically and Neurologically:
o Drooling begins
o Moro and rooting reflexes have disappeared
o Sucking, palmer grasp, plantar grasp are fading
o Makes consonant sounds (like with “K” or “N”)
o Laughs out loud and show many expressions
o Begins to show memory
o Separation/Individuation begins, know that they are
separate individual than their mother
At 6 months of age…
* Developmentally and Physically:
o Feeds self with fingers
o Works for toys
o Reaches for objects
o Turns to rattle
o Imitates speech sounds
o Speaks single syllabus. Like: “Ma” or “Da”
o Rolls from back to abdomen
o Teething may begin with eruption of 2 lower central incisors
between 6-10 months of age
o Sequence of Teeth Eruption is shown to the right. As a
quick guide you can take the child’s age in months and minus
6. This will give how many teeth they should have at that age.
• Between ages 6-8 months of age, they begin to fear
strangers. Stranger anxiety is prominent during this time.
• Talk softly and meet child at their eye level. Maintain a safe
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distance from infant and avoid any sudden intrusive gestures. Start with least invasive to most invasive procedure.
Try to keep them on mom’s lap as much as you can. You can do the assessment on the mom first, then on the
child to show the child that it doesn’t hurt.
At 9 months of age…..
* Developmentally and Physically:
o Creeps on hands and knees
o Sits for prolonged time
o Pulls self to standing position
o Stands holding furniture
o Responds to simple verbal commands
o Understands “no-no”
o Eruption of lower incisor may begin between 6-10 months of age. Eruption of upper incisors begin between 8-12
months of age. For the pain, you can massage gums, give them Ibuprofen or Tylenol. Don’t give hard, cold items to
put on/in mouth, because these are damaging to gums and cause bleeding.
At 12-14 months of age….
* Developmentally and Physically:
o Birth weight triples
o Says 3-5 words besides ‘dada’ and ‘mama’
o Plays repetitive games
o Waves bye-bye
o Indicates wants without crying (which used to be their way to communicate)
o Bangs two cubes together
o Recognizes objects by names
o Stands alone for few seconds
o May be walking on their own
o Has 6-8 deciduous teeth
Common Health Considerations
* Vaccine preventable diseases- discuss vaccines if parents are concerned over getting child immunized
* Diaper Rash- discuss typical topical ointments
* Eczema- what ointments child has been using and what reactions they’ve been having to them. Children who
develop eczema are at a higher risk for developing asthma later on in life
* Teething- discuss when their first tooth should erupt
* RSV- discuss when the important seasons to protect their child are: between November and April. If their child is
premature, they should talk to their doctor about getting Synagis (helps prevent serious complications from RSV)
* Jaundice
* SIDS- don’t lie baby on belly, prone position
* Abuse- look for signs of abuse
* FTT- failure to thrive, check growth chart carefully
* Colic- discuss parent’s feeling in regards to child being colicy, remind them to take slow, deep breaths and a time
out, and tell them that this will get better in time
* Apnea of Prematurity- home monitor and protect from SIDS because these children are at greater risk for SIDS
* Flu
*** REFER TO: ***
—> Vaccine-Preventable Diseases and the Vaccines that Prevent Them
—> 2016 Recommended Immunizations for Children from Birth Through 6 Years Old
*** KNOW WHEN COMMON IMMUNIZATIONS ARE GIVEN FOR THE EXAM ***
Well Child Checks and Immunizations
• As nurses it is very important to educate the family regarding routine well child checks
• Let them know that this is a great time to discuss questions/concerns regarding their infants development, behavior
and general well being
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Fatemeh Sahrapour
• Topics usually addressed during these visits include immunizations, safety in the home/at the playground, optimal
nutrition, toilet training, and environmental concerns such as lead paint exposure
—> Refer to “Recommendations for Preventive Pediatric Health Care” chart
Safety Considerations for the Infant
* Risk for:
o Suffocation- positioning is very important, always have them on their back, not even their side. Also, avoid placing
blankets, stuffed animals, etc. in their bed
o Aspiration- keep small items out of their reach and cut food items up to small chewable pieces
o Falls- place baby gates at top and base of stairs
o Bodily damage from sharp objects
o Poisoning from ingestion- store hazardous items in safe place
o Motor vehicle accident prevention/approved car seat that is correctly positioned
*** Refer to Box 31-1 in Perry for a list of safety promotion and injury prevention tips during infancy ***
American Academy of Pediatrics Recommendations:
• AAP advises parents that all infants and toddlers ride in a rear-facing car seat until age 2, or until they reach the
maximum height and weight for their seat
• Once the child has outgrown their forward facing seat that they will need to ride in a belt-positioning booster seat
until they have reached 4 feet 9 inches tall and are between 8 and 12 years of age
- In 2014, the carseat law has changed:
…If a child + carseat are < 65 lbs combined we need to
use a latch system.
…If a child + carseat are > 65 lbs combined, then we
can use a seat belt restraint instead.
- Parents can’t take child home without a car seat. In
the NICU, they do a “car seat” challenge to see if the
child can tolerate being in car seat for a period of time.
This will let nurses know if child is ready to go home.
Caring for the Infant in the Hospital
•Keep parents (caregivers) updated and educated
•Explain all procedures to parents (caregivers); why
we’re doing it and what results are
•Use swaddling to secure/protect infant and invasive
lines (NG’s, IV’s)
•Use no-no’s (arm/elbow restraints) to prevent infants
from pulling out invasive lines
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GROWTH AND DEVELOPMENT OF THE TODDLER AND FAMILY CENTERED CARE
Toddler Period: 12 to 36 Months
● Terrible two’s or three’s
● Time of intense exploration
● How do things work and how can “I” control others…they try to control others through temper tantrums,
negativism, and obstinacy. Although these can be challenges, reassure parents that behaviors are appropriate and
needed for intellectual growth and developmental achievement
Psychosocial Development of the Toddler
Erikson: Autonomy Vs. Shame and Doubt (Phase 2: 12 to 36 months)
● Toddler is acquiring a sense of autonomy while overcoming a sense of doubt and shame.
● Exhibit ritualistic behaviors and negativism responding “no” or “me do”
● Toddlers will throw temper-tantrums when scolded. But they need to have a sense of sameness and reliability that
will provide them with a sense of control and help limit some of their outbursts and temper tantrums
● Development of “ego” common sense and the ability to reason
● Early stages of “super ego” or conscience emerge
Cognitive Development of the Toddler
Piaget’s Sensory Motor Stages: (12 to 24 months of age)
● Tertiary Circular Reactions begin to emerge
● Awareness of casual relationships between two events is apparent. so if they see a light switch and they turn it on
and see a light come on, from there on every time they will want to turn the light switch on. So they’re not able to
transfer new knowledge to new situations, that’s why every time they see a light switch, they must reinvestigate its
function.
● Able to recognize different shapes and their relationship to one another
● Also aware of space and the relationship of their body to dimensions such as height. They can stretch and stand on
a stool. They can pull strings to reach objects. Parents find high places and locked cabinets the only places
inaccessible to toddlers
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Piaget’s Final Sensory Motor and Preoperational Phase: (19 to 24 months of age)
● More complex pre-operational thought takes place during this period
● Object permanence, still exists even though they don’t see it. They actively seek out objects in several potential
hiding places.
● Imitation, symbolization
● Mimicry: imitating household activities
● Gender role behavior becomes increasingly common, especially during the 2nd year. They begin to identify with
parent of the same gender and attempt to copy them in their gestures and their words.
Piaget’s Pre-conceptual/Pre-operational Phase of Cognitive Development: (2-4 years of age)
● Subdivision of the pre-operational stage which lasts from 2-7 years of age rudimentary socialized behavior of
● Is primarily one of transition that bridges the purely satisfying behavior of infancy and the rudimentary socialized
behavior of latency
● Do not think in operation/logical fashion-problem solving. They primarily think on the basis of their perception of an
event, only with what they see and hear directly
● Egocentrism, magical belief
● Child is concerned with the “why” and “how” of things
Physical Development of the Toddler
● Growth slows considerably during toddlerhood
● Birth weight is QUADRUPLED by 2 ½ years of age
● Height increases by 3 inches per year during this time period
● Head circumference is usually = to chest circumference by 1-2 years of age
● 2-year-old’s height in cm x 2 = average estimation of their adult height
● Anterior fontanel closes between 12-18 months. Posterior fontanel closes between 6-8 months.
● A “pot-belled” appearance
● Bowed legs common, that usually straighten themselves out between 3-4 years of age.
● Visual acuity 20/40
● Report persistent strabismus. Although strabismus is common in infants, it usually disappears by 3-4 months of
age. It’s important to notify physician immediately when we see this at this age, because it can be fixed. The more
we delay fixing strabismus, the child can have permanent visual impairments from this.
● Senses become increasingly developed. They want to smell, touch, taste…are very curious.
Gross Motor Development of the Toddler
● Major gross motor development during toddler years is development of locomotion
● By 12-13 months of age toddler walks independently, using a wide stance for extra balance
● By 18 months, they try to run, but fall easily
● 24 months toddler can walk up and down stairs with assistance
● 30 months toddler can jump using both feet
● Begin to tiptoe
● Steady gait
● Assess toilet training readiness. Physical signs for toilet training readiness include:
● voluntary control of anal and urinary sphincters, accomplished by 18-24 months of age
● ability to stay dry for 2 hours
● decreased # of wet diapers
● waking dry from nap
● regular bowel movements
● have achieved gross motor skills, such as sitting, walking, and squatting
● have fine motor skills in order to be able to remove their clothing to be able to use restroom
● mental readiness, such that they recognize urge to use the restroom
● should be able to communicate when they need to go to the bathroom
● must be able to follow directions
● need to be able to sit on a toilet for at least 5-10 minutes without fussing or getting off
Fine Motor Development of the Toddler
● 12 months toddler can grasp very small objects
● 15 months toddler can cast and retrieve objects
● 18 months can throw a ball over hand
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24 months toddler can turn pages in a book
30 months they can hold crayon in fingers
Can stack blocks
Draw stick figures
Because play is so important to a child, we need to incorporate play in the hospital
Nutritional Considerations of the Toddler
● During the period of 12-18 months growth rate slows and this decreases the need for calories, proteins, and fluids
● Caloric requirements= 102 kcal/kg/day
● Toddlers usually required 3 meals and 2 snacks per day. They pretty much eat what the rest of the family is eating.
● At 18 months may have physiologic anorexia. They become very picky, fussy eaters with a strong taste preference.
● To help prevent food jags in this age group, parents should prevent one food in various physical forms. The child
may need to progress to eating new foods in a step wise fashion, such as seeing food, smelling, touching, tasting it,
and then eating it. This is normal behavior for a toddler. They are very investigative during this period and want to
explore their surroundings.
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Vitamin C enhances iron absorption
Toddlers can drink from a cup with lid
Use a spoon
Like to eat with fingers, make sure their food is cut up to prevent choking
Best with routines…like to use same plate, cup. Encourage family to bring in these favorite items
No food mixing or food touching on the same plate
Keep servings small, preferably 1 tablespoon of solid food/year of age is a general rule
Need 2-3 servings of whole milk daily
Need 4-6 ounces of 100% fruit juice = enhanced iron absorption. Need at least 1 cup of fruit/day because vitamin C
enhances Fe absorption. Be cautious with fruit though and make sure not to give any more than 4-6 ounces and
that is 100% fruit juice to prevent diarrhea, DM, and dental caries development, over and under nutrition.
● Milk is the cheapest source of Ca and Phosphorus intake for child. They should only have an average of 2-3
servings, which is 24-30 ounces/day of milk. Must continue whole milk until child is 2 years old. Then go to low-fat
milk to reduce total fat intake. Also intake iron fortified cereals and iron rich foods.
● Continue to take vitamin D sources of food for bone development
● Good sources of calcium: cheese, yogurt, milk, beans, green vegetables such as broccoli or collard greens.
Calcium fortified foods that children do like include waffles, cereal, some white bread, OJ.
Developmental Skills and Language
● 15 months-tolerates separation from parents momentarily
● 18 months-temper tantrums emerge. Show strong emotions. They use ownership words, like “mine”. If we use timeout, it’s recommended we use 1 minute of time out/year of age.
● 24 months-parallel play, like to play side by side. They’re not good with sharing at this age group. So it’s really
important to start implementing sharing concepts during this age.
● 30 months—separates from parents easily, have an increased independence from parents
● By about 30 months, they begin to use to 400 words, 2-3 word sentences
Safety Considerations of the Toddler
Prevention is the number one intervention!!! Prevent:
➢Aspiration- Remind parent which foods are at greatest risk for choking: grapes, hot dogs, round/hard candies…so
cut these up. General rule is that if food is small enough to through a toilet paper hole, then it’s a possible hazard
➢Suffocation risks
➢Falls- monitor their play
➢Strangulation- make sure no cords or blankets, etc. in crib that baby may choke on
➢Burns- because they can climb now. Tell parent to use back burner when cooking and monitor temperature in tub
➢Drowns- monitor child near any water.
➢MVC- car crash. Use appropriate size seat and place correctly. Monitor.
➢Remind parents of the importance of immunizations and give them schedule on well child checks and
immunizations. Not all well child checks require immunizations, but are a good way to measure child’s development
➢Ensure toddler safety in the hospital by wearing gloves, and using correct bed (when they’re a toddler, they need to
be put in a cage crib, make sure sides are up and locked).
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Safety Tips to Give Parents:
● Use federally approved car seat
● Supervise play, focus on child and not on phone
● Supervise toddler around all sources of water including buckets and bathtubs
● Cover electrical outlets
● Latch second story windows
● Place gates at top and bottom of stairs
● Examine toys for small pieces that may cause aspiration. Govt. no longer polices/inspects toys on market.
● Garage doors should have safety mechanisms in place
● Foods should be adequately cut to small pieces
● Keep all toxic substances out of reach
Lead Exposure
• Although statistics have decreased dramatically since 2007 the following content is on point. Worldwide, 30
countries have already phased out the use of lead paint.
• Kids absorb up to 70% of lead, adults about 20%.
• Often undetected, with no obvious symptoms
• Can lead to learning disabilities, behavioral problems, malformed bones, slow growth.
• Very high levels can cause seizures, coma, and death
• Sources: lead-based paint, contaminated dust in homes built before 1978, drinking water from lead pipes,
contaminated food, soil (lead does biodegrade/decay), toys
• What parents can do: have child screened if there is concern of lead exposure, frequently wash child’s hands, toys,
pacifiers, only use cold tap water for drinking, cooking, test paint and dust in the home if built before 1978.
Normal Growth and Development Concerns Related to the Toddler
• TOILET TRAINING
• SIBLING RIVALRY- occurs when there’s a new child in the family and toddler no longer gets all of the attention, and
act out, and may revert to more infantile behaviors such as demanding a bottle when they’ve been weaned off for a
few months, or clinging, or soiling under pants, etc. This is normal behavior because they’re feeling left out. Parents
should spend as much time with toddler as possible.
• TEMPER TANTRUMS
• NEGATIVISM
• REGRESSION
• BREATH HOLDING- occurs when child is having a temper tantrum. If they’re not getting what they want, they may
hold their breath. Let parents know this is common and child won’t be harmed from doing this. Make sure patient is in
a safe environment in case they do faint. Just remember that they are doing this to gain independence and be
autonomous. We must provide them with consistency in expectations and prioritize rituals, and have consequences
that are reasonable for child’s level of development to help them manage behavior. When child demonstrates
appropriate behavior, make sure to provide positive feedback about the behavior so that child knows that they aren’t
bad, but the behavior is.
• AUTISM- during toddlerhood autism is also being diagnosed at around 18-36 months of age. It occurs in around
1/150 children in the US. Boys are 4X more affected than girls. Cause is unknown. Various therapies exist. Although,
there is no cure. It’s common that speech and language are delayed in these children. Developmental Red Flags: If
a child isn’t babbling or gesturing by 12 months, it’s a red flag. Another is if they’re not saying single words by 16
months or 2 word phrases by 24 months, they need to be recommender for immediate hearing and language
evaluation. Earlier treatment results in better outcome.
Potty Training and Child Abuse
• Potty training is one of the leading causes of child abuse.
Tips for the Hospitalized Toddler: Making the Experience Less Scary
● Utilize your hospital child life specialist, they’re trained in teaching children medical procedures & helping them cope
● Games/Play:
○ Stacking objects and knocking them down
○ Putting objects in container and dumping them out
○ Playing with toys that make noise or play music
○ Scribbling with crayons
○ Peek-A- Boo
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Parents should be present and participate in toddler’s care as much as possible to make the experience less scary.
Offer toddler choices to make them feel like they have control; taking medication isn’t a choice, but offering it in a
cup vs. a syringe can be.
Offer child to carry security objects to a procedure; bears, blankets, etc.
Sing to them. Use encouraging words
They like to be independent, so encourage their sense of autonomy by having them play & do things on their own.
Note that toddlers can regress once hospitalized due to stress of the environment. They’ll regain their
developmental progress once they’re less stressed.
Common Stressors and Fears of the Hospitalized Toddler
● Fears of strangers and new places
● Separation from parents
● Fear of being abandoned
● Fear of losing control and autonomy
● Fear of moving with medical equipment connected to them
Caring for the toddler in the hospital
● Make friends with parents/caregivers first, so that toddler can see that you’re not a stranger and the parents trust
you and therefore they’ll start trusting you also
● Keep children on parents lap for assessment if possible
● Get down to the kids eye level
● Put on a big smile and lower your voice
● Pretend to do procedures on parents first
● Let them hold/feel equipment
● Let them “help” you do things, they like being helpers and commend them for doing a good job
● Tell them what you are going to do in simple terms (download “simply sayin" app on phone)
● Explain what you are doing and what they will feel, smell, taste or hear (download “Simply Sayin” app)
● Allow them 2 choices that you can live with
● Give one instruction at a time
● Expect treatments to be resisted. Sometimes you’ve done everything you can, you’ve called child life, etc. But
they’re still scared. In this case, you just have to do it.
● Use firm direct approach
● Prepare child immediately before procedures, this is when you can call in a child life specialist
● Distractions works wonders: bubbles, tablets, etc. they’ll district child and let you focus on doing your procedure
● Restrain adequately; no-no’s (prevent child from pulling things out and it restrains their elbows or arms and keeps
child from bending them), papoose (used temporarily that holds a child down during a procedure) , holding (mom
can help with this)
Restraints Used In Pediatrics: This is a no-no
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GROWTH AND DEVELOPMENT OF THE PRESCHOOL AND FAMILY CENTERED CARE
Preschool Period: Ages 3-5 years
…During this stage the preschool begins to:
o Gain control of their bodily functions. Most children by this age should be completely potty trained. Some children
however, are heavy sleepers and have accidents at night and may have to wear pull ups
o Experience brief & prolonged periods of separation. They tolerate this better however than they did in toddler years
o Interact cooperatively with other children and adults. They learn how to share and take turns. They learn how to say
“that’s not fair” or “it’s my turn”
o Use language for mental symbolization. They make up different names for certain objects.
o Have increase attention span and memory. So, if you promise them something, you better come through because
they will remember!
Psychosocial Development of the Preschooler
* Erikson’s Initiative Vs. Guilt: (Phase 3: 3 -5 years of age)
o Primary psychosocial task is acquiring a sense of initiative. They like to please others and it’s very important to get
a sense of acceptance from their parents and friends. They play, work, and live to the fullest and feel a real sense of
accomplishment and satisfaction in their activities, especially if those activities are recognized by their peers,
teachers, parents. They love getting praise and feeling like they’ve done a good job.
o Feelings may include guilt, anxiety and fear when their thoughts differ from expectations.
o Identify with same sex parent
o Rivalry with opposite sex parent. This isn’t seen that much.
o Development of superego or conscience. They start learning the difference between right/wrong and good/bad and
they do truly feel bad when they do something wrong. So you always have to reinforce that they’re not bad, but
that the behavior was bad! This is so important. If preschoolers are criticized or punished for taking initiative,
they could develop a sense of guilt for wanting new experiences, which they can carry in to school and even
adult life.
Cognitive Development of the Preschooler
* Piaget’s Cognitive Theory: Pre-operational Phase
* (2 stages: Preconceptual phase from 2-4 and the phase of Intuitive thought from 4-7 years of age)
o Less egocentric, they’re not extremely focussed on themselves
o Preschoolers use language with out understanding their meanings. So watch what they’re hearing/listening to.
Teach them that if they don’t understand a certain word, they really shouldn’t be using it because it may have a totally
different meaning than they think it does
o Time is still incompletely understood. They don’t really understand the difference between days, weeks, months yet
even though they know the days of the week. So, refer to events of the day like “dinner”, “lunch”, etc.
o Preschoolers thinking is describe as “magical”, they believe their thoughts are all-powerful. If they were thinking
something bad and that bad thing does happen, then they believe that they are responsible for that.
Physical Development of the Preschooler
* Physical proportions no longer resemble those of the squat, pot-bellied toddler. They have a more slender but
sturdy frame.
* Preschoolers gain an average of 5 pounds annually
* Age 3– average weight is 14.6 kg (32 lbs.) Height—95 cm or 37.25 in
* Age 4—average weight is 16.7 kg (36.75 lbs.) Height—103 cm or 40.5 in
* Age 5—average weight is 18.7 kg (41.25 lbs) Height—110 cm or 43.25 in
Gross and Fine Motor Skills of the Preschooler
* By age 3 the preschooler is walking, running, climbing, and jumping well, stands on one foot, copy a circle, can build
a tower of 9-10 cubes, have a vocabulary of over 900 words, and talk using about 3-4 sentences combined. They ask
many questions. They dress and feed themselves almost completely but still need parents to assist them especially
with buttons or zippers, turning clothes right side out, putting on shoes because they don’t know difference between
left and right yet, brushing their teeth, etc. So help them, but give them as much autonomy as you can because they
think they are big boys and girls, reassure them that they are and that you’re there just to help in case they need you.
* By age 4 the preschooler is able to skip and hop on one foot, catch a ball, throws overhand, walks up and down
stairs alternating feet (but still need supervision going up/down stairs…remind them that they need to walk slowly,
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never carry toys up/down stairs, hold on to side of wall or hand rail, watch them if they have their blanket with them
because thy may trip and fall), uses scissors (they learn how to use scissors at school, so they’ll want to use the ones
at home so tell parents to get ones with plastic safety covers, never let kid walk with scissors), copies square, draws
three part stick figure, has 1500 word vocabulary, talks in 4 or 5 word sentences, has imaginary playmates (these are
important for many reasons, so let the child know that it’s ok to have an imaginary playmate), is very independent and
want to do things on their own with minimal assistance.
* By age 5 the preschooler skips on alternating feet, jumps rope, begins to skate with good balance, walks
backwards, ties shoe laces, has a vocabulary of 2100 words, talks in sentences using 6-8 words, names 4 or more
colors, knows days of the week and months of the year but the concept of time is still confusing to them, they don’t
quite understand tomorrow, next week, or next month. You can relate things to “breakfast, lunch, or dinner time”…
they seem to have a better understanding of this. Make sure that with all these activities, they have the proper
protective equipment on and have proper supervision.
Nutritional Considerations of the Preschooler
* Preschoolers may still have food fads and be picky eaters
* The 2010 Dietary Guidelines for Americans recommend an average intake of 1400 -1600 calories per day for a
moderately active child of 4-8 years of age
* Fruits, vegetables and whole grains should be increased
* Be aware of sugar-sweetened beverages.
* Diet should contain adequate Ca+ and Vitamin D. APA recommends a decreased fat diet.
* Servings should be small, approximately ½ cup portions
* The amount and variety of foods kids eat will vary from day to day. Remind parents that the quality is much more
important than the quantity. If they don’t like hospital food encourage parent to go get food that they are used to
My Plate and Preschoolers
• To help parents how to provide their children balanced, nutritious meals, this food guide is provided by USDA
• Due to the increase in childhood obesity it is imperative for nurses to educate children and families regarding the
importance of incorporating a healthy diet and physical activity to achieve optimal health.
• Tell parents that it’s important to serve as a role model for their kids for healthy eating
• By age 5, children become agreeable to trying new foods, especially if encouraged by an adult. They love helping
in the kitchen, so encourage parents to get their kids involved.
• By age 5, they are ready for social side of eating, like sitting down with family of longer periods of times. Meal times
can be a battle grounds as far as table manners go.
• Another thing you do to try to get child to eat is to have a tea party with them, and they’ll enjoy preparing the food.
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Play of the Preschooler
• Preschoolers love to play!! It’s a huge part of their growth and development. Play should provide physical, mental,
and social development.
• Imaginary play mates are very common during the preschool period (and usually emerge between 2.5-3 years of
age and for the most part are relinquished when child enters school. Imaginary friends serve purposes such as:
being child’s friend in times of loneliness, accomplish what the child is still attempting, and experience what the
child wants to forget or remember. Reassure parents that child’s fantasy is a sign of health. It helps differentiate
make-believe and reality), as well as dramatic play and imitation. They like to dress up, hide and seek, etc.
• They like reading and being read to, painting, and coloring, etc.
• Activities for physical growth and refinement of motor skills include running, climbing, jumping.
• They enjoy a variety of activities, especially enjoy associative or group play
• Parents should watch television programs with child and discuss it with them. Limit time of viewing.
• Play is such a big part of their life that reality and fantasy become blurred at times.
• Mutual play or play between a child and parent fosters development from birth through the school years and
provides enriched opportunities for learning by maximizing their verbal/language abilities.
Safety Considerations for the Preschooler
* Supervision of play in playgrounds/around water to reduce falls, injuries, drowning (they can drown in just inches).
Never, even for a second, leave a child unattended around water.
* Education regarding potential hazards such as crossing the street. Look both ways, read the street signs (teach
child what they mean)
* Appropriate child restraint seats in motor vehicles. It is the law!! It’s important to teach families about appropriate
use, size of car seats, and right placements of child restraints.
* Rear facing car seats are used by infants for as long as possible, to the upper weight limit of the harness
* Never forward facing before their first birthday and about 20-22 lbs
* When we’re turing them forward, toddler must be in a 5 point harness until upper limits of harness are reached
(which is usually 40-65 lbs)
* This requires that children from age 4 up to 4 feet, 9 inches be in a booster seat.
* If parent owns a car with no back seats (a single cabin vehicle), must push front seat as back as possible, and
always make sure air
bag is turned off
* Use of helmets to prevent
head injuries
* Prevent choking
hazardous foods. Still
need to cut foods up
pretty small.
* Safety considerations for
the hospitalized child:
* bed is in lowest
position
* side rails are all the
way up and locked
* call light is within
reach, teach them how
to use and when to use
call light
* prevent choking
hazards by making
sure their food is
appropriate for their
age. Assist them to cut
food. Make sure head
of bed is up and that
they’re positioned
appropriately for
eating.
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Sleep and Activity of the Preschooler
* Sleep patterns vary, but the average preschooler sleeps about 12 hours a night and infrequently takes naps
* The preschool years are a prime time for sleep disturbances, which are associated with their increased autonomy,
negative sleep associations, night time fears, inconsistent bedtime routines, a lack of limit setting, nightmares
(frightening dreams that are followed by full arousal) or sleep terrors (partial arousal from deep, non-dreaming sleep).
* Resistance to going to bed is common. Parents should know this is normal during this age and they should ignore
attention seeking behavior and not to take the child into the bed room or allow them to stay up past a reasonable
hour. Other measures that may help: keeping a light on in the room, providing transitional objects, such as their
favorite toy or blanket, or leaving a cup of water at bed side.
* Parental consistency is very important to all these treatment approaches.
Health Promotion of the Preschool
* Vision and Hearing Screening between the ages of 3-5 years old (***Review Lab***)
* Dental Health. Remember that children don’t have the fine motor control to effectively brush their teeth so we still
need to assist them with this.
* Prevention of communicable diseases that are common during this period:
* chicken pox
* diphtheria
* Roseola
* Mumps
* Pertussis
* Scarlet fever
* Immunizations- as a result of immunizations, the incidence of these diseases have declined
* Well child checks- check for developmental markers (bring child to these check ups will help us recognize any
abnormalities early) and give due immunizations
* Recognizing signs of child neglect.
* Identifying children at risk for abuse: physical, mental or sexual. Some warning signs include:
* physical evidence of abuse or neglect
* conflicting stories about accident
* when cause of injury is blamed on another person such as a sibling
* if injury is inconsistent with child’s health history
* inappropriate responses of caregiver such as aggravated emotions, refusing to sign for additional tests, or
refusing to agree for necessary treatment
* child report of abuse and previous reports of abuse in family
* Repeated ED visits with inconsistent injuries
* Caregiver report of child injury occurring during their absence
* As nurses it is our responsibility to call and report our suspicion of abuse!!!
* Munchausen Syndrome by Proxy is another form of child abuse. It is rare but serious. It is where the caregiver,
usually the biological mother deliberately exaggerates or fabricates symptoms or induces symptoms in their own child
for their own attention. Common symptoms include: N/V/D, seizures, and altered mental status. These are usually
only witnessed by the perpetrator. Consideration that indicate a child may be a victim of this abuse is if their
symptoms resolve after being separated from the perpetrator. This usually confirms the diagnosis. Can put monitors
in the patient room to collect evidence.
Tips for Hospitalized Preschoolers
• Continue to stimulate the process of growth and development through play in the hospital
• Utilize Child Life Specialist
• Play for the preschoolers: coloring, painting, drawing, puzzles, dress up, pretend play
Common Stressors and Fears of the Hospitalized Preschooler
• Misconceptions from inability to distinguish reality from fantasy
• Fear of long separations from loved ones
• Fear of loss of control
• Fear of bodily injury or harm
• Reaffirm to your patient that the hospital procedures are not punishment and that they haven’t done anything
wrong. Be honest with them and tell them the truth in clear explanations. Set normal limits and provide structure
while they’re in the hospital. Encourage parents to participate as much as possible. Continue to give positive
reinforcement throughout hospitalization.
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Fatemeh Sahrapour
MODULE: GROWTH AND DEVELOPMENT OF CHILDREN
Part II: School Age and Adolescent
Readings:
School Age Growth and Development
Perry: 985-1009
Adolescent Growth and Development
Perry: 1010-1047
Other Common Injuries/Problems
Perry: 1498-1509
Acne
Perry: 1516-1518
Promotion of School Age/Adolescent
ATI 2013: 50-66
West Nile Disease:
http://www.cdc.gov/ncidod/dvbid/westnile/wnv_factsheet.htm
http://www.mayoclinic.com/health/west-nile-virus/DS00438
GROWTH AND DEVELOPMENT OF THE SCHOOL AGE CHILD AND FAMILY CENTERED CARE
School Aged Children = 6-12 years old
- Stage begins with the shedding of the first deciduous (baby) teeth and ends at puberty
- Time of gradual, but steady growth and development
- Children will gain 2-3 kg/year and grow 5 cm/year during this time
Growth and Development
* Age 6 years
- Physical and motor – height and weight gain continues slowly, lose front teeth, increase in dexterity, vision
matures. So what was considered a passing (20/40) at age 4 is changed to 20/30. This is an active age when kids
like to be in constant motion. But also like to engage quiet things like drawing or coloring.
- Mental – develops concepts of numbers. They understand the difference in time with regard to morning or
afternoon. They can obey 3 commands in succession. They can differentiate the left hand from right hand.
- Adaptive – cuts, paste, and folds paper likes simple card games. They can read from memory, which is seen when
they like to read the same books over again.
- Personal-social – has a great need to play with children own age, will not hesitate to cheat to win because winning
is very impertinent to them, may mimic adult behavior, increases socialization. Are learning to share and cooperate.
* Age 7 years
- Physical and Motor – jaw begins to expand to accommodate permanent teeth
- Mental – develops concept of time (they are able to read an ordinary clock), able to notice if items are missing from
pictures, can repeat 3 numbers in sequence backward
- Adaptive – brushes and combs hair neatly, is less resistant and stubborn, can cut meat with a table knife
- Personal-social – takes part in group play, boys prefer playing with boys, girls with girl. They like to help and being
given specific tasks to accomplish. They become less resistant/stubborn. They like to have choices, but you can’t
give them too many because they become overwhelmed easily.
* Age 8-9 years
- Will weigh between 43-87 lbs
- Physical and Motor - movements are more fluid and graceful but are always in constant motion: jump, chase , skip,
fine motor control increases: learn cursive writing in school, dresses self, more limber because their bones are
growing faster than their ligaments
- Mental – give similarities and differences between 2 things from memory, can count backward from 20 to 1, knows
days of week and months in order, awareness of time increases, describes objects in detail, reads more, grasps
concepts of fractions (taught in school at this age): whole and parts, understand cause and effect, understand
concept of space, they really like to collect different items
- Adaptive – likes to help with routine household chores, is afraid of failing in school, is more critical of self,
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- Personal-social – easier to get along with because they’ve moved on from resistant/stubborn phase, likes reward
system, better behaved, competes and play games, has preference in friends, they start to play with the opposite
sex but still majority is play within their own sex, develops modesty, becomes interested in boy/girl relationships but
they wont’ admit it, enjoys participating in organizations, clubs, and group sports
* Age 10-12 years
- Physical and Motor – 54-128 pounds, 50-64 inches in height, posture similar to adults, remaining permanent teeth
also erupt except for the wisdom teeth, pubescent changes begin to appear for girls, in boys there’s a slow growth
in height followed by a period of rapid weight gain and may become obese in this period
- Mental – writes brief stories or letters, uses telephone for practical purposes (not a social event yet), responds to
commercial advertising and want everything they see on t.v.
- Adaptive – learn to cook or sew some because they can follow directions, raise pets, responsible for personal
hygiene although they need frequent reminders (especially boys), may be left alone briefly
- Personal-social – loves friends, chooses friends more selectively and may have a best friend, enjoy conversation,
develop interests in opposite sex, more diplomatic, demonstrate affection to their parents but as you get closer to
the 12 year mark they may not want to show it in front of their friends (especially boys), wants to please parents
and likes their family but may not show it
Cognitive Development
* Concrete operations (Piaget)
- Thinking style becomes more logical, organized, and flexible…but not abstract
- Concrete thoughts: time is concrete, rules of grammar although they may still have trouble with tenses (past/
present), understand emotions of others (toddlers are very egocentric but now they understand what it means to
hurt someone’s feelings), can only understand simple analogies (this is the beginning of abstract thinking, it is just
starting)…everything is very black and white, very literal. So it’s important to consider what you say to them, they
take things very literally. And if you say something, you have to follow through with it. It’s important to use the same
words to describe things that they use so they can understand us.
- Uses thought processes to experience events and actions
- Develops understanding of relationships between things and ideas
- Is able to make judgments on the basis of reason (“conceptual thinking”)
- Masters the concept of conservation. They are able to understand when the amount of something remains
constant across 2 or more situations. This can be applied to measurement, number, mass, length, area, volume.
For example: understand when total amount of liquid poured in to different shaped containers remains unchanged.
Younger children though would think that if the container is taller or wider, then it contains more water.
- Develops classification skills. They can group and sort objects by shared characteristics, can make comparisons.
This skills is useful in school in understanding concepts in sciences and social studies.
Psychosocial – Industry vs Inferiority
* A sense of industry (Erikson)
- Stage of accomplishment of new skills and knowledge (this is what industry refers to). Industry is achieved through
learning and a feeling of doing things well. Their major task is school and if they don’t do well/struggle in school,
then they have difficulty achieving that sense of industry. So it’s very important for us to find something these kids
are good at and feel good about.
- School agers need frequent reassurance that they are doing things correctly
- Eagerness to develop skills and participate in meaningful and socially useful work
- Acquisition of sense of personal and interpersonal competence. If children develop a sense of inferiority of
inadequacy, they will feel like they’re not accomplishing the same things as their friends and are different. This will
make them feel inadequate and have low self-esteem.
- As their world starts to expand, their most significant relationships become school and their neighborhood. Parents
are no longer the complete authority. The parents used to be their whole world, but now they start to understand
that there’s a whole world outside their family.
- Peer approval: a strong motivator. Have big fears of being ridiculed, and this fear will motivate a lot of their
behavior. They may develop nervous behaviors. For ex. a nervous laugh or nose rubbing. It’s very common and it’s
important that we not draw attention to it, because then they’ll focus on it and demonstrate the behavior more. Tell
parents that kids outgrow this.
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- Growing sense of independence. They will also have a separation of the sexes because they are starting to
develop gender identification.
- Through this stage their friends are mostly of the same sex. They may have a rivalry with the same sex parent. For
example, boys will be competitive with their father for the attention and affection of their mother.
Morals
* Development of conscience and moral standards (Kohlberg)
- Ages 6-7: reward and punishment guide choices. They focus on concrete rules and have a hard time
understanding reasoning and are always out for the best deal. There’s no loyalty or gratitude when it comes to
decision making. So it’s not loyalty, it’s what they think is fair. And they think fair is always on their side. So they
basically don’t treat others as they would like to be treated.
- Moral development is difficult because they still see concrete rules: right vs wrong, fair vs unfair even though they
don’t completely understand what “fair”, they still have their own sense of fair.
- Older school age: child is able to judge an act by the intentions that prompted it
- Rules and judgments become more founded on needs and desires of others
Social Development
* The peer group is an extremely important socializing agent in this age group.
* Identification with peers is a strong influence in achieving independence from parents
* Sex roles are strongly influenced by peer relationships
* Through peer relationships they learn how to deal with dominance and hostility, how to relate to people in positions
of leadership and authority, and how to explore ideas and their physical environment.
* It’s important to let children speak for themselves, even to their health care provider. Parents often model what child
will say. But as a nurse, you should try to engage the child in the conversation. This will help child learn to speak for
themselves. Parents can assist by modeling what child should be saying.
Play
* Involves an increase in physical, intellectual abilities, and fantasies.
* Rules and rituals: They like to follow rules. Part of the enjoyment of play is knowing the rules, because knowing
rules means that you belong.
* Team play: the need to conform and follow rules accurately is very strong in this age. Teaches child to think about
team goals as opposed to just personal goals.
* Quiet and solitary games and activities are also enjoyable. They should be able to ride a bike without training
wheels during this age.
Developing Body Image
* In general, children like their physical selves less as they grow older
* The head is the most important part of the body (hair and eye color are the characteristics used most often to
describe their physical selves). They are acutely aware of their bodies and the bodies of their friends and adults. They
are also very aware of those who are different and stick out.
* Body image is influenced by significant others
* Increased awareness of “differences” may influence feelings of inferiority (e.g., hearing or visual defects)
* It’s normal for kids to be curious about sexuality and that should be addressed with education.
* School aged children are more modest than preschoolers and emphasize privacy. As a nurse give them privacy and
only uncover what needs to be uncovered.
Body Changes
* The onset of physiological changes begins around age 9, especially for girls. It’s a time for rapid growth of height
and weight. The average 6 year old is 45 inches tall and weighs 45 lbs, but the average 2 year old is 59 inches tall
and weighs 88 lbs.
* At first, the differences between boys are girls are small, but later girls experience a height spurt and menses starts
about a year later. Towards the end, girls pass boys in height and weight.
Health Promotion
* Nutrition- quality of child’s diet depends on quality of family’s diet. Children typically become more open to try
different foods. They like fast food partly because of the commercials they see. Important for children to learn about
what makes a healthy diet and consequences of not eating a healthy diet.
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* Sleep and rest- sleep averages 9-11 hours/night during this stage, but is very individualized based on age, health
status and activity of child. May resist going to bed between ages 8-11. But as they approach 12, are less resistant.
* Exercise and activity
• Sports- controversy regarding early participation in competitive sports, as well as concern for physical and
emotional maturity in competitive environment. Generally, children enjoy competition.
• Acquisition of skills
* Dental health- start seeing a dentist around 1 year of age or 6 months after child has gotten their first tooth in. Teach
them to brush after meals, snacks, and at bed time. Have regular dental checkups and fluoride treatments. Be on the
lookout for periodontal disease. You’ll start seeing braces.
* Sex education
* Understand Tanner’s staging of sexual development. As child nears sexual maturity, they are typically done with
linear growth, so they may have concerns of being short.
* Sex play is a part of normal curiosity during pre-adolescence, children are experimental by nature. Middle
childhood is the ideal time for formal sex education. It’s important to give children truthful information. Also,
important for parents to speak about this to their kids. Sometimes as nurses, we can facilitate the conversation
* School health
* School programs are involved in ongoing health maintenance: school screenings and referrals
* Screen for scoliosis early before rapid growth spurt in adolescence, because it can make the curvature worse.
* Obesity- prevention is important. The best way to prevent obesity in a child is to prevent it in their parent.
Encourage active, healthy lifestyles
* Cancer screening
* Asthma screening
* Immunizations
Nutrition
* American Academy of Pediatrics
- Appropriate food choices; council families & kids, & give referrals if needed. Ask parent: “What concerns do you
have about your child’s eating habits?” “What does your child usually eat for snacks?” “Does your child eat (any of
the healthy food items)?” “How often does you child drink soda or juice?” It’s important to ask the child as well.
- Fast food
- Provide guidance: Stress importance of breakfast and teach them healthy dietary habits. Advise parents to avoid
the use of food as a reward, this can promote obesity. Let parents know that they must emphasize physical activity.
Injury Prevention
• Bicycle safety- helmet (must sit low on the forehead, parallel to the ground when the head is upright. It shouldn’t
move side to side), right sized bike (child must sit on the bike and be able to comfortably place the balls of both feet
on the ground)
* Trampolines- AAP doesn’t endorse the use of trampolines, even the ones with nets aren’t any safer
* Water safety- swim lessons important but not encouraged in children < 4 years because it can provide them with a
false sense of security
* Motor vehicle accidents- the most common cause of severe injury and death in school-aged children either as a
pedestrian or passenger. Children must use an approved carrier-restraint system until they reach 4 feet 9 inches.
Keep child disciplined in the car: keep arms inside care windows, don’t interfere with driver, don’t let them ride in the
bed of pick up truck, etc. Emphasize safe pedestrian behavior: wear light clothing, walking on side walks, etc.
* Sports injuries- majority involve soft tissues rather than bones, children should be trained for their sport, young
athletes are the most susceptible to the effects of concussions because their brains are still developing. Reduce by
wearing protective gear, and adhering to rules of sport, and learn about concussions. All children who experience
concussion must rest (physical and mental: no tv, sports, homework, etc.) and be evaluated by physician.
Symptoms resolve in 7-10 days but can take up to a month. Medical clearance required to return to play after any
type of injury, and especially head injuries.
* Firearms- research has shown that guns at home are a serious risk to families. A gun in the home is more likely to
harm a member of the family than an intruder. Having guns in the home triple the risk of a homicide, and suicide is
5x more likely. Teach families to not own a gun or at least keep it in a safe place: keep gun unloaded, have gun and
ammunition in separate places and always in a locked space. Remember children don’t understand how dangerous
a gun is no matter how many times they are told.
* Poison/substance abuse- cleaners and chemicals are kept in locked cabinets, teach them to say no to drugs
* Stranger safety- teach children: that they shouldn’t be speaking to strangers, that adults shouldn’t be asking them
for help for anything, and that they should immediately remove themselves from someone who they’re in fear of.
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Health Problems
* Attention deficit disorders or ADHD- a developmentally inappropriate degree of inattention, impulsiveness, and
hyperactivity. It’s diagnosed based on symptoms, that have to be present between ages 4-18 years of age and must
occur in more than one major setting. For example: if they are impulsive at home but fine at school, then they don’t
have it.
* Symptoms: carelessness in school work and home activities, easily distracted by external stimuli, may exhibit
forgetfulness in daily activities, fidgety, squirmy, difficulty engaging in quiet time games, talk excessively, poor
impulse control, difficulty waiting for turns or waiting in line, and frequently interrupt other people’s conversations.
The earlier it’s diagnosed the better the outcome; the more normal the course of emotional and psychological
development and less negative impact on school performance. ADHD frequently causes a negative response
from adults and other children. Other children know that the disruptive behavior is affecting their lives. This repeat
exposure to negative feedback can cause child to have negative self-concept a sense of industry.
* Diagnosis: involves a thorough history account, MD will send a questionnaire to school for child’s main teacher to
record observations and give one to parents. A physical exam including vision and hearing screenings. A detailed
physiological and neurological developmental exam and psychological testing .
* Management: multiple approaches including family education, counseling, medications (Psycho-stimulants such
as Ritalin. Children on these medications need to be assessed frequently for appropriate growth and milestones.
They are typically seen every 6 months. SE: appetite suppression, suppression of growth acceleration, N/V, sleep
disturbances. If they are taking an extended release medication, it’s something that can be given at home so
other children won’t even know the child is on meds other time child will take it from nurse and it’s important to
keep the nurse visits discrete so other children won’t point to child as being different: self-esteem issues), and
having child placed in appropriate classroom.
• School phobia- This isn’t referring to the 5 year old who is scared of school for the firs time, but those that
demonstrate extreme reluctance toward attending school over a long period of time, due to severe anxiety and
school related experiences. It can occur in all ages, but is most common in those 10 years and older.
• Symptoms: anxiety that verges on panic, physical symptoms: dizziness, HA, stomach pains…develop as a
protective mechanism and disappear when child realizes that they can go home, and on weekend. Onset is
sudden and precipitated by a school related incident: bullying, trouble with teachers, etc.
* Bullying- when one person asserts power over another one who is considered weaker either through a social,
physical, or emotional means. It can and does result in depression, suicide, psychosomatic symptoms, and
psychosis. It is intended to harm or embarrass the victim. It involves either one person doing the bullying or a group
of people. A lot of people see bullying as a part of normal social development “boys will be boys”, so they ignore it.
But this is not true or ok. Girls can be bullies too and sometimes are the worst. Education needs to involve parents
and school adults so they can stop the behavior.
* Scabies and ringworm- Seen frequently in this age, especially in elementary age.
* Scabies is an infection caused by scabies mite and lesions are created when the pregnant female mite burrows
into the epidermis to deposit her eggs and feces. The inflammation that results causes intense itching. You’ll a
gray, brown thread like appearance on the skin. You may see a black dot at the end of the burrow where the mite
is physically located. Most commonly occurs between fingers, folds in wrists, in armpits, behind knees, and
inguinal areas. Scabies is highly contagious, so all people who have close contact with child should be treated.
* Ringworm “Dermatophytosis” is caused by a fungus. It’s not a worm. Invades stratum corneum (horny outer layer
of skin), hair, and nails. These are superficial infection and are on the skin and not in the skin. Common forms are
called Tinea capitis (on head), Tinea corporis (on body), Tinea pedis (athlete’s foot), Tinea cruris (Jock itch).
Teach families: good hygiene, it is very infectious so children should be taught not to share personal items,
infection can also be acquired from animal to human transmission, household pets also need to be examined.
For Tinea captitis, Ketoconazole and Selenium Sulfide shampoos used to treat and child can return to school
after treatment has started. When it’s on the head or body they are started on oral medication: Griseofulvin may
be prescribed. Ringworm is very difficult to get rid of; can take
weeks or months. For Tinea corporis, the patch is round or oval,
red and scaling, it spreads out peripherally and clears centrally.
If you touch it, you can feel the raised ridges of the ring.
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GROWTH AND DEVELOPMENT OF THE ADOLESCENT AND FAMILY CENTERED CARE
Adolescence is considered the transition between childhood and adulthood. Is characterized by a rapid physical,
cognitive, social, and emotional maturation. The final 20-25% of height is achieved. Is defined as beginning with the
appearance of the secondary sex characteristics and ending with cessation of body growth which is around 18-20
years of age.
Growth and Development
* Primary sex characteristics
- External and internal organs necessary for reproduction
* Secondary sex characteristics
- Play no direct role in reproduction
- Result of hormonal changes: voice change (deepens in males), hair growth (in axillary and pubic areas), breast
enlargement in females, fat deposits begin. Anterior pituitary and hypothalamus stimulate the gonads. The gonads
begin to produce gametes and release the sex appropriate hormones. These hormones are produced by the
ovaries, testes, and adrenal glands and their levels change throughout life span. Adrenal cortex only secretes a
small amount of these hormones before puberty. The maturation of the gonads then produces the biologic changes
we see in puberty. Hormones:
- Estrogen (feminizing hormone, produces in low levels during childhood, for boys there’s a gradual production
throughout maturation, for girls it increases until about 3 years after menarche…the levels then remain at this
maximum amount throughout their reproductive life, which after they grow past the stage of reproduction
estrogen levels begin to fall again)
- Androgen (masculinizing hormones, are secreted in small, then gradually increasing amounts for up to 7-9
years. There’s a rapid increase in both sexes. In boys, a rapid increase continues until about age 15. This is
what is responsible for the rapid growth in the early teen years. Testosterone is secreted by the testes. In boys
levels reach maximum at time of maturity.
Sexual Maturation
* Tanner stages of sexual maturity
- Sexual maturity scale that is used for males and females. It is a scale of physical development in children and
adolescence.
- It defines physical measurements of development that are based on the external primary and secondary sex
characteristics, such as size of breast, genitalia development, testicular volume, development of pubic/axillary hair.
- This is important to use because it helps us define what stage of sexual maturity they may be in.
- These stages occur in an orderly sequence***
- For girls it starts with the appearance of breast buds; can happen anywhere between ages 9-13. The pubic hair
is developed on the mons pubis; can happen from 2-6 months after the appearance of breast buds. Then hair
under arms appears. Following will be the initial appearance of menstruation; which is about 2 years following
the appearance of breast buds. The average age of menarche for girls in the US is 12.5 years old.
- For boys, first pubescent changes involve testicular enlargement, a thinning, reddening, and increased
looseness of scrotum, which occurs anywhere from 9.5-14 years of age. Then we see penile enlargement, pubic
hair growth, voices change, facial hair growth, and about 1/3 of boys may experience a temporary
gynecomastia, which disappears within 2 years.
Physical Growth
* As said before, adolescence really occurs with sexual maturation accompanied by dramatic increase in growth
* Adolescent growth spurt
- Final 20%-25% of total height achieved during puberty
- Usually occurs within 24 to 36 months, which is termed: “the adolescent growth spurt”
- The age of onset, duration, and extent of growth is variable from one person to the next
- Growth spurt begins in girls between the ages of 9-14.5 years. It begins in ages 10.5-16 in boys. During this time
period the average boy gains anywhere from 4-12 inches in height and gains 15.5-66 lbs. Growth in height ceases
in boys at age 18-20. The growth spurt is slower in the average girl and weight gain is less extensive. She can gain
2-8 inches in height and 15.5-55 lbs in weight. For girls growth in height ceases about 2-2.5 years after menarche.
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• Characteristic sequence of changes, there is an order to the growth. Begins with growth of the extremities (arms,
legs, neck, hands, and feet), then followed by growth in hips and chest and increase in shoulder width. This is
followed by increases in length of the trunk and depth of the chest. At this point acne may appear for both sexes.
Physiologic Changes
* Size and strength of heart, blood volume, and systolic blood pressure increase. Blood volume reaches a higher
value in adolescence and is typically higher in boys than girls due to increased muscle mass in boys.
* Pulse rate and basal heat production decrease, become more aligned to what we’d see in an adult
* Adult values are reached for all formed elements of blood
* Respiratory volume and vital capacity increase
* Physiologic performance capabilities increase, which is a result of the increased size and strength of muscles.
* Experience an increase in cardiac, metabolic, and respiratory functioning as well.
Psychosocial
* Adolescence = Sense of identity (Erikson)
- Early adolescence: group identity vs. alienation
- They begin to feel pressure to belong to a group. This belonging allows them to see differences between
themselves and their parents, they’re trying to establish separation and do things differently (ex. dress
differently) because they don’t want to be seen as a part of their parents.
- They don’t want to be seen as being different, or stand out, because it can make them feel alienated from their
peer group. If they do’t have that group, they aimlessly wander around without clear values or goals. They might
remain in a state of what’s called role diffusion; they lack direction.
- During this time they may be vulnerable to negative peer influences and may become involved in drug use.
They may also become intolerant of people who they see as different from themselves because they fear
shattering their own identity, which is very fragile at this time. They have difficulty making and maintaining close
personal relationships with others.
- Development of personal identity vs. role diffusion
- During adolescence they begin to explore independence and develop own sense of self/identity.
- Those who get encouragement and reinforcement through this time of personal exploration, will come through
this stage having developed a strong sense of themselves and a feeling of independence and control. But those
who had difficulty coming through this stage will remain unsure of their beliefs and desires and may feel
insecure and very confused about themselves and their future. So, it’s essential that they complete this stage
successfully. This success then leads to fidelity, which Erikson describes as the ability to live by society’s
standards and expectations.
- Sex role identity is explored and formed. Children are influenced in developing this identity by their friends and
peers and as well as the adults in their lives.
- Emotionality- adolescents sway very quickly in their emotions between being mature one minutes and very child
like the next minute. They’re very moody; one minute are outgoing and enthusiastic, the next are depressed and
withdrawn. As a result of these mood fluctuations, they are labeled as unpredictable or unstable. As they go further
into adolescence, they are better able to control those emotions and approach their problems calmly & rationally.
Cognitive Development
* Adolescence = Formal operations period (Piaget)
* Abstract thinking is present. They are no long restricted to the real and actual and can now think to what’s possible,
they are thinking to what’s beyond the present time.
* Formal operations
* Thinking beyond present
* Mental manipulation of multiple variables, so they can consider time, distance, speed involved when taking a trip.
* They can understand consistency vs. inconsistency. So they’ll notice if you don’t practice what you preach.
* Concern about others’ thoughts and needs. This is when they become more accepting of members of other cultures
and developing their sense of empathy and compassion toward others.
Moral Development
* Internalized set of moral principles (Kohlberg)
- Because they’re trying to gain independence from the adults around them, they want to find their own morals and
values. They’re establishing their own set of moral principles.
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- Ans so they question existing moral values and relevance to society, and how it all fits in to what they’re
establishing for themselves.
- Understanding of duty and obligation, reciprocal rights of others (if they do something wrong, they should make
amend for it). So they begin to connect the consequences of their actions to others around them.
- Concepts of justice, reparation
Social Development
* During adolescence, their social development is going through a big change. One from where they’re going from
being protected by/dependent on their parents to establishing mutual affection and a sense of equality between
them and their parents. The process is difficult and involves a lot of turmoil.
* Goal: to define identity independently from parental authority, emancipation from parents. Some of this may begin
with teenager displaying rejection of parents.
* Because of the turmoil, adolescent may display a sense of ambivalence toward their parents.
* They struggle between having privileges and having responsibilities.
* Intense sociability; if they’re not accepted or don’t establish these peer relationships intense loneliness develops.
* Acceptance by peers; peers become a very strong influence in their lives. Peers become a measurement for them
what is normal. Peer groups provide a sense of belonging, help them to establish feelings of strength and power…
that’s another reason why they’re so important to them. Peer groups become a transitional world between their
dependence on their parents and their own autonomy.
* They choose best friend relationships that are typically with members of the same sex. Those friendships are
important are they’re looking to establish their own identity. In these relationships, each person really cares about
what the other person thinks/feels….Is an important link in process of forming their eventual intimate relationships.
Interests and Activities
* Leisure activities revolve around peers
* Activities allow teenagers to set priorities and structure their time
* Teenagers make use of social media, whose role is prominent in this age group. It allows for instantaneous access
to their peers. Teach parents/child to protect themselves online in regards to what information/identifiers they share.
- Facebook, Twitter, blogs
- Internet chat rooms
- Social networking
- Cyberbullying- is public humiliation
- Sexual predators
Adolescent Sexuality
* Critical time in development of sexuality
* Hormonal, physical, cognitive, and social changes occur that all have an impact on ones sexual development.
Sexual orientation (a pattern of sexual arousal or romantic attraction toward a person of same/opposite/both
genders) is an important part of developing their sexual identity. The development of sexual orientation includes
several developmental milestones that occur during late childhood all the way through out late adolescence. These
include: the realization of romantic/erotic attraction, erotic daydreaming, proceeds on to dates with out sexual
activity, on to sexual activity with people they identify as the preferred gender. They develop a public self
identification of sexual orientation when they have their first public relationship. By age 17, most teenagers have
their sexual debut.
* Sexual activity is common by late teens
* Teenagers begin to identify sexual identity (heterosexual, gay, lesbian, bisexual)
* Relationship between love and sexual expression develops
Self-concept and body image
* Feelings of confusion are common in early adolescence from the sudden growth that occurs
* Teenagers are acutely aware of appearance, compare appearance with those of others
* Teenagers may try to hide their bodies by wearing loose fitting clothes or advertise them by wearing tight clothes
* Blemishes/defects are magnified out of proportion that becomes a major focus for these teenagers.
* The right clothes and hairstyle are very important. They spend a great amount of time in front of the mirror trying to
figure out who they are and what they look like to other people.
* As a nurse, make sure you give them privacy and respect. As you’re doing a procedure, make sure they’re covered
as much as possible. Allow them to dress/undress privately.
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Health Promotion
* Immunizations- meningitis and HPV will be given at 11-12 years of age. A booster dose at 16 years of age for Tdap
and meningitis. Flu vaccine yearly for everyone.
* Nutrition- the rapid increase in height and weight is accompanied by greater nutritional needs. Caloric and protein
requirements are higher. Total fat intake recommended is 25-30%. Caloric intake should be tailored to meet the
adolescent’s increased growth needs and their activity level. Added sugars and caffeine should be reduced.
Reducing the intake of sugars from beverages has shown a significant reduction in BMI in children and
adolescents. Usually meet their protein needs just fine unless they’re anorexic or are having financial hardship.
There’s an increase in need for Calcium (1100 mg/day for adolescents 14-18 years of age), Iron (for expansion of
muscle mass and blood volume), and Zinc (for generation of skeletal and bone tissue) during periods of rapid
growth. Girls with heavier periods are susceptible to iron deficiency. Numerous time commitments may impact their
eating habits. They snack frequently and often these snacks are not healthy. Good nutrition can also be linked to
positive body image in teens.
* Exercise and activity- encourage this. To improve health outcomes, school aged children and adolescents should
participate in 60 minutes or more of moderate to vigorous physical activity daily.
* Dental health- important although the rate of cavity formation is not as great as seen in childhood. Teens should
have regular dental check ups every 6 months. Dental sealants (clear, plastic sealants painted over put and
fissures) are a good way to prevent cavities. Early adolescence is when corrective orthodontics are worn and cause
them embarrassment. They need to be reassured they are temporary. Late adolescence is when third molars
appear. They need to be evaluated to see if emergence of wisdom teeth will shift their teeth back to how they were.
* Vision- regular vision checkups are important. Visual refractory difficulties reach a peak that isn’t exceeded until
person reaches their 50s. Glasses may cause them stress because it changes their physical appearance. If use
contacts, use meticulous hand hygiene when placing/caring for contacts.
* Hearing- excessively loud music, ear bud use may damage ears, use is ok as long as volume is low
* Posture- altered posture is seen, sometimes the rapid skeletal growth is associated with slower muscular growth
and so some teens may appear slumped and may fail to sit up or stand up right as much as they should. Scoliosis
(manifested as a painless curvature of the spine) is more common in girls than in boys. Majority of cases are
idiopathic. Most cases don’t require treatment but there’s no way to predict which curvatures will progress and
require correction. So all of them that are found should be referred for further evaluation.
* Body art- piercing and tattoos, part of identity formation, seek body art as a way to express personal identity.
Piercing should be done professionally to prevent infections, cysts, keloid formation, bleeding. HCV, HBV, HIV are a
risk if using unsterilized needles.
* Tanning beds- tanning is associated with an increased risk for skin cancer, such as melanoma. AAP requires that
children < 18 years of age be prohibited from using tanning beds, even with parental consent.…parents can’t
consent to this. This is the law in Texas. Other skin effects include: skin dryness, pruritus, N/V, photo drug reactions,
disease exacerbations. Many adolescents also may be on Accutane, or other antibiotics that might be given for
acne, which require careful monitoring of UV ray exposure. These drugs makes them more sensitive to UV rays.
* Sex education- Give them accurate, truthful information. Discuss what is being heard from their peers and correct
any misinformation. Teach safe sex. Create an environment where they are comfortable asking questions.
Injury Prevention
* MVA’s/texting- remain the leading cause of death in ages 16-20 years, most vulnerable ages: 15-24. During
adolescence their peak physical, sensory, and psychomotor function really give them a feeling of strength and
indestructibility. Ability to drive combined with the need for freedom/independence make automobiles attractive. Their
lack of experience in driving, phone use/texting, driving while drinking, all contribute to the high mortality rate. Parents
should let child know that it’s ok to call to be picked up if they have been drinking, so as not to drive under influence.
AAP recommends that states adopt a graduated DL system for teenage drivers; where there’s 3 sequential stages
including a learners permit, then an intermediate or provisional license, then a 3rd stage is a regular DL. Also
important to enforce seatbelt use.
* Firearms- major cause of intentional fatal injuries in US. Adolescence is the peak age group for being a victim or an
offender in an injury involving firearms. This has to do with availability of guns in home, which is also linked to
unintentional death in children and adolescents, and increased risks for homicide and suicide. Families should be
assessed for the presence of guns in the home and educated on safety precautions: making sure the firearms are
unloaded and kept in a safety cabinet.
* Sport injuries- overuse injuries are common in adolescents because they feel that they’re indestructible from their
increased strength and vigor. These result in more time missed from the activity than fractures. Teenagers should be
taught about the use of helmets or shoulder/elbow/knee pads in any contact sport.
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Nutritional and Eating Disorders
* Obesity
- Defined as increase in body weight caused by accumulation of excessive body fat in relation to lean body mass
- Obese: generally considered when body mass index (BMI) is in >95th percentile for age, gender, and height
- Overweight: generally considered when BMI is between the 85th and 95th percentile
- Proportion of obese children and adolescents (ages 1-19 years): 17% it is increasing due to poor dietary habits and
sedentary lifestyles.
- 90% of obese teens remain obese into their 30s, setting person up for health problems: T2DM, obstructive sleep
apnea, non-alcoholic liver disease, HTN, hyperlipidemia, depression, low self-esteem, etc. This is one reason why
we do the screenings for acanthosis nigricans.
- Causes for obesity: genetic, environmental, psychological, perinatal factors (mom’s diet and physical condition)
- Treatment: early recognition and intervention: diet modifications through dietician, behavioral modifications,
pharmacological (although this is avoided), bariatric surgery, counseling
* Anorexia/bulimia
- Anorexia: they refuse to eat to maintain a normal body weight resulting in severe weight loss in the absence of
other obvious physical causes. Mean age of onset is 13 years, but can range from 10-25 years or more. This stems
from the preoccupation with self image…what they think they look like to others.
- Bulimia occurs in older adolescents and is characterized by binge eating followed by purging either by laxatives,
vomiting, diuretic abuse, or engage in rigorous exercise. The binging/purging can occur as many as 8 times
throughout the day. This is life-threatening: electrolyte imbalances, etc. Cause isn’t clear, but there’s a distinct
psychological component. Commonly the initiator is dieting and the relentless pursuit to be thin. They actually see
themselves as being overweight: distorted body image. Impact of media is huge. Can be triggered by an
adolescent crisis, like the ending of a relationship, parental issues, etc.
- It’s important that we screen for these disorders. Don’t be afraid to ask questions.
- Physical effects: cardiac, stunt growth, hair, nails, teeth, etc.
- 3 major goals for treatment: the reinstitution of normal nutrition/reversal of malnutrition, the resolution of disturbed
pattern of family interactions, individual psychotherapy to correct deficits or distortions in psychological function,
nutritional therapy sometimes even involving re-feeding via NG tubes, pharmacotherapy, hospitalized if they’re
severely malnourished if threat of death.
- Therapist often establishes a behavioral contract with adolescent; if they feel like they’re getting to a point where
they’ll engage in binge eating/purging, they make a goal to eat a certain amount of calories/day for example. They
will also institute family therapy as well.
Health Problems
* Substance abuse
* starts with experimentation to move away from reality/problems
* teens need to know that it’s ok to say “no”
* Smoking/smokeless tobacco
* we’ve seen a decline in use, peak was in 1999
* although the rate has declined, it’s still the chief avoidable cause of death
* reasons for engaging: imitating adult behavior, to look older/mature, peer pressure (don’t want to be different), to
control weight. Children are less likely to smoke if they are engaged in high performance sports activities and if
the parents don’t smoke.
* Smokeless tobacco is anything placed in the mouth but not ignited. Can cause cancer. Can lead to periodontal
disease and tooth erosion. E-cigarettes deliver nicotine without the tobacco and are marketed to youth. They are
promoted as a safer alternative to smoking, but they have not been regulated by the FDA yet and there haven’t
been any studies showing that they are safe for use. Amount of nicotine varies depending on brand and the
different flavors have been shown to be enticing to the adolescent. Other smokeless tobacco: snuff (ground
tobacco), chewing tobacco, dissolvable tobacco that melt in mouth within 3-30 minutes and are in shape of sticks,
pellets, or strips. The dissolvable tobacco contain 3x more nicotine than average cigarette. All smokeless tobacco
do contain nicotine as well as other chemicals that cause cancer. Smokeless tobacco is very addictive due to the
nicotine and so it’s hard to quit. Craving is one of the signs of addiction. Due to the development of tolerance over
time, more and more nicotine is required to get that same buzz.
* Direct effects of both smoke and smokeless tobacco include: bad breath, dental problems, different cancers,
heart problems, and also nicotine poisoning
* Hookah- water pipes used to smoke tobacco. They come in different flavors. Have the same health risks
associated with smoking and electronic smoking. Water filters out some of the chemicals, but you’re still
absorbing majority of the nicotine which is addictive. It is not a safe alternative to cigarettes. It is more addictive
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than smoking. It is a social activity. Smokers may absorb more of the toxic substances found in cigarettes than
cigarette smokers do because of the prolonged session when using hookah. An hour long hookah session
involves 200 puffs, while an average cigarette involves 20 puffs. Amount of smoke inhaled during a hookah
session is about 9,000 mL, compared with 500-600 mL that are inhaled when smoking a cigarette.
* Acne- Not caused by dirt, but by testosterone that stimulates the sebaceous glands to enlarge and produce oil,
which then in turn clogs up the pores. White heads, black heads, and pimples are often present in teen acne. Half of
all teens experience acne by the end of their teen years. It’s more common in boys. Degree of acne can vary. The
impact of acne shouldn’t be underestimated and can be devastating; affects appearance and self-esteem. They don’t
want to stand out and be different. Adequate rest, exercise, well-balanced diet, reducing emotional stress all play a
part in managing acne, as well as medications: Retin-A (but can be irritating to skin), topical benzoid peroxide (antibacterial agent), systemic antibiotics reserved for moderate/severe acne that doesn’t respond to topical treatment.
Today we see a combination of topical and systemic medicines. Young women may respond to oral contraceptives,
because it reduces endogenous androgen production. Accutane is only used for severe cystic acne that hasn’t
responded to any other treatment. Drug may have SE: adolescents prescribed should be monitored for depression,
suicidal ideation, and teratogenic effects (sexually active women must use effective contraceptive during treatment)
and for 1 year after treatment has ceased, also monitored for elevated cholesterol and TGA levels and liver enzymes
(which you must be fasting for). Significant elevation may require discontinuation of the medicine.
* Depression- common among teens, especially among those who attempt suicide. Depression is characterized by
both subjective symptoms and objective signs that reflect teen’s sadness and despair, helplessness, hopelessness,
boredom, loss of interest, isolation. They may also feel guilty. Be on alert for these signs and anyone who exhibits this
behavior should be referred for thorough psychological depression. It can be manifested differently in teens and in
children than it does in adults. Teens may be able to mask depression by displaying impulsive, aggressive behaviors:
defiance, disobedience, behavior problems, as well as psychosomatic symptoms…can all indicate that there is
underlying depression.
* Suicide- deliberate act of self injury that causes death. Suicidal ideation is the preoccupation with suicidal thoughts.
Suicide attempt is intended to cause death or serious injury. Para-suicide describes behaviors that range from
gestures, verbalization, to an actual serious attempt. Reasons for suicide and depression vary. We know that
teenagers make suicidal pacts. Methods can vary: substances, firearms, hanging, etc. You must assess for these
symptoms and you act on them.
NURSING ALERT!!!
* Adolescents who express suicidal feelings and have a specific plan should be monitored at all times. They should
not have access to firearms, prescription or over-the-counter medications, belts, scarves, shoestrings, sharp objects,
matches, or lighters.
* No threat of suicide should be ignored or challenged. Threats must be taken seriously!
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Fatemeh Sahrapour
MODULE: FAMILY CENTERED CARE & PAIN IN CHILDREN
Readings:
Stressors of Hospitalization/Family Centered Care
Perry: 1109-1125
Informed Consent
Perry: 1130-1131
Pain Management
Perry: 828-860
Family Centered Care
ATI 2013: 2-7
Pain, Hospitalization, Play
ATI 2013: 77-96
FAMILY CENTERED CARE
*What is a Family?
- There is no simple definition. In the most basic of terms, a family is a group of individuals who share a legal or
genetic bond, but for many it means so much more.
- Legal Bonds- this refers to a family that’s legally bound through marriage, adoption, guardians, and includes the
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rights, duties, obligations, and contracts that they entered in to. Legal bonds can be changed, expanded or
dissolved.
Blood Bonds- individuals who are directly related through a common ancestor. These include close and distant
relatives.
*Types of Family
- Nuclear or Conjugal- parents and their children living in the same residence or sharing the closest of bonds
- Extended- includes all the relatives being in close proximity, seen in generations X, Y, Z where relatives live maybe
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not next door to each other, but at least the same city. A family household that is extended, these families can live
together and share household duties. This type of family can also be called a joint family or a multi-generational
family depending on which members are included.
Complex- Is an extended family which has 3 or more adults + their children. It is usually formed through divorce
and remarriage or may be formed through polygamy in societies where that practice is acceptable. Some families
may be complex without formal legal bonds between adults.
Step- Families were adults have divorced and remarried bringing children from other unions together to form a new
nuclear family. Often called a blended family. The children may come from several different parents or may be new
to the family.
Traditional- Classic family, where the father works outside the home to support the members financially while the
mom stays at home and rears the children and takes care of home. There may be a role reversal.
Adopted- Family shares legal bonds but not genetic bonds. But it can also be an emotional or spiritual bond where
no formal legal bonds are present.
Foster- Includes one or more adult parents who serve as temporary guardians for one or more children to whom
they may or may not be biologically related. In time, more formal arrangements may be made. Foster children can
be legally adopted.
*Why Family Centered Care?
- Recognizes that the family is the one constant in child’s life.
- Two basics concepts:
- Enabling- when we can enable a family through education and practice to acquire the competencies they
require to take care of their child, they are able to meet the needs of their family…
- Empowerment- this empowerment returns to the family a sense of control, and this is something we can give
the family, a sense of control that they had lost when their child got sick.
- Two basic things to remember:
- Control
- Communication- when we communicate, we offer education (teaching new skills), we are fostering and honoring
the family’s sense of strength, abilities, and action. It’s the family that will take care of the child upon discharge,
so it’s imperative that we give them these skills, knowledge, and encouragement. Refer to Box 26-3 for key
elements of family centered care.
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- Promoting Healthy Families
- Disease Prevention
- Health Promotion
- The Family is the Driver
- Best Approach?
- Education- it is important that we help guide families through the stages of child growth and development and
milestones of each stage. If we can get problems identifies early, we may get better outcomes.
- Anticipatory Guidance- we do this by helping the family understand the medical treatment and diagnosis,
encouraging the children to ask questions about their bodies and conditions, referring families appropriately to
agencies or support groups, an above all COMMUNICATE!*** And it’s important to understand the different
parenting styles so that we can have this communication with families, to promote family health.
*Parenting Styles/Influence
- Parenting Styles
- Authoritarian- children are expected to follow very strict rules established by the parent and a failure to follow
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these rules will result in punishment. These are the “because I said so” parents. They often fail as parents
because they aren’t giving reasoning to the children about the action, so the children don’t understand why
they’re dong what they’re doing. Parents have very high demands, but the children are just not responsive. The
children are obedient and proficient but often in tests show lower confidence/self-esteem, happiness, and social
competence than other children.
- Authoritative- Like authoritarian parents, these parents do have guidelines that they expect their children to
follow, however they’re more democratic. They’re responsive to their children and are willing to listen to their
questions. They’re more nurturing and when their children fail, they’re often more forgiving and don’t give heavy/
strict punishment. They are assertive, but are not intrusive or restrictive. Their disciplinary methods aren’t
necessarily punitive. They desire their children to be assertive, socially responsible, and cooperative. These
children are usually very happy, capable, and successful in their lives.
- Permissive/Indulging- These parents make very few demands on their children. They rarely discipline their kids.
They have low expectations of maturity and self- control. These are non-traditional parents and are very lenient.
They don’t like confrontation and will avoid it. It doesn’t mean that they’re not nurturing and communicative, but
the problem is that they’re often more of a friend than a parent. It’s almost like they’re living their life through
their children. These children rank low in happiness and self-regulation. They often have problems with authority
and perform poorly in school.
- Uninvolved- These parents also place very few demands on child. There’s not a lot of responsiveness and there
is little communication. They fulfill the child’s basic needs, but are detached. In extreme cases, they may even
reject or neglect their children’s needs. These children lack self-control, have low self-esteem, and are less
competent than their peers.
Parenting Influence- There are key characteristics parents should always exhibit when working with their children:
- Engagement- They need to be engaged, invested in child’s activities, and spending quality time with child.
- Consistency- They must be consistent in what they do with child, and can’t deviate. A child needs consistency,
so that they know what it is that they’re expected to do and can do.
- Validation- This builds self-esteem. Validate their feelings even though to you it seems inconsequential or idiotic.
Remember that a child sees things differently. Validate their fear, letting them know it’s ok to be scared, but you
will work through the fears. Validate other emotions as well.
Parental Guidelines
- Safety- Most important item to address with parents!
- Realistic Expectations- of their children and themselves
- Discipline- how to incorporate discipline into the family setting, knowing when it’s appropriate to use it, focusing
on the importance of consistency, and focusing positive reinforcement and NOT negative reinforcement.
- Children need to be given choices but parents have to be careful in the choices that they offer. The influence
that they have is tremendous. We know that children who spend a lot of time with parents are directly influenced
by their behaviors, choices, and beliefs.
…Now we can address family-centered care of the pediatric patient who is ill…
*Family Stressors
- Remember their child’s illness may be the very first crisis a family faces. The crisis is dependent on the family and
their reactions:
- Severity of illness?
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- Frequent Flyer? Do they have previous experience with illness/hospitalization. Sometimes if they know what to
expect, it can be a stressor because if something different happens, then they know disease has progressed.
- Medical Procedures involved?
- Coping Abilities? What are their personal strengths? Does the person have a family/support system. What other
stressors are on the family system?
- Cultural/Religions Beliefs?
- Common themes we see in families with hospitalized child- families become helpless, they question the skills of
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the staff (they may ask the same question to several different staff members until they get the answer that they
want), they don’t understand explanation/hear it because they’re stressed so you have to consistently reinforce
teachings, they need simple explanations, they need their fear and uncertainty respected, they need
reassurance, they need to see staff being compassionate & concerned for their child, attending to every detail.
Sibling Response- The sibling’s lives have all of a sudden turned upside down. They become scared, lonely, and
angry. They start noticing their parents pay more attention to the sick child and become jealous and resent their
sick sibling for it, then they feel guilty for that jealousy. Their behavior often regresses to that of a previous
developmental stage. It’s ok for example, to put a child that has just been potty trained back in diapers if they
regress because it lowers the stress level lot parents. These children need someone to be talking to them about
their sibling’s situation because they are emotionally stressed about it.
*Children and Hospitalization…..
- Young children as patients are so vulnerable to stress and are so use to routine and may not have the coping
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mechanisms necessary to deal with this new situation. They experience parental separation, loss of control, and
they don’t feel well and don’t understand why, and don’t understand fear. Their parents experience fear of what’s
happening to their child, guilt, confusion, loss of routine, and loss of control.
Let’s see how different aged children react to hospitalization, remember there are short-term and long-term
negative outcomes.
- The most common things we see: regression, separation anxiety, apathy, fear, sleep disturbances especially in
children < 7 years of age.
- Other factors that make hospitalization difficult: child with a difficult temperament (what is their age? If they’re 6
months - 5 years of age they’re typically more temperamental), gender, do they have a low average IQ?,
frequent flyer syndrome?
Infants- pain is not localized but generalized to them and they are totally in pain, we have to make sure to relieve
this pain, they have a loss of routine, sleep deprivation, and vulnerable immune system because many of them are
too young to have had their vaccinations.
Toddlers
- Have the basic fear of the loss of their love, the unknown, they wonder if they’re being punished, the
immobilization and isolation will influence their physical and psychosocial development, can regress to earlier
behaviors, and will go through the stages of separation anxiety.
- Separation Anxiety, review box 31-8 in text book.
- Protest- they will not be consoled by the parent, they want to go home, and reject strangers or new nurses
- Despair- they’ll enter despair, their sleep pattern will alter, they’ll lose weight because they won’t eat, they’ll
have diminished interest in play, they’re sad and unresponsive to stimuli
- Detachment or Denial or what’s going on- they won’t even acknowledge their parents, and they’ll be friendly
to other people who come along
Preschoolers- they’ll have fears about their body image and bodily harm, have a limited understanding of what’s
going on, their fears are about intrusive things like IVs or shots or tubes, they have the same perception of
punishment and rejection, they worry about pain and that they won’t look the same, they also regress, they view
death as temporary, they cry when their parents leave (separation anxiety) but they’ll calm down after they’re gone,
may find physical exams threatening and so you may have to modify your procedures (remember they’re very
concrete thinkers so be careful with how you speak to them and explain procedures. You really do have to prepare
them for interventions because they have increased understanding).
School Age- They can tolerate separation but really want their parents to be near. They also fear the unknown,
bodily harm and disfigurement, the concept of death changes at this time (from age 6-8 they think of death as the
boogie man and from 9-10 years they have a more realistic concept which can add to their fears), they’re very
concerned about their self-image and may even use avoidance to cope with physical discomfort. They want to
know what’s going on, the rationale, and want to participate in self-care…Give the information they’re asking for on
a level that they can understand.
Adolescents- Be honest with them. They have concerns over privacy, their sense of control, and independence.
They are very concerned about their body image and being different than their peers. Any developmental problems
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that they may be going through may be magnified by their illness. They can also be non-compliant. They worry
about the future. We must empower them as much as possible and allow them choices as appropriate.
*Family Centered Care: The Good, The Bad and the Ugly………..
* What happens to parents when they don’t know......
* You have the power to make a difference!
*Prepping for Hospitalization
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Prevent and minimize separation from parents
Make their room a home away from home! They can have things in room that will help them be more comfortable
Minimize everyone’s loss of control
Promote freedom of movement, particularly with adolescents
Maintain child’s routine as much as possible, talk to parents about this
Encourage independence, for example with their self-care
Help them understand what’s going on! Talk in simple language and be straight forward.
Promote Play to teach the child. This will also often help parents learn what’s going on. For example, when taking
their BP, tell them you’re going to give their arm a big hug, and let them pump it up. Demonstrate things you’re
dong. Distract the child. Use the treatment room as appropriate, so that you keep their room a “Safe” place.
Provide opportunities for play that are developmentally appropriate.
Prevent and minimize fear about pain and imagery (e.g. isolation rooms in the ICU can be very scary!)
…Hospitalization can also have positive effects: it can strengthen the family relationship, it can offer educational
opportunities, can help a child become independent and self-reliant and gain self-mastery.
*Cultural Competency
- With FCC we need to be sensitive to cultural differences. Remember that culture refers to a particular group with
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it’s own set of values, beliefs, norms, patterns that are learned, shared, and transmitted from one generation to
another.
Be aware and appreciate cultural values of patient and family. Be sensitive to their needs.
Have knowledge of cultural values.
Skill in collecting data that is important in working with families of different culture
Aware that encounters can happen indirectly or directly
We must have the desire to be engaged and sincere in wanting to learn more about other cultures
Be aware that there may be rituals, diets, and alternative therapies that are important to family in care of the child.
This thought process must extend to spirituality, and the need to be aware and sensitive of dealing with other
religious beliefs and practices
—> So…familiarize yourself with the information. It is always about communication and never forgetting – the patient
is the priority (and their family!)
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PAIN IN THE PEDIATRIC POPULATION
• Children have a right to adequate assessment and management of pain
• It is your role as the nurse to
• Advocate for the child
• Educate patient and family in regards to pain control
➢There are very few encounters with healthcare providers that do not result in either physical or emotional pain. So if
we can control their pain and relieve their fears early, then they’ll have better experiences in the future.
➢The type of pain children experience includes:
➢procedure related pain
➢operative and trauma associated pain
➢acute or chronic pain from illness or injury
➢Pain assessments should be performed and recorded frequently by the nurse. Pain should be considered 5th VS
• During childhood the prevalence of pain depends on child’s ongoing health status.
• Most healthy children receive more than 20 immunizations before 2 years of age
• If the child is born with health concerns, the number of painful encounters can reach into the hundreds. So it’s
important to know the child’s past health history, how long they’ve been in the hospital, what they’ve experienced,
and what their pain tolerance has been in the past, and what works best for them according to what they’ve been
through. Ask parents, they are good historians and can tell you what works best for the child.
• Research suggests that pain is untreated or under-treated in children and is related to:
•Inconsistent practice in pain assessment
•Administration of analgesics at sub-therapeutic levels
•Prolonged intervals between medications
•Lack of monitoring and evaluation of relief
•So as a nurse, it’s important for you to assess, plan, implement, and evaluate. Always assess patient’s pain level 30
minutes before you give medicine and around 30 minutes-1 hour after you give medicine to see if it’s effective or not.
If not, contact physician to alter medicine.
What is Pain?
•Pain is whatever the child says it is and exists when ever a child says it does!
•So pay attention to children: look at them objectively, listen to them subjectively in regards to their description of pain
•If a procedure is invasive it will hurt whether the child tells you it does or not. They require the same treatment.
Pediatric Pain Experiences
• Procedure-related pain such as dressing changes, IV line placement, PT sessions w/out adequate pain control.
• Operative pain
• Trauma –associated pain
• Acute and Chronic pain from illness or injury
• These can all influence a child’s future response to pain.
• Fear and anxiety have a large effect in pediatric patients, which is especially true in procedural pain. So we want to
make sure to provide adequate analgesia, especially for the first procedure as this will highly influence future pain
perception for child.
Assessment of Pediatric Pain
• The child’s report of pain is the most reliable diagnostic measurement of pain
• Behavior and physiologic measures are also used to evaluate pain in infants, non-verbal children
• Individualization is the key!! Pain assessment and treatment is individualized and not one patient is the same.
• Know your options; if the medication ends up not working on your patient, then know what your back up is. You must
tailor your care according to your patient’s response. And in order to know how they’re responding to that
medication, you must evaluate them.
Influential Factors in Regards to Assessing Pediatric Pain
Always take into consideration the child’s:
•Age- can influence how pain is perceived and communicated
•Developmental level
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•Past experiences with pain- can affect their future perception of pain, so control their pain well the first time
•Socio-cultural differences in attitudes toward pain and how child expresses pain
•Anxiety, Fears, and Fatigue- can all increase sensitivity to pain
•Cognitive impairment- may affect child’s ability to report pain accurately
•Family and friends may decrease sensitivity to pain by staying with the child
•Personal genetic wiring for pain
Pain Free Me
• Takes a multidisciplinary approach
• Nurses must utilize proper assessment techniques and tools
• Work closely with:
• Physicians
• Pain Specialist- Pediatrics Pain Team
• Anesthesia
• Child Life Specialists
Ranges of Pain
• Pain level ranges from a scale of 0 - 10
❖The patients pain score will determine the appropriate intervention
• Mild = 1-3, we treat non-pharmacological methods
• Moderate = 4-6, give medicine
• Severe 7-10, give medicine
• We will actually combine pharmacological with non-pharmacological treatments to get patient best pain relief
Facial Response to Pain in the Neonate
- Also important to pay
attention to patient’s body
movement and whether they
are consolable or not. They
give you clues in regard to
how they’re feeling.
- In older children it’s important to note if their body posture matches what they’re telling you. Some kids don’t want to
verbalize their pain because they’re scared they’ll stay in the hospital longer. Some kids, will do the opposite that
report that they’re experiencing the worst pain ever, and yet are playing video games, etc. It is not your job however
to refute what patient is saying. So see what they’re allowed to have based on their pain rating. Also start with your
non-pharmacological methods, then progress to pharmacological methods of treatment.
Various Pain Scales Available
Because the assessment of pain in children is complex and challenging, there are various pain scales to help…
• Become familiar with what your hospital uses
• Pain scales will be different depending on what unit you work on and what age child you are caring for; so consider
if patient is non-verbal in which case different scales will be used
• Remember pediatrics goes from infancy through young adulthood
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Various Neonatal Behavioral Pain Scales
• PIPP- behavioral measure of pain for premature infants
• CRIES- (neonatal post-operative pain scale) pain is rated on a scale of 0-10, and the behavioral indicators include
crying, changes in VS, expression, and altered sleeping patterns. Can be used for 32 weeks of gestation to 20
weeks of life.
• NIPS aka N-PASS— used to measure pain in pre-term and full-term neonates.
• NFCS- used for assessing post-op pain in infants
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Other Behavioral Pain Scales
• Useful for measuring pain in infants, preverbal children, & those with limited ability to communicate
• FLACC- measurement used to assess pain for children between the ages of 2 months and 7 years or individuals
that are unable to communicate their pain from post-operative pain
• COMFORT (ICU settings)- also used for infants.
Pain Rating Scales for Children
• Children from 3 to 7 years of age may comprehend how to use a pain rating scale
• Visual report scales can be used for children > 3 years of age:
•FACES- uses drawings of happy or sad faces to depict levels of pain
•VAS (visual analog scale)- used for ages 7 years and older, but may be effective in children as young as 5
years old. These rate pain on scale of 0-10, and the child points to the number that best describes their pain
•OUCHER• Ages 3-12 Years
• The OUCHER scale is an ethnically based self-report tool. This tool has 3versions: Caucasian, AfricanAmerican and Hispanic. Although this covers a wide variety of patients, it still has limitations - females
are not represented nor are several other cultures. When a child does not fit into one of the three
cultures listed, he or she should be allowed to pick which scale they prefer. Generally children at the
age of five can use this tool, although some children as young as three are able to use this tool.
• When introducing this tool, be very specific with the words you choose. Ask them to state exactly
where the pain or hurt is. Be careful not to use the words 'happy' or 'sad' to describe their pain or hurt.
"Johnny, this is my poster called the OUCHER. It helps children to tell me about their hurt. Do you
know what I mean by "hurt"? (Have the child explain). This picture (point to the bottom picture) shows
'no hurt', no hurt at all. This picture shows just a little bit of hurt (point to the second picture), this
picture shows a little bit more hurt (point to the fourth picture), this picture shows pretty much hurt
(point to the fifth picture), and this picture shows the biggest hurt you could ever have (point to the sixth
picture)." With older children the words can be modified to say 'pain' instead of 'hurt'. Ask the child to
point to the picture that is most like their hurt. Chart the number corresponding to the selected picture.
If a child points in between pictures then the number corresponding to this area should be charted.
•WONG-BAKER
Objective Data for Nurses to Assess in Evaluation of Pain
• Facial expressions (grimace, wrinkled forehead, eyes closed shut)
• Body movements (restlessness, pacing, guarding)
• Moaning and crying
• Decreased attention span
• Vital signs- it won’t be the thing that decides pain exists, rather we use these objectives as part of the whole
package in determining patient’s pain level
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Subjective Data for Nurses to Assess in Evaluation of Pain: Questions to Ask
• Adapt questions to appropriate age and developmental level of child!!! Also depending on how the child describes
the pain, the specific words that they use, you may want to use those words back to them.
• “When did your pain start?”
• “Where is your pain?”
• “Can you rate your pain on a scale of 0-10?”
• “What makes the pain worse?”
• “What makes the pain better?”
• “Does it hurt anywhere else?”
• “What does the pain feel like?”
Physiological Signs of Pain
• In the acute phase, pain affects many systems within the body and causes:
•Increased heart rate
•Increased blood pressure
•Diaphoresis
• The body’s normal response when revved up is to calm down
• So patients who have chronic pain will not continue to have the same physiological response to pain as they would
if they had acute pain
• Therefore VS alone should not be used to rule out pain
• It’s important to look at the whole picture when evaluating their pain level: objective data, subjective data, and
physiological measurements
Pain Management
• Unrelieved pain can lead to potential long-term physiological, psychosocial and behavioral consequences
• So we must use both pharmacological and non-pharmacological measures to reduce our patient’s pain
• Non-pharmacological measures can help reduce perception of pain, decrease anxiety & provide a sense of control
Non-pharmacological Measures Used in Pediatrics
• Positioning- make sure they’re comfortable and not lying on side where they had surgery, use pillows to guard area
• Reinforcing breathing and relaxation techniques
• Providing ice or heat (whichever they prefer) to swollen or injured area
• Maintaining a calm environment (low noise, reduced lighting)
• Music therapy
• Pet therapy- has been shown to decrease patient’s pain, anxiety and increase their healing
• Splinting- is the stiffening of a body part to avoid pain caused by movement of the part, as from a fracture or other
injury. again use pillows for positioning
• Cluster your care
• Offering warm blankets
• Assisting with guided imagery
• Offering distractions (video games, cartoons, videos)
• Providing comfort with physical contact (holding, rocking)
• Administering sucrose pacifiers for infants during procedures
…Interventions should be determined in conjunction with the family and the child. The severity of the pain will also
guide the choice of treatment in regards to pharmacological management
Various Routes of Pain Management
• Oral- We start with oral route when possible, but we have consider if patient is NPO, intubated, etc. —> IV
• Tylenol- for mild to moderate pain
• Ibuprofen- for mild to moderate pain
• Tylenol #3- combines Tylenol with Codeine, for moderate to severe pain
• IV
• Morphine- for severe pain
• Fentanyl- for severe pain
• Dilaudid- for severe pain
• PCA/PNCA- patient, parent, or nurse controlled analgesia
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• Morphine- moderatet to severe pain
• Hydromorphine- moderatet to severe pain
• Fentanyl- moderatet to severe pain
Epidural
• Ropivacaine
• Levobupivacaine
Refrigerant sprays (cooling sprays)
• Ethyl chloride
• fluoromethane
Transmucosal
• Oralet (Fentanyl)
Transdermal
• Fentanyl or Morphine patch- know where it’s located on your patient and how often it needs to be changed
Topical
• EMLA
• LMX
Pharmacological Management
• Non Opioids: for mild to moderate pain or in addition to opioids for severe pain
•Acetaminophen is very common and is available IV, PO and PR (suppository)
• Non-steroidal anti-inflammatory drugs (NSAIDS) used for mild to moderate pain, they do put patient at risk for
bleeding so get a baseline CBC and monitor for any bleeding•Ibuprofen
•Ketorolac
•Naproxen
• Opioids: for moderate to severe pain
•Combination of Acetaminophen and Codeine= Tyenol #3. It’s important to remember that there’s a limit to
how much Tylenol a patient can get. Know how much your patient takes/day. Combining an opioid and nonopioid medication treats pain peripherally and centrally, offers greater analgesia with less adverse effects like
respiratory depression, constipation, or nausea.
•Morphine is the gold standard and most commonly prescribed
•Hydromorphone
•Fentanyl
•Methodone
•Tramadol
•Meperidine
• PCA- Patient controlled analgesia
• Widely used to manage acute postoperative pain, pain from injury, and chronic conditions
• There’s a form to fill out to set up a PCA. It is a 2 nurse check
• Know how doctor orders PCA: can be patient, parent, or nurse controlled. Must be written explicitly.
• Consists of programmable pumps and activation buttons
• MD has to order the following:
• Medication to use. The most common in a PCA pump: Morphine, Fentanyl, Dilaudid, Hydromorphone
• Program settings: PCA only (where patient can push it), PCA + basal (a slow, steady dose), basal only
• Medication infusion rate/dose
• Bolus volume- if a patient is allowed a bolus for breakthrough pain
• Maximum allowable hourly dose
• Lock out time- that patient has to wait before being able to push the administration button again.
• Narcotic Side Effects:
• Respiratory Depression #1- it’s important to have room set up ready to manage patient if they have distress.
The items you need include: Ambubag, mask, and O2. Also it’s important to have any antidotes on hand.
Remember Narcan is the antidote for narcotics. So it’s important to know what class of meds you’re giving.
• Constipation- order a stool softener, monitor bowels and make sure they’re drinking plenty of fluids
• Nausea/Vomiting- can give medications before giving them narcotic that will alleviate this: Phenergen, Zofran
• Dizziness- tell them to get up slowly, rest both feet on ground before standing
• Itching- can have MD prescribe Benadryl
• Increased sleepiness- can be from too much Benadryl, so we can adjust the dose
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Hope for the Best…Be Prepared for the Worst
❖All patients receiving narcotics should be placed on a cardiopulmonary monitor and continuous pulse oximetry to
monitor for respiratory depression
❖Always have the following at the patients bedside:
• 15 L oxygen flow regulator
• Various oxygen delivery devices (nasal cannula, simple face mask)- depending on what spO2 is
• Ambu bag with appropriate size face mask- Need at least 15 L to fill up Ambu bag that will be attached to O2
flow regulator
• Code sheet- because patient could go into respiratory and cardiopulmonary failure due to narcotics
• PRN order for Naloxone (to reverse narcotic) if respiratory depression does occur
Evaluation of the Effectiveness of Pain Therapy
• You will not know how effective the treatment is unless you evaluate the patient!! Patient should be evaluated 30
minutes to an hour after administration for effectiveness.
• If pain regimen not effective then it needs to be changed!!
• Remember what works for one patient may not work for the next!
• Know the options available and you need to know safe dosages
Remember…
• It is your responsibility as a nurse to ensure that your patient does not suffer from untreated pain or from pain
inflicted during procedures. You can combine pharmacological and non-pharmacological options for good pain
control.
• Even the smallest child deserves the best pain control that can be safely achieved!
• It is important to obtain a good history and perform a thorough exam. Use valid pain scales and functional
assessment tools. Partner with patients and their families to manage pain and determine goals. If patient can’t
communicate, look for the behavioral cues like: restlessness, body tension, etc. Provide patient with research
backed alternative modalities. Believe your patient! Remember pain is what patient says it is and occurs when they
say it does.
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Fatemeh Sahrapour
MODULE: PHYSICAL ASSESSMENT OF THE PEDIATRIC PATIENT
The goal of this module is for the student to adapt general principles of history taking and physical assessment to the
infant and child.
Readings:
Physical Assessment of Child
Perry: page 790-827
Communication in Pediatrics
Perry: pages 771-790
Physical Assessment
ATI 2013: pages 8-22
OBTAINING A CHILD’S HISTORY
- We need to take child’s health history and physical assessment; physiological, psychosocial, and developmental. Be
alert to verbal and non-verbal cues. Focus on specific areas depending on reason of admission. Try to create an
environment and routine in the hospital that reflects one that they’re used to at home. Introduce yourself to parents
first so that the child doesn’t think you’re a stranger.
Communication
• Building a rapport is important.
- Use of effective communication.
- Avoid: socializing which can block communication, giving advice, offering premature reassurance, giving overready encouragement, defending a situation or opinion, using cliches or stereotypical comments, limiting
emotional expression by asking directed or closed-ended questions (you want open-ended questions to find out
more about a child), use closed ended questions in an emergency when you want to find out specific
information quickly, avoid interrupting, etc.
- Strategies to assist in data collection
- Introductions- Introduce yourself and ask patient what name they prefer to be called.
- Purpose- define why you are doing this interview
- Privacy
- Focus- remove any distractions as possible, and focus your questions asking for a specific response
- Involve child- start out by talking to a family member to help child gain trust. Ask direct age appropriate
questions to the child.
- One question at a time- this will give you more accurate responses
- Honesty- it is the basis for trust between the two parties
- Style of language- try to understand what child is trying to tell you, ask for clarification if needed
- Interpreter as needed
• Listen Carefully- what is the tone and is it congruent with what is being said. Are other issues coming up that need
to be dealt with?
Data to Collect
• Patient Information• Watch for non-verbal cues. If they’re uncomfortable answering questions, explain why the information is
important to collect. If having the information isn’t urgent, you can return later
• Collect: Who is the guardian of the child?
• Physiological Data
– Chief complaint- Record this in their own words. Is there more than 1 problem? What made the person
seek help now?
– History of present illness? Have information presented in chronological order. You can reference as: “Prior
to admission”. Include: date, precipitating factors, onset, what made it improve/worsen, etc.
– Past history- The perinatal history is more important the younger the child, so what was mom’s pregnancy
like? Was it a vaginal delivery or C-section? Was the patient in the ICU? How much did baby weigh? What
childhood illnesses have they had? Chicken pox, etc.
– Current health status- What meds are they taking right now? Are immunizations up to date? Allergies?
• Psychosocial data- family composition, living arrangement, safety in the home, car safety, etc.
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• Developmental data- birth weight to present weight, how old were they when their teeth started coming in, when did
they have had control, when did they walk, what were their first words, scholastic achievement, how do they interact
with peers, habits such as pica (eating of non-food items that can lead to lead poisoning) or sucking their thumb,
use of drugs, stool/urination patterns, etc. Compare to what the parent says about the child’s milestones vs what
you’ve assessed/know to be true.
• Review of systems- Good chart on page 774 on things to look for when doing a review of systems. This is data
obtained when talking with child or parent. Touch upon every body system. Data collected this time will guide you to
a more thorough and focused assessment.
Assessment: Physical Examination
http://youtu.be/8gnO4Py0_08
- The physical assessment process begins the moment you see the child. The purpose is to help you with the plan of
care and help you obtain baseline data information. Determine based on the age of the child if it’s best for the parent
to stay or for you to do the exam alone; usually the parent likes to stay and this is preferred. Make experience as nonthreatening as possible for child and parent.
General Appraisal
• Height- is measured without shoes.
Need a height or length for every child,
to plot them on growth curve or to
calculate the dosage for those drugs
that are based on body surface area.
This measurement is often called a
recumbent measurement because
they’re lying down until up to 36
months of age, after which can stand.
• Weight- use the same scale, with no
clothes on for an infant, and some
clothes on (usually just the underwear)
for the older child.
• Head Circumference- done from
child’s first through 36th month of life,
and sometimes until their 5th birthday
if child has an underlying condition that
required us to keep track of the growth of baby’s skull, such as spinal bifida, fracture, increased intracranial
pressure. Measure at widest part of occipital, to above ear and above brows. Use paper or metal measuring tapes
because cloth stretches.
• Chest circumference- is measured at the nipple line
• Abdominal circumference- measured at the umbilicus- for example, for babies who’ve had surgery you want to
make sure everything is flowing through the gut as it’s supposed to
• Vital Signs- Approach• Assess VS when infant is quiet. If this isn’t possible, then document what was going on when you took VS
• Generally best to count respirations first (before infant is disturbed), then pulse, then temperature
• Temp – record route. The most accurate temp methods are Oral and Rectal. The temporal and tympanic
are good for screening to see if they have a fever, but not for accurate measurements. It’s important to use
the same route and method for consistency. Use Centigrade; normal is 37 degree C via oral route. Axillary
temp can be used on a child of < 4-6 years of age & any uncooperative, immunosuppressed, neurological
impaired child, or one whose had oral surgery. Leave for 5 minutes in middle of axilla with one arm close
to chest. Hold child in arms to take it. Oral: for 5-6 years of age. Leave under tongue for 3 minutes. No
liquids 30 minutes before. Rectal: use only when no other feasible route due to risk of perforation. Use a
lubricated thermometer for 1-2.5 cm for 2-5 minutes. Contraindicated in neonate, immunosuppressed
child, diarrhea, or bleeding disorder. Tympanic: point in mid canal between opposite eye brow and side
burn, straighten ear canal so sensor measures heat from ear drum and not sides of canal. In infants the
ear canal points upward so you have to pull the pinna of the ear downward and back. Children ages 3 and
older have canals that point downward and forward, so pull pinna up and back.
• Pulse – must get apical pulse on infants 2 years and younger, and also preferred on all other children if
possible. Count for 1 full minute. You can use the 30 seconds x 2 method for measurements that follow
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that initial assessment. Compare radial and femoral pulses at least once during infancy to detect the
presence of a circulatory impairment. Record child’s behavior when you took the pulse.
• Respirations – Count for 1 full minute. Record child’s behavior at time of assessment. Infants are
diaphragmatic breathers.
• BP – Use the correct sized cuff, measure in both upper and lower extremities at least once to make sure
the BP is the same and there isn’t a heart deformity (to detect cardiac abnormalities such as coarctation of
aorta). In the child it may not be possible to hear the diastolic pressure, you may hear it at 0. For a child 12
years or less, record the diastolic pressure at the first muffled sound heard. For a child 13-18, record the
diastolic pressure as the disappearance of sound. When you can’t hear the BP on a child, you can inflate
the cuff and palpate the pulse; note when the pulse is first felt (this is systolic BP).
• Record behavior (again, were they crying when you took the VS)
• Do not want to be in hurry. Parents appreciate calm, easy way with child. Avoid invasive procedures when you
can, such as rectal temperatures.
• Children take words literally, so explain things simply and use words they understand. For example: When
taking their BP say “I’ll give your arm a hug”. When taking their temperature say “Let me see how hot you are”.
When taking their HR say “Let’s see if we can hear your heart making noises”, let them listen as well with your
stethoscope. Give them choices so that they feel in control, but only 2 options, those that you can live with,
such as: “What arm should I use?” See if they want to help you, and if so praise them for doing that. If they
want to sit in their mother’s lap, that’s ok.
Skin and Hair
• Skin color
• Note variations, mottling, bruises. Bruises are common on shins, knees, and lower arms. If they’re in other places
and are in various stages of healing, you might suspect child abuse.
• Freckles common with white babies
• Mongolian spots found on dark-skinned infants, which is usually a patch of darker skin over the buttocks that
looks like bruising. These fade over time.
• Observe buccal mucosa and tongue to confirm color change; usually pink regardless of skin color. Press the
gums lightly for 1-2 seconds to detect an unusual color. Jaundice in the gums or sclerae of the eyes is associated
with liver damage. Cyanosis can be associated with respiratory and cardiac disorders.
• Palpation
• Temperature- usually cool to touch, use the back of your hand,
• Texture- usually smooth and soft
• Moistness- usually dry to touch, excessive sweating without crying or exercise could be an endocrine disorder or
congenital heart problem.
• Turgor- Used to assess dehydration status or edema. Skin turgor is one of the best indicators of hydration status.
In the child and baby this is measured in the abdomen. Pinch a small amount on abdomen. Poor turgor is when
skin tents or stands up. There should be a quick return post-pinching to previous contour. For edema press
against the bone for about 5 seconds, release and see how rapidly indentation disappears. If rapidly, then nonpitting. Slow disappearances indicate pitting which is associated with kidney or heart diseases.
• Capillary refill- determines the adequacy of tissue perfusion. It is usually < 2 seconds.
• Skin lesions
• Hair inspection- any areas of hair loss? ringworm? check for lice: comes from a direct exposure of another child that
has infestation of lice in their hair. Eggs hatch in 6-10 days, then cause pruritus and itching. Nits can be found
behind ears, nape of neck, and on hair strands. Pull and part hair to look for these. Also look for unusual hair
growth, like on the spine which may indicate a spinal deficit.
Skull
• Usually round with predominant occipital in infants.
• Head control- Usually the child starts to hold the head erect by 2 months. By 4 months, should be able to hold up
head erect in the midline. If unable to do this at 6 months, then further investigation is needed for cerebral or neck
muscle injury.
• Shape changes as child matures
• The head circumference is measured until 3 years of age and maybe older when child has :
– Hydrocephalus
– Microcephaly
• Inspect facial expressions for symmetry
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• Palpate skull of infant. The anterior fontanel is usually at 5 cm at 6 months of age. Then gets smaller and closes
around 12-18 month of age, and sometimes at 24 months. The posterior fontanel closes between 2 and 3 months
of age. It should be flat and firm. If child has a tense, bulging fontanel this could be indicative of increased ICP or
the cild could be crying. If the child has a soft, sunken fontanel this is indicative of dehydration. Abnormal softness
of the skull may be normal in the first 6 months because of incomplete ossification of the bones or widened sutures.
If persistent, this could be indicative of hydrocephalus or Ricketts. Craniosynostosis is marked asymmetry, head is
misshapen and could be due to premature closure of sutures.
Eye Structures
• Size and spacing- should be the same size, look for bulging with retracted eye lids which might indicate a tumor or
a sunken appearance which indicates dehydration. Hypertelorism is widely spaced eyes that could be normal or a
sign of an endocrine disorder.
• Eyelids- pull down and look at conjunctiva which should be pink and glossy. Ptosis or drooping eyelid could be
injury to an eye nerve. A sunset sign is where the sclerae is seen between the upper lid and iris and indicates
retracted eyelids or hydrocephalus.
• Eye color
• Pupils- also use PERRLA on infants. Are they round, clear, equal in size, reactive to light? The cranial nerves 2, 3,
4, and 6 innervate eye structures. For pupil respond to light: after shining a light in to one eye, a brisk constriction of
pupils is normal. For accommodation (CN II): look at a near object, then look at a distant object. The pupils should
constrict with near objects and dilate with distant objects. Tiny black marks in sclerae of heavily pigmented children
are considered normal
• Eye Muscles
• Extra-ocular movements- test by holding an object and move through the 6 positions, watching the child’s eyes
as he follows. This tests CN III (Oculomotor), IV (Trochlear), VI (Abducens). The eyes should move together.
• Corneal light reflex- shine light on child’s nose between the eyes. Reflection on the cornea should be equal in
each eye.
• Cover-uncover test- we shouldn’t see any movement in either eye during this test.
• Vision Tests
• Blink reflex on infant- moving the hand toward the baby’s open eyes a quick blink is normal
• Tracking object- a baby should be able to follow an object that’s held 6 inches from their face. If visual fixation
and following are not present by 3-4 months of age, further ophthalmic evaluation is needed.
• Vision charts- different vision charts exist
• Ophthalmoscope- MD or NP perform this assessment. The optic disc margin should be sharply defined, round,
and yellow to creamy pink. Blurring could mean increased ICP.
• Strabismus- cross-eyed, or one eye deviation when looking at an object. This lazy eye needs to be corrected
by age 4-6 or amblyopia can occur (is blindness from disuse of that eye or when vision in one of the eyes is
reduced because the eye and brain are not working together correctly). We test for this when doing the coveruncover test and the corneal light reflex test.
Ear Structure
• External ear- low set ears are associated with renal
disorders. The ears and the kidneys are formed
near the same time in utero. To determine this,
draw a line from the corner of the eye to the
occipital protuberance of back of head. If the top of
the pinna meets the line, the ears are low set.
• Drainage?- clear or blood-tinged could be CSF
caused by basilar skull fracture. Don’t irrigate ears
if discharge is present.
• Hearing assessment- shake a rattle next to each
ear to see if head turns to sound. Use Whisper test
for a toddler. An abnormal reaction is when there’s
no reaction to a loud noise, no turning to sound at 4
months, babbles with no speech sounds, and no
speech by age 2.
• The age of child in the picture of the right is > 3
years because the canal is curving down.
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Nose and Sinuses
• External nose- determine if there is pain or tenderness upon palpation. Should be none.
• Nasal patency- nasal flaring should not be present. Breathing should be noiseless. Obstruction in children is
common. If they’re struggling to breathe, there may be nasal obstruction present. Use bulbed syringe to suck out
drainage from their nose.
• Smell assessment- Tests CNI (Olfactory), usually done on older children. Alternate odors with child’s eyes closed.
• Internal nose
• Mucous membranes- should be damp and pink
• Nasal Septum- should be straight
• Discharge?
• Sinuses- especially in older children, sinus problems may result in HA, pain, or swelling around one or both eyes.
Mouth, Teeth, Throat & Gums
• Lips- look to see if they’re pale or cyanotic, which is an indicator of poor tissue perfusion.
• Teeth- how many are present? cavities? etc. Babies should start teething before 6 months of age.
• Odors- Does their breath smell sweet like that of a diabetic acidosis patient. Is it a bad smell indicating infection? or
just poor hygiene?
• Gums- normally pink, inflammation and tenderness could be from an infection or poor nutrition.
• Sucking Reflex- is it present?
• Buccal mucosa- is normally pink.
• Tongue- normally pink and moist. Look for thrush (white adherent patches on palate or buccal surfaces). Tongue
should move in all directions to help with speech.
• Palate- inspect using a tongue blade and light. Have infant suck your little finger.
• Tonsils- Should be pink without exudate. Fissures may be present from previous infections.
• Gag reflex- usually done at end of exam because it’s unpleasant. As child says “Ahhh”, watch the uvula go up and
down. This tests CN 9 & 10. Moistening the tongue blade will lessen the tendency to gag.
Neck
• Inspect neck- assess for size, symmetry, swelling, or abnormality. A short neck with skin folds and no swelling is
normal for infants. Head control is seen at 2 months of age; when lying on their stomach they can raise up their
head. Look for webbing; if present could be Turner’s Syndrome.
• Lymph nodes- Palpate just as in adults, around ears, along jaws, occipital area, cervical chain in neck. Seeing if
they're enlarged, warm, firm, or tender indicating a
presence of a local infection. They should be firm, clearly
defined, non-tender, and slightly movable up to 1 cm.
• Trachea- palpate down the front of the neck to determine
position. Normally it’s in the midline. Deviation could
indicate a tumor or a collapsed lung.
• Thyroid- lobes can only be felt if they’re enlarged.
• Range of motion- Touch the chin to each shoulder, chest,
and then look up to the ceiling
• Torticollis- persistent head tilting from a birth injury to
the sternocleidomastoid muscle.
• Brudzinski Sign- pain with flexion of the neck toward
the chest. The stretching of the meninges is indicative
of meningitis.
Pediatric Respiratory Differences Compared to Adults
• Children have a more narrow airway than adults. This
causes an increased in airway resistance that causes an
increased effort/force to move O2 to trachea and to the
lungs. Edema or swelling can occur in response to a
virus or bacteria or an irritant causing the airway to
further narrow becoming more resistant.
• Nose breathers until 4 weeks of age. Newborns breathe
through their nose. They don’t open their mouth when their nose is obstructed because the neurological pathways
that coordinate this aren’t yet fully developed. They only breathe through their mouth when they cry. So nasal
potency is very important.
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• Diaphragmatic/abdominal, and not thoracic, breathers until age 6.
• Alveoli small and few. They change in size and shape and increase in numbers until age 12.
• The intercostal muscles and ribs are primarily cartilage, therefore their efficiency to assist with ventilation is
decreased. At age 6 years the intercostal muscle develop, at which point they become thoracic breathers.
• Normal Respiratory Rates- the younger the child, the higher the RR
Child Cooperation When Listening to the Lungs
• Diversional activities
• Finger puppet – assess them first
• Let them play with your stethoscope fist
Assessment
• Observe pattern of respirations
• Rate – normal, tachypnea, slow for the child?
• Depth – normal, hypopnea (shallow), hyperpnea (deep)
• Ease – effortless, dyspnea (labored), orthopnea (difficult breathing except in an upright position), intercostal and/
or substernal retractions present?, flaring nares?, bobbing head (head of sleeping child with sub occipital area
supported on caregiver’s forearms when it bobbs forward in synchrony with each inspiration), grunting?,
wheezing?
• Labored breathing – continuous, intermittent, steadily worse, sudden onset, at rest or on exertion, associated with
wheezing or grunting or pain?
• Rhythm – variation in rate and depth respirations
• Other Observations
• Evidence of infection – elevated temp, enlarged cervical lymph nodes, enflamed mucous membranes, purulent
discharges from nose, ears, and lungs…what does the sputum look like?
• Cough - characteristics (moist? dry? productive?), nature (when is it heard? paroxysmal (sudden, violent
outburst)? with out without wheezing? Croupy? brassy?), frequency (associated with swallowing?)
• Wheeze – expiratory or inspiratory, high-pitched or musical, prolonged, slowly progressive or sudden, associated
with labored breathing?
• Cyanosis – distribution, where is it? (peripheral, perioral, facial, trunk as well as face), degree, duration,
associated with an activity?
• Chest pain – localized or generalized or referred, characteristics?
• Sputum – volume, color, viscosity, odor
• Bad Breath – possibly associated with lung infection
Respiratory
• Observe child breathing
• Watch chest movements for symmetry. At 2 years of age, the chest is less round. The lateral diameter is > AP
diameter. If a child > 2 years has a round chest, this could indicate asthma, CF, or COPD. A pigeon chest (aka
Pectus carinatum) is where the AP diameter is increased. A funnel chest (aka Pectus excavatum) is where the AP
diameter is decreased.
• Rate- young children use their diaphragm as their primary breathing muscle. Watch or feel for the rise and fall of
their abdomen to count the rate. They are abdominal or diaphragmatic breathers until the age of 7 years. Upon
inspiration, the chest and abdomen should rise simultaneously. Asymmetric chest may be associated with a
collapsed lung. A sustained rate of > 60 breaths/minute is a sign of distress. The child can develop hypoxemia if
not treated. When RR is this high, the inspired O2 doesn’t reach
the alveoli for gas exchange, but stays in the upper airway.
• Palpate
• Chest wall- palpate chest wall for any crepitus, which is the
crinkly sensation caused by escaping air into the subcutaneous
tissues. This is usually from a serious injury, usually near a
fracture.
• Tactile Fremitus- you should feel vibrations equally on both
sides of the chest while the child talks. An increased sensation
is due to lung consolidation, such as in pneumonia, and is not
normal. Vibrations and tingling are normal. Decreased sensation
could be from air being trapped in the lungs, such as with
asthma.
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• Auscultation- you should use the diaphragm of a pediatric stethoscope to hear the higher pitched sound better. But
if you don’t have a pedi stethoscope, then use the bell of an adult stethoscope because the diameter is smaller and
thus won’t pick up as much sound. To help hear breath sound, the child has to breathe or blow deeply and the best
way to have them do this is to present it as a game. For example, make them blow bubbles or having child blow
cotton balls across a table.
• Use consistent method to evaluation- start at the top and go from side to side down the back comparing left to
right, then down the front.
• Normal breath sounds- vesicular, broncho-vesicular, and broncho-tracheal sounds
• Abnormal breath sounds
• Egophony- an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung
consolidation and fibrosis. It is due to enhanced transmission of high-frequency noise across fluid, such as in
abnormal lung tissue, with lower frequencies filtered out.
• Whispered pectoriloquy- Whispered pectoriloquy refers to an increased loudness of whispering noted during
auscultation with a stethoscope on the lung fields on a patient's torso. Usually spoken sounds of a whispered
volume by the patient would not be heard by the clinician auscultating a lung field with a stethoscope.
• Bronchophony- Bronchophony, also known as bronchiloquy, is the abnormal transmission of sounds from the
lungs or bronchi. Bronchophony is a type of pectoriloquy.
• Stridor- noise from air moving through a narrowed trachea and larynx. The upper airway is obstructed either
with Croup or aspiration.
• Wheezing- noise from air passing through a narrowed lower airway either due to constriction, inflammation, or
secretions such as asthma.
• Cough- a reflexive clearing of the airway associated with a respiratory infection.
• Hoarseness- inflammation of the larynx
• Crackles- high pitched sound at end of inspiration. Air is passing through watery secretions in small airways
• Rhonchi- squeaking or kissing noise heard with inspiration or expiration. Air is passing through partially thick
secretions.
• Auscultation of breath sounds - to determine airway patency
• Intensity, pitch, quality, and relative duration of inspiration and expiration
• Entire chest including anterior, posterior and axillary areas moving from side to side,while comparing L to R
• The bell of adult or diaphragm of pedi stethoscope must be firmly placed against chest wall
• Best heard with deep inspiration
• Absent or diminished breath sounds. This is an abnormal finding warranting investigation. Fluid, air, or solid
masses in the pleural space all interfere with the conduction of breath sounds. Although in young children the
breath sounds are easily transmitted through the thin chest wall, so that unilateral breath sounds may not be
heard. Diminished sounds in certain segments of the lung suggest pulmonary areas that may benefit from
postural drainage and/or percussion.
• Pleural friction rub- similar to the sounds made when cupping your hand to the ear and rubbing the finger of the
other hand across the cupped hand. The most common site to hear is the lower anterolateral chest wall between
the mid-axillary and mid-clavicular line.
• Lab data – CBC (Hgb and RBC reflect the body’s ability to carry O2), Blood gases (reflect oxygenation status by
measuring the blood pH, O2 saturation, and the partial pressure of O2 and CO2), pulse oximetry (measures the
arterial Hgb O2 saturation percentage & correlates approximately with the arterial pO2 values on an OxiHGb
dissociation curve)
• Definitions
• Tachypnea
• Bradypnea
• Dyspnea
• Apnea
• Hyperpnea
• Hypoventilation
• Kussmaul breathing
• Cheyne-Stokes
Cardiac
• Inspection and Palpation is done first
• Feel for the apical impulse, which is the PMI (point of maximum intensity). The left ventricle taps the chest wall,
that’s what is felt. It is normal and especially felt in thin children.
• In children < 7 yrs – you’ll feel this at the 4th intercostal space
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• In children > 7 yrs – you’ll feel this at the 5th intercostal space
• Heave- an obvious lifting of the chest wall during contraction, which may indicate an enlarged heart
• Lift- a sensation of the heart lifting up against the chest wall, this could be from an enlarged heart or an extra
forceful contraction
• Thrill- is the rushing vibrations that feels like a cat’s purr when you put hand over heart, it’s caused by turbulent
blood flow such as a defect in the heart valve or a possible murmur.
• Cardiac Auscultation
• Sound is easily transmitted in liquid and travels best in the direction of
blood flow, so auscultate the heart sounds in the direction of the flow of
blood just beyond the valve. Auscultate for quality such as distinct vs
muffled, clear vs diffuse, and pounding/loud vs weak (intensity). Use the
bell of the stethoscope for lower pitched sounds.
• Apical pulse- count for 1 minute in infants and children that have wellknown cardiac problems. Brachial or radial pulses should be the same
rate. Newborn=120; 0-2yrs=110; 2-6 yrs=100; 6-10 yrs=90; 10-16
yrs=85 (average rate)
• Rhythm- normal cycle of irregular rhythm associated with respiration
called sinus arrhythmia where the child’s heart beats faster on
inspiration and lower on expiration. This is often times what is found on
a normal exam. Ask child to take a deep breath and hold while you
listen. It should become regular with breathing cessation.
• Heart Sounds- due to the closer of the tricuspid and mitral valves when
the ventricular contraction begins
• S1- closure of the tricuspid and mitral valves when ventricular contraction begins. These close almost at the
same time for the one sound, which is called the “lubb” sound
• S2- closure of the aortic and pulmonic valves, which prevent leakage back into the ventricles during diastolic
sometimes heard as a single sound, sometimes heard as a split sound that is a fraction of a second apart. This
is the “dubb” sound.
• S3- rarely heard in children
• S4- rarely heard in children
• Splitting- is normal, more blood returns to the R ventricle causing the pulmonic valve to close a fraction of a
second later than the aortic valve. It’s most apparent during inspiration during deep breathing. It could also be an
atrio-septal defect when the splitting is fixed, meaning it doesn’t go away/doesn’t return to the one sound when
you have regular breathing.
• Murmurs- blood is passing through a defective valve or vessel or heart structure problem.
• Blood Pressure
• To help remember normal BP in children:
• In children ages 1-7 years and add 90 to their age. This is usually what they systolic BP is.
• In children ages 8-18 years, you double their age and add 83 to get their systolic BP.
• Hypertension
• Hypovolemic shock
• Palpation of pulse
• Compare strength R to L
• Check all the pulses: carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis. Femoral and
brachial pulses are important to compare! A weaker femoral pulse is associated with coarctation of the
aorta!***
• Cyanosis could also indicate a heart defect
• Capillary refill should be < 2 seconds
Abdomen
• Inspect
• Shape- look for symmetry, a sunken abdomen may indicate dehydration, look for contour and bulges upon
inspiration
• Umbilicus- check for an umbilical hernia (is common in children < 3 years of age) or protrusion, the cord falls off
in 7-14 days after birth. To assess for an inguinal hernia (protrusion of the peritoneum through the inguinal wall),
palpate where the femoral pushes are taken and have the child cough or laugh.
• Rectus muscle- could be depressed or bulging
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• Movement- peristaltic waves are visible,
rhythmic contractions of the intestinal
wall that move food through the
digestive tract. It usually indicates an
intestinal obstruction such as pyloric
stenosis when you can see the
peristaltic waves.
• Auscultation
• Borborygmi- loud gurgling heard
especially when hungry. Divide the
abdomen in to 4 quadrants and just like
in the adult, you should hear a sound
once/10-30 seconds. Listen for 5 minutes total for entire abdomen before
you determine that there are no bowel sounds. A hard, board-like, and stiff
abdomen is very serious. It may be a sign of paralytic ileus and intestinal
obstruction.
• Percussion- of the abdomen is done to find the major organs. You find
different tones when you percuss over stomach (which is hollow) vs liver
(which is dense)
• Palpation- if there’s a large mass or an enlarged kidney, stop palpating because this may release cancerous cells if
it happens to be a kidney cancer.
Inquinal & Genital Area
• This is often be performed during their bath or diaper change
• Assess femoral pulse. Remember: absence of femoral pulse is significant, could be from coarctation of the aorta!!!
• Can be stressful to child, especially beginning in the preschool age, so preferably do it with the parents in the room
• The urethra and penis are centered at the tip of the glands, opening ventral or underneath the shaft is the
hypospadias, and the opening dorsal or at the top is the epispadias. The scrotum should hang freely from the
perineum behind the penis. The left testes is usually lower than the right, and proportionally larger in infants.
Joints, Bones, Muscles
• Compare bones for length. Count the fingers and the toes and account for any fusions (polydactyly and syndactyly)
• Assess for pain on movement
• Hypertonia- where muscles are rigid, this can be associated with an active seizure or cerebral palsy
• Joint swelling and pain. Examine for this while moving the joint.
• Range of motion
• Active- ROM is active if they are moving all extremities very well. you can observe for this in their activities
• Passive- joints and extremities are moved for the patient. Watch their facial expressions for signs of pain
• Muscle strength- can play a game with the child (standing on one leg or hopping on one foot) or have them
squeeze your finger to assess for this. Leave this for the end, because once you have them moving it’s hard to
bring thumbtack under control again.
• Note: Toddlers initially walk bow-legged to help with their balance
because their head is so much bigger than the rest of their body and
because they have a big diaper between their legs. We also check for
a pigeon-toed child where the toe is turning in.
Posture
• Level shoulders and hips. For the hips we are looking for a dislocation
or a subluxation of hip. We look for skin folds on each leg. These skin
folds should be equal on both legs. Uneven skin folds may indicate a
hip dislocation or difference in leg length. This is called: Allis Sign. Also
check for a height symmetry. The Ortolani Maneuver test is shown in the
picture above. The Barlow Maneuver test is shown in the bottom picture.
These tests must be performed by the ANP or MD. They both check for a
dislocation or subluxation of hip. If you hear an audible clunk on
abduction of hip or if the hip comes out, you don’t have the knowledge to
put the hip back in place.
• Head held erect
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Shoulder contour is symmetric
Spine with normal curves after age 6
Spinal alignment
Scoliosis check on 5th, 6th, 7th grader: have child bend at waist and touch floor. No lateral curve should be
present. A lateral curve to the spine or a one sided rib hump is an indication of scoliosis.
Neurological
• Cognitive
• Behavior
• Communication skills
• Memory- their recall and language. Ask them to repeat random numbers you’ve told them.
• LOC
• Cerebellar
• Balance- have them touch their nose with their finger, while standing on one foot.
• Coordination
• Gait
Reflexes
• Moro- startle with sudden noise (this is commonly seen up to 6 months)
• Palmar grasp- when they have a strong grip when their hand is touched (up to 3 months)
• Plantar grasp- curl toes around finger when touched (up to 8 months)
• Placing- when they lift their foot when it touches a surface (happens just after birth until various times)
• Stepping- when baby’s foot touches something solid, baby will pick up leg as if stepping (birth until 4-8 weeks)
• Tonic neck/“Fencing”- when the leg is held in one arm and the opposite arm is held out (starts at 3-4 weeks of age
and disappear after 3-4 months)
• A persistence of primitive reflexes, loss of reflexes, or hyperactive reflexes could be a cerebral insult
• A deep tendon reflex is also done in children where you hit the tendon with a hammer above the elbows, knees, in
the fossa area, arm tendon, and the Achilles tendon.
• Image 1 shows the Tonic neck/“Fencing” reflex. Image 2 shows Moro reflex. Image3 shows Stepping reflex.
Denver II Developmental Test
• Screening test done until up to 6 years of age. It requires special training and a standardized kit. It can be adjusted
for premature babies up to 24 months of age.
• It has up to 125 items on it and measures: gross motor, language, fine motor, and personal/social skills
Assessment Approaches Guidelines
General
• Place frightening equipment out of site
• Make a game out of assessment. Make it fun, so that they won’t know they’re dong something you want them to do
• Provide toys
• Provide privacy
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Provide time to become acquainted
Make eye contact with child
Focus on parent, then child’s toy, then child to get them engaged
Compliment child whenever you can. Thank them for cooperating.
Involve child and parent or ask parent to leave, depending on the age of the child.
Avoid prolonged explanations. Keep it simple
Begin in non-threatening way
Allow them to have a choice, but make sure that the choice is something you can live with. Usually, offer them 2.
Let them use equipment or check it out
Do assessment in an organize manner
Examine painful areas last
Give reward when you can; stickers
Age-Specific
Infants
• Parent may hold during assessment
• If quiet, auscultate heart, lungs and abdomen first
• Smile, talk gently to baby
• Let baby hold on to block or toy
• Avoid abrupt, jerky movements
• Take advantage of examination opportunities, if the baby is crying, inspect the baby’s mouth
• Do traumatic things last
Toddler
• Play games
• Count fingers, tickle toes
• Use minimal physical contact initially
• Introduce equipment slowly
• Perform traumatic procedures last
• Use short phrases
• Have parent remove clothing
Pre-school Child
• Give choices
• Keep parents close by
• Expect cooperation; tell them what you want them to do: “Open your mouth please”
• Make up story about procedure “I’m seeing how strong your muscles are” blood pressure
School-age Child
• Prefer sitting
• Respect need for privacy
• Request self-undressing
• Give gown to wear
• Explain purpose of equipment
• Teach about body function and care
• Allow them to help
Adolescent
• Give gown
• Allow them to undress in private
• Expose only the area to examine
• Explain findings during exam, such as “Your muscles are firm and strong”
• Emphasize normalcy of development
Characteristics of Children
• Body surface area large for weight
• Fontanel and open sutures palpable up to 18 months
• Tongue large relative to small nasal/oral
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Short narrow trachea
Rapid heart rate
Up to 18 months of age, kidneys do not concentrate urine effectively
Water weight proportion is high
All brain cells present at birth
Head proportionately larger
Higher metabolic rate
Faster respiratory rate
Up to 5-7 years, diaphragm is primary breathing muscle
Bone soft and easily bent and fractured until puberty
Muscles lack tone, power/coordination during infancy
Blood volume is weight dependent
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Fatemeh Sahrapour
MODULE: CARE OF THE CHILD WITH GI DISORDERS
The student will adapt general principles of gastrointestinal pathology and illness to determine appropriate nursing
care to the infant and child.
Readings:
Gastrointestinal Dysfunctions
Perry: 1255-1278, 1289-1299, 1308-1317
Nutritional Deficiencies
Perry: 1246-1255
Feeding Difficulties
Perry: 905-910
GI Disorders
ATI 2013: 234-262
Review as needed
Perry: 1276-12886 (Hirshsprungs, ulcerative colitis, Crohn, TEF,
intussusception, short bowel, peptic ulcers, and hepatitis)
CHILD WITH GASTROINTESTINAL DISORDERS- PART 1
• Dehydration
• Water and electrolyte imbalances occur more frequently and more rapidly in infants than in older children and adults
• Infants are less prompt to adjust. They have an increased ECF until age 2 years; they have more water, Na, and Cl
outside the cell than inside the cell. Interactions with the environment can impact the composition of this fluid;
temperature, dryness of air, etc. Fluid losses such as fecal loss, urinary loss, and insensible loss with the heat,
humidity, and if child has a fever, contribute to the imbalance.
• There is 7 mL/kg/24 hours of water loss for each degree > 37.2 C
• What are 3 characteristics of infants that make them susceptible to fluid depletion?
• ↑surface area relative to their body mass, which causes greater insensible loss
• High rate of metabolism, so there’s a greater need for water to excrete through the kidneys
• Immature kidney function, they aren’t able to fully concentrate or dilute urine or regulate the electrolytes.
• Implications: so they can get dehydrated from concentrated formulas, for example, if mother doesn’t mix formula
correctly the infant can become fluid overloaded (over-hydrated with excessive water/dilute formula) or dehydrated.
Maintenance of Fluids
• A child needs to have a certain level of fluid to maintain homeostasis & metabolism. How much fluid does he need?
• 100 ml/kg for first 10 kg of body weight
• 50 ml/kg for 2nd 10 kg
• 20 ml/kg for remainder amount of his body weight
• Divide by 24 for hourly rate
• What is fluid requirement for child weighing 34 kg for the day?
• 100 ml (for first 10 kg) (100 x 10 = 1000)
• 50 ml (for second 10 kg) (500)
• 20 ml (for remaining 14 kg) (280)
• Total of 1780 per day
• 74.17cc/hr (total divided by 24 hours)
• If child is dehydrated, then would need to give more than maintenance depending on how dehydrated. So we’d give
him maintenance fluids and then more fluids to compensate for his dehydration. You may see an order for 1.5x
maintenance. This would mean that we take 74.17 mL/hour + (74.17/2) = amount of fluid we infuse. Then you add
to this what the child is getting PO.
Dehydration Effects
• Signs of fluid overload: crackles in the lung, bulging fontanels, skin turgor, edema
• We have mild, moderate, and severe levels of dehydration
• Na is mostly in the ECF. K is mostly in the intracellular fluid. When ECF volume is decreased, so is the Na, as
usually most is lost from the ECF. Replacement of fluid should then mostly include Na. The following are the
different forms of dehydration:
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• Isotonic loss- loss of extracellular water and Na, but compensation so electrolytes are WNL/within normal limits
(Na 130-150). This is the primary form of dehydration. There is no movement between the intra and extracellular
fluid, so you find ↓ blood volume – shock. This is most common in children. You see it in the skin, muscles, and
kidneys. You see hypovolemic shock symptoms.
• Hypotonic loss/Hyponatremia- where more electrolyte loss than water loss causing H2O to move from EC to
IntraCellular to help body compensate → resulting in a ↓ blood volume & a Na level of < 130
• Hypertonic loss/Hypernatremia- > H2O loss than electrolytes or ↑ in electrolytes. Fluids shift from a lesser
concentrated ICF→ECF to compensate and our Na > 150. We have more neuro signs than blood volume signs,
This is the most dangerous and can occur when the child is given large amounts of fluid by mouth that contain
large amounts of solute or in children that receive high protein NG feedings that place an excessive solute load
on the kidneys.
Nursing Care of Child with Dehydration - Assessment
• Weight- is the most important determinant of fluid loss in infants and young children. However, if the pre-illness
weight is not known, then we need to rely on other signs too. Weight is a reflection of acute loss. It’s measured in
mL/kg of water loss anywhere from 50-100 mL/kg.
• LOC changes- child may be irritable, lethargic, a decreased response to stimuli.
• Skin turgor- a decrease in skin elasticity.
• Cap refill- prolonged (>2 or >4 for severe dehydration)
• ↑ Heart rate
• BP changes- eventually it decreases
• Sunken eyes and fontanels- this happens a lot in infants
• Skin- mottled and cool
• Specific gravity- it would rise > 1.020
• Intake and output- output would decrease
• Mucous membrane- dry
• No tears
Diarrhea & Vomiting
• Important considerations in infants/children as it cause significant fluid losses
• Cause of Diarrhea: inflammation due to an infection
• Infection (Rotavirus)- occurs especially in infants that attend day care because it happens after exposure to other
children. Most often transferred via fecal-oral route. Infants are immune up to 3 months of age because they get
Ab from mother, so we see it in children between 3-24 months. There’s a vaccine that is given at 2 months, and
at 4 months. It does have an 85% protection. Rotavirus causes severe diarrhea.
• Giardia parasite- is common in toddlers. It can be treated with Flagyl or Furoxone. It can be transmitted from
diaper contaminations or daycare settings. One of the tests available to diagnose Giardia is where you have to
swallow a string and a gel cap. Retrieve the string later and sample the stool to see if the Giardia parasite is on it.
• Pinworm- Eggs are ingested or inhaled from a crowded day care. They hatch in upper intestine, they mate there,
and then the females migrates to the anus to lay eggs. It causes itching and the child will scratch anus and get it
in their mouth. The contamination is 2-3 weeks long. It can live on toilet seats, door knobs, or food, or linen. Treat
pinworm infection with Vermox in children that are 2 years of age or greater. Repeat in 2 weeks if it’s not gone.
Treat the household. You know you have it using the tape test. Press tape wrapped around tongue blade to anal
area, and collect it in morning before they use bathroom. Put it in bag and bring to lab.
• You can prevent these infection using hand washing, keep clean diaper change area, keep nails short
• Other causes of Diarrhea: toxic reaction to antibiotic or dietary ingestion
• We want to know the history of illness as it helps determine cause/etiology, and therefore how to treat it.
• Goals of Therapy for Patients with D/V
• Assessment of Fluid and Electrolyte Imbalance
• Rehydrate
• Fluid Therapy and eventually diet
• Treat the etiology or underlying cause
• We need to look at the lab results too, because it gives us information as to what the etiology is:
• Get a stool sample from child’s diaper. If stool is explosive and watery, this could indicate a glucose intolerance. If
there are neutrophils or RBCs in the stool, it could be from inflammation or gastroenteritis. If there are eosinophils
in stool, they could be from a protein intolerance or a parasite infection.
Oral Rehydration Therapy (ORT)/Oral Rehydration Solution (ORS)
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• Is the first line of treatment to treat dehydration
• It’s used to enhance and promote the reabsorption of Na and water to help reduce vomiting. If we are successful
then we don’t have to bring child to hospital. We want to reduce the volume loss from diarrhea.
• It’s a special solution; It is less costly than IV therapy. So because IV therapy is costly and traumatic, we want to
see if we can get the child rehydrated orally first.
• Begin with small amounts and frequent feedings if vomiting. The solution usually contains some glucose to prevent
hypoglycemia and some bicarbonate to help reduce the vomiting and to decrease and correct acidosis. Also to help
with vomiting and thus allow for oral hydration, we give them Ondansetran/Zofran.
• Rehydration: 75-90 mEq Na/liter
• Give 50 cc/kg for mild dehydration over 4 - 6 hours
• Give 100 c/kg for moderate dehydration over 4 - 6 hours
• Replacement/Maintenance: 40-60 mEq Na/liter.
• Pedialyte – 45 mEq/liter
• After hydration, start adding water, breast milk, lactose free formula
• Start them on a regular diet for older child along with ORS
• If they continue to have diarrhea, weigh the diaper, and replace that volume of stool loss with ORS 1:1. So if we
have a diaper that weighs 100 grams, then replace them with 100 cc ORS.
• Clear juices or soda can lead to hyponatremia and are not given.
• Give solids as soon as child will eat them
• Continue breastfeeding along with ORS
• Can give ORT popsicles.
IV Therapy
• Is used if child is severely dehydration and/or shock, or if he’s vomiting so much that he’s unable to ingest ORS, or
if we need to replace abnormal loss, or if he has gastric distention and can’t drink
• Fluid type based on etiology and signs
1. Saline, dextrose, water- usually we infuse just saline, but we also may need to add dextrose to it if we need to
replace water because you can’t give water by itself in IV. It needs to be attached to the glucose molecule to
help get the water into the cell.
2. Bicarbonate- will need to be added to the IV solution if child is experiencing acidosis with dehydration
3. Rapid replacement with isotonic or hypotonic loss is good but if it’s a hypertonic loss, then we can’t do a rapid
replacement due to the water intoxication. Our brain cells are most sensitive to this.
…So we start with an isotonic solution such as normal saline or Lactated Ringers. This helps to expand the
ECF quickly. Sometimes 2 mL/kg as an IV bolus over 20 minutes is a common order.
Other Nursing Considerations
• Teach- our job is to teach the parents how to care for the child.
• Some vomiting ok with ORT
• ↑ stools ok with food ingestion
• Monitoring of I&O at home is needed (how many wet diapers, how many times they’ve voided, etc.)
• If child is hospitalized
• IV therapy and maintenance is our job. That child probably had a very hard time getting IV started because he
was dehydrated and veins are small. So we must maintain his IV. Pay attention to the rate of the IV, and assess
the child based on the rate of the IV. Is it too much or is it not enough? Potassium may need to be added the
fluid, but we don’t want to add it until after the child has voided, so to make sure he has good kidney function.
• Accurate weight done qd or bid
• NPO possibly if child is lethargic , but we try to feed them as best we can. But if he’s getting IV, he’s most likely
not able to use his mouth.
• Strict I&O
• Frequent Vital Signs
• Infection control: good hand washing at hospital and at home with family, clean areas
• Lab obtainment and monitoring. Obtain stool sample.
• Skin assessment and take care of the skin, for example: their bums always in a wet diaper from diarrhea.
Nursing Diagnoses
• Fluid Volume deficit related to excessive GI losses in the stool or the emesis.
• Altered nutrition: less than body requirements related to diarrheal losses and inadequate intake.
• Risk for transmitting infection related to microorganisms invading GI tract.
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• Impaired skin integrity related to irritation caused by frequent loose stools
• Anxiety/fear related to separation from the parents, an unfamiliar environment, distressing procedures
• Altered family processes related to situational crisis and/or a knowledge deficit
Water Intoxication
• When you are administering IV therapy, make sure there isn’t a fluid overload and child isn’t getting too much.
• Watch for a water intoxication aka water overload. It can cause CNS symptoms (due to ↓Na level)
• It can be caused by:
• IV fluid overloading
• Rapid dialysis
• Tap water enemas, which aren’t done much anymore
• Incorrectly mixed formula
• Excess water ingestion
Constipation
• Defined as trouble with defecation for 2 weeks, or less than 3 stools/week, or painful bowel movement with blood
streaking.
• Causes/Reasons for constipation• At newborn time when child doesn’t pass the Meconium stool. It is supposed to pass and is usually passed within
first 24-36 hours of life.
• Hirschspring Disease- is a lack of innervation to lower colon causing stool to sit in bowel. It’s diagnosed in the first
months of life. This is also referred to as a Megacolon; it is a part of the lower colon that becomes very large
because the stool just sits there. The child is very constipated and the older child will pass a ribbon like stool that
is very fowl smelling. To fix this, surgery is done to remove the part of the bowel that isn’t innervated. The child
may have a colostomy for a temporary time period.
• Encopresis- is constipation with fecal soiling (involuntary defecation, especially associated with emotional
disturbance or psychiatric disorder). Some of the psychosocial rationale for encopresis/constipation is that the
child is afraid of going to the bathroom. It could be painful. He may deliberately try to hold in the stool. Over time
the rectum stretches an the stool is accommodated and the urge to defecate passes. When he finally has a
bowel movement it’s very painful and this reinforces the desire to hold the stool.
• Some of the psychosocial causes- stress in the family, life or family changes, fear of school bathrooms, always
being in a hurry because your parents always rush you, etc.
• Treatment- slow down child’s life so he doesn’t always feel so hurried, increase child’s fiber, fluids, maybe give child
stool softeners, and with infants adding corn syrup to their formula can help too.
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CHILD WITH GASTROINTESTINAL DISORDERS- PART 2
Gastroesophageal Reflux (GER)
• Is the transfer of the gastric contents into esophagus- problem is with a relaxation of lower esophageal sphincter
• Complications:
• Aspiration
• Esophageal irritation, bleeding
• Children who are susceptible to GER are those who are premature, BPD (bronchiopulmonary dysplasia), CF
(cystic fibrosis), asthma, CP (cerebral palsy), a child that has had a TEF (tracheoesophageal fistula) repair, children
on ECMO (extracorporeal membrane oxygenation) usually done in the ICU, neural disorders, and scoliosis patients
• Often GER in infants is resolved by the age of 1 year or maximum 18 months
• Gold standard for diagnosing this is the 24 hour intra-esophageal pH monitoring done through an NG tube.
• GERD (Gastro-esophageal Reflux Disease) is tissue damage resulting form GER
• Symptoms of infants• spitting up, vomiting, irritability, arched back due to the pain of movement down esophagus, weight loss, failure to
thrive, and respiratory problems (as a result of aspirating some of these gastric contents)
• Symptoms of older child• heart burn, abdominal pain, coughing, pneumonia if they’re aspirating
Care of Child with GER
• 4 steps of treatments, you start with the least invasive. If baby has GER but is still gaining weight, then we don’t
perform the invasive procedures. We try just the formula thickening and changing to the hypo-allergenic formula.
But if baby has GER and isn’t gaining weight, then add medication and consider surgery. Older children will need to
modify their diet, alter their sleep positions, reduce their weight, and prevent smoking because cigarette smoke
causes or at least irritates GER. Foods such as caffeine, chocolate, and spicy foods can weaken the lower
esophageal sphincter and aggravate the symptoms. Staying away from these foods along with weight management
really helps.
1. Feeding alterations• Give them small, frequent feedings
• thicken their formula or breast milk with 1 teaspoon or 1 table spoon of rice cereal per ounce, depending on
the severity of their GER. This helps to decrease vomiting by keeping the food down in stomach longer. We
aren’t supposed to do this until they are 4 months of age. However, we should weigh the risk with the
benefits, and monitor them closely. If this helps with their GER, this might be worth a try…but we’ll keep an
eye on infant for any kind of non-tolerant behavior.
• May try a trial of hypo-allergenic formula to feed babies
• May need to place an NG or Gtube feeding if GER is severe
2. Positioning• position child in a non-prone
position during sleep, but we also
don’t use a car seat after eating
because it causes abdominal
pressure. We want to place them
prone while they’re awake, but due
to SIDS we don’t do that when
they’re sleeping. Older children can
be left on any side. Keep them up
right for 30 minutes after eating by
elevating their crib 30 degrees or
putting them in an infant seat. Do
not lay baby flat. Burp the baby as
needed to help eliminate any type
of gastric pressure.
• If a child is sitting up, you can see that the food sits at the bottom of the stomach and not being pushed
upward. And if the child’s feet were flatter toward the ground it would be better because having the feet be in
an upward position puts more pressure on the stomach and pushes the food upward.
• If the baby is lying on his back it’s very easy for the food to back up into esophagus if the sphincter isn’t
closed shut because the esophagus is located at the back of the stomach.
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• If the baby is prone, the food will sit at the bottom of stomach toward the front and thus won’t back up to the
esophagus that’s at the back of the stomach. However you must do this only when baby is awake and you
are watching them. You never want to place a child on their stomach when they sleep due to risk for SIDS.
3. Pharmacology• H2 antagonists- (Cimetidine or
Ranitidine) helps reduce the
acid & prevent esophagitis
• Proton pump inhibitors- (Nexim,
Prevacid, etc.) can help block
the acid production, we give this
30 minutes prior to feeding.
Reglan can be used, but we
limit it because its SE aren’t
good for children.
4. Surgery• Nissen fundoplication: this is the
passage of the gastric fundus
behind the esophagus to
encircle the esophagus (to help
esophageal sphincter
reinforcement and thus function)
• For the surgery, make sure to
offer parents support: educate
them on types of medications
they’ll be giving their child and why, and when to give them, the positioning of their child (putting child up on
their shoulder or on their stomach when they’re awake), how to mange their spit ups (bibs, etc.), if you are
putting rice in their bottle enlarge the nipple slightly, avoid vigorous play after feeding so that they don’t
regurgitate, and to NOT feed the child just before bed time. Give medications 30 minutes before breakfast
and 30 minutes before the evening meal.
Appendicitis
• Definition- inflammation of the vermiform appendix, the blind sac at the end of cecum
• The average age of a child with appendicitis is about 10 years old
• Complications- could lead to necrosis and perforation into the perineum causing peritonitis and ileus. This can lead
to hypovolemic shock.
• Symptoms- fever, vomiting, increased WBC, and abdominal pain. The pain occurs first around belly button and then
it goes to the right side. The pain then is at McBurney’s point (McBurney's point is the name given to the point over
the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
(navel). This point roughly corresponds to the most common location of the base of the appendix where it is
attached to the cecum). If you have temporary relief of pain that means the appendix has erupted/perforated. The
pain gradually returns. Perforation usually happens 8 hours after the pain on the left side is felt.
• Diagnosis- done with a CT scan or ultrasound.
• Treatment
• Preferably removed by surgery before perforation. Then need to give hydration and antibiotic as follow up. It’s
usually done laparoscopically.
• Surgery and care after perforation. If it perforates, then we must give them pre-op antibiotics. Have to have an
NG to suction and have to be hydrated with IV fluids. Post-operatively, you do the same thing and add wound
care. The wound may be open to prevent infection or may be closed. Use of a Penrose drain will help get the fluid
that’s accumulated to drain out. May have to have a wet to dry dressing that’s irrigated, especially if it’s open.
Also must manage child’s post-op pain. When assessing for pain, note that the younger child will be rigid,
motionless, lying on his side with flexed knees. School aged children will miss school and will lie down. Older kids
will complain of pain.
Good Review of These Conditions Was Done in Adult Class
• The care of the child who has he following conditions won’t be covered because it’s similar to the adult• Inflammatory Bowel Disease
• Ulcerative Colitis
• Crohn’s Disease
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• Peptic Ulcer Disease
• Hepatic Disorders
• Acute Hepatitis (A, B, C, D, E. G)
• Cirrhosis
• Biliary Atresia
Cleft Lip and Palate
• What is it? Is a separation of the 2 sides of the lip, sometime this can include the bone of the upper jaw. A cleft
palate is an opening in the roof of the mouth in which the two sides of the mouth didn’t join together. Cleft lips and
palates can be unilateral or bilateral.
• Incidence- 1/1000 births in White children, 1.7/1000 births in Asians, 3.6/1000 births in Native Americans, 1/2000
births in AA. Cleft lip and palate together is more common in boys. Cleft palate alone is more common in girls.
Unilateral clefts on the left side are the most common.
• Etiology- Most often due to anti-depressant or anti-seizure medication like Phenytoin use during pregnancy or
smoking during pregnancy. Smoking or even just being around it during pregnancy is very dangerous. There’s a link
between cleft lip & palate as well as spinal bifida and low folic acid levels.
• Pathology- It’s failure of maxillary processes to fuse with elevations on frontal prominence during the 6th week of
gestation. Normally the union of the upper lip is complete by 7th weeks. Fusion of the secondary palate occurs
between week 5 and week 12 of gestation. Failure of the tongue to move downward at the correct time will prevent
the palatine process from fusing.
• Diagnosis- Cleft palate is not obvious at birth. So you will assess thee mouth with your finger by sticking your
gloved finger in baby’s mouth and feel for a hole at the roof of the mouth. You feel a continuous opening between
the mouth and the nasal cavity. Feeding can be a problem when a child has a hole in the palate and isn’t able to
elicit a sucking response. The ability to swallow is normal. Cleft lip is obvious at birth. Fetal ultrasound may be able
to detect after week 13-14. But it’s harder to detect cleft palate.
Repair of Clefts
• Cleft Lip- surgical intervention (repaired at 2-3 months of age), it will cause some scarring
• Cleft Palate- more involved using a multidisciplinary team approach that includes pediatrics, plastic surgery,
orthodontics, otolaryngology, speech/language, audiology, nursing, social work, etc. (repaired at 6-12 months of
age, however we want the repair to happen before child starts forming words/talking. The exact age depends on the
severity). The goals of surgery:
1. Closure of cleft- the child will have multiple surgeries for the repair
2. Prevention of complications
3. Facilitation of normal growth/dev.
• Prognosis• If child receives good physical care, they will have better outcomes of healing. Post-op, there will
be problems with mouth muscle functioning, teeth, some hearing loss (may have otitis media
and scarring of the tympanic membrane) and often times ear tubes are put in at the time of
surgery. May have a speech impediment and possible problems with body image.
Nursing Considerations for Cleft Lip and Palete – Pre-op
• Emotional care of parents at birth, parents may think that they don’t have
the perfect baby, and some cultures reject the baby
• Maternal-Infant attachment issues may occur if the mother is afraid to touch
the baby or if she doesn’t like to look at him.
• Nutritional issues- feeding the child is very challenging. Remember the child
has a problem with sucking and not swallowing. So bottle and breastfeeding
will be a problem as liquid will escape via the cleft through the nose. When
feeding these babies, especially cleft palate, the head must be kept upright.
Special nipples must be used called cleft palate nipples. We can use large,
soft nipples with large holes (Nursettes or Lamb’s). The new gravity flow are
also available and can attach to a squeezable plastic bottle that acts like a
bulb syringe. You can cut a larger hole in regular nipples. Breastfeeding is
possible and may be more successful in infants with cleft lip. The compliant
breast creates a seal on the lip and palate resulting in more effective
sucking and milk transfer. Breast milk will reduce the incidence of otitis
media. The mother needs to position and stabilize the nipple in the back of
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the infant’s mouth allowing the movement of the infant’s tongue to facilitate milk letdown. It’s harder to breastfeed
though with a cleft palate baby.
• Feeding1. Keep upright
2. “Cleft palate” nipple
3. Breastfeeding is possible
4. ESSR (Enlarged nipple, Stimulate the suck reflex, Swallow fluid appropriately, Rest when infant signals with a
facial expression)
5. Trouble with nipple feeding- use a wide based nipple such as a Playtex nurse or a Nook nipple will help to
create the type of suction and grasp that is needed. Nipples need to be compressed by infant’s tongue and
the existing palate. Vertical with a single slit so the infant can suck the flow of milk. Steady pressure is
important. The infant swallows lots of air so frequent burping is needed. If unable to use a nipple, then use a
rubber tip medicine dropper and aseptic syringe, a Breck feeder (a syringe with a soft rubber tubing). Rubber
tubing should extend to the back of the mouth to reduce
the chance of regurgitation through the nose. Formula is
deposited in the back of the tongue and controlled by the
bulb and suction compression. Or lastly, we may need to
use spoon feeding and thicken the milk with some cereal.
• Haberman Feeder
• Now called a special needs feeder. It has a one way flow
valve so fluid enters mouth when compressed and not back
to the nipple.
• Notice the upright sitting position that allows gravity to help
baby swallow the milk
Nursing Considerations – Post-op – CL repair (Cheiloplasty)
• Protecting operative site
• Metal or adhesive strips may exist to protect lip
• Elbow restraints (No-Nos)- must be used to keep arms straight and prevent baby’s hand from touching lip, used
for 5-10 days. They will be wrapped around elbows to prevent bending. This is frustrating to the baby because
they’re used to putting things in their mouth.
• Jacket restraint will be used if baby is able to roll over. We want to prevent them from rolling over and having their
face rub up against the sheets.
• Pain control- give them if they’re restless
• Feeding- start with clear liquids, and move to formula as tolerated
• Clean suture line with swab and saline. May put an antibiotic ointment on it. Watch for secretions, you may have to
use some gentle suctioning. Set child upright in an infant’s seat will help swelling go down.
Nursing Considerations – Post-op – CP repair (palatoplasty)
• These babies can lie on abdomen, because they don’t have anything external that they might hurt.
• The surgery goal: is to close the opening between the nose and the mouth, help patient develop normal speech,
and aid in swallowing and breathing and normal development of associated structures of the mouth.
• No objects in mouth- no straws, suction, or thermometer.
• May have oral packing for 2-3 days
• Altered breathing is possible post-op as pathway may become swollen, so watch for this
• Restraining of arms using No-Nos to protect mouth (4-6 weeks)
• Pain control using medications
• Soft foods upon discharge initially. When child is discharged, they should be able to tolerate fluids well from a
syringe, a cup, or a cleft palate nipple.
• Avoid using a regular nipple for 3-4 weeks after surgery
• Sutures will dissolve but are visible for several weeks. The mouth should be rinsed with water after every feed to
help remove food particles from the area.
Discussed in other Classes or Review for Clinical as Needed
• Tracheoesophageal Fistula- will see in OB class
• Hernias- happen in children too
• Intussusception- bowel tunnels in to itself, a paroxysmal segment of the bowel telescopes to a distal segment.
Mucous & blood streaks enter into intestinal lumen. A classic, current, gel-like stool is formed. Child has colic pain.
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• Malrotation- the right and left side of gut are turned around so that they’re on opposite sides
• Celiac Disease- intolerance to the protein gluten found in wheat, barley, rye, and oats
• Short Bowel Syndrome
Pyloric Stenosis
• What is it? The lower portion of the stomach that connects to the small intestine is called the Pyloris. In PS the
muscles in the this part of the stomach enlarge, narrowing the opening of the pyloris and eventually preventing food
from moving to the SI.
• Incidence- This happens in babies between 2-5 weeks of age. It can cause forceful vomiting can cause result in
dehydration. These aren’t the common wet-burps or spit ups you see after feeding. 3/1000 infants are affected with
PS. Caucasians develop PS more frequently than babies of other races. Boys develop PS 4-5x more often than
girls. PS may be inherited.
• Etiology- Because the stomach outlet becomes blocked, babies vomit. They thus don’t have any weight gain
• Diagnosis- when you see babies having a forceful projectile vomiting of large amounts of breast milk, that may go
several feet across the room. The bay is usually very hungry and nurses eagerly because nothing gets down into
the SI. The vomited milk is curdled because it has stayed in the stomach and the acids there curdle it. It is
diagnosed with an X-ray, Barium swallow, or Ultrasound.
• Surgical Treatment - Pyloromyotomy- the banding at the bottom of the stomach is cut to help it enlarge. Before
surgery, we must ensure that baby’s fluid and electrolyte balance is under control.
Nursing Considerations
• Pre-op
• Nothing by mouth
• IV therapy- important because they’re most likely dehydrated as nothing by mouth is entering their SI, so their
fluid and electrolytes are out of balance and we must restore the levels
• I&O important
• Trying time on parent so support them– baby fussy, hungry… but aren't able to console through feeding
• Post-op
• Feeding started 4-6 hours post-op, this is usually the time when they’ve woken up from the anesthesia
• Start with glucose water or electrolyte water
• Offered slowly, frequently, we then start them on breast milk
• Vomiting may still happen initially, but it won’t be projectile.
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CHILD WITH GASTROINTESTINAL DISORDERS- PART 3- NUTRITION
General Guidelines for Infant Intake – Formula Fed
• By 3 weeks of age- 2-3 oz. each feed/6x per day —> about 18 oz. day
• Caloric intake required- 108 kcal/kg/day
• So if you have a 3 kg newborn (6.6 pounds) = 3 x 108 = 324 kcal/day. Formula usually comes 20/kcal/oz. Divide
this into 324 kcal.day that is needed. Therefore 480 ml or 16 oz of formula is needed per day. This levels at about
32 oz/day, regardless of how many times a baby is fed/day during the first 6 months.
• When educating family on how to mix formula, tell them that they boil tap water if there are known contaminants in
water such as Lead. Bottled water can be used, but parents should know that it’s not sterile unless specifically
indicated on label.
• If the local water doesn’t contain Fluoride, then it will need to be added as a supplement after 6 months of age.
General Guidelines for Infant intake – Breast Fed
• Recommended for first 6 months of age and preferably up to a year
• Uses demand feeding- infant lets mom know when it’s time to eat
• Every 2-3 hr because of the easy digestibility of the milk; 6x/day for a new born & 4-5x/day for a 6 month old
• Satiation happens when suck less and they fall asleep
• Supplemental water not needed. Extra water or juice could lead to water intoxication and hyponatremia.
• Good feeding also depends on consummatory behavior of baby (coordination of sucking, swallowing, & breathing)
Cow’s Milk
• Not good for baby• It is high in protein, low in fat and lipid content
• It can cause intestinal bleeding, which can lead to iron deficiency anemia
• It has an unmodified protein content that may trigger an undesired immune response and increase the incidence
of allergies in children and early age.
• Whole milk can NOT be given before 1 year of age. Whole milk can be given at age 1, 2% at age 2, and skim
milk after the age of 2 years.
• Formula is modified cow’s milk
• It is modified to resembles nutritional content of breast milk. It is altered by removing butter fat and decreasing
the protein content and adding vegetable oil and CHO. Some have a whey : casein ratio of 60:40
• Similar composition of vitamins, mineral, fats, CHO, and essential AAs as breast milk
• Addition of DHA (Omega 3 FA); shown to improve brain functionality, eye sight, and general development
• Honey shouldn’t be added to any food or formula due to the risk of Botulism
Infant Formulas
• 4 Main Types
1. Cow’s Milk based- has 20 kcal/oz and comes in liquid, powdered, or concentrated format
2. Soy based- also 20 kcal/oz and comes in liquid, powdered, or concentrated format. These are given to baby’s
who can’t tolerate cow’s milk or lactate protein.
3. Casein or whey hydrolysate based- comes in liquid, powdered, concentrate format. These are also given to
baby’s who can’t tolerate or digest cow’s milk or lactate protein or soy based formulas. The peptide chains of
the casein or whey proteins are already digested. It’s better to use than soy because it’s less antigenic. Bad
part is that it doesn’t taste good.
4. Amino Acid based- Is formula with protein already digested and is used in babies who are sensitive to others
Other Comments
• Juice
• babies < 6 months- should not be given juice
• babies > 6 months- can substitute juice for 1 milk/day (4-6 oz/day)
• If a baby has 12 or > oz of juice/day, it can lead to obesity or exacerbate colic and result in diarrhea
• Offer juice in a cup to prevent caries. The best juice to give is white grape juice because it’s absorbed the easiest.
• Solids
• are introduced between 4-6 months of age; no later than 6 months and no sooner than 4 months (if you start
earlier, it leads to GI problems and food allergies because the baby’s system can’t handle it yet)
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• Start with iron fortified infant rice cereal and give for at least 18 months of age. This provides iron fortification. It
can be mixed with formula up to 1 year and with whole milk after 1 year. After 6 months of age, you can also mix
it with fruit juice (vitamin C) to enhance the absorption of iron.
• At 1 year, well cooked table food is appropriate.
Vitamin Disturbances
• Vitamin D-deficiency rickets. Children at risk are:
• Breast fed babies whose mother has inadequate intake of vitamin D or breast fed longer than 6 months
• Children exposed to minimal sunlight are at risk
• Children that have diets that are low in calcium and vitamin D
• Children who consume milk products not supplemented with vitamin D as primary source of milk
• AAP recommends now that ALL babies (breast fed and formula fed)
• Must be supplemented with 400 IU of Vitamin D orally shortly after birth until they take 1 L of fortified formula/day
• If a baby is breast fed exclusively after 4 months, at which point the fetal Iron are depleted- they will need Iron
supplementation of 1 mg/kg/day until they are taking solids fortified with Iron. Formula for babies already have Iron
in them, and will give formula fed babies the required Iron that they need.
• Other children at risk for vitamin deficiency are those with disorders that impact their vitamin absorption• Of fat soluble vitamins like A and D. For example, CF children need to have supplementation of these fat soluble
vitamins in a water soluble format.
• High doses of salicylate can lead to impaired vitamin C storage, so children with RA (rheumatoid arthritis) must
have supplementation of vitamin C. Also, smoking causes vitamin C to not be absorbed as readily as it should be
• There is a correlation between upper respiratory infections and vitamin D deficiency
• Vitamin A – given to children with measles, who develop complications such as Croup and diarrhea
• Folic acid- is required 0.4 mg/day for all women who are child bearing age, before becoming pregnant. This will
help prevent neurological and spinal disorders such as spinal bifida. Contraceptives and antidepressants
decrease foil acid absorption.
• Overuse with complimentary and alternative medicine (megavitamins). Excessive vitamin supplementation is
problematic. For example,vitamins A and D are fat soluble and are stored in the fat and can reach toxic levels.
Mineral Disturbances
• Iron- if a baby is being breast fed exclusively after 4 months (when mother’s fetal stores are depleted), then baby
will need Iron supplementation of 1 mg/kg/day at 4 months, until they can start taking Iron fortified cereal. Babies
who are formula fed already have required supplementation because the formula already comes with Iron in it.
• Low levels of Zinc- result in failure to thrive
• Intaking megadoses of one mineral can cause lead to taking an under-dose of another mineral
Vegetarian Diets
• Be sure to get specific as there are many kinds and variations. Different types: Lacto-ovo (exclude meat but can
consume dairy (milk and eggs) products), Lacto (exclude meat and eggs, but do consume milk), Pure vegetarians
or Vegans (don’t eat any products of animal origin including milk and eggs), Zen macrobiotics are even more strict
vegans (do allow small amounts of fruits, vegetables, and legumes)
• Breast fed babies of vegetarian moms may need supplementation of Iron and vitamin B12. They need to make sure
they consume foods containing essential Amino Acids.
• In counseling them about their diets, make sure to tell them that spinach is NOT a good source of Iron.
General Food Guidelines
• New food pyramid- see attached pyramid and description of it
• Has a decrease in fats and sweets
• Renamed groups for ease of understanding
• However, the rest is the same
Introduction of New Food to Children
• Safety first- watch for anything they might choke on or have an allergy to. So seeds and nuts aren’t something we
give them right away and wait unit they’re in pre-school. Foods to start off with: well-cooked beans, cereals, grains,
iron-fortified cereals. When you start with cereal, give that for a while, then you can mix the cereal with juice if you
want after 6 months of age. Then start with vegetables, then fruit, then meat, and eggs. Leave a week in between
each food you introduce to detect allergies. Make sure you cut up the food in very small pieces to avoid choking.
Also avoid foods that are a choking risk: hard candies, popcorn, etc. be aware of what all they can choke on
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• More is not better- just one table spoon is plenty to begin with.
• Folic acid to adolescent females
Kwashiorkor
• Is an edematous malnutrition disorder. It results from a lack of food from bottle
feeding and in unsanitary conditions. It can occur in both developed and
undeveloped countries. Maybe because child has a chronic disease, or untreated
acute anorexia nervosa. It can also be due to a lack of proper nutrition knowledge.
But this is extreme malnutrition. Watch for this when the child is being weaned from
the breast. It can happen from a diet that is high in grain or tubers. It is seen
between the ages 1-4 years, when child is no longer breast fed.
• Inadequate protein intake
• Adequate calories
• Early symptoms: fatigue, irritability, lethargy. As protein deprivation continues, start to see growth failure, loss of
muscle mass, generalized swelling, & decreased immunity. A large protuberant belly is common from ascites.
Edema masks loss of body mass. Allowing this to continue can cause blindness. Susceptible to infection and death.
Marasmus
• Malnutrition of both protein and calories
• It is non-edematous. It is a wasting and stunted growth. The child has old, flabby, and
wrinkled skin. Child is very lethargic. This is seen in undeveloped countries where the
adults eat first and the child eats whatever is left. Or it can be seen in times of drought or if
there’s an underlying health disorder in the child.
• Physical and emotional deprivation
Nursing Considerations of Both
• We don’t see this a lot in the US, but one in a while we’ll see a toddler who’s come in and
has only been fed milk.
• Treatment includes good nutrition especially protein
• Management goals
• Rehydration
• Medications- antibiotics and antidiarrheals
• Adequate nutrition
• If weak, need IV and need to be given supplements
• We aim to prevent this from happening again and we provide education, so that it doesn’t
• In villages in certain countries, they supply these children with RUTF (ready to use therapeutic food), it is a paste
based on peanut butter and dry skim milk with vitamins and minerals. It requires no mixing with water or milk.
Food Allergy vs Food Intolerance
• Food Allergy• Reaction involving immunologic mechanism
• Caused by exposure – especially to protein
• Sensitization occurs, and so the 2nd exposure is worse
• Food Intolerance• Reaction know or unknown
• No immunologic mechanism
• If a food allergy is inherited - it’s called atopy
• Both parents have allergy, child will have it
• 50% chance child will have it if only one parent has it
• Can be detected in cord blood (IgE)
• Some reactions occur within a minute, they’re an asthmatic attack with wheezing and dyspnea. This called lead to
death very rapidly. Some take longer to form, such as when a rash is formed, hives, or cramping.
• It’s best to exclusively breast feed until 4-6 months of age. This reduces the chance of getting an allergy. But make
sure you introduce solid foods by 6 months of age, because a child is ready now.
• A child with a history of a food allergy needs to have an emergency plan ready. Need to wear ID bracelet and have
epi cartridge available with 0.001 - 0.3 mg/kg IM. An epi pen junior is 0.5 mg/kg IM for an 8-25 kg child. A regular
epi pen is 0.3 mg for a child who weighs 25 kg and greater. Benadryl and Sertraline are ok for cutaneous and nasal
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signs, but if it’s airway sign you must use the Epi pen. If a child has a reaction to epi, you’d see things like
tachycardia, hypotension, irritability, HA, and N/V.
Food Sensitive children
• Need to avoid unfamiliar food
• Fast food and other restaurants
Some are out-grown such as milk and egg; Peanuts typically are not
Common food allergens: milk, eggs, wheat, legume, fish, nuts, chocolate, pork, strawberries, etc.
Most commonly: 1.5% of children are allergic to eggs. 2.5% of children are allergic to cow’s milk. 1% is allergic to
peanuts. 0.5% are allergic to seafood.
• Cow’s Milk Allergy• Child is allergic to cow’s milk protein in formula
• Symptoms- GI (colic, diarrhea, vomiting, GER, abdominal pain), Respiratory (coughing, wheezing), Other (rash
on the skin, can be anaphylactic and long-term can lead to growth failure, we can also test for blood in the stool)
• Treatment- Eliminate dairy products for 12 months, and then slowly reintroduce them. Formula that we
reintroduce them to is casein hydrolysate (Pregestimil, Nutramigen). Remember these don’t taste very good.
These are the formulas that are pre-digested. If child doesn’t tolerate these, we then can try the Neocate, which
is the AA based formula. Soy is not recommended to transfer the child to, because if they had an allergic reaction
to cow’s milk, there’s a high incidence of them having an allergic reaction to soy (50%). Goat’s milk isn’t
recommended either because it doesn’t have folic acid and has other things that isn’t good. If a breast fed baby is
exhibiting signs of cow’s milk allergy, then the mother needs to eliminate cow’s milk/dairy from her diet and take
vitamin D and Ca supplements.
• Conversion- sometime the baby will convert products that have milk baked in with it. After about a year, you can
slowly reintroduce milk back into the diet to see if he has any type of reaction. Typically children will outgrow
allergies by age 3-5 years. Milk and eggs are common allergies that they outgrow but peanuts are usually not.
• When a child has an allergy, we want to make sure that they’ve had all their vaccinations. But, be careful with
influenza vaccine because it is egg-based.
• Lactose Intolerance• Is the deficiency of the enzyme lactase. It can be present at birth or can come secondary to some other issue or
have a late onset in life. Late onset usually occurs at 3-7 years of age
• Symptoms- abdominal pain, bloating, flatulence, diarrhea. Occurs 30 minutes - 2 hours after consuming lactose.
You usually don’t see an anaphylactic reaction with lactose intolerance.
• Treatment- decrease use of dairy products or use lactose-free dairy products. Soy-based formula or breast milk
can be used. Small amount of milk at meals is better than drinking it alone. You can buy pre-treated milk that has
lactase in it or you can give them enzymes such as lactase, or lac-aid.
Spitting up – Spit Happens
• Make sure to burp baby frequently
• Keep them upright after feeding them
Colic (aka Paroxysmal Abdominal Pain)
• Definition- when baby is just not happy. He cries a lot, for 3 or more hours/day of continued crying for more > 3 x/
week, for > 3 weeks. Crying is not from anything you think you can control such as hunger, a wet diaper, or any
other outer signs. The child just can’t be calmed. He feels like he has cramping. He has a loud cry. He brings his
legs up to his abdomen. This happens at 3 months of age and is usually resolved by 12-16 weeks of age. There are
theories as to why colic occurs (overeating, too rapid feeding, or swallowing a lot of air when feeding, surrounding
stress or tension), but nothing is proven.
• Coping- walk with baby or rock them. Place him across your lap on his belly while you rub his back. Swinging them
really helps, they like the rocking motion. Take breaks and let someone else take care of baby for a while. If all else
fails, put them in the car and go for a ride. You might want to change their feeding practices. Correct a stressful
environment. Support the parent. Reassure parent that they’re not doing anything wrong. Cow’s milk, soy milk,
smoking, gas, too much air, or the diet of a breast feeding mother (broccoli in mom’s diet causes a lot of gas int eh
baby and should be avoided) all may contribute to a colicky baby.
Failure to Thrive
• Definition- inadequate growth resulting from the inability to obtain or use calories required for growth. It used to be
defined as organic vs non-organic, but we have been moving away from these terms as they aren’t as black and
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white as they use to be. Organic used to mean it was resulting from something
physical, that there was a disease process for why they weren’t growing. Nonorganic was resulting from psychosocial factors, like maternal deprivation,
environmental causes, etc. Then there’s always idiopathic, meaning that it’s
unexplained. A FTT child will usually be below the 5 percentile of height and
weight. They will fall off the growth curve line as shown in the chart on the right.
• Treatment
• Reverse malnutrition- if its’ the cause of the growth failure.
• Treat underlying cause
• Catch up on growth
• Consistent nursing care
• Is parental attachment an issue? – If yes, education.
• Increase calories with supplement such as adding polycose ( or hyper cal
formula) to formula to give more calories. Make sure they’re not just
increasing the volume.
• Teaching parent to play with child through demonstration, not lecturing.
• When feeding make sure child is in a quiet, calm, and unstimulating
atmosphere. Talk to the child. Give them directions using face to face
interaction. Be persistent. Introduce new foods slowly. Have a routine.
• Get a good history of the mother and child. Know how they feed the child and
what happens at meal time. What does the growth pattern look like on the growth chart? Keep track of their
height and weight. Document all foods that are consumed. Look at their behavior, interaction, and how child plays
Energy Drink – Effects of
• 30-50% adolescents drink high energy drinks
• High and unregulated amounts of caffeine, taurine, guarana, vitamins, herbal supplements, sugars or sweeteners
• Marketed to the teenager. They are not regulated by the FDA, and this is a concern. They are sold as nutritional
supplements which shields them from caffeine restrictions imposed on sodas and the safety testing and labeling
required of pharmaceuticals.
• Heavy caffeine consumption is linked to seizures, mania, stroke, and sudden death. Caffeine, taurine, guarana
have stimulant properties, cardiac and hematological activity.
• No therapeutic benefit
• Many ingredients understudied and not regulated. Pediatrician advise to NOT use them.
• Diet and substance use history should be required when screening for episodic or chronic energy drink
consumption, both alone and with alcohol. Screening is especially important for athletes, children with high risk
behaviors, health conditions such as seizures, HTN, DM, and cardiac anomalies, and children with behavioral
problems such as sleep disturbance, anxiety, and poor nutrition.
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Fatemeh Sahrapour
MODULE: CARE OF THE CHILD WITH RESPIRATORY DISORDERS
The student will adapt general principles of respiratory system pathology in providing care to the infant and child who
is ill or to prevent illness.
Readings:
Common Disorders
Perry: 1195-1243
Newborn/Infant Disorders
Perry: 910-915
RDS/BPD
Perry: 685-693
Respiratory Disorders
ATI 2013: 147-194, 477-483, 426-434
NURSING CARE OF THE PEDIATRIC POPULATION WITH RESPIRATORY DYSFUNCTION: PART 1
Anatomy
Do infants/children have the same respiratory anatomy as adults? No they don’t!
Anatomical Differences in Pediatrics
● Narrow and short airway- putting them at increased risk for obstruction with mucous or edema
● Alveoli small in size and number- a small surface area for gas exchange
● Infants are preferential nose breathers, they can breathe through their mouth, but like the nose generally until 2-4
months of age. So if there’s nasal obstruction from secretions, it puts them at risk for respiratory distress.
● Shorter, open, and more horizontal eustachian tubes- giving infectious agents easy access to middle ear
● Abdominal or diaphramatic breathers until 6 years of age
● The muscles that keep their airway open are weak
● Bigger tongues than adults- and these bigger tongues put them at risk for obstruction.
Normal Respiratory Rates
• shows that the younger the children are, the father they
breathe. Because the thorax and the lungs are the same
size, infants must breathe 2-3x more often than an adult for
adequate respiration. Adult lungs are stretched out and
never completely compressed, so there’s always a reserve
of air within them that’s not at the moment undergoing gas
exchange.
Newborn
1-11 months
2 years
4 years
6 years
8 years
10 years
12 years
14 years
16 years
18 years
35
30
25
23
21
20
19
19
18
17
16-18
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Characteristics of Respirations
● Newborns and infants have episodes of
periodic breathing, where they normally
breathe with an irregular rhythm and may
have pauses up to 20 seconds between
breaths.
● This is completely normal, as long as
they don’t show signs of hypoxemia, or
bradycardia during these episodes
● If they do become hypoxic and present
with bradycardia, then they are classified
as having apnea.
Urgent Respiratory Threats
● Apnea
● Apnea of Prematurity: AOP
● Apnea of Infancy or ALTE (Apparent life threatening event)
● SIDS or Sudden Infant Death Syndrome
Apnea
• Cessation of breathing for longer than 20 seconds OR for a shorter period of time when associated with hypoxemia
or bradycardia- generally occurs in premature infants and newborns that are classified in different categories
depending on the age of onset.
Apnea of Prematurity (AOP)
● A developmental disorder in premature infants, which occurs as a direct consequence of immature respiratory
control. In an infant of < 36 weeks gestational age. Apnea may become evident in the first 2-3 days after birth.
Apnea spells are considered clinically significant if the episodes are > 20 seconds duration or shorter episodes that
are accompanied by hypoxia and/or bradycardia. The frequency and severity of symptoms is inversely proportional
to gestational age and almost all extremely low birth weight infants (generally below 1000 grams) are affected.
● Apnea of Prematurity: Diagnosis of Exclusion
● Hypoxemia
● Anemia
● Infection, including sepsis
● Metabolic disorders
● Unstable thermal environment (especially warming)
● Antepartum administration of magnesium sulfate or opiates to the mother
● Administration of opiates or general anesthesia to the infant
● Neurologic disorders, including intracranial hemorrhage and neonatal encephalopathy
● Necrotizing enterocolitis (NEC)
● Congenital anomalies of the upper airway
● Seizures
● Nursing Priorities- frequent visual/physical assessments and continuous cardiopulmonary monitoring. Continuously
monitor patient for changes in color and tone; make sure they’re pink and active (moving all extremities) or are they
cyanotic and flaccid? Continuously monitor their VS, especially their respirations, HR, and spO2 (pulse oximetry),
and have room prepared with emergency equipment just in case.
● Warning Alarms: lower thresholds, need MD order for specific settings:
○ Apnea ≥15 or 20 seconds
○ Heart rate ≤70 or 80 beats per minute
○ Oxygen saturation (SpO2) less than 80 or 85 percent
● Treatment- Treatment of apnea is instituted if:
● Apneic spells are frequent, prolonged, or associated with bradycardia or frequent decreased SpO OR the
2
infant requires intervention with bag and mask ventilation, or multiple episodes of tactile stimulation. Therapy
often is needed for several weeks in AOP until the apnea resolves as the respiratory control of infant matures
● Non-pharmacological mangement- provide gentle, tactile stimulation (rubbing their chest, stroking the bottom
of their feet) if child becomes apneic. Continuous cardiopulmonary monitoring with apnea settings on. Bagmask ventilation, environmental temperature control, head and neck position, maintain nasal patency, oxygen
supplementation to maintain SpO2 90-95%, NCPAP.
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● Pharmacological- commonly used as Methylxanthines (Theophylline PO, Aminohylline, or Caffeine IV or PO)
stimulate respiratory neural output by inhibiting adenosine receptors. Caffeine is preferred agent because of
it’s longer half-life, wider margin of safety, and lower frequency of adverse effects. Caffeine SE: feeding
intolerance and tachycardia, tremors, irritability
● These infants are at an increased risk for SIDS, but he majority will grow out of it.
● D/C planning includes a lot of teaching- Parents must become CPR certified, what to do if child shows apnea at
home, show them how to provide tactile stimulation, how and when to give medication, home monitor use and
safety. Studies have NOT shown a benefit of putting babies on home monitors, but because they lower parent
anxiety they’re still being prescribed.
Apnea of Infancy or Apparent Life-Threatening Event (ALTE)
● Refers to idiopathic or pathologic apnea occurring in infants > 37 weeks gestation (as opposed to AOP)
● It is an event that is sudden and frightening to the observer, in which the infant exhibits a combination of:
○ apnea
○ change in color
○ change in muscle tone
○ choking, gagging or coughing
● Usually involves a significant intervention such as CPR.
● The definition of ALTE may include apnea, but an ALTE may occur without apnea. Short periods of apnea < 15
seconds can be normal at any age.
● These children are admitted to the hospital for 24-48 hours for evaluation and monitoring in hopes of finding an
underlying cause. These infants are also at a risk for SIDS.
● Diagnosis can be determined by different invasive and noninvasive tests, by exclusion: labs, upper GI, Ph probe,
EEG, CT, EKG, CXR, skeletal survey, PCG (pneumocardiogram to monitor respirations, HR, nasal air flow, O2
saturation), and Polysomnography (aka sleep study to rule out obstructive sleep apnea. Polysomnography records
your brain waves, the oxygen level in your blood, esophageal manometry, tidal CO2 measurements, heart rate and
breathing, as well as eye and leg movements during the study)
● Treatment:
● depends on if underlying cause found. If any underlying cause is found, then they will treat the problem. If no
cause if found, the patient will be sent home with a home monitor. So educate family regarding monitor use,
electrode placement, and troubleshooting. Teach patient that if monitor goes off, look at the infant first to
determine that they are breathing. Then, determine the cause of the alarm…not to focus on the alarm, but to
focus on the infant, making sure that they’re pink, breathing, and moving all their extremities.
● Be prepared for emergency resuscitation by having the room fully stocked with appropriate sized Ambu-bag,
mask, O2 regulator and tubing, code sheet printed out)
● Nursing Care: close and continuous monitoring, providing gentle tactile stimulation, educate and support family
● D/C: Teach home care – apnea monitoring, med administration, and monitoring for their SE (if caffeine is given,
some of the SE can include tachycardia generally an HR of > 180, restlessness, vomiting, and irritability), CPR
class for family members.
Sudden Infant Death Syndrome (SIDS)
● SIDS is a medical term that describes the sudden death of an infant which remains unexplained after all known and
possible causes have been carefully ruled out through autopsy, death scene investigation, and review of the
medical history. Time of death occurs during sleep.
● Cause of SIDS is unknown
● Many doctors and researchers now believe that SIDS is caused by several different factors, including:
○ Problems with the baby's ability to wake up (sleep arousal)
○ Inability for the baby's body to detect a build-up of carbon dioxide in the blood
● Peak time for SIDS – 2-4 months of life
● Incidence – takes 2250 lives each year, making it the leading cause of death from ages 1 month to 1 year.
Increased incidence in winter. Increased occurrence in lower socio-economical class.
Back to Sleep Campaign
● Since its inception in 1992, SIDS death in the US has declined by more than 50%
● But…significant disparities still exists, so we have a lot of educating to do. But reinforce with the parents that
evidence based research has shown and proven that infants that are placed on their to sleep are at greater risk for
SIDS. It has been found that prone sleeping may cause oropharyngeal obstruction or affect the thermal balance or
the arousal state. Also rebreathing of CO2 while in the prone position may be a possible cause for SIDS. Infants
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that sleep on soft mattresses or bedding may not be able to move their heads from side to side, and this increases
their risk for suffocation and lethal rebreathing. Even lying baby on their side isn’t appropriate anymore.
Infant Risk Factors for SIDS
● Preterm infants
● Multiple births- where mother has been pregnant several times
● Low birth weight
● Low ABGAR scores
● Recent viral illness
● Hx of ALTE or AOP
● Siblings of SIDS victims
● Males
● African Americans, Native Americans, Hispanics all have a greater risk for SIDS
Lower Incidence of SIDS in Infants Who…
• are placed in supine position to sleep
• sleep in their own crib
• sleep on firm mattresses
• are breast fed
• are put to sleep with pacifier
• are immunized
Nursing Education For Parents/Caregivers to Reduce the Risk of SIDS
● A (alone), B (back), C (crib), S (smoking)
● Healthy infants on back to sleep (for naps and for night time). Not even side-lying position is acceptable anymore
because the child can easily turn onto their stomach.
● No soft bedding, baby crib bumpers, blankets, quilts or pillows anywhere in your baby’s sleep area. Use a firm
sleep surface, such as a mattress in a safety-approved crib, covered by a fitted sheet.
● No stuffed animals or towels while sleeping. Keep soft objects, toys, and loose beefing out of baby’s sleep area.
● Infant to sleep in same room as caregiver. No co-sleeping though. Baby should NOT sleep in an adult bed, on a
couch, or on a chair alone, with you, or with anyone else. Infant should sleep in own bed/crib
● Do not let baby get too hot; dress infant in light clothing. Make sure nothing covers the baby’s head. Dress baby in
sleep clothing, such as a one-piece sleeper, and don’t use a blanket.
● Change the position of the baby’s head to prevent flattening of the baby’s skull (called positional plagiocephaly)
● Offer pacifier during naps and at bedtime, the research has shown that it decreases the risk for SIDS
● Encourage breastfeeding for as long as possible
● Schedule and go to all WCC
● Have child immunized
● Don’t smoke or let anyone smoke around your baby.
SIDS- After Occurrence
● Finding the infant, dead in the crib. There is generally no attempt at resuscitation due to signs of prolonged death:
rigor mortis (one of the recognizable signs of death, caused by chemical changes in the muscles after death,
causing the limbs of the corpse to stiffen), corneal clouding. Once EMS arrives, they notify coroner of time of death.
● Arrival at the ER
● Questioned by MD and police officers- must perform an autopsy
● Returning home without the child
● Nurses Role
● Provide compassionate care- grieving lasts a year
● Support Parents- make sure they get involved in a support group
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Fatemeh Sahrapour
NURSING CARE OF THE PEDIATRIC POPULATION WITH RESPIRATORY DYSFUNCTION: PART 2
Upper Respiratory Tract Infections
Common Upper Respiratory Tract Infections
●Nasopharyngitis
●Pharyngitis
●Tonsillitis
●Influenza
●Otitis Media
- Infants and children are susceptible to respiratory
tract infections caused by bacteria and viruses due
to the small diameter of the airway and are at
grater risk of significant narrowing due to
inflammation.
Acute Nasopharyngitis
● Acute nasopharyngitis also known as the “common cold”, and like most viruses it usually lasts 7-10 days
● Caused by these common viruses:
▪ Rhinovirus
▪ RSV
▪ Adenovirus
▪ Influenza virus
▪ Parainfluenza virus
●Clinical Manifestations of Nasopharyngitis in Younger Children
●Fever
●Irritability
●Restlessness
●Sneezing
●Post nasal drip
●Cough
●Diarrhea
●Runny or dry nose- make sure to keep their nose clean and dry. Their nares are small so if they become
obstructed with secretions they will have a hard time breathing because they are primarily nasal breathers. Then
they aren’t going to want to eat because they can’t breathe appropriately.
●Decreased appetite
●Clinical Manifestations of Nasopharyngitis in Older Children
●Sneezing
●Chills
●Muscular aches
●Post nasal drip
●Cough
●Dry throat
●Runny or dry nose
●Decreased appetite
●Nursing Assessment
▪ Eyes- red, puffy
▪ Nose- red, swollen, make sure she’ s not flaring
▪ Mouth- cough
▪ Throat- red, sore
▪ Respiratory effort- make sure breathing effectively, rising and falling appropriately, and not retracting
▪ Lung sounds- check for adventitious sounds
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V/S- especially her RR
Sp02- make sure she’s keeping at least > 92% on room air, if she falls short of that, make sure you give O2
▪ Intake and Output- monitor carefully because children with any respiratory condition are at risk for dehydration
▪ Formulate a Nursing Diagnosis for Nasopharygitis
● Impaired breathing pattern related to presence of semi- thick nasal discharge
● Acute pain related to inflammation of the throat
● Ineffective airway clearance related to thick secretions characterized by difficulty in breathing
● Imbalance nutrition less than body requirements related to respiratory distress AEB…..
● Knowledge deficit related to not familiar with the sources of information
● What is the Plan: Nursing Interventions and Symptomatic Treatment for Nasopharyngitis
● Elevate HOB at least 30 degrees
● Maintain adequate fluids- because they’re at risk for dehydration
● Suction nares PRN, especially before she goes to bed and before she eats
● Saline nose drops before feeding and sleep, and before suctioning
● Humidification- will help thin secretions
● Tylenol/Ibuprofen- if still running a fever
● Promote rest- most children will still be trying to play, and when you see a child that doesn’t want to play this is
very concerning. There are some activities that we can do with a child that aren’t too draining.
● Goals
● Decrease work of breathing
● Increase Spo2
● Less or no pain
● Decrease temperature
● Maintain fluid balance
● Increase PO intake
● Sleep through the night
● Evaluation
● How effective was your interventions based on pt. evaluation? Did the suctioning help? Is her nose clear?
Does it appear that she’s breathing easier? Is she flaring or retracting? How is her spot (again put her on
supplemental O2 if she’s below 92%)? If she’s lying flat in bed, we want to make sure the HOB is elevated to
put her in the best possible position to facilitate gas exchange.
● Did you achieve your goals set for this patient?
● Patient Teaching for Nasopharyngitis- Remember discharge teaching starts upon admission
● Teach parents how to treat the symptoms at home- show them how to use nasal saline sprays or drops, and a
bulb suction for a baby’s nose.
● Instruct family on the importance of hand washing
● Instruct them on when to call Dr. or go to ER
● Warn against the use of over-the-counter cough medications (decongestants and antihistamines) especially in
children less than 6 years of age- because they’ve proven to be ineffective and can be harmful; causing heart
palpitations, hyperactivity, and even death. They’ve also been shown to worsen asthma symptoms. Most
pediatricians recommend other cold and flu remedies. Older children may feel slight improvement and have
been shown to sleep better after a topical vapor is rubbed on to the chest or the soles of their feet. Chicken
soup also works to help kids feel better, it has been shown to increase the WBC count.
▪
Pharyngitis
● Inflammation of the throat with exudate that can cause pain when swallowing
● Can occur at any age. Average age of occurrence 5-10 years
● 80-90% of acute pharyngitis cases are viral in nature. But….may be bacterial
➢ Group AB Hemolytic Streptococcus/GABHS
• Clinical Manifestations of Pharyngitis
● Inflamed throat
● Strawberry tongue
● Exudate
● Pain when swallowing
● Head ache
● Fever
● Abdominal pain
● Cervical lymphadenopathy
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● Sand paper rash: face,trunk, axillary perineal/ Scarlet fever
● Nursing Assessment●Throat
●Respiratory effort
●Lung sounds
●V/S: Temp., HR, RR, B/P
●SpO2
●Skin
●Pain
●Viral or Bacterial Pharyngitis
● Must do throat swab!!
▪
Quick Strep/ Rapid Antigen Test
Throat Culture
• Treatment Plan for GABHS or Strep Throat• If positive culture, must be treated with ABX: Penicillin or Amoxicillin
●If allergic to penicillin may use a cephalosporin such as cephalexin (Keflex), Clarithromycin (Biaxin),
Azithromycin (Zithromax, Zmax), or Clindamycin
●Nursing Management of Pharyngitis
● Monitor V/S
● Monitor I & O’s
● Monitor Pain
● Administer IV ABX as ordered
● Cold/warm compress to neck
● Warm saline gargles
● Encourage fluids
● Recommend soothing /soft foods
● Humidification
● Encourage low level activities
● D/C Planning& Teaching: Pharyngitis/Strep Throat- Teach parents about the importance of
● Disease transmission and prevention
● High contagiousness of this condition
● Importance of hand washing
● Make sure the child does not return to school until they have been on ABX for a full 24 hours
● Importance of giving the child ABX until finished
● No sharing utensils
● No eating or drinking after others
● Change out toothbrush after 24 hours of being on ABX
▪
Complications of GABHS (Group A beta-hemolytic Streptococcal Infection)
● Rheumatic Fever:
➢ Usually occurs 2-6 weeks after pt. infected with GABHS
➢ ASO titers done
➢ Treated with PCN
➢ Prophylactic treatment required and depends on age of child and severity of condition
• Acute Glomerulonephritis
●Most common post-infectious renal diseases in childhood
●ASO titers done
●Symptomatic treatment
Tonsillitis
● Inflammation/infection of the tonsils
● Occurs most often with pharyngitis
● May be viral or bacterial● Diagnosis by early rapid strep test/throat culture to determine causative agent
● Classic S&S- red, inflamed, enlarged, touching tonsils aka “kissing tonsils”, difficulty swallowing and breathing.
Child may breathe through mouth because the adenoids enlarge and block the space between the posterior nares
making it difficult or impossible for air to pass from the nose to the throat
● Treatment depends on if causative agent is bacterial or viral
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● non-pharmacological
● pharmacological- if it’s bacterial they’ll treat with an antibacterial, if it’s a virus then they’ll provide supportive
measures (warm, salt water gargles, throat lozenges, Tylenol if patient in pain)
● surgical- if tonsillitis becomes severe, then they’ll remove the palatine tonsils and it will be nurse’s job to
prepare them for surgery and monitor child post-op. You can prepare these children with use of child life
specialist and the educational materials that are provided in hospital. MD will consent the patient and you will
be responsible for obtaining signing of the consent and making sure family did understand what the MD told
them. When patient gets back from surgery, they’re placed on their side or in a prone position with their head
to the side to facilitate the drainage of the secretions. Careful suctioning is done if needed. Tell them to avoid
coughing or blowing their nose. If you see reddish brown secretions, this is normal after surgery. But if the
secretions turn bright red and the patient is swallowing more than usual, this is a sign of increased bleeding.
Watch for bleeding for up to 10 days post-operatively. The most obvious sign of bleeding is the child's
continuous swallowing of the trickling blood. Notify surgeon immediately. During this time, teach the family and
the patient to avoid red colored liquids and milk based foods (because they increase the production of
mucous) initially. You will advance from a clear, soft diet to a regular diet. D/C instructions include teaching pt
to avoid irritating and spicy foods, avoid gargles and vigorous tooth brushing, avoid coughing or clearing
throat, avoid using straws and chewing gum, how to take medication appropriately to control pain/discomfort.
● Management of Tonsillitis
● Non-pharmacological measures➢Humidification
➢Warm salt water gargles
➢Throat lozenges
• Pharmacological measures➢Tylenol
➢Antibiotics if bacterial
• Surgery➢Recurrent infections/obstructive sleep apnea
• Tonsillectomy and Adenoidectomy
● Pre-Op teaching/consent
➢ Room set up
● Post-Op teaching and care
➢ Positioning: abdomen/side lying
➢ Monitor for bleeding
➢ Minimize activities that precipitate bleeding
➢ Monitor I & O’s
● Discharge teaching instructions
Question
A 13 year old s/p tonsillectomy- How should we position her post-op and why? What are we continuously monitoring
for?
● Assessment finding: Pale, lethargic, cap. refill >4secs
● Vital signs: HR 160, B/P, 80/50, RR 12, Spo2 92% on RA
● Labs: Hg 10, HCT 30
Eustachian Tube in Infant vs Adult
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Otitis Media
● Inflammation of the middle ear. It is one of the most prevalent diseases of early childhood. Increase incidence
between 6 months and 2 years. Infants who breast feed have a lower incidence than those who bottle feed, related
to positioning of the baby. If parents have a history of otitis media, their children will be at greater risk for it. Children
who are around passive smoke, in a household with many members, attend day care, cleft lip/palate, have Down’s
Syndrome, are at increased risk for it. Most common in winter months
● Risk factors
➢ Environmental
➢ Life style factors
● Usually triggered by
➢ Bacterial/ viral infection
➢ Allergies
➢ Enlarged tonsils
• Mainly results from blocked Eustachian tubes from edema
Acute Otitis Media (AOM)
• A bacterial infection that causes inflammation of the middle ear space with rapid onset. It is generally caused by
Streptococcus Pneumonia, H.Influenza, and Marxella Cateralis. Usually follows an upper respiratory infection.
●S&S●Painful ear
●Pulling or rubbing the ears
●Fever
●Fussiness or irritability
●Fluid leaking from the ear
●Changes in appetite or sleep
●Trouble hearing
➢Diagnosis
● Made by a visual inspection with otoscope of tympanic membrane to check for its mobility. Done by MD or Np
➢Treatment
● Tylenol/Ibuprofen
● Benzocaine
● Cold packs
● ABX- usually Amoxicillin
● Surgery
➢Nursing Objectives• Relieving pain either with Tylenol or Tylenol with Codeine, ice pack, or Ibuprofen, or Benzocaine (which is a
numbing agent administered to patient’s ear)
• Facilitate drainage when possible, prevent complications of recurrence
➢Teaching
• Educate family in care of the child. Teach them how to hold baby during feeding, making sure child is sitting
upright. Maintain childhood immunizations. Encourage breastfeeding at least until 6 months. Propping the
bottle is discouraged because of the pooling of milk because the child is in a supine position. Decrease
exposure to tobacco smoke and known allergens, as they increase the risk of patient developing AOM. If
these treatments don’t work, patient may need to have surgical incision into the eardrum to relieve pressure of
drain fluid (myringotomy). They may also need a tympanostomy, tube placement, and also an adenoidectomy
procedure to treat recurrent chronic otitis media. 3 bouts in 6 months, 6 and 12 months, or 6 by 6 years of
age.
Otitis Media with Effusion (OME): Glue ear
● Is generally caused by middle ear infections, may lead to “glue ear”, which is OME, where sticky fluids build up and
affect the child’s hearing. This may also lead to unclear speech and behavioral problems.
● S&S- OME may have no symptoms at all. The most frequent presentation is covert and overt hearing loss, which
mostly fluctuates with season and may be affected in changing position. Patient may describe it is a plugged ear or
a stuffy or wooly feeling in the air. The only signs that show the parents that the condition even exists, is that their
child is talking loudly or not responding to verbal commands (difficulty hearing), or have their music/tv turned up
really loud. No c/o pain. No fever. Speech delay. Sometimes it can be detected on routine audiometry.
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● Diagnosis: Visualization of tympanic membrane and use of an otoscope to test for mobility of the tympanic
membrane. An RN will not be using a otoscope to assess the tympanic membranes. This is an advanced
assessment skill used by PA, Dr., NP.
● Treatment: OME can be treated with bilateral myringotomy/PE (pressure equalizing) tubes, surgical placement of
tympanovstomy tubes. Tympanovstomy tube placement and adenoidectomy are surgical procedures that may be
done to treat recurrent OME. The tubes facilitate drainage of fluid and allow ventilation of middle ear. This
procedure is now done using laser in an outpatient setting, and takes only 15 minutes and usually the tubes come
out on their own in 6-12 months.
Croup Syndromes
● Croup is a general term applied to a symptom complex characterized by hoarseness, a resonant cough, described
as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress
resulting from swelling or obstruction in the region of the larynx and trachea. Croup can affect the larynx, bronchi,
and trachea. Croup syndromes are described according to the primary anatomical area affected.
● Include
● Acute epiglottitis or Acute supraglottitis
● LTB or Acute laryngotracheobronchitis
Acute Epiglottitis or Acute Supraglottis
● Is a serious obstructive inflammatory condition
● Occurs predominately in children ages 2 years to 5 years old- but can occur from infancy through adulthood.
● H. Influenza B is the main culprit- bacteria***
● Considered a medical emergency due to fast onset
● Epiglottitis looks worse than they sound, there’s a high degree of toxicity, no cough, and dysphagia***
• Clinical Manifestations of Epiglottitis
● Sudden abrupt onset of:
▪
High fever > 39 degrees
Sore, red, swollen throat
▪ Absence of cough
The 4 D’s
▪ Dysphonia- a muffled, hoarse, or absent voice.
▪ Dysphagia- difficulty swallowing due to the pain
▪ Drooling- also due to the pain
▪ Distressed respiratory effort- inspiratory stridor as the larynx becomes obstructed
Agitation/Irritablity
Tripod position- the child may insist on sitting upright and leaning forward, with the chin thrusted out, mouth
open, and the tongue protruding
Expiratory Stridor
▪
▪
▪
▪
▪
• Diagnosis of Epiglottitis Based on:
• Clinical manifestations- classic symptoms just discussed
• Radiography- a lateral neck x-ray, which will show a thumb sign from an enlarged epiglottis
• Blood cultures- to show what antibiotic to use
• Therapeutic Management of Epiglottitis
●
●
●
●
●
●
●
●
Avoid looking in mouth without emergency equipment readily available
Calm environment
Encourage position of comfort
Let caregiver stay with child
Emergency intubation/tracheostomy if child is in severe respiratory distress, otherwise will do the following:
Humidified oxygen
Antibiotic therapy
Corticosteroids- to help with inflammation and swelling
• Nursing Management of Epiglottitis
▪
▪
Frequent assessments- remember it’s a medical emergency so assess patient quickly and report symptoms
Continuous cardiopulmonary monitoring
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▪
Maintain airway patency
NPO
▪ IV fluid administration as prescribed
▪ ABX
▪ Provide emotional support
▪ Discharge planning- home teaching includes completing a 7-10 day course of antibiotics. For children under
the age of 4 years, Rifampin is used for treatment for 4 days.
▪
Laryngotracheobronchitis (LTB)
● Most common of croup syndromes affecting children < 5 years of age
● Mostly caused by para-influenza virus types 1 & 2, RSV, influenza A & B***
● This condition usually starts as an upper respiratory tract infection that descends to adjacent structures
● Inflammation and swelling of the mucosa lining, the larynx, and trachea causes a narrowing of the airway that result
in the onset of the classic symptoms like the croupy, barking cough
● They sound worse than they look, have a seal-like cough***
● Clinical Manifestations of LTB
● Gradual onset of low grade-fever- ***
● Ill with URI for several days- see a runny nose or cough that’s escalated into a severe cough with hoarseness
(because the inflammation of the trachea and larynx is causing severe swelling)
● Inspiratory stridor
● Seal like barking cough and hoarseness
● Tachypnea- fast breathing
• Diagnostic Tests:
● Clinical signs and history- parents may report that child went to bed feeling fine and then woke up with a
barking, brassy cough. Most children with Croup can be managed at home with humidification but if you get
them in the hospital it’s because they’ve had increased RR, nasal flaring, retractions, grunting, and the parents
were scared and brought child to the ER.
● Cardiopulmonary monitoring & Pulse oximetry for hypoxemia- In the ER the nurse will hook child up to a
cardiopulmonary monitor and pulse oximetry to keep an eye on O2 saturation levels
● Chest X-ray- MD will order a chest x-ray, in which the classic pencil sign showing narrowed airway appears
● Nursing Management for Mild-Moderate Symptoms
➢ Humidification,
Medications- (IV therapy for hydration and steroids for inflammation), O2 therapy
in ER is what’s recommended, child will then be stabilized at sent home if showing good
response to treatment. Encourage fluids if mild symptoms to prevent dehydration
➢ Uncommonly – children will need intubation and be sent to ICU. Admitted if moderate to severe symptoms. If
LTB is severe, nebulized Epi is often used in children with severe disease, stridor at rest, retractions, or
difficulty breathing. Also in severe LTB, administration of Heliox is used to decrease the work of breathing and
relieve airway obstruction.
➢ Observation
● Nursing Management for Severe Symptoms:
➢ Oxygen
therapy & Closely monitor pulse oximetry- to monitor O2 status
epinephrine- to help with stridor
➢ Corticosteroids- to help with inflammation
➢ IV therapy- to prevent dehydration
➢ Placing patient on NPO status for RR > 60/ minute, because this puts them at risk for aspiration
➢ ABG/VBG monitoring for acidosis
➢ Accurate & frequent assessments- continuous vigilant observation & accurate assess. of respiratory status
because changes in therapy are performed based on your observation as a nurse, child’s response to the
therapy, and tolerance of the procedure.
➢ Early signs of airway obstruction include increased pulse, RR, sub-sternal, supra-sternal, and intercostal
retractions, nasal flaring, and increased restlessness
➢ Intubation equipment readily available & patient’s code drugs listed on a sheet and readily available
➢ Nebulized
• Nursing Care Goals for Croup Syndromes
• Maintain airway patency, meet fluid & nutritional needs, discharge planning, home care teaching
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• Home care includes monitoring for worsening of symptoms, continued humidity, adequate nutrition/nourishment.
• Nursing Diagnosis for Croup Syndromes
• Ineffective breathing pattern related to tracheobronchial obstruction, decreased energy and fatigue
• Impaired gas exchange related to altered O2 supply
• Altered nutrition: less than body requirements related to expenditure of glycogen stores and inadequate food
and fluid intake prior to admission
• Fear/anxiety in parents or child related to acute illness, uncertainty of prognosis, unfamiliar surrounds and
procedures
• Knowledge deficits in parent- related to diagnosis, prognosis, treatment, and home care needs
Lower Respiratory Tract Infections
● Bronchitis
● Bronchiolitis
● RSV
● Pneumonia
Bronchitis
● Inflammation of the large airways
● Usually follows an URI in children < 4 years of age
● Usually caused from virus
● Self-liming, child recovers with symptomatic treatment within 5-10 days
● Clinical Manifestations of Bronchitis
● Course, hacking, dry/non-productive cough with increased severity at night, may turn productive in 2-3 days
● Audible wheezing
• Treatment for Symptomatic Bronchitis:
➢ Antipyretics- if they do run a fever
➢ Analgesics- such as Tylenol and Ibuprofen
➢ Humidity- help with inflammation
➢ Hydration
➢ Cough suppressants- are often used by parent, just remind them that these may interfere with clearing of
secretions. Also remind parents about the cautious use of anti-tussants, decongestants, and anti-histamines
especially in children of < 6 years in age
Bronchiolitis
● An acute viral infection, mostly caused by Respiratory Syncytial Virus (RSV)
● Primarily affects the bronchi and bronchioles
● Rare in children > 2 years of age
● Occurs most often in winter and early spring
● Affects boys more than girls
● Clinical Manifestations of Bronchiolitis
● URI (upper respiratory symptoms such as rhinorrhea, pharyngitis, cough, and fever
● Progress to lower tract, more cough, labored breathing, shallow respiration, nasal flaring, retractions, cyanosis
● Child acting more ill, may refuse to eat, spits up more
● May also have emphysema, increased nasal mucous, wheezing, fever
● Apnea may be the first recognized indicator of RSV infection in infants < 1 month of age
Respiratory Syncytial Virus
● Is the most frequent cause of hospitalization in children less than 1 year old
● Peak infection season is November – April
● Is transmitted through direct person-person contact & by droplet inhalation if the person is actively coughing and/or
sneezing
● Treatment is primarily supportive unless child is in high risk groups and may receive Synagis prophylactically. High
risk groups include: infants born before 35 weeks of gestation, infants with chronic lung disease, and infants born
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with hemodynamically significant congenital heart disease. Preemies are often born before getting enough
antibodies from their mothers to help fight RSV. They are also at increased risk for severe RSV disease because
their lungs are less developed and their airways are narrower than those of full-term babies. Synagis is the only
product available in the US used for the prevention of RSV infection. It’s a monoclonal antibody and is given monthly
in an IM injection to prevent hospitalization of patients who are at high risk for developing RSV. It can be given in 3
or 5 doses depending on patient and severity. Since RSV infections are so common and the symptoms are so
severe, why doesn’t everyone get Synagis? One of the reasons that younger infants, especially if they were born
premature, are at most risk of the severe complications of RSV infections. The other reason is the cost, $900/month,
once/month, for entire season. Most insurances do cover this however.
• Pathophysiology of RSV
• Edema of bronchioles and thick secretions
• Obstruction and hyperinflation
• Increased respiratory effort=respiratory distress
• Respiratory Failure
• RSV Clinical Manifestations
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Fever
Cough
Tachycardia
Cyanosis
Tachypnea
Retractions
Wheezing
Sepsis like appearance
Apneic episodes (in the very young)
Dehydration
• Diagnosis RSV
➢ Rapid RSV antigen testing done via nasal aspirate or nasal wash or nasopharyngeal swab
➢ Chest X-Ray
• Nursing Diagnosis for Bronchiolitis/RSV
• Ineffective airway clearance related to increased airway secretions, fatigue from coughing, dyspnea, air trapping
• Ineffective breathing patterns related to inflamed tracheo-bronchial tree and progression of bronchiolitis,
increased work of breathing and decreased energy
• Fluid volume deficit r/t inability to meet fluid needs and increased metabolic demands
• Altered tissue perfusion r/t partially obstructed airways
• Nursing Management for RSV
• Children admitted to hospital with suspected RSV infection are assigned separate rooms or grouped with other
•
•
•
•
•
RSV infected children. Contact and standard precautions are used: hand washing, not touching the nasal
mucosa and conjunctiva, and using gloves and gowns when entering the patient’s room
Maintaining respiratory function- by doing frequent assessments, monitor their VS, look for signs of respiratory
distress telling you that your child is deteriorating. Notify MD if these signs are noticed
Supporting overall physiologic function
Hydration
Reducing child’s and family’s anxiety- group nursing activities to promote rest
Preparing child and family for home- teaching them about med administration, symptoms of RSV, and when to
call doctor. Isolate the child to keep RSV from spreading. Direct contact from secretions can live on countertops,
paper tissues, cloth, and skin for several hours. Always use gloves and gowns when entering patient’s room and
use good hand washing techniques.
Pneumonia
● Inflammation of the pulmonary parenchyma or infection in one or both lungs is common in childhood but occurs
more frequently in early childhood
● May occur as a primary disease or as a complication of another illness
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● May be caused from virus, bacteria, fungus or aspiration. The most useful classification of pneumonia is based not
he etiologic agent. Causative agent is either inhaled into the lung directly or comes from the blood stream
• Clinical Manifestations of Pneumonia
• Fever-Usually high > 39.5 C (103 F)
• Respiratory:
Cough
Tachypnea
Rhonchi
Crackles
Chest/abdominal pain
Retractions
Flaring
Pallor
• Behavior:
• Irritable
• Restless
• Lethargic
• Gastrointestinal:
• Anorexia- doesn’t want to eat
• Vomiting
• Diarrhea
• Abdominal pain
•
•
•
•
•
•
•
•
Supportive and Symptomatic Nursing Care of a Child with Pneumonia
● Thorough respiratory assessment, and a continuous assessment. You are monitoring: VS and pulse oximetry
● Administration of supplemental oxygen as ordered
● IV fluids- to prevent dehydration
● Antibiotics- depending on causative agent
● Pharmacological/non-pharmacological pain relieve measures
● Elevate HOB to get good chest expansion
● Possible Chest tube placement- to remove fluid or air that’s accumulated in the lung
● Daily chest x-rays
● Provide calm environment- allow for presence of caregivers as they provide a source of comfort for patient
● Teach and support patient/family, prepare for d/c- teach regarding O2 needs, medication needs, positioning
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NURSING CARE OF THE PEDIATRIC POPULATION WITH RESPIRATORY DYSFUNCTION: PART 3
Long Term Respiratory Dysfunction
● Asthma
● Cystic Fibrosis
● BPD (Bronchopulmonary Dysplasia or Chronic Lung Disease)
● Neonatal Respiratory Distress
Asthma
• A chronic inflammatory disorder of the airways characterized by:
● Recurring symptoms
● Airway obstruction
● Bronchial hyper-responsiveness
● What Causes Asthma?
● Exact cause is unknown. It has no cure. Even if you feel fine, still have the disease, can flare up at any time
● Allergies- has an influence in the persistence and severity of disease
● Frequent viral respiratory infections
● Early warning signs that indicate patient is at risk for developing asthma include:
➢ Eczema starting in the early months
➢ Frequent lower respiratory symptoms
➢ Respiratory problems appearing before the first birthday
➢ Having a family history of asthma
• Diagnostic Evaluation of Asthma
● The classic manifestations of asthma include:
➢Dyspnea
➢Wheezing
➢Coughing
● History/Physical Exam:
➢History of chronic cough with an absence of infection
➢Diffuse expiratory wheezing
● Pulmonary function test- provide an adjective measure of evaluating the presence and degree of lung disease
as well as the response to therapy
● Incentive spirometry- performed reliably on children 5-6 years of age
● Peak expiratory flow rate (PEFR)- measures maximum flow of air that can be forcefully exhaled/second
● Bronchoprovocation testing- direct exposure of mucous membranes to a suspected antigen at increasing
concentrations. This helps identify allergens.
● Skin prick testing and immunological testing- for allergen specific IgE, used to ID environmental triggers
● Laboratory tests- like a CBC
● Frontal and lateral view chest X-ray
• Clinical Manifestations of Asthma
● As a nurse assess airway potency, RR, symmetry, effort, and use of accessory muscles, breath sounds in all
●
●
●
●
●
●
●
●
●
●
●
●
●
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lung fields, monitoring for:
Cough
Shortness of breath
Audible wheeze
Malar flush, red ears
Cyanosis of nail beds
Circumoral cyanosis
Dyspnea
Nasal flaring
Retractions
Hyperresonce on chest percussion
Coarse and/or crackles and wheezes throughout all the lung fields
Sweating
Posture/ tripod position
Changes in speech
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● Restlessness
● Anxiety
● Fatigue
Nursing Alert!!
● A child with asthma who sweats profusely, remains sitting upright, and refuses to lie down is in severe respiratory
distress!!! Pay close attention to this child and have emergency equipment readily available
● A child who suddenly becomes agitated or an agitated child who suddenly becomes quiet may have serious
hypoxia and require immediate intervention
● Asthma Triggers
● Allergens: indoor (dust mites, mold, etc.) and outdoor (trees, pollen, pollution, etc.)
● Irritants (tobacco or wood burning smoke, odors, sprays)
● Exercise
● Sudden weather or temperature changes (extreme cold or hot)
● Seasonal allergens (grass, trees, weed pollen)
● Animal dander
● Strong emotions
● Food
● Medications
● Treatment Plan
● Asthma diagnosis & treatment plan are based on symptoms and classified into one of following 4 categories:
Step 1. Mild intermittent- Symptoms occur < twice a week
Step 2. Mild persistent- Symptoms occur more than twice a week, but not daily
Step 3 or 4: Moderate persistent- Daily symptoms occur in conjunction with exacerbations twice a week
Step 5 or 6: Severe persistent- Symptoms occur continually, along with frequent exacerbations twice a week
● Non-Pharmacological Therapy for Asthma
● Aimed at the prevention and reduction of exposure to airborne allergens and irritants
● Nurses Role: Family and patient teaching on “Allergy proofing the home and community” (see box in
text pg. 1227)
● Pharmacological Therapy for Asthma is Aimed toward:
➢Preventing and controlling asthma symptoms
➢Reducing the frequency and severity of the child’s asthma
➢Reversing airflow obstruction
➢Providing long term suppression of inflammation
➢Asthma Medications- 2 general categories, often used in combination to achieve desired control:
❑ Short term acting medications or quick relief meds used during an asthma attack
• Bronchodilators used to treat symptoms and exacerbations. Include SABA (short acting beta 2
agonists). They’re for short- term use to open narrowed airways and relieve the feeling of chest
tightness, wheezing, and breathlessness providing quick relief of broncho-constriction and bronchospasms . They can also be used to prevent exercise induced asthma. These are taken on an only
as needed basis. Cholinergic agonists can relieve broncho-spasms.
➢Albuterol
➢Xopenex
➢Terbutaline
➢Metaproterenol
❑ Long term control medications or Preventative medications
• Used to achieve and maintain control of inflammation. These are used on a daily basis to control
asthma and reduce the number of day or night symptoms. They are not used for the relief of
symptoms. Children with symptoms more than 2x/week or who wake > 2x/month should be on a
controller medication.
➢Inhaled corticosteroids: QVAR, Pulmicort, Flovent
➢Long acting bronchodilators (LABA): Salmeterol
➢Leukotriene Receptor Agonists
➢Methylxanthines: Theophylline
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• Asthma Medications: come in a variety of forms, including: Metered-dose inhalers, Dry powder
•
•
•
inhalers, Liquids that can be used in nebulizers, Pills. Inhaled forms are preferred because they deliver
the medication directly to the air passages with minimal side effects. But the choice of medication is
based on the frequency and severity of symptoms and child’s condition. Many asthma meds are given
by inhalation with a nebulizer or a metered-dose inhaler (which should always be attached to a spacer,
especially when an inhaled corticosteroid is administered, to prevent yeast infection the mouth). MDI's
are equipped with a face mask or mouthpiece depends on child’s age and cooperation. Instruct child to
breathe slowly and deeply for a better distribution to the narrow airways.
Choosing the Right Medication depends on:
➢ Severity and frequency of symptoms
➢ Child’s age
➢ Child’s developmental level
➢ Child’s coordination- must be able to push down on inhaler and breathe in at same time
Medications most commonly used with a MDI:
➢ Corticosteroids
➢ Cromolyn sodium
➢ Nedocromil sodium
➢ Xopenex
➢ Albuterol
➢ Metaproterenol
➢ Terbutaline
➢ Salmeterol (Serevent)
➢ Methylxanthines (theophylline)
Asthma Medication Side Effects (not AE, these should be expected):
• Albuterol- shakiness, tremors, tachycardia, hyperactivity
• Glucocorticoids- thrush, modest reduction in height
● Nurses Role: Observe, monitor, teach, support, encourage, teach…
➢ Observe
for any signs of difficulty breathing, they’re grunting, have nasal flaring, have a decreased spO2,
increased HR, RR. Let MD know immediately.
➢ Teach family on how to avoid known allergens
➢ Take medication appropriately and caution about their AE and the dangers of overuse of SABA/LABAs
➢ Monitor for medication toxicity while they’re in the hospital- shakiness, irritability, jitteriness, increased HR
➢ Show how to use PEFM (peak expiratory flow meter) if child >5 years of age
➢ Provide calm, supportive environment
➢ Formulate an asthma action plan to use at home and at school. It’s very important that every patient have one.
➢ How to use an epipen if severe attack from allergen occurs
● Recall:
● Asthma has NO CURE…It an only be controlled with medications. Use when needed but not to use
indiscriminately, and not to be substituted for avoiding the symptom producing allergen.
● PROGNOSIS: May become asymptomatic at puberty. But it’s very hard to predict
● WARNING: If child’s asthma attack is not controlled with quick-acting medication, at risk for Status
Asthmaticus.
Nurse Warning!!
● Shortness of breath with air movement in the chest restricted to the point of absent breath sounds accompanied by
a sudden rise in respiratory rate is an ominous sign indicating ventilatory failure and imminent respiratory arrest. So
you’re listening to your patient and you don’t hear any air movement, and then they have a rise in their RR, this is
an ominous sign of respiratory arrest.
● Children who continue to display respiratory distress despite vigorous therapeutic treatment with bronchodilators
such as Albuterol and Epinephrine are considered to be in Status Asthmaticus.
● Status Asthmaticus is:
● A life threatening episode of airway obstruction, unresponsive to common treatment
● Medical Emergency
● Can result in respiratory failure and death if untreated
● It may develop gradually or rapidly
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● Therapy for Status Asthmaticus is aimed at:
❖ Improving ventilation
❖ Decreasing airway resistance
❖ Relieving bronchospasms- achieved by administering humidified O2, especially in those with spO2 < 90%. For
the inflammation, they’ll give inhaled aerosolized SABA. These are recommended for all patients who come in
with Status Athmaticus. They’ll give 3 treatments of these agonists spaced 20-30 minutes apart. A systemic
corticosteroid may be given to decrease effects of inflammation. Anticholinergics may be given for bronchodilation. Additional therapies in acute asthma attacks include the use of IV Magnesium. It is a potent muscle
relaxant that acts to decrease inflammation and improve pulmonary function and peak flow. Antibiotics may be
used if patient has a secondary bacterial infection like Pneumonia or Sinusitis.
❖ Correcting dehydration and acidosis
❖ Allaying child and parent fears/anxieties by providing a quiet, calm, family-centered environment
• Status Asthmaticus and the Nurses Role
●
●
●
●
●
●
●
●
●
Maintain patent airway
Administer humidified O2
Administer 3 neb tx of a beta2-agonist, 20-30 apart (usually Albuterol)
Obtain IV access: hydration and to correct acidosis, IV Epi/Magnesium Sulfate
Monitor ABGs and serum electrolytes
Administer corticosteroids, either PO, IV, or IM to help with inflammation
Prepare for emergency intubation if patient goes into respiratory distress
Have crash cart, code sheet and code drugs readily available
Establish calm environment, allowing parent presence at all times
Cystic Fibrosis
● Is a chronic autosomal recessive disorder of the exocrine glands. It is the most common inherited metabolic disorder
● Thick and copious mucous obstructs the small passageways of the affected organs
● CF is inherited as an autosomal recessive trait. What does this mean? Two copies of the abnormal gene must be
present for the trait to develop. The affected child inherited the defective gene from both parents. What is the % that
they will have child with CF? The overall risk is 1/4 if both parents carry the gene. The mutated gene for CF is
located on the long arm of chromosome 7. It codes for a protein of 1480 AA called CF-Transmembrane Regulator. It
is responsible for the abnormal mucus secretion and obstruction that occurs in the following areas:
● Bronchial – chronic bronchial pneumonia, emphysema
● Small intestine – meconium impaction, bowel obstruction
● Pancreatic duct – malabsorption syndrome
● Bile duct – biliary fibrosis, portal hypertension
• How is Cystic Fibrosis Diagnosed? Average age of dx is 14 months
● Universal Newborn Screen, DNA identification, Abnormal nasal potential
● 2 Positive sweat chloride tests (traditional diagnosis)- a consistent finding of abnormally high NaCl
●
●
●
●
concentrations in the sweat is a unique characteristic of CF:
➢ Normal < 40 Meq/L
➢ Positive > 60 Meq/L in children
➢ >40 Meq/L in infants
Chest Radiography: patchy atelectasis, obstructive emphysema
Positive family history
72 hour stool sample- steatorrhea (undigested fats), azotorrhea (foul-smelling stools)
Enzyme Analysis- Absence of pancreatic enzymes
• Clinical Manifestations of Cystic Fibrosis
➢ Thick,
sticky mucous- is the primary factor responsible for many of the manifestations of the disease, such as
mechanical obstruction of the mucous glands. Instead of forming a thin, freely flowing secretion, the mucous
glands produce a very thick muco-protein. This accumulates and dilates them. Small passages in the organs
become obstructed. The earliest sign you’ll see in the post-natal period is meconium ileus. It is a bowel
obstruction that occurs when the meconium in your child's intestine is even thicker and stickier than normal
meconium, creating a blockage in a part of the small intestine called the ileum.
➢ Bowel obstruction (newborn)
➢ Intussusception (telescoping bowel)
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➢ Impaction
in infants and toddlers
characteristics: steatorrhea (fatty), frothy, foul smelling, floats. This is because in the pancreas, the thick
secretions block the ducts, which eventually causes pancreatic fibrosis. This blockage prevents essential
pancreatic enzymes from reaching the duodenum, which causes marked impairment in the digestion and
impairment of nutrients.
➢ Chronic cough
➢ Difficulty in gaining weight
➢ FTT- failure to thrive
➢ Skin is salty
➢ Stool
• Goals of CF Therapeutic Management
1.
2.
3.
4.
Prevent or minimize pulmonary complications
Ensure adequate nutrition for growth
Encourage appropriate physical activity
Promote a reasonable quality of life for the child and family, which will require a multi-disciplinary approach
• Management of Pulmonary Problems
● ABX- to treat pulmonary infections
● Physical exercise is also very important and is a good adjust to daily ACT. Remember exercise stimulates
mucous excretion and provides a sense of well-being and increased sense of self-esteem.
● Bronchodilators to improve ventilation. These may be given in an aerosolized form to open up the bronchi for
easier expectoration. These are administered before percussion and postural drainage, especially when
patient is exhibiting signs of active airway disease or wheezing.
● Mucolytics- remove muco-purulent secretions. Another aerosolized medication that’s popular is DNase or
Pulmozyme, which decreases the viscosity of the mucous.
● New FDA medication “Orkambi” approved June, 2015. The U.S. Food and Drug Administration today
approved the first drug for cystic fibrosis directed at treating the cause of the disease in people who have two
copies of a specific mutation. Orkambi (lumacaftor 200 mg/ivacaftor 125 mg) is now approved to treat cystic
fibrosis (CF) in patients 12 years and older, who have the F508del mutation, which causes the production of
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an abnormal protein that disrupts how water and chloride are transported in the body. Having two copies of
this mutation (one inherited from each parent) is the leading cause of CF.
● Airway clearance therapies or ACT’s such as the ones listed below. These improve ventilation and remove
muco-purulent secretions. These treatments are usually performed 2x/day, usually upon rising and in the
evening, and more frequently if needed especially during periods of pulmonary infection. You want to perform
the procedures at least 30 before and after patient’s meal to avoid inducing N/V.
➢ Chest Percussion Therapy
➢ Postural drainage- kids like wheel barrow pose, walk on their hands & you hold their feet, works great!
➢ Flutter mucous clearance device
➢ Positive expiratory pressure or PEP devices
➢ Active-cycle-of-breathing techniques
➢ High frequency chest compression
• Management of Gastrointestinal Problems
● Pancreatic Enzymes- should be taken at the beginning of the meal and should be taken WITH IN 30 minutes
of eating. These can be swallowed whole or sprinkled on food.
● Encourage well-balanced, high protein, high calorie diet due to their impaired intestinal absorption
● Fat soluble vitamins: A, D, E, K given in water soluble form for easy digestion
● Prevent/treat constipation- treat with laxatives or stool softener
• Management of Endocrine Problems
● The incidence of diabetes mellitus (DM) or Cystic fibrosis related diabetes (CFRD) is greater in children with
CF than in general population. CFRD is the most common complication associated with CF.
● By age 30 years, approx. 50% of people with CF will develop diabetes
● Close monitoring of blood glucose levels is imperative
● Nursing Care/Goals for Patient with CF
➢ Main
goal also is to prevent respiratory infection
assessment of Respiratory, GI and Endocrine system
➢ Provide supplemental oxygen as needed
➢ Provide ACT therapy/ but not before meals or immediately after meals, to avoid inducing N/V
➢ Administer pancreatic enzymes with all meals and snacks
➢ Teaching regarding consuming a high calorie, high protein diet, medications, therapy
➢ Encourage compliance with therapeutic medication and diet regimen
➢ Continuous
• Cystic Fibrosis Family Support
• Long disease process
• Persistent need for treatment
• Child and family activities are built around treatments- so always involve family around treatment plans
• Life long medications expensive
• Poor prognosis● The median predicted survival age for the patient with CF in 2012 was 38 years
● Increased survival rates due to lung, heart, pancreas, and liver transplantation
● Despite considerable progress CF remains a progressive and incurable disease
• Encourage support groups
• Anticipatory grieving- it’s a long disease process and life-long medications become very expensive
Bronchopulmonary Dysplasia: BPD
● Affects infants who are born early- usually more than 10 weeks before their due dates- and still need oxygen
therapy by the time they reach their original due dates are diagnosed with broncho-pulmonary dysplasia (BPD).
● BPD can be mild, moderate, or severe. Diagnosis depends on how much extra oxygen a baby needs at the time of
his or her original due date. It also depends on how long the baby needs oxygen therapy.
● To help confirm diagnosis of BPD, and rule out other conditions, the following test may be performed:
➢ Chest x ray- shows: alveolar damage, inflammation lungs, and scarring of lungs
➢ Blood work- to rule out infection
➢ Echocardiogram- to rule out pulmonary HTN
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• Bronchiopulmonary Displasia (BPD) or Chronic Lung Disease (COD)
• Description- pathologic process related to alveolar damage from lung disease, prolonged exposure to high peak
inspiratory pressures, antimatter alveoli and respiratory tract.
• Prognosis: Mortality is 10-25%
• Clinical Manifestations of BPD▪
▪
▪
▪
▪
▪
▪
▪
Dyspnea
Barrel chest
Inability to wean from ventilator following a course of respiratory distress syndrome
Wheezing
Cyanosis
Irritability
Nasal flaring
Retractions
• Therapeutic Management for BPD
●
●
●
●
●
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●
Administer maternal steroids
Administer exogenous surfactant post-natal
Use nasal CPAP
Prevent air leaks
Use high frequency ventilation
Maintain adequate oxygenation
Administer bronchodilators
Administer diuretics
Administer immunizations
• Care Management for BPD
●
●
●
●
●
●
●
Monitor oxygen saturations and VS closely
Avoid hypo/hyperoxemia. So anticipate ABG or VBGs to be done routinely.
Cluster care, provide infant additional time to rest
Observe for signs of fluid overload or pulmonary edema
Assist in preventing upper respiratory infections- includes judicious hand washing and PPE when indicated
Provide increased calorie feedings with human milk fortifiers or protein supplements
D/C teaching should include:
● Home ventilatory need
● Medications, and their AE
● Immunizations- go to all well child check ups
● Preventing respiratory infections and frequent hospitalizations
Neonatal Respiratory Distress Syndrome (RDS)
● Is seen almost exclusively in preterm infants. Most common lung problem in a premature baby. The name is applied
to respiratory dysfunction in the neonate and is primarily a disease related to developmental delay in lung
maturation. Deficiency in pulmonary surfactant in the infants immature lungs. Surfactant is a substance that keeps
the tiny air sacs in the lungs open.
● Responsible for more infant deaths than any other disease. Carries the highest risk in terms of long term respiratory
and neurologic complications.
● Diagnosing RDS is based on the clinical manifestations of:
!
Tachypnea (> 60 breaths/min)
Dyspnea
! Nasal flaring
! Retractions
! Grunting
! Fine inspiratory crackles
!Cyanosis and/or pallor
!Chest X-ray which shows common characteristics of RDS such as:
!A diffuse granular pattern over both lung fields, resembles ground glass and represents alveolar atelectasis
!Dark streaks representing dilated air-filled bronchioles
!
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• Nursing Management:
Use of warmer
Close monitoring
➢ Pulse oximetry and blood gas monitoring
➢ O2 therapy with CPAP
➢ Surfactant Administration
➢ Minimize unnecessary physical stimulation
➢ Positioning to facilitate breathing
➢ Teach parents CPR and home monitoring
➢
➢
• Supportive Measures for RDS
●
●
●
●
●
●
Maintain adequate ventilation and oxygenation
Maintain acid-base balance
Maintain a neutral thermal environment
Maintain adequate tissue perfusion and oxygenation
Prevent hypotension
Maintain adequate hydration and electrolyte status
• Nursing Responsibilities with Surfactant Administration
●
●
●
●
Assisting in the delivery of the product
Collecting and monitoring of arterial blood gases
Continuous monitoring of oxygenation with pulse oximetry
Assessment and documentation of the infants tolerance of the procedure
• Surfactant
• The administration of exogenous surfactant to pre-term neonates with RDS has become an accepted and
common therapy in most neonatal centers worldwide. Surfactant may be administered at birth as a preventative
or prophylactic treatment of RDS or later in the course of RDS as a rescue treatment. Studies have shown that
early administration of surfactant decreased the overall incidence of BPD, need for mechanical ventilation, and
fewer air leaks.
• Nursing Responsibilities Before and After Surfactant Therapy
• Assisting in the delivery of the product- infant is temporarily intubated, then the surfactant is administered down
•
•
the endo-tracheal tube. The child is supported with O2 delivery. He is then turned from one side to the other to
let the medication get deep down into the alveoli. Once this is done, the child is extubated. He is then supported
with oxygenation. The MD or anesthesiologist will be intubating. The RT is administering surfactant down tube.
Then you collect and monitor ABGs, perform continuous monitoring of oxygenation, with pulse oximetry
Assessment and documentation of the infants tolerance of the procedure is also the nurse’s responsibility.
• Nursing Management of RDS
• Close monitoring
• Pulse oximetry and blood gas monitoring
• O2 therapy with nasal CPAP or a ventilator for severe respiratory distress, depending on patient’s condition
• Minimize unnecessary physical stimulation- cluster your care
• Use of radiant warmer or may be in an incubator
• Positioning to facilitate breathing
• Teach parents CPR and home monitoring for later discharge
Injuries of the Respiratory System
• Foreign Body Obstruction
• Most common from 6 months to 5 years
• Causes- Swallowing of small items getting lodged in the bronchi
• S&S: sudden, violent coughing, gagging, wheezing, vomiting, brief episode of apnea, cyanosis. A child who is in
•
severe distress is one who can’t speak, become cyanotic, and suddenly collapses***. These 3 show that
child is truly choking and required immediate intervention. They can die within 4 minutes if nothing is done.
Diagnosis
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▪
Good history
Physical Exam
▪ X-ray
▪ Endoscopy can be diagnostic and therapeutic if ever there was a doubt about foreign body obstruction.
Foreign bodies are rarely coughed up and must be removed by endoscopy
Treatment
▪ Removal of object via back blows and chest thrusts in infants, abdominal thrusts in children, or endoscopy
● Keep environment and child quiet until object removed
▪
•
• Aspiration Pneumonia
• Occurs when foods, secretions, or liquids enter the lung and cause inflammation and chemical pneumonitis.
• Children who have difficulty swallowing, unable to swallow because of paralysis, weakness, or congenital
anomalies, or an absent cough reflex, or in a child who is force fed especially if they’re crying or breathing
rapidly, and tracheoesophageal fistula are at high risk for aspiration.
• Classic S&S- increasing cough, fever, foul-smelling sputum, decrease in oxygenation, and evidence of chest
infiltrates on a chest x-ray.
●Treatment
➢ O2 administration as needed
➢ Elevate HOB at least 30-45. If they are at risk for vomiting or can’t protect their airway, then put them in side
lying position
➢ Encourage slow, frequent feeding
➢ Positioning
➢ Antibiotics if infection present
➢ Safety teaching- teach parents how to prevent aspiration pneumonia
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Fatemeh Sahrapour
MODULE: CARE OF THE CHILD WITH RENAL/GENITOURINARY DISORDERS
Readings:
Renal and GU Disorders
Perry:
1393-1407
Review as needed
Perry: 1409 - 1415 (Review of renal failure,
dialysis as concepts covered in med-surg classes)
THE CHILD WITH GENITOURINARY ALTERATIONS
- Infants and toddlers have a lower GFR than adults, therefore they are less able to concentrate urine and absorb
-
amino acids, which leads to increased risk for dehydration. A kidney doesn’t become mature in function until 2
years of age.
NB bladder capacity is 30 mL, and increases to about 90mL at one year of age. Expected output in infant and child
is 0.5 - 2 mL/kg/hour, so that at 1 year of age, a child may be voiding 400-500 mL/day. He will void about 9-10
times/day until age 3 years, at which point it decreases to 3-8 times/day.
Note that the bladder volume of a 1 year is close to 90 mL. One of these formulas may be used to calculate: Child’s
age + 2 ounces so 1yr + 2oz = 3 oz = 90 mL Or Child’s wt in kg x7 in ml so 10kg x7 = 70 mL
Take child’s age, add 2 ounces to it. Multiply is by 30. This tells us the bladder capacity.
Remember in assessment, low-set ears are associated with kidney problems.
URINARY TRACT INFECTIONS
• Cystitis: infection of the bladder
• Pyelonephritis: infection of the kidney
• UTI’s caused by ascending bacteria– E. coli most common organism
– Others include: group B strep, Klebsiella peumoniae, Proteus, Enterobacter, Enterococcus, Staph.
– Viruses and fungi can cause infections
• Occurs more frequently in girls than boys (infants and older), primarily because of the length of the urethra. Closure
of the urethra at the end of micturition may return contaminated bacteria into the bladder. The longer male urethra
and the antibacterial properties of the prostatic secretions inhibit the entry and growth of pathogens in boys.
• There’s evidence that supports that there are fewer UTIs amongst circumcised male infants than uncircumcised
male infants. However the difference isn’t enough for the APA to recommend routine circumcision in the newborn.
• It’s the most frequent in uncircumcised males < 3 years
• The single most important factor in the cause of a UTI is urinary stasis where the bladder isn’t completely emptied
out and urine stays in the bladder or it refluxes back up the ureter and stays in the ureter, so teach parents to have
children go on a schedule.
Clinical Manifestations
• Often kids have atypical symptoms and show unrelated signs, so it’s not easy to tell. But the tell-tale signs are:
incontinence in toilet-trained children, foul-smelling urine, frequency, and urgency.
• Infants
– Nonspecific and resembles symptoms of a child with a GI tract disorder.
– Fever or hypothermia in neonate
– Irritability
– Poor feeding, Vomiting
– Signs of dysuria, such as constant squirming and irritability or screaming when urinating (either from a
diaper rash or a burning int he urethra) or urinating more frequently than he has in the past.
– Change in urine odor or color
– Constant diaper rash
• Children
– Abdominal, back, or suprapubic pain
– Frequency, urgency
– Dysuria
– New or increased incidence of enuresis, daytime incontinence who has been toilet trained already
– Fever
• Adolescent
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– Hematuria, frequency with painful and small urinations
– Fever with upper tract
Diagnosis
• Upon suspicion when obtaining history and doing a physical
• Urinalysis, culture. For the older child, try to get a midstream urine, for the younger child who is not toilet trained,
you will have to do a catheterization, because it has to be sterile for the urine culture. In the culture we will be
looking for WBC, RBC, or protein…all of which don’t belong there. When trying to get a sample, don’t encourage
drinking large amounts of fluids as this could dilute the sample and not show the bacteria. The presence of nitrites
on a dipstick is a good predictor of an infection and you can gets these results before the culture is returned, and
it’s very inexpensive, has 100% accuracy, an allows for an earlier treatment. However, some organisms that cause
UTIs don’t produce nitrites, causing some false negatives.
• Cloudy urine, fishy smell
• Suprapubic aspiration done on some children. It’s the most accurate way to obtain urine samples in children who
are < 2 years of age. This is where a needle is inserted just above the symphysis pubis into the bladder and you
aspirate urine back in to the syringe.
• Blood tests
• Catheterizations
• VCUG (Voiding Cystourethrogram)- For recurrent UTIs, further investigation is done using radiology exams. A
catheter is placed in to the bladder, a contrast is used to fill up the bladder through the catheter. X-rays are then
taken to see if the contrast is going back up through the ureter and into the kidney. So we thus can confirm that the
urine does flow back up and cause kidney infection. The goal is to get the child to void while there is an X-ray of
him being taken while he is voiding, so you can see the contrast coming through the urethra, looking for any type of
structural defects.
• IVP (Intravenous pyelogram)- X-rays are taken after the child has been injected through his vein with contrast. So
you’ll see the contrast in the kidneys and in the ureter as the nephrons filter the contrast, and into the bladder. The
goal here as well is to get the child to void while there is an X-ray of him being taken while he is voiding, so you can
see the contrast coming through the urethra, looking for any type of structural defects.
• DMSA- a scan used to identify anatomical abnormalities that contribute to the development of the infection and any
changes that have occurred from recurrent infection.
Therapeutic Management
• Goals
– Eliminate infection
– Identify contributing factors to reduce recurrence risk
– Prevent systemic spread
– Preserve renal function
Usual Treatment of UTIs
• Antibiotics
– 7-10 days specific to organism. We start with something broad until the culture comes back (can take
24-72 hours for the results of culture)
– Start with penicillins, sulfonamide, trimethoprim/sulfisoxazole, cephalosporins, nitrofurantoin, tretracyclines
– Possibly IV antibiotics in hospital if the UTI worsens. But as of 2011, the APA says that if a child can take
the medicine orally then do so because there are no additional benefits from receiving it IV.
– Cranberry juice has been shown to have some beneficial properties
• Follow up important- to teach parents how to take care of a child with a UTI to prevent further infections that can
result in renal damage and reflux. Urine samples are done monthly for 3 months, then every 3 months for 6 months.
New AAP Guidelines for UTI (Fall 2011)
• Child of 2-24 months of age
– Diagnosis is based on cathed or suprapubic urine that shows 50,000 WBCs/mL. Bagged urine is no longer
acceptable for diagnosis/confirmation of UTI. Or it can also be diagnosed during a urine sample of 50,000/
mL with a child that has fever, an US of kidneys/bladder showing anatomic abnormalities, or a VCUG - US
shows hydronephrosis for VUR (vesicoureteral reflux) or recurrence of febrile UTI
– Treatment is 7-14 days antibiotic therapy
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Education to Avoid UTIs
• Wiping/cleaning from front to back and avoid constipation, as both can help E.coli navigate back up to urethra
• Good fluid intake
• Void frequently; don’t “hold it”
• Avoid bubble baths, these are contraindicated in children
• Wear cotton underwear
• Prophylactic antibiotics- may need to be given to those children who have recurrent UTIs. Given at night time since
there will be less frequent voiding so the urine stays in the bladder with the antibiotic for a longer amount of time.
• Void after sexual activity
• Follow up appointments important
VESICOURETERAL REFLUX (VUR)
• Backflow or reflux of urine from bladder into the ureter and possibly
the kidneys. With each void, urine is pushed up the ureters so it
doesn’t come out until the next void, thereby causing UTIs.
• High incidence of UTIs with VUR (primarily pyelonephritis, which
has the same symptoms as a UTI but the child appears sicker and
does have a fever)
• Secondary UTI can result from stones or obstructions, such as a
tumor, stricture, or psychological (afraid to use the bathroom, so
they’ll just hold the urine)
• Diagnostic Evaluation
– Voiding cystourethrogram (VCUG)- to assess the amount of stasis of reflux
– Renal scan- looks for scarring and functional abnormality. Scarring of the kidney occurs when there’s
infection from reflux. Infected urine goes back into the kidney.
– Urodynamic studies for voiding dysfunction- a child is observed as he is voiding to see what the pressures
of the urinary stream are, or to see if there are any abnormalities with the way his urine is streamed. The
good news is that children usually outgrow this as they get older.
• Therapeutic Management
– Low-dose prophylactic antibiotics to prevent UTI
– Lab tests (BUN, creatinine) to test for kidney function
– Urine culture done every 2-3 months or when the child has fever
• VUR Repair/Surgery: re-implantation of the ureter into the bladder. The
ureter opening at birth isn’t sitting on the right side of the bladder, which
is on top. Or the ureteral valve isn’t fully developed and can’t close
properly, then surgery is done. It’s seen performed with recurrent UTIs,
severe forms of VUR, non-compliance of meds, or if child has an
intolerance of antibiotics.
• There’s a new procedure called a sub-trigeminal injection, where gel is
injected around the ureter to make sure the ureters are longer and
creates a bulge to narrow the passage.
• Follow-up care important to prevent UTIs
• Pre and post-op• Post-op the child will have long skinny tubes or catheters
coming from each kidney to keep ureter patent until it heals.
These come out into the bladder through the urethra and
taped to a foley bladder catheter. Each catheter will have its
own bag to measure the urine. It’s important to monitor each
catheter separately to determine its output. When it heals, the
urine will stop in the urethral caths and they will be discontinued, and you will see all the urine coming in
through the foley.
• Meds for pain and bladder spasms
OBSTRUCTIVE UROPATHY
• Hydronephrosis- enlargement of the kidney develops with obstruction of the ureter. This is the backup of urine
above the obstruction causing dilation of the renal pelvis and destruction of the renal parenchyma. Dilation of the
ureters form a reservoir that reduces the effect on the kidneys for a long time. The ureteral obstruction can cause a
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backup of urine up into the kidneys. The problem may also be stenosis of the ureter that doesn’t allow for urine to
come down to the bladder. This can cause hydronephrosis.
• Links
– Boys are more affected.
– Ear defects. You will see them low-set and will suspect a kidney function problem.
– Or it could be a chromosomal anomaly
• Nursing Consideration
– Urinary diversion- If we have a damage such as a stricture in the ureter, then the ureter will be cut above
the stricture and will be diverted to a pouch made from a segment of the bowel. They will implant the
utterers into that segment of bowel and tie it up/close it off, make it into a pouch and form a stoma that
comes to the skin.
– Maintaining urine flow is our goal.
– Fluids are thus encouraged.
– Body Image
Defect in Development: Renal/GU
BLADDER EXSTROPHY
• Congenital anomaly: bladder wall is outside of the body through a defect in lower abdominal wall, upon birth. In
utero, the bladder wall and abdominal fail to close. This is an exposed and everted bladder that is bright red with
constant seeping of urine from exposed ureteral or urethral orifices. It can be malodorous and susceptible to
infection. It can have tissue ulceration and renal damage. Requires a great deal of surgery to get the bladder back
inside to where it has to be. Our job is to keep the bladder moist and in tact.
• Clinical Manifestations- any or all of these may be present.
– Exposed bladder mucosa
– Displaced anal opening
– Widened symphysis pubis- bones didn’t close in utero like they were supposed to.
– Defects of external genitalia
• Therapeutic Management
– Cover bladder with non-adhering plastic wrap to keep it from drying, because the bladder mucosa is
needed to stay in tact for surgery. Don’t use petroleum jelly or gauze as it tends to damage the bladder
mucosa.
– Requires surgery to correct, usually >1 procedure. There will not be a sphincter until the bladder grows
and then a second surgery to correct epispadia and create a urethral opening or sphincter. Another
surgery may be required to create an umbilicus. They may also have a stoma as the new sphincter creates
constriction problems. Or the bladder may be removed if it’s too small or defective. The ureters then
connect to the intestine to create a urinary reservoir accessed by a stoma. A mitrofanoff is procedure
where the stoma exits through the appendix.
• Assessment
– Determine parents’ understanding
– Newborn: patency of anus, urine output, condition of bladder mucosa, and testes
– Older child: urinary continence, history of UTIs, self-perception, social interaction (usually post surgical
repair)
• Implementation
– Goals of therapy are to preserve renal function, attain
urinary control, reconstructive repair, and improve
sexual functionality, especially in the males. So we…
– Focus on maintaining integrity of bladder
– Provide emotional support to family
– Encourage verbalization of fears, concerns
– Lab values, UA
– Older child: psychosocial implications
External Defects
• Hypospadius: congenital anomaly where meatus is below normal placement on glans of penis (ventral surface)
• Chordee: downward curvature of penile shaft. We need to release the constriction that’s causing the binding
• Epispadias: dorsal placement of urethral opening, so when he voids, he squirts up instead of at the end of urethra
• Other anomalies: undescended testes and inguinal hernias. The abdominal contents can protrude through the
inguinal wall into the scrotum, which is what an inguinal hernia is.
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HYPOSPADIAS & EPISPADIUS
Therapeutic Management
– Surgical intervention should be done before potty-training (<18 months) and before
child has developed body image.
– Goal: make urinary and sexual function as normal as possible. The outcome of
surgery is a sexually adequate organ that can void standing up in a normal fashion.
• Assessment
– Assess urinary function: checking for UTIs, urinary stream, dribbling, family history
of GU problems
– Family’s understanding of hypospadias and surgery
– Usually these children aren’t circumcised at birth. During the surgery they take a
small piece of the foreskin to create the urethral tube. This is what used to be done.
But now there’s a new procedure that doesn’t require use of the foreskin.
• Implementation
– Pre/post-op teaching
– Care of catheter/stint that is there to keep the meatus or urethra open. Since, there is a lot of swelling that
goes along with surgery, we don’t want the are to swell closed. So there’s a tube in place during healing.
Teach parents how to care for the stent. They will have no tub baths, swimming, or sand box play, or rough
activities.
– Increase fluid intake
– VS
– Observe urine for cloudiness
– Diversional activities and pain relief
ENURESIS
• Child can’t control bladder function at age expected (around 5 yrs old)
• Nocturnal enuresis: bed-wetting at night
– Primary: not dry at night for long periods of time
– Secondary: Bed-wetting occurs after control attained
– The incontinence must not be related to direct physiological effects of a substance such as diuretics or
general medical conditions such as DM, DI, spina bifida, seizure disorder, or sickled cell anemia
• Diagnostic Evaluation
– History and clinical symptoms: Find out why this is happening? Is it structural? or is it infection? Do they
have spina bifida (where they can’t feel when the bladder is full)?
– Happens most often in little boys ages 6-8 years. Many don’t have co-existing psychopathology. But some
do have developmental disorders, or learning problems, or behavioral difficulties, such as increased motor
activity and aggression
– R/O infection: UA for C&S
• Therapeutic Management. If this is found to be a behavioral issue, meaning enuresis not from a physiological or
structural problem:
– Have child take part in caring for wet sheets. But remember this is not a punishment.
– Do not put a diaper on child
– Limit nighttime fluid intake and have child void before going to bed
– Imagery: keep a diary
– Rewards
– Behavioral conditioning: reduce shame and guilt of child. Don’t make it be a manipulative behavior.
– Medications
• Imipramine hydrochloride (Tofranil) antidepressant- because it has anticholinergic action in bladder
that inhibits urination. It can be given at bedtime. Once enuresis has stopped or cured, you can
withdraw. However, sometimes child relapses once it’s taken away.
• Other meds that can be given: Oxybutynin reduces bladder contractions, anti-diuretics such as
ADH/vasopressin (DDAVP) help decrease the nighttime urinary volume to less than functional
bladder capacity. DDAVP can be administered as a nasal spray at night. It’s relapse occurrence is
high after it has been stopped.
• Assessment
– Get parents’ understanding of problem and types of interventions tried. Primarily it’s an alteration of the
neuromuscular bladder functioning. It is benign and self-limiting. It is temporary, regressive behaviors from
birth of a sibling, trauma, ADHD children who have accidents as they get too involved in their play.
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– Get UA specimen and a history of the number of episodes for diagnosis and to measure effectiveness of
treatment.
• Implementation
– Provide correct info to family so they choose best treatment to meet their needs
– Follow-up to determine effectiveness
– Watch for child abuse in these children
NEPHROTIC SYNDROME
• It is the most common of glomerular injuries in children. Happens more often in children than in adults.
• Characterized by proteinuria, hypoalbuminemia, hyperlipidemia (because there is a decreased protein in blood that
causes liver to synthesizes more proteins to make up for the loss of protein, so it breaks down more lipids), edema
• Primary: Disorder within the glomerulus. It is the most common type found in children.
• Secondary: From a systemic disease.
• May be congenital or inherited
• Etiology- increased glomerular permeability to plasma protein which results in large urinary protein loss. Primarily
seen in children between ages 2-7 years. Rarely do we see it in children < 6 months of age. It’s unusual to see in
children after the age of 8 years. Incidence is higher in males. Clinical Manifestations of a large number of
glomerular disorders, in which increased glomerular permeability in plasma protein results in massive urinary
protein loss. Pathology is thought to be some glomerular injury in that the basement membrane of the glomerulus
becomes increasingly permeable to proteins like albumin. It’s supposed to be tight and not let protein though. This
reduces the amount of albumin in the serum, decreasing the colloidal osmotic pressure in the capillaries. This
causes fluid to accumulate in the interstitial spaces causing edema in the body cavities particularly in the abdomen,
called ascites. This reduces the vascular fluid volume (hypovolemia) fro third spacing. Large amounts of fluid, but
dehydrated as the fluid is in the interstitial spaces.
• Mnemonic:
• P= protein in the urine
• R= tired and not in good spirits
• O=
• T= terrible appetite; N/V/D
• E= edema, worse in the morning
• I= increased weight gain, weight is a sensitive indicator of edema and dehydration
• N=
• Clinical Manifestations– Edema- in the faces, around eyes, ankles, gonadal and lower extremity and generalized edema
– Pallor
– Fatigue
– Anorexia
– Abd. Pain
– Recent URI
– Wt. Gain
– Clothes feel tight from the edema/ascites
– Normal BP, decrease in urinary output
• Diagnostic Evaluation
– Clinical presentation
– Age of child (between 2-8 years)
– Lab results
• Massive proteinuria – 3+ on dipstick
– Hyperalbuminuria
– Hypoalbuminemia
– Hypovolemic
– Usually no hematuria…so this is about protein in the urine and is not about the blood
• Goals of Therapy
– Decrease excretion of urinary protein
– Decrease fluid retention in tissues
– Prevent infection- which is challenging because they’re on long-term steroid therapy
– Minimize complications
• Therapeutic Management
– May be hospitalized for edema, tests, start steroid therapy
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– No added salt diet or greater restriction- this doesn’t decrease edema, rather it helps to prevent further
edema. Sometime the salt restriction isn’t abided by because kids need to eat and like salty foods better
– Prophylactic antibiotics
– Diuretic therapy (Lasix) to help reduce edema. They may be fluid restricted but again it’s not because
they’re over hydrated, but because they’re edematous.
– An increased protein diet hasn’t shown a benefit.
– May receive SPA – Serum albumin infusion, if protein is too low in the blood
– Prednisone 2mg/kg/d (max 60 mg), and then it’s tapered down. This is the first line of therapy.
• May be on steroids for 4-6 wks, then tapered down over a 3 month period of time.
• May be steroid resistant and need kidney biopsy
• Steroid-dependent: relapse when dose is tapered; may need to use another immunosuppressant
• Nursing Care
– VS, I&O, weights, assess for edema, abd. girth
– Check urine for protein (cotton ball in diaper and squeezing out the urine if it’s an infant)
– Give appetizing foods
– Support edematous areas: such as legs, scrotum, or abdomen
– Cleanliness is important for these children
– Family’s understanding of disease and treatment
– Teach home monitoring and SE of steroid medications (growth retardation,
immunosuppression so be weary of URIs, etc.). Recovery is good. It’s a self-limiting
disease. We’ll start to see diuresis as urinary protein excretion diminishes within 7-21
days after starting the steroid. But again remember they can relapse, it can reoccur.
GLOMERULONEPHRITIS
• Group of kidney diseases where the glomerulus is injured. Capillaries of glomerulus are inflamed, so we will see
blood in the urine
• Occurs from infection, systemic disease process, or primary defect in glomerulus itself.
• Acute post-streptococcal glomerulonephritis (APSGN) is the most common cause: hematuria, proteinuria, edema,
renal insufficiency. This is a reaction that occurs 1-3 weeks after a strep infection. Most step throat infections don’t
cause this, but it can be a risk for anyone that does get strep. Primarily affects a child that’s 6-7 years of age.
• APSGN is immune reaction to strep infection of throat or skin. Usually occurs 1-3 wks. after strep infection has
already resolved. The thought is that after streptococcal infection, if followed by the release of membrane like
material from this specific organism, gets into the circulation. It’s antigenic antibody formation. An immune-complex
reaction occurs after the appropriate period of time. These become trapped in the glomerulus capillary loop. These
swell and decrease the filtration of plasma leading to excessive water accumulation and sodium retention. This is
why we see HTN and edema.
• Clinical Manifestations
– Hematuria: smoky or tea-colored blood in the urine- different than in nephrotic syndrome***
– Proteinuria- so an increased SG, BUN, creatinine
– Edema - in face and peri-orbital (this is worse in morning) that then spreads to abdomen and extremities
– Anorexia
– Decreased urine output
– HTN- different than in nephrotic syndrome*** So monitor and treat BP
– Fever (maybe)
– Fatigue, Pallor, Irritable
– Cardiomegaly, pulmonary edema, and pleural effusion
– O= out of sorts, irritable, etc.
• Diagnostic Evaluation
– History
– Presenting symptoms
– Lab results: if there’s blood in urine, BUN, creatinine
• Therapeutic Management
– There is no specific treatment. It usually heals on its own in 4-10 days, up to 2-3 weeks . Recurrence is not
common. Follow up weekly and then monthly, until it’s resolved.
– Aimed at treating symptoms/degree of renal dysfunction.
– May be hospitalized for Acute Renal Failure: F&E imbalances. He may need a diuretic.k Prevent
complications from fluid volume overload.
– AntiHTN: limit fluids/Na; diuretics & antiHTN meds. Monitor and treat HTN as this can be life-threatening.
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Fatemeh Sahrapour
– Prognosis excellent for APSGN
• Assessment- ongoing while being treated and afterward
– Watch for F&E, I&O, promote rest
– VS, daily wt, lab values. Remember daily weight is the most useful assessment of fluid balance.
– Understanding of illness/hospitalization
– Signs of improvement- increased urine output with a decreased weight. Child begins to feel better. His BP
will fall. His appetite will return. His BUN and creatinine will return to normal range values. Hematuria may
decrease or may be present for 2-8 weeks afterwards. Watch for any type of renal failure (Acute or Chronic
Renal Failure where the child has to be on dialysis).
• Nursing Care
– Regular diet – NAS (no added salt), low Na foods
– Fluid restriction (insensible loss + urine volume = what child is allowed to have/day)
– Parent education
– Once we get the BP and urinary output under control, treatment can be continued at home and he can
return to clinic for us to monitor his progress. But if child has edema, HTN, hematuria, and oliguria..then he
needs to be treated in the hospital.
Comparing and Contrasting Nephrotic Syndrome and Acute Glomerular Nephritis
Patho, Diagnosis, Treatment
Causative Agent
Presenting Clinical Features
Appearance
Complaints
Appetite
Blood Pressure
Activity Level
Urine Appearance
Pathophysiology
Diagnostic Evaluation
Treatment Regimen
Nursing Assessments/
Interventions/Goals
Family Education
Nephrotic Syndrome
AGN
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Fatemeh Sahrapour
MODULE: CHILDHOOD IMMUNIZATIONS AND INFECTIOUS DISORDERS
Note: The exact immunization schedule often times changes each year. The common schedule such as the 2, 4, 6
and 12 months have been fairly consistent and are ones to be familiar with. It is important to know where to locate the
current schedule and to be aware of the type of immunzations that are given, why they are given as well as the
implications and side effects of these vaccines.
In the Silvestri NCLEX-RN review book, there is a question that leads one to believe that the pneumococcal vaccine
is given yearly to children at risk. That is not true. It is given per schedule as discussed in text and in lecture. The
influenza is given every year. The publisher has been notified and it is to be corrected in the next printing.
Readings:
Immunizations
Perry: 886-899, 1022-1023
Communicable Disorders
Perry: 964-973, 1592-1593
Conjunctivitis
Perry: 1097 Pink-eye WebMD slide show
Healthy Children - Conjunctivitis
Immunizations
ATI 2013: 147-194, 477-483, 426-434
Schedule Changes - this web site has up to date information
on the lastest recommendations for immunizations. The CDC
updates the schedule routinely. Therefore the textbook might
be slighly different.http://www.cdc.gov/vaccines/
http://www.cdc.gov/vaccines/schedules/index.html
CHILDHOOD IMMUNIZATIONS AND INFECTIOUS DISORDERS- PART 1
Immunizations:
- What are they?
- Who decides which ones we give?
- How is that determined?
Immunization- Definition – “the process by which a person becomes protected against a disease”. If the process
confers protection then that protection is called immunity.
Vaccine approval process
- The FDA is responsible for regulating vaccines. Pre-licensure trials occur in 3 phases:
◦ Phase 1- initial human studies for safety and immunogenicity (how well people are responding to these
vaccines). Phase 1 is performed on a small number of people who are very closely monitored. These are
are volunteers.
◦ Phase 2 – dose ranging studies. They also continue to monitor the safety and immunogenicity of vaccines.
But they’re studying a larger number of people, several hundred are enrolled.
◦ Phase 3 – provides documentation of effectiveness and additional safety data that’s required for licensing.
Thousands of people are enrolled.
● If at any point in the clinical or animal trials, the FDA thinks the enrolled volunteers are in danger, they can stop the
process. Once they’ve passed phase 3, the vaccine sponsor can go ahead and apply for FDA licensure…
● Apply for licensure through FDA. FDA reviews the application for efficacy and safety in order to base its
recommendation or opposition for the vaccine. Until the vaccination is given to the population, many of the
adverse effects can’t be anticipated. So many of the vaccines will undergo phase 4/“post-marketing” studies/“post
licensure” studies.
◦ Phase 4 – These are formal studies on a vaccine once it is out on the market. The vaccines can be administered
to anyone. FDA will continue to monitor everyone who receives vaccine for any AEs.
VICP and VAERS
● VICP – Vaccine Injury Compensation Program- It was developed in 1986. A lot of people decided that their
children were being harmed. A large number of lawsuits were being brought to the national court system directly
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suing these pharmaceutical companies. The companies then said that they don’t make a lot of money off the
vaccines (the way they do off other drugs). So many just stopped making these vaccines. The government saw
this risk of vaccine shortages, and so they developed this program. So compensation comes from the government
and not the companies. The companies then continued making these vaccines. So, an individual who may be
claiming a vaccine related injury or death, if they were to file a petition for compensation with the court, they would
also be represented by an attorney and the case will go to the national courts. If the court finds that this person
has a legitimate claim, they will be awarded compensation that comes from the program (which is administered by
the Health and Human Services). All of the vaccines on the childhood schedule are covered by this program.
● VAERS – Vaccine Adverse Event Reporting System- The government relies on this system, through which they
identify problems after the marketing process begins. It’s a national safety surveillance program and is cosponsored by the CDC as well as the FDA (who is again responsible for licensure of these vaccines). They
monitor adverse events (potential SE that may occur after administration of vaccines that are licensed for use) to
see if they start seeing trends nationwide. It’s a public database. For example, the rotavirus vaccine that was given
orally was pulled off the market because it caused intussusception. Further research was then done to develop a
new one.
Vaccine Information Statements
● VISs- Required to be given prior to receiving each dose of vaccine, allowing the parent to ask questions regarding
vaccine before administration. This is all part of informed consent.
● Available at
◦ www.cdc.gov/vaccines/pubs/vis/#download
◦ Immunization Action Coalition – http://www.immunize.org
● When administering vaccine: write down lot number on the bottle, where you administer & which side, and
document that you gave parent vaccine information statement.
ACIP
● Once a vaccine is found to be safe, there’s a group of individuals that look at all possible evidence available on
this particular vaccine to determine whether it should be recommended as a routine vaccination.
● About ACIP (Advisory Committee in Immunization Practices)
◦ Members● Medical and public health experts
● 15 voting members. Each member must submit and application to the Health and Human Services.
The secretary of the HHS looks for their expertise, and selects each of these members, then there’s an
interview, and a nomination process. 14/15 members have expertise in vaccinology, immunology,
pediatrics, internal medicine, nursing, family med, virology, public health, and preventative medicine.
15th member is a consumer (a parent that represents the public).
● 8 additional ex-officio members who represent other federal agencies that are also responsible for
immunization programs of the US.
● 30 additional non-voting members of liaison organizations that help bring immunization expertise.
◦ Meetings
● 3 meetings each year at the CDC in Atlanta, GA. It’s also broadcasted on the web. You can attend
these meetings but must undergo a clearance process.
● Also participate in work groups, broken up by specific vaccine preventable disease. These work
groups are active all year.
◦ Determination of recommendations on how to use these vaccines in order to control diseases in the US.
The recommendations then stand as public health advise that will lead to a reduction in incidence of vaccine
preventable diseases as well as an increase in safe use of vaccines.
Principles of vaccination
● Immunity – immunity of body to tolerate self and eliminate anything it considers foreign or “non-self”; “self” vs “nonself”. Discriminatory function gives us protection from infectious disease, since microbes identified as foreign by
the immune system.
● Immunity = antibodies to the organism. Is specific to single organism or a group of very closely related organisms.
● 2 mechanisms for acquiring immunity. Vaccines can be:
◦ Active
◦ Passive
Forms of immunity
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●
The most effective responses are produced to a live antigen. However, an antigen doesn’t have to be live in order
to produce an immune response.
● Active immunity
◦ Protection from our own immune system , produces humoral immunity (antibody) and cellular immunity
◦ Permanent- confers long-term immunity against an organism aka immunologic memory where memory B
cells continue to circulate the blood and bone marrow. If re-exposed to antigen, the memory B cells produce
antibodies very rapidly.
◦ Can receive active immunity by◦ surviving infection by disease causing organism
◦ vaccination that produce an immune response and confer immunologic memory
● Passive immunity
◦ protection from another- like protection babies get via
placenta (Antibodies transferred across placenta during
last 1-2 months of pregnancy and last for up to a year
after baby’s birth. This is the reason why we don’t
immunize children under age 1 year with Measles,
Mumps, Rubella, or Varicella) or breast feeding
◦ Temporary - wanes with time. Example, Syngis must be
given every 30 days.
Live vs. inactivated
● Classification of vaccines –
◦ Live attenuated- are produced by modifying a disease
producing virus (wild virus) or bacteria in a lab. The
resulting vaccine organism retains the ability to replicate
and produce immunity (Abs) but doesn’t cause illness.
◦ Inactivated- can be produced from whole or fractions of
viruses or bacteria
● Whole- made form entire organism but inactivated
● Fractional- either protein or polysaccharide based.
● The more similar the vaccine is to a disease causing organism
the better the immune response is to the vaccine, providing greater immunity.
VACCINE-PREVENTABLE DISEASES
Diphtheria
● Transmission- respiratory droplet or skin to skin
● Clinical features
● incubation period of 2-5 days, can involve any mucous membrane, typically
classified based on the site of infection…so either the interior nasal,
pharyngeal, or tonsilar.
● Complications● are attributed to the toxin the bacteria produces, causing neuritis and
myocarditis. Death can occur in 5-10% of people infected with diphtheria.
● Vaccine● (Diphtheria, Tetanus, acellular Pertussis) recommended at 2, 4, and 6 mos.,
and at 15-18 months. Booster is given at 4-6 years. A different booster: Tdap
is given at 11-12 yrs. New recommendation: Tdap given for all pregnant
women with each pregnancy (because of pertussis)
● DTaP is only given up to age of 7 years, no older. So beyond age 7 years,
anyone who needs protection from those same diseases will get the Tdap.
The reason why the letters are capitalized is because it stands for a full
strength dose of the vaccine. If a lower case letter is used, then the vaccine is 1/2 strength dose. For ex., in
Tdap, Tetanus is the only full strength dose
Tetanus
● Transmission- contaminated wounds, tissue injury, any puncture wound
● Clinical features-
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◦ Incubation period for tetanus is 8 days. (just understand that
incubation periods differ for each disease)
◦ There are 3 clinical forms for tetanus◦ Local- not common
◦ Cephalic- rare
◦ Generalized- most common, because it affects the whole
body. Symptoms are descending from the head down,
affecting the jaw “lock-jaw” aka trismus, where person
can’t open their jaw, difficulty swallowing, muscle rigidity, and spasms
● Complications
◦ Most common: laryngospasms, HTN, contractures, pulmonary embolism, aspiration pneumonia, and death
● Vaccine● DTaP recommended at 2, 4, and 6 mos., and 15-18 mos. Boost at 4-6 years. Tdap at 11-12 yrs. New
recommendation is for Tdap for all pregnant women with each pregnancy.
Pertussis
●Transmission- through respiratory droplets. Incubates for 7-10 days.
●Clinical features
◦ Has a mild, insidious onset: a runny nose, fever, and non-specific cough. It
then progresses to rapid coughing “fits” with a high pitched “whooping”
sound. They cough over and over again, and as they try to catch their
breath there’s a big pitched whooping sound. “Whooping cough”
◦ Vomiting, that’s caused by fits of rapid coughing.
◦ Coughing can persist for up to 10 weeks.
●Complications
●Pneumonia, seizures, encephalopathy, and death. The younger they are
when they get it, the more likely they are to be hospitalized, and die. Rates
are higher for infants < 1year of age, and highest among hispanics. Next
rates are highest amongst white adolescents age 10-17 years.
●Vaccine● DTaP recommended at 2, 4, and 6 mos., and 15-18 months. Boost at 4-6 years. Tdap at 11-12 yrs. Newest
recommendation is for Tdap for all pregnant women during each pregnancy! Because it was seen that
mom’s are the ones who are passing the pertussis. It is given at 28 weeks. This will give mom enough time
to build the antibodies that will be transferred via placenta. Other possible sources are anyone who is close
to the newborn, so all of these people should get boosters- because with this vaccine, immunity does start to
wane about 2 years after getting vaccine. And even if they are getting their own vaccine at 2 months of age,
that still doesn’t give them enough immunity if they are exposed to it. They won’t have a strong enough
immune response until they get the 3rd dose at 6 months of age.
Hepatitis B
● Transmission- blood, bodily fluids,
● Clinical features
● Incubation period average 90 days
● Feeling of malaise, fever, HA, myalgia, icteric phase characterized by jaundice,
clay colored stools, hepatic tenderness, hepatomegaly. But at least 50% of
cases are asymptomatic, and this is more common in children.
● Complications- cirrhosis, liver cancer, and death
● Vaccine- recommended: first dose at birth, 2nd dose at 1-2 mos., 3rd dose at 6-18 mos.
…“I just don’t understand why we vaccinate infants against hepatitis B when it is a disease
associated with high-risk behaviors.”
What is the risk of getting Hep B?
- Approximately 1.4 million Americans have chronic hepatitis B.
- Babies develop a robust response when given at such a young age.
- Each year 2000-4000 Americans die due to chronic hepatitis B. We know that once
an infant is affected, they will go on to develop chronic Hep B vaccine.
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What is the risk for infants?
- 24,000 HBV-infected women give birth annually in the U.S., because remember 50% of cases are asymptomatic.
- Once infected, approximately 90% of infants will develop chronic hepatitis B.
- Once chronically infected, approximately 25% will die from cirrhosis or liver cancer, typically before age 5 years.
…Administration of hepatitis B vaccine within 24 hours of birth is 70-90% effective in preventing transmission in
exposed infants. When these infants whose moms are Hep B + are given the vaccine with
HBIG (Hepatitis B Immunoglobulin), it is 85-95% effective in preventing transmission.
Hepatitis A
● Transmission● fecal-oral route, many times passed trough restaurant workers
● Incubation period- 28 days
● Clinical features● Abrupt onset of fever, malaise, anorexia, nausea, abdominal discomfort, passing of dark urine, jaundice
● Children who are < 6 years of age are usually asymptomatic. Older children and adults are symptomatic.
● Complications- Liver failure.
● Vaccine- 2 dose vaccine; recommended at 12 and 18 mos. Must have the 6 months interval between doses.
Hib (Haemophilus Influenza Type B)
● Transmission● Gram negative bacteria via respiratory droplet
● Clinical features● Can cause meningitis: fever, decrease mental status, stiff neck, epiglottitis
(airway obstruction), cellulitis, septic arthritis, pneumonia, osteomyelitis,
pericarditis
● Complications ● hearing impairment, neurological impairment, death
● Vaccine● recommended at 2, 4, 6 months, with a 4th dose at 12-15 mos.
Pneumococcal (PCV)
● Transmission● through respiratory droplet
● Clinical features● has an abrupt onset: fever, chills, pleuritic chest pain,
productive cough, dyspnea, tachypnea, hypoxia
● Complications
● pneumonia, bacteremia, and meningitis
● Vaccine● PCV13 (Prevnar) recommended at 2, 4, 6, & 12-15 months
Rotavirus
● Transmission
◦ fecal-oral route. It is very contagious. Short incubation period of 2 days. It spreads very quickly.
● Clinical features
◦ it can be asymptomatic
◦ most often though vomiting, severe dehydrating diarrhea, fever. The GI
symptoms subside within 3-7 days
● Complications
● Kids can die from the severe dehydration, causing electrolyte imbalance.
● Vaccine
● It is the only vaccine currently given orally, because the bug replicates in
the gut, and thus is also shed in the stool. So it’s very important to wear
gloves when changing diapers and to practice good hand hygiene.
● recommended at 2, 4, and 6 mos. If a child comes in at 16 weeks (4 months), and they haven’t received the
first dose of the vaccine, they will not receive any doses of it. And once they turn 8 months of age they can’t
get any doses of rotavirus vaccine.
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● The
doses mentioned are all based on studies that have been done in the sequence listed. So changing the
sequence of administration doesn’t ensure the same effectiveness and safety.
Measles, Mumps, Rubella (MMR)
● Transmission- respiratory or airborne. For any of them, incubation is
anywhere from 10-14 days.
● Clinical features- f
●ever, runny nose, cough, rash, parotiditis (swelling of the parotid
glands associated with mumps), HA, muscle aches
● Complications
◦ pneumonia, hearing loss, encephalitis, seizures, swelling of the
testes that can lead to sterilization, pancreatitis, arthritis, up to
death (especially in measles or rubella)
● Vaccine recommended at 12 months, then 2nd dose/boost at 4-6 years.
Again the first dose isn’t given until 12 months of age because of the presence of maternal antibodies. So if we give
vaccine before 12 months, the antibodies that are there from mom will fight the attenuated vaccine administered.
So the vaccine will be futile and child won’t develop any immune response of their own vaccine. But by 1 year of
age, the antibodies from mom should be gone. The only time that the vaccine might be given earlier is if they’re
traveling outside the country to places we know have huge outbreaks, we can give a dose to children as long as
they’re at least 6 months of age. This will give them protection for a few weeks, getting them through their travel
time period. Because by the time they’re back, any antibodies they have from mom will have nullified the vaccine.
Polio (IPV)
● Transmission
◦ fecal-oral or oral-oral route
◦ does still occur in 3rd world countries. But remember travel puts us all at risk.
● Clinical features
◦ flaccid paralysis that presents with asymmetrically diminished
deep tendon reflexes, weakness, paralysis of certain muscles,
and death if for example your diaphragm is paralyzed. Back in
the day, people were placed on iron lungs to breathe, what are
now ventilators.
● Complications
● Vaccine recommended at 2, 4, 6-18 mos. Third dose can be given
anywhere between 6 and 18 months). Boost at 4-6 years (IPV =
inactivated polio vaccine)
Varicella aka “Chicken Pox”
● Transmission- airborne droplet or direct contact with lesions
● Clinical features- Lesions, are the “hallmark” of chicken pox, of the rash are vesicles that
contain fluid inside. The fluid is where the virus is and is what’s contagious. Rash appears
on fist of the head, face, and then the trunk. You’ll see successive vesicles that are in
varying stages of development.
● Complications
● Bacterial infection on the open lesions, can become massively septic
● Pneumonia
● CNS manifestations
● Reye’s syndrome
● Death
● Amputation
● Vaccine- recommended at 12 months, boost at 4-6 years. The booster dose is given now because we were seeing
that after a few years, some children would still come down with chicken even though they had gotten the first dose
Meningococcal (MCVaccine)
● Transmission- through respiratory droplet
● Clinical features- fever, HA, stiff neck, photophobia, altered mental status, meningococcal sepsis (fever, petechial or
purpuric rash, hypotension, leading to organ failure)
● Complications-
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● brain
damage, hearing loss, hydrocephalis, myocarditis, seizures
current vaccine covers Meningococcal A, C, W, and Y strains. It is recommended at
11-12 years of age, boost at 16 years.
● You’re at the highest risk for menigococcal disease between 17-21 years of age. There are
now new Meningococcal B vaccines. Meningococcus B is one of the 5-6 strains of the
bacteria that can cause illness, and is the most sever in children. It’s currently not
recommended for younger children, but it’s left to provider’s discretion. This might change.
● Vaccine-
Human Papillomavirus (HPV)
● Transmission- usually direct sexual contact
● Clinical features & Complications● may be asymptomatic
● if symptoms present- anogenital warts, recurrent respiratory papillomatosis
(papule in the esophagus), cervical intraepithelial neoplasia (precursor for cervical
cancer), or full blown cervical, anal, vaginal, vulvar, penile, or head and neck
cancer
● Vaccine recommended at 11-12 years of age. When given at this age, we see a very strong
immunological response. Also it’s given at this age because we want to catch people before
they become sexually active. It’s recommended to be given to boys and girls.
Seasonal Influenza
● Transmission- droplet, direct or indirect contact. Incubation period: within 2 days.
● Clinical Features- Abrupt onset: high fever (>101), fatigue, sore throat, non-productive
cough, HA,
● Complications- pneumonia, Reye’s syndrome especially in adolescence, myocarditis, and death
● Vaccine recommended yearly for everyone ≥ 6 mos. Dosing for children with the flu vaccine is different depending
on their age. For children 6 mo. to ≤ 9 years of age will get 2 doses the very first season they get the vaccine.
They’ll get 1 dose, and the 2nd 28-30 days later. From there on out, they’ll only receive 1 dose each year during flu
season. Once a child hits 9 years of age or older, it doesn’t matter if they’ve receive flu vaccine or not before, they’ll
only get 1 dose of it during flu season.
● Flu vaccines are designed to protect against the types of flus most likely to occur during the upcoming season.
Typically protection will be against influenza A & B viruses, H1N1 type viruses, and H3N2 viruses. It used to be that
the vaccine would protect against 3 strains, but now it has become a quadrivalent vaccine protecting against 4.
● The 2015-2016 types of influenza vaccine this year: IIV3, IIV4, LAIV4. The first dose primes their immune system.
The second dose gives them immunity.
● Live virus- spray given in nostril. Not given to people allergic to eggs, have asthma, or are under the age of 2 years.
● Flu shot- inactivated
Routes of Vaccination
• IM – majority of vaccines given by this route
• SC – MMR, varicella, and IPV (can be given IM or SC)
• Oral – rotavirus
• Intranasal – intranasal flu (live attenuated influenza)
• Intradermal – not used in children (TB test is NOT a
vaccine!)
Sites of Vaccination (KNOW)
• IM
• Use: 22-25 gauge needle. Choose injection site that is appropriate to person’s age and body mass.
• Newborn (1st 28 days): Length = 5/8”. Injection site: anterolateral thigh muscle
• Infant (1– 12 months): Length: 1”. Injection site: Anterolateral thigh muscle (vastus lateralis)
• Toddlers (1-2 years) & Children/Teens (3-18 years): Length: 1-1.25” in anterolateral thigh muscle or 5/8-1” in
deltoid muscle of arm
• SC
• Use: 23-25 gauge needle, 5/8” in length. Choose injection site that is appropriate to person’s age and body mass.
• Persons < 12 months/Infants: Fatty tissue over anterolateral thigh muscle and upper outer triceps if needed
• Persons ≥ 12 months: Fatty tissue over anterolateral thigh muscle or fatty tissue of upper outer triceps
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Fatemeh Sahrapour
Immunization Summary- Vaccine and Recommended Age Given (Childhood)
(Fill in the arrows from the Power Point)
Vacc Name
Birth
1 mo
Hep B
dose1
dose2
2 mo
4 mo
6 mo
9 mo
12 mo
15 mo
18 mo
4-6 yrs
dose3
Rota
dose1
dose2
dose3
DTaP
dose1
dose2
dose3
Hib
dose1
dose2
dose3
dose4
PCV13
dose1
dose2
dose3
dose4
IPV
dose1
dose2
dose3
Flu
dose4
dose5
dose4
annually
MMR
dose1
dose2
VAR
dose1
dose2
Hep A
dose1
dose2
Immunization Summary- Vaccine and Recommended Age Given (Adolescents)
Vaccine Name
11-12 yrs
Tdap
dose1
MCV
dose1
HPV
dose 1
dose 2 - +2 months
dose 3 - +4 months
Flu
annually
16 -18 yrs
dose 2
CHILDHOOD IMMUNIZATIONS AND INFECTIOUS DISORDERS- PART 2
Precautions/Contraindications/Side Effects
Precaution- Weigh the risks vs. benefits of using the vaccine…use it but be cautious with it.
Contraindication- You should not administer it to this child. It will cause them harm.
- Reactions that aren’t true contraindications/are normal…You would still continue to administer vaccine: seizing if
you have a family history of seizures, sight redness, swelling, rashes, muscles soreness, developing a low-grade
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Fatemeh Sahrapour
fever, recent exposures to infectious disease, premature babies, current otitis media, being on antibiotic therapy.
and a lot of time it’s the provider’s discretion to decide weigh the pros and cons of administering the vaccine.
Immunization
Precautions
Contraindications
DTaP, DT,
Td, Tdap
• Fever ≥ 105 within 48 hrs of prior dose
• Collapse or shock like state
• Seizures within 3 days of prior dose,
• Inconsolable crying lasting ≥ 3 hrs within 48 hrs
of prior dose
• Encephalopathy within 7 days of previous dose
• Allergic reaction to vaccine
• Moderate to severe illness (when you think child
needs to go to ER) with or without fever
• GBS (Guilain Barre Syndrome) < 6 wk after
previous dose…because the vaccine is most
likely what’s caused the GBS
Hib
None identified
Rotavirus
• Altered immunocompetence
• Moderate to severe acute gastroenteritis
• Moderate to severe febrile illness
• Chronic GI disease
• Intussusception
• Severe allergic reaction after previous dose
• Infants born to HIV + mother
• Known or weakened immune system
IPV
• Pregnancy
• Anaphylatic reaction to neomycin or steptomycin
MMR (live
virus)
• Recent IgG administration (If an IgG has been
administered first, then the MMR shouldn’t be
given for 3-6 months, depending of dose of IgG
received. If MMR is given first, then IgG
shouldn’t be given for 2 weeks).
• Thrombocytopenia, thrombocytopenic purpura
• Pregnancy (because the MMR is a live virus
vaccine)
• Known altered immunodeficiency
Varicella (live
virus)
• Recent IgG administration. Same rules apply
as the MMR.
• Severe allergic reaction after previous dose
• HIV
• Immunodeficiency
• Pregnancy
• High dose of corticosteroid use
PCV
• Moderate to severe illness with or without fever
• PPSV within last 2 mos.
• Severe allergic reaction a a previous dose
Hep B
• Preterm birth (need to wait until after child is ≥
2000 gm)
• Anaphylatic reaction to common baker’s yeast
(is a component of the vaccine)
Hep A
Seasonal
Influenza
• Anaphylactic reaction to vaccine
• Moderate to severe illness with or without fever
• GBS within 6 wks of previous dose
• Egg hypersensitivity (if they are able to have
cooked eggs without reacting, then getting the
seasonal flu shot is ok. If have an anaphylactic
rxn to cooked eggs, they can get the shot as well
but under supervision and specified conditions of
an allergist)
• Severe allergic reaction to previous dose
• LAIV * (live attenuated influenza virus) is nasal.
Not given to: children <2 years or > 49 years,
immunodeficient, on long-term Aspirin therapy,
history of GBS or asthma
MCV
• Allergy to vaccine component
• History of GBS
HPV
• Pregnancy
• Hypersensitivity to yeast or any vaccine
component
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Special situations
● Chemotherapy- or anyone with altered immunocompetence, but again it’s all up to the provider’s discretion, and
dependent on the CD4 and T lymphocyte levels.
● Steroid Therapy- if they have been receiving corticosteroids (at least 2 mg/kg/day…so we’re not talking about a
child who’s using an inhaler, but rather a much stronger dose) for > 14 days, we’ll defer live virus vaccines (MMR,
Varicella) for 1 month after they’ve stopped using them.
● Bone Marrow Transplant- they are immunosuppressed before getting the transplant to prevent adverse reactions.
Revaccination (starting from scratch) will happen about 6 months after child has received transplant.
● IgG Therapy● these products can cause a diminished response to live vaccines. Again, if an IgG has been administered
first, then the MMR or other live virus vaccine shouldn’t be given for 3-6 months, depending of dose of IgG
received. If MMR is given first, then IgG shouldn’t be given for 2 weeks.
● Also, there is no waiting period after administering Synagis (passive vaccine given for RSV) to administer
other vaccines.
● Simultaneous administration of an antibody and vaccine is recommended for post-exposure of certain
diseases such as Hepatitis B (Hep B + HBIgG), Rabies, and Tetanus. This is post-exposure prophylaxis so
we’re trying to prevent the transmission from mom to baby.
● Household/close contacts● Any household member who is immunocompromised or is living with an immunocompromised child should
receive all age appropriate vaccines, expect the small pox vaccine. Remember small pox vaccine isn’t on
the recommended schedule because it has been eradicated from the world. But when you travel to certain
countries, it’s given. The only time we wouldn’t give a live virus flu vaccine to a person who lives with an
immunocompromised patient is when that person is in need of being in a protective environment, such as if
child is in need of a bone marrow transplant and was staying in the hospital waiting to get it, any of the
contacts shouldn’t get the live virus vaccine, rather contacts would get the inactivated vaccine, the flu shot.
Questions
●
A clinic nurse prepares to assess a child coming to the clinic for complaint of right ear pain. The nurse
understands that the patient’s immunization record should be reviewed when?
a. Hospitalization
b. Well child visits
c. Sick child visits
d. School screenings
e. All of the above- a child’s immunization record should be reviewed at every clinic visit because it’s an opportunity
to give them what they may be missing.
●
A clinic nurse is assessing a child who is scheduled to receive a varicella vaccine. Which of the following is a
contraindication associated with receiving a live virus vaccine?
a. The child is currently experiencing intermittent episodes of diarrhea
b. The child has a current temperature of 100.8 (this is low-grade, so it’s ok)
c. The child has an immunodeficient family member or household contact
d. The child has a severely deficient immune system
●
The nurse prepares to administer an IM injection to a normally developed 2 year old patient. The nurse selects
which needle to administer this injection?
a. 1 ½ ʺ needle
b. 5/8ʺ needle- for a newborn up to a month
c. 1ʺ needle
d. 3/4ʺ needle
●
A nurse prepares to administer an IM injection to a 4 month old infant. The nurse selects which site to administer
the injection?
a. Vastus lateralis
b. Ventrogluteal
c. Dorsal gluteal
d. Rectus femoris
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Nursing Care of Children with Communicable Disease
●
The responsibility of the nurse when caring for children with communicable disease is to ◦ Prevent the spread
◦ Provide comfort
◦ Prevent complications
Conjunctivitis aka Pink Eye
◦ Bacterial- characterized by large amounts of purulent discharge- highly contagious. Can be caused by Staph.,
Strep., Haemophilus, or Pseudomonas organisms. Treat with antibiotic.
◦ Viral- characterized by redness and a small amount of discharge that isn’t purulent, along with intense itchinghighly contagious. Caused by Adenovirus, Picornavirus, Rubella, or Measles
◦ Allergic- redness, cobblestone look to the eyelid, thin watery discharge
◦ Can use a warm, wet compress to soothe the eye. Spread through hand to eye contact.
Strep Throat
● Caused by a Group A Beta Hemolytic Streptococci. It is highly contagious.
● Abrupt onset. Characterized by: sore throat, HA, fever, abdominal pain, enlarged tonsils or cervical nodes, and
beefy red throat.
● Complications- Rheumatic Fever (usually results from an untreated Strep throat infection and may not present for
6-9 weeks after initial infection), and Acute Glomerular Nephritis
● Treatment- antibiotics: Penicillin, but if child is allergic then they get Erythromycin. Children are considered noncontagious 24 hours after they’ve started their antibiotic treatment. Make sure child completes entire antibiotic
regimen, even if they’re feeling better to prevent resistance. Make sure to change child’s toothbrush after recovery
to prevent reinfection from occurring.
Fifth Disease
● Called “Fifth” disease because it was the fifth identified childhood disease.
● Caused by Human Parvovirus B19. Transmitted by respiratory secretions or blood
● Clinical Manifestations- Bright red cheeks occurs first. Then child will break out into a lacy rash that covers body, it
usually is seen on upper and lower extremities. It takes a while for the lacy rash to go away.
● It is most contagious before the slapped cheek and lacy rash appear…while they present only a clear runny nose,
low-grade temperature, and HA. So stopping the spread is very difficult.
● It can cause an aplastic crisis in patients who have a history of Sickled cell anemia.
● The most critical complication occurs when a pregnant woman who has never had the disease becomes infected
during the first half of the pregnancy. It can cause hydrops fetalis (fetal anemia) and intrauterine death. Some
patients, they will try to do a transfusion in utero.
● So if you are pregnant, then go to the OBGYN to see if you’ve had the disease before or not. They will test your
antibody levels. If you have had it before then you’re ok and won’t come down with it. If not, then you will be
monitored closely.
Impetigo
● Caused by a bacteria. It is very contagious and is common in toddlers and pre-schoolers.
● Manifests as a red macule that becomes vesicular. It ruptures vey easily. the exudate will dry and present as a
honey colored crust.
● To manage the crust, apply warm, moist compress several times during the day to help remove crust. A topical
antibacterial ointment will be prescribed and applied after the crust is removed. Sometimes an oral antibiotic is
given as well.
● Biggest complication is glomerulonephritis
Hand, Foot, and Mouth
● Transmission- viral (most commonly by Coxsackievirus A16 or Enterovirus 71), common in < 5 years of age. But
can occur in older children and adults. Most frequently seen in the summer and fall. The illness is generally mild.
● Symptoms- Starts off with common cold symptoms such as fever, sore throat, runny nose, anorexia, and
progresses to sores/blisters inside mouth/buccal/tongue area, skin rash on palms, top of hands, buttocks, and soles
of feet. Blisters usually clear out in 7 days. May have vomiting and diarrhea. Virus an be shed in stool for 2-3 weeks.
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● Incubation- 3-6 days. Contagious for 2-3 weeks after infection starts. Respiratory shedding is limited to a week or
less. Transmitted via respiratory route; coughing, sneezing, or direct contact with blister fluid, or fecal-oral route.
● Treatment●Symptomatic because it’s a virus. Encourage rest. Drink lots of fluids like: water, milk, avoid acidic drinks
such as coffee, OJ, or soda that will hurt blisters in mouth. Offer them soft foods because of blisters.
Popsicles such as Pedia-lyte pops to numb the blisters.
●Tylenol or Ibuprofen for fever. Magic mouth wash that has Lidocaine in it.
Questions
●
A nurse instructs the mother of a child diagnosed with bacterial conjunctivitis regarding patient care and infection
control. Which of the following, stated by the mother, indicates that further teaching is needed?
a. I should wash my hands frequently after caring for my child
b. I need to administer eye drops as the doctor prescribed
c. I can have my child share towels or linens with others
d. I can apply moist, warm compresses to the infected eye to ease discomfort
●
A nurse provides home care instructions to the parent of a child with Fifth disease. She explains that which of the
following is a complication associated with Fifth disease?
a. Miscarriage
b. Deafness
c. Infection
d. Rheumatic fever
●
When caring for a child with impetigo, the nurse would expect to :
Apply topical steroids to the affected area
b. Apply topical antibiotics to the affected area as ordered
c. Apply dressings to the affected area and change daily- dressings are not applied to blisters. They are left open to
the air, other than the times when we apply antibiotic ointment or warm, moist compresses.
d. Apply anti-parasitic ointment to the area as directed- no, because it’s caused by Staph or Strep.
a.
●
A nurse on a hospital unit receives a call that a child will be admitted for rheumatic fever. The nurse knows she will
inquire about which of the following when taking a history from the parent:
a. Has the child complained of back pain?
b. Has the child complained of headache?
c. Has the child had nausea or vomiting?
d. Has the child had a sore throat or fever within the last 2 months?
CHILDHOOD IMMUNIZATIONS AND INFECTIOUS DISORDERS- PART 3
DISCUSSING VACCINES WITH PARENTS
Reliable information and websites for parents
● Baby 411, Denise Fields and Ari Brown, MD
● Do Vaccines Cause That? A Guide to Evaluating Vaccine Safety, Martin Meyers, MD and Diego Pineda, MS
● Vaccines and Your Child: Separating Fact from Fiction, Paul Offit, MD and Charlotte Moser
● American Academy of Pediatrics: www.aap.org/immunization
● Centers for Disease Control and Prevention: www.cdc.gov/vaccines
● Immunization Action Coalition: www.immunize.org
Question 1
What is the science? Do vaccines cause autism?
• Review of alleged linkage
●
1998 - Wakefield published a case report of 12 children with IBD and regressive developmental delay
Hypothesis: MMR caused bowel dysfunction, which resulted in neurodevelopmental disorders
● 2004 - 10 of Wakefield’s original 13 authors published a formal retraction
● 2010- Lancet retracts study
● 2011- BMJ investigation labels Wakefield’s study “an elaborate fraud”
●
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• Why MMR? A victim of timing…
Question 2
Is thimerosal, a mercury derivative, harmful? What is Thimerosal?
●
Thimerosal has been used as a preservative in vaccines since 1930; only known risk is hypersensitivity
Thimerosal is 49.6% by weight ethyl mercury
● Ethylmercury has a short half-life and does not cross the blood brain barrier due to its molecular size
●
"Although the names may sound the same, methylmercury and ethylmercury are very different. An analogy is the
difference between methyl alcohol and ethyl alcohol: Methyl alcohol is antifreeze, and ethyl alcohol is a Bud light." - Dr. Ari Brown
• Evidence mercury doesn’t cause autism
●
●
●
●
●
In 1971, methyl mercury poisoning from fumigated grain caused pregnant women to deliver babies with epilepsy
and mental retardation; not autism
Denmark stopped using thimerosal in 1991; autism rates have risen since that time
Symptoms of mercury poisoning and autism are different
Exclusively breastfed babies will ingest more than 2 times the quantity that was ever in vaccines and 15 times that
contained in the influenza vaccine
IN 1999- CDC removed thimerisol from pediatric vaccines
Question 3
Do vaccines overwhelm the immune system?
• No, Our immune systems encounter challenges everyday:
“ …an upper respiratory viral infection exposes a child to 4-10 antigens, and a case of strep throat 25-50.”
• Children are exposed to fewer vaccine antigens today than in the past . . .
Questions 4 & 5
Is the current vaccine schedule harmful? Do we give too many immunizations too soon?
• No
Question 6
If vaccines don’t cause autism, then what does?
• Genes and Autism
● Studies of identical twins found that when one had autism, the likelihood that the other twin had autism ranged
from 70-90%; for fraternal twins, the likelihood was less than 10%
● Known syndromes currently account for 20% of cases
● Families with one autistic child raise their chances by 25X that another child will have autism
• How are parents responding?
• Too often parents are seeking a delayed or altered immunization schedule. Dr. Bob’s alternative vaccination
•
•
•
•
schedule is not founded on science. There’s no way to show that this schedule works because the
recommended immunization schedule has been tested in that order for safety and efficacy and there’s no way
to prove that changing up that order will produce the same effectiveness in immunity. Also vaccinating later will
leave children to be vulnerable to these diseases during that waiting period.
Trends in delay or refusal of vaccines
● Between 2003-2008, % parents who refused or delayed vaccines increased from 22-39%
● Approximately 1 in 8 parents has refused at least 1 recommended vaccine
● The children of these parents were significantly less likely to be UTD (up to date) at 19 months of age
Vaccine exemptions in Texas- the numbers have risen over the last decade. In 2003, Texas passed a law allowing
philosophical exemptions to vaccines. Before that Texas only allowed medical and religious exemptions.
How should we talk to our patients about vaccines?
● Corroborate- Restate/acknowledge parent’s concern
● About Me- Tell them your education status, experience with vaccines, why they should trust you, etc.
● Science- Proven that the flu vaccine can’t give you the flu, etc.
● Explain/Advise- Get vaccines on the schedule to protect against diseases and that many are still out there
A great resource for you…http://violentmetaphors.com/2014/03/25/parents-you-are-being-lied-to/
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Fatemeh Sahrapour
MODULE: CARE OF THE CHILD WITH CEREBRAL DYSFUNCTION
Note: The exact immunization schedule often times changes each year. The common schedule such as the 2, 4, 6
and 12 months have been fairly consistent and are ones to be familiar with. It is important to know where to locate the
current schedule and to be aware of the type of immunzations that are given, why they are given as well as the
implications and side effects of these vaccines.
In the Silvestri NCLEX-RN review book, there is a question that leads one to believe that the pneumococcal vaccine
is given yearly to children at risk. That is not true. It is given per schedule as discussed in text and in lecture. The
influenza is given every year. The publisher has been notified and it is to be corrected in the next printing.
Readings:
Cerebral and Neurological Disorders
Perry: 1417 - 1436, 1439 - 1458
ATI 2013: 107-136
THE CHILD WITH CEREBRAL DYSFUNCTION
ANATOMY OF THE PEDIATRIC SKULL
• Fontanels
• Flexible necks
• Large heavy heads
• Insufficient musculoskeletal support
THE CRANIUM
• 80% brain
• 10% cerebral spinal fluid
• 10% blood
HEAD INJURIES
- According to national statistics and Safe Kids Worldwide, unintentional injuries are the #1 health risk for children
and the leading cause of death in children older than 1 year of age
- Estimated that 500,000 children per year sustain a traumatic brain injury
- 21700 children per year die as a result of brain injury
- What are the major causes of head injury in children?
- falls
- motor vehicle injuries
- bicycle/motor bikes
- sports related injuries
- child abuse
- Can range from mild to debilitating
- Traumatic brain injuries (TBI) can lead to severe brain damage or death if not recognized and treated appropriately
- The recovery after a brain injury varies widely and the most important predictor of treatment outcomes is the initial
Glasgow Coma Scale, where we look at pupil response, motor exam, and associated brain injuries we see on CT
scan. Generally, if a person doesn’t fall into a coma, a stable outcome occurs. For the comatose patients, they are
at a GC scale of < 8, they have a recovery outcome of 38-73% with a mortality rate of 11-41%. Also, normal
pupillary responses prior to surgery shows a favorable outcome in about 84% of patients. When both pupils are
dilated, a poor outcome or death occurs in majority of these patients. Also associated intracranial injuries such as
cerebral contusions will adversely affect the outcome of patient. A rapid diagnosis and urgent surgical treatment
improves the chances of recovery in patients with severe head injuries, fractures, epidural, subdural hematoma.
CLOSED HEAD INJURIES
- Concussion
• Most common head injury in children
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• Hall mark s/s of concussion include confusion and amnesia. It’s an alteration in neurological or cognitive
function with or without loss of consciousness. It occurs immediately after a head injury. Basically the brain
was shaken. It usually resolves on its own within 7-10 days but can take up to several months depending on
severity.
• This patient may be watched over night in the hospital or may be sent home with strict instructions for parents
to notify MD if they notice a change in child’s behavior, they are very sleepy, pupil size change, vomiting that is
forceful, or if child is complaining of sever HA…because these are all signs of increased ICP
Contusion
• Visible bruising and tearing of cerebral tissue, small petechiae or little bleeds in brain tissue.
• The degree of brain damage in the contused areas varies according to the extent of vascular injury
Epidural Hemorrhage/Hematoma
• Bleeding between the dura mater (thick membrane that covers the brain) and the skull to form a hematoma.
The dura is peeled off the skill, and it’s arterial blood that’s lying underneath.
• Usually occurs when a skull fracture tears an underlying blood vessel.
• They’re not as common as subdural hematoma and usually occur in younger adults
• Classic symptoms: brief loss of consciousness, followed by a period of awareness that may last several hours
before the brain function deteriorates sometimes leaving the patient in a coma. It is very serious and if not
treated immediately the patient can die.
• The neurosurgeon will go in there and evacuate the hematoma, and patient usually has a good outcome if it’s
recognized immediately
Subdural Hemorrhage
• Bleeding between the dura mater and the arachnoid membrane (surface of the brain), usually due to
stretching and tearing of veins on brain’s surface. These veins rupture when head injuries suddenly jolts or
shakes brain. The dura is still attached to the skull, and it’s venous blood that’s lying underneath.
• Traumatic, acute subdural hematoma are among the most lethal of all head injuries, associated with more
severe generalized head injury. They often occur with cerebral contusions.
• These are more common than epidural hematomas, occurring most often in infancy as a result of birth trauma,
falls, child abuse, or violent shaking (shaken baby syndrome)
Fractures (can be open or closed)
OPEN HEAD INJURIES
- Penetrating trauma- like gun shot wounds or objects that break the barrier of the skull
- Fractures
- Linear- This is the most common type of skull fracture. In a linear fracture, there is a break in the bone, but it
does not move the bone. These patients may be observed in the hospital for a brief amount of time, and can
usually resume normal activities in a few days. Usually, no interventions are necessary.
- Depressed- This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull
is actually sunken in from the trauma. This type of skull fracture may require surgical intervention, depending on
the severity, to help correct the deformity.
- Diastatic- Diastatic fractures widen the sutures of the skull and usually affect children under three. These are
fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head
that fuse when we are children. In this type of fracture, the normal suture lines are widened. These fractures are
more often seen in newborns and older infants.
- Comminuted- Comminuted fracture: A fracture in which the bone has broken into several pieces.
- Basilar- This is the most serious type of skull fracture, and involves a break in the bone at the base of the skull.
Patients with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They
may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These
patients usually require close observation in the hospital. Classic raccoon eyes, bleeding around nose, ear, and
ethmoid sinuses
- These make patient more susceptible to infection
HEAD INJURY PRESENTING SYMPTOMS
- Minor injury
- May or may not loose consciousness
- Headache
- Confusion, amnesia
- Listlessness
- Pallor
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- Vomiting, generally projectile
- Irritability
- Seizure
- Severe injury
- Decreased LOC/GCS
- Changes in vital signs
- Bulging fontanel (infant)
- Retinal hemorrhages
- Unsteady gait
- Hemiparesis, numbness on one side
- Quadriplegia, numbness in all 4 extremities
- Elevated temperature
WARNING SIGNS AFTER A HEAD INJURY (THE FIRST 24 HOURS)
- Changes in LOC: increased drowsiness, confusion, difficult to arouse
- Seizures
- Bleeding or water drainage from nose and ears
- Pupils slow to react or unequal
- Visual problems
- Loss of sensation to any extremity
- Slurred speech
- Projectile vomiting
DIAGNOSTIC EVALUATION OF CHILD/INFANT WITH HEAD INJURY
- History and Physical
- Baseline VS
- SpO2
- LOC/GCS- do frequent GCS
- ABG- to determine if they’re acidotic or alkalonic, or determine what their CO2 level is
- Alcohol level
- Drug screen
- CBC- to determine if signs are from infection like meningitis
- X-ray
- CT Scan- provides a more definitive diagnosis or type and extent of injury
- MRI- to evaluate for cerebral edema or any structural brain abnormalities, and to rule out cervical spine injury
SECONDARY COMPLICATIONS FROM A HEAD INJURY
- Changes in LOC- this is why you do frequent GCS testing. Remember 15 is the highest you can get on that scale
and 3 is the lowest. Pay attention to any changes that will be reflected in the score.
- Coma
- Increased ICP
- Infection- especially if it’s an open or penetrating wound
- Cerebral edema- brain is swelling
- Hemorrhage
- Seizures
- Hypoxic brain damage- from a decreased O2 supply to the brain
- Brain herniation- caused by compression, the brain can slip into the brain stem
- Brain death
NURSING CARE MANAGEMENT S/P HEAD INJURY
- ABC’s (airway, breathing, circulation)
- Cervical spinal cord stabilization- we don’t want to turn patient until the cervical spine X-ray has cleared patient.
The neck brace has to stay on until cervical spine injury has been ruled out.
- HOB elevated & head midline
- Thorough PE- physical assessment thorough, log roll patient because we don’t want to miss anything on the back
of their head, or ears
- Vital Signs- baseline, then take them at least every hour depending on MD orders, look for trends, look for a wide
pulse pressure (for ex. 125/60) and a low pulse. This could be sign indicating Cushing’s Triad. The Cushing
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response refers to the changes the body experiences to compensate for rising intracranial pressure. Cushing's
triad of signs includes hypertension, bradycardia and apnea.
Sp02- monitor for trends
Glasgow Coma Scale- 15 is the highest or best, 3 is the worst.
Pain- assess and treat. Don’t just put them on a narcotic when they come in, will alter neurological assessment.
We can give them Tylenol or Ibuprofen to control their pain until we are able to give them a narcotic.
Drainage- from nose, ears, incision site? CSF leakage?
NPO- they are at risk for vomiting and aspiration, seizures
IV Fluids- keep them hydrated
Strict I&O
Monitor labs closely- especially Na, and serum osmolality, pay attention to their urine output, how much is it?
Because these patients are at risk for DI or SIADH
Seizure precautions- pad side rails, bed in lowest position, call light within reach
Monitor for S&S of ICP- if they’re complaining of HA, pupillary changes, if they’re vomiting, changes in behavior
Quiet room and dark, cluster care
Support/educate family
GLASCOW COMA SCALE
- Eye opening:
- 4 = spontaneous
- 3 = to voice
- 2 = to pain
- 1 = none
- Verbal Response:
- 5 = normal conversation
- 4 = disoriented conversation
- 3 = words, not coherent
- 2 = no words, only sounds
- 1 = none
- Motor Response:
- 6 = normal
- 5 = localized to pain
- 4 = withdraws to pain
- 3 = decorticate
- 2 = decerebate
- 1 = none
➢ Every brain injury is different, but generally, brain injury is classified as:
•Mild: GCS 13-14
•Moderate: GCS 9-12
•Severe: GCS 3-8 (You cannot score lower than a 3.)
➢ LOC remains the earliest indicator of improvement or deterioration in neurologic status.
- FLACC Scale- Used on infants or patients that are unable to provide self report
- FACES Scale- for older children
- Numbers Scale- works best for children above the age of 8 years
LEAKING OF CSF FROM INCISION SITE, NOSE, EARS
- You’ll see a halo sign on the sheets, where there’s blood at the center surrounded by clear liquid leakage and a
visible ring surrounding it. This is a CSF leak. Get a chemical strip and dip it for glucose. It will be positive if it’s
CSF.
INCREASED INTRACRANIAL PRESSURE (ICP)
-
Increase in the volume of the cranium leads to increased intracranial pressure
Infants can compensate when sutures are still open
Changes in level of consciousness (LOC) is the first sign of IICP
Changes in vital signs follow: Cushings Triad: Late sign
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CAUSES OF INCREASED INTRACRANIAL PRESSURE
Head Injury
Subdural Hematoma
Epidural Hematoma
IVH
Fractures
Meningitis/Encephalitis
Hydrocephalus
Status Epilepticus
Reye’s Syndrome
Cerebral Edema
SIGNS OF ICP
- Infants
- Tense bulging fontanel
- Separated cranial sutures
- Increased head circumference
- Irritability and restlessness
- Drowsiness
- Increased sleeping
- Poor feeding
- High pitched cry
- Children
- HA
- N/V
- Diplopia- double vision
- Blurred vision
- Seizures
- Drowsiness
- Lethargy/Increased sleeping
SEVERE OR LATE SIGNS OF INCREASED ICP IN INFANTS AND IN CHILDREN
• Changes in LOC• Decrease response to painful stimuli
• Decreased consciousness
• Coma
• Seizures- impaired sensory and motor functions
• Eyes- These changes are considered a medical neurological emergency; MD notified immediately
• Papilledema- bulging or swelling behind optic disc that is caused by increased intracranial pressure. The
swelling is usually bilateral and can occur over a period of hours to weeks.
• Alterations in/unequal pupil size and reactivity to light- sometimes a fixed or dilated pupil
• Impaired eye movement
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• Posturing• Decerebate- arms are extended outward, and it looks like they’re celebrating. This is indicative of severe
brain stem injury. It is the worst of the 2 postures.
• Decorticate- abnormal posturing where person is stiff with arms bent, clenched fist with legs pointed out
straight. It looks like they’re doing a mummy pose. This is a sign of severe brain damage
• Flaccid- decreased motor function/ability
• HA
• Changes in VS• Cushing’s Triad: Bradycardia, Increased Systolic BP, Altered Respiratory Pattern
• Cheyne-Stokes respirations- increased RR, then slow RR, followed by apnea periods
• Decreased motor response to command
MEDICAL MANAGEMENT OF INCREASED INTRACRANIAL PRESSURE
• Neurosurgery consult stat- especially if patient has abnormal (decorticate or decerebrate) posture with unequal or
fixed or dialed pupils
• Emergency craniotomy- to remove the bleeds of fracture that might be penetrating brain
• Mechanical ventilation- they’ll be sedated and paralyzed
• Central/arterial line
• CPP (cerebral perfusion pressure) = MAP (mean arterial pressure) - ICP. This represents the pressure gradient
driving cerebral blood flow (CBF) and hence oxygen and metabolite delivery.
• NGT/DHT
• Foley- for strict output
• ICP monitoring• EVD- extra-ventricular drainage device, which is externally monitored
• Bolt- tells you pressure inside the patient’s brain
• Normal pressure ranges from 3-5. When we sneeze, can go up to 10-15. High ICP must be treated immediately.
NURSING MANAGEMENT OF INCREASED ICP
• Same as monitoring a patient with a head injury
• Strict Bed rest
• NPO/IV fluids
• Strict I &O’s
• Pain control- non-narcotic if you’re monitoring their mental status, or narcotic if you want to lower their ICP
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• HOB elevated
• Head midline- you don’t want head turned to the side, cutting off vein and O2/blood supply to brain
• Decrease stimuli- keep room dark and quiet
• Cluster care
• Suctioning- as needed only, not routinely
• Restraints- if they’re getting combative, note changes in behavior reflect changes in ICP
• Elimination- Foley to monitor I&O hourly
• Safety
• Nutrition- either a Dobhoff tube or TPN depending on length of stay
• Seizure precautions
• Coping
- Again, monitor strict I&O because patients with head injury are at risk for DI and SIADH
Diabetes Insipidus
SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
High urinary output
low urinary output
low levels of ADH
high levels of ADH
Hypernatremia
hyponatremia
Dehydrated
overhydrated
Lose too much fluid
retain too much fluid
Both will present with excessive thirst
PHARMACOLOGICAL MANAGEMENT OF INCREASED INTRACRANIAL PRESSURE
• Mannitol- osmotic diuretic that helps with cerebral edema
• Hypertonic Saline solution
• Corticosteroids
• Analgesics, Sedatives, Paralytics- for patients whose increased ICP isn’t responding to usual treatment, because as
this pressure is rising, their CPP is decreasing. So make sure we’re not restricting blood flow to the brain in any way.
• Anticonvulsants- prophylactic because they’re at risk for seizures
• Antibiotics- for penetrating head injury or fracture to prevent any type of infection like meningitis.
SIGNS AND SYMPTOMS TO REPORT IMMEDIATELY TO MD
Changes in:
•V/S & Labs
•LOC/GCS
•Behavior
•Pupils
•Pain
•Posturing
…Initially R and L pupils are normal in size, and as the brain becomes more compressed, pupil constriction changes.
In this picture you can see that the lesion or bleed is on the L side of the patient’s brain.
CONFIRMING BRAIN DEATH
- Fixed and dilated pupils- non-reactive
- Absent corneal reflexes- rubbing a Q-tip across cornea normally causes a blink, absent in this patient
- Absent gag reflexes- sticking a tongue blade at back of patient’s throat
- Apnea test- turn off ventilator and see patient takes a breath after 30 seconds, build up of CO2 should initiate a
breath in that patient. But if they’re brain dead, they won’t take a breath
- Cold caloric test- put water in patient’s ear, in a normal and awake patient the causes a sensation of nausea and
nystagmus and as a result the eyes will move in the opposite direction to try to keep the vision steady, but in a
brain dead patient the eyes won’t move at all.
- EEG-cerebral silence- a complete flat line
- Cerebral blood flow exam/No flow to the brain
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TEACHING THE FAMILY/CAREGIVERS TO PREVENT HEAD INJURIES
- Never leave infant unattended on bed, couch, chairs
- Always have infant/child secure in high chair
- Always have infant/child in appropriate size car seat. Make sure older children are secured with seat belt.
- Place car seat in appropriate position in regards to age/weight/manufacturers recommendations
- Fire arm security and safety
- Make sure helmets are worn during bike rides/horse back riding/ skating/ skateboarding, sports
- Monitor child’s play on playgrounds and around roads/stairs/steps
- Never shake a child
QUESTIONS
- An adolescent client who has a closed head injury is being admitted to the critical care unit from the emergency
department. Which of the following assessment findings are indicative of increased ICP? (Select all that apply)
A.
B.
C.
D.
E.
Report of severe headache- YES
Dilated pupils- YES
Generalized rash
Deep, fast respirations- YES
Abdominal pain
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- A nurse is caring for a child who was recently admitted to the emergency department after a MVC. The child is
unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding.
Which of these interventions is the priority nursing action at this time?
A. Keep the neck stabilized- because the greatest risk to the child is further cervical injury, so we want to keep
this neck stabilized, until cervical injury can be ruled out.
B. Cleanse the laceration
C. Obtain vital signs
D. Establish IV access
INTRACRANIAL INFECTIONS
- Meningitis- inflammation affecting the meninges lining the brain and spinal cord
- Encephalitis- inflammation affecting the brain
MENINGITIS
- Viral or Aseptic- Caused by viral illness (mumps, measles, herpes, CMV, adenovirus, HIV)
- Short lived, self limiting, complete recovery. Occurs most often in very young children (< 2 months of age)
- Can have a generalized rash, but wont’ have a purpuric or petechial rash you see in bacterial meningitis
- Give Tylenol or Ibuprofen if they complain of any HA or body aches, and to control their temperature.
- Keep them as comfortable as possible until virus runs its course.
- Bacterial or Septic
- Caused by pus-forming bacteria
➢Group B Strep, E Coli, L monocytogenes: in children < 2 months of age
➢S. pneumoniae, N. meningitidis: in children > 2 months of age
➢Meningococcal meningitis: School age, adolescents, college students
- There has been a drastic decline in Meningitis cases due to vaccines➢ H. Influenza type B (Hib)- given at 2, 4, 6 months, and between 12-18 months of age
➢ Pneumococcal conjugate vaccine- 2, 4, 6 months, and between 12-18 months of age
➢ Meningococcal conjugate vaccine- given between 11-18 years of age, with a booster 5 years later
SYMPTOMS OF BACTERIAL MENINGITIS IN NEONATES
- Refuse feedings & Poor sucking ability
- Vomiting or diarrhea
- Poor or weak muscle tone & Lack of movement
- Weak cry
- Full/tense bulging fontanel
SYMPTOMS OF BACTERIAL MENINGITIS IN INFANTS AND YOUNG CHILDREN
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SYMPTOMS OF BACTERIAL MENINGITIS IN CHILDREN AND ADOLESCENTS
- Usually abrupt onset
- Fever
- Chills
- Headache
- Vomiting
- Seizure
- Agitation
- Nuchal rigidity- resistance
to neck flexion due to
meningeal irritation.
Positive Kernig and
Brudzinski sign indicate
nuchal rigidity.
- May develop:
- Photophobia, Delirium,
Stupor, Hallucinations,
Drowsiness, Coma
DIAGNOSTIC EVALUATION
❖Physical Assessment
❖Lumber puncture is the definitive diagnosis test for meningitis
❖ It is important that the gram stain, CBC, determination of glucose and protein content are done. Culture
and sensitivity testing are done to ID causative organism. But a patient with meningitis has an elevated
WBC, often predominantly polymorphonuclear leukocytes (the shape of the WBCs). The glucose in
bacterial meningitis is reduced.
❖ Patient is bent over to open up spaces between lumbar vertebrae. Explain patient and family for what to
expect afterwards. Use EMLA cream between C5-C7 area and let it stay on for at least 30 minutes and
cover it up with a Techyderm so it doesn’t dissipate. Lie still for several hours after procedure to prevent HA
or a CSF leak.
❖It’s the nurse’s role to collect and label CSF tubes
• Tube 1: Cell count
• Tube 2: Stat gram stain and culture (C+S) (2 cc.)
• Tube 3: Glucose and protein
• Tube 4: Cell count (for comparison to Tube1)
• Tube 5 (optional): virology, mycology, cytology, etc.
❖CT Scan- done to rule out any other abnormalities that may be going on.
❖Blood culture- to rule out other infections
CSF ANALYSIS
Manifestations
Bacterial
Viral
• WBC count
Elevated, increased polys Slightly elevated, increased lymphs
• Protein count
Elevated
Normal or slightly increased
• Glucose content
Decreased
Normal
• Gram stain; bacteria culture Positive
Negative
• Color
Clear
Cloudy
- Why would glucose be low in patients with Bacterial meningitis? Bacteria eats glucose! What other reasons could
cause glucose to be elevated?Why is the protein elevated in bacterial meningitis? Bacteria are composed of proteins,
inflammation causes an increase in protein. What are other possible causes for protein to be elevated?
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NURSING ALERT
• A major priority of nursing care of a child suspected of having meningitis is to:
1.Initiate contact and respiratory isolation precautions immediately! Protect yourself and others
2. Then initiate antibiotics as soon as they are prescribed by physician. Child is placed on respiratory isolation for
at least 24 hours after initiation of antibiotics, and C&S results confirmed
THERAPEUTIC MANAGEMENT
- Isolation precautions
- Initiation of antibiotics- within 20 minutes of patient’s arrival, suspecting meningitis
- Restrict hydration initially
- Maintenance of ventilation- ABCs
- Reduction of increased ICP
- Management of systemic shock
- Control of seizures- implement precautions!
- Control of temperature- they can have extreme hyperthermia
NURSING MANAGEMENT OF BACTERIAL MENINGITIS
- ABC’s
- Cardiopulmonary Monitor
- IV placement- think long-term, keep the big veins safe if you can.
- ABX- At least 7-10 days antibiotics so possible PICC Line of Central Line.
- Strict I & O’s
- Quiet Room
- Cluster Care
- HOB elevated
- Pain control
EDUCATION REGARDING BACTERIAL MENINGITIS
- If family exposed they will need to take Rifampin
- Long term antibiotics needed at least 10 days
- Hearing loss is common due to ototoxicity from high dose antibiotics and from having meningitis it self.
- Auditory evaluation 6 months after the illness has resolved
SEIZURES
• A result of uncontrolled electrical discharge from nerve cells to the cerebral cortex, and are characterized by sudden,
brief attacks of altered consciousness, motor activity, and sensory phenomena. It can be associated with a variety of
cerebral or systemic disorders such as a focal or generalized disturbance of cortical function. Sensory symptoms
arise in the parietal lobe and the motor symptoms arise in the frontal lobe.
• The most common pediatric neurologic disorders
• Approx. 4% of children will have at least one seizure by age of 15 years, with 1/2 of those being febrile seizures
RISK FACTORS
- Genetics
- Fever
- Head trauma
- Infections
- Noncompliance with mediations
- Stress
- Tumor
- Withdrawal
- Fluid and electrolyte imbalance
- Flashing lights or video games
- Toxin or chemical exposure
- If your patient does have a history os seizure
explore with them their possible triggers.
FEBRILE SEIZURES
- One of the most common neurologic conditions of childhood
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Affects approximately 2-5% of children between the ages of 6 months and 5 years of age
Occurs with fever > 38.0 C. Use Acetaminophen or Ibuprofen to make child more comfortable.
Recurrence is common
Parental reassurance. Although frightening, febrile seizures stop on their own after a few minutes and don’t cause
any other health problems. Remind parents that child shouldn’t be held or restrained during a convulsion, and to
prevent choking the child should be placed on their side or their stomach, and do NOT put any items in child’s
mouth. Time seizure, if it lasts longer than 10 minutes, take them to the ER. Once seizure has ended take child to
MD to check for the sources of fever. This is urgent if child shows signs of stiff neck, extreme lethargy, or continued
vomiting, as these are signs of meningitis as well.
Signs: having jerky movements, convulsions, shaking, twitching, or moaning, and may become unconscious
TREATMENT OPTIONS
- Anti-epileptics:
- Fosphenytoin
- Phenytoin
- Diazepam
- Lorazepam
- Gabapentin
- Cerebyx
- Tegretol
- Ketogenic diet- one high in fat, low CHO, and adequate protein that puts them in a state of ketosis and studies
have shown that as many as 50% of children on this diet will have a decrease in seizures
- Vagus nerve stimulation- performed under general anesthesia, device is implanted into left chest wall and is
connected to an electrode placed at left vagus nerve. The device is programmed to administer intermittent vagal
nerve stimulation at a specific rate to child’s needs. In addition to routine stimulation, the child may also initiate the
vagal nerve stimulator by holding a magnet over the implanted device at the onset of seizure activity. This will
either abort the seizure or lessen its severity.
- Surgical management- in certain situations it may be needed, like a corpus colosotomy, depending on severity of
seizures, how often they’e having them, etc.
NURSING INTERVENTIONS
- Side rails up
- Bed in lowest position
- Padded side rails
- Call light with in reach
- Waterproof mattress- patient may become incontinent while seizing
- Oxygen and suction at BS (bedside)
- Medical identification bracelet for seizure and fall precautions
WHAT DO YOU DO IF YOUR PATIENT HAS A SEIZURE?
- Remain Calm
- Time the seizure
- Position child for safety- to the side lying position because this decreases their risk for aspiration. Be prepared to
suction any oral secretions patient may have. Position child for a patent airway.
- Loosen clothing
- Never restrain child
- Never attempt to open their jaw or insert an airway during seizure activity. NEVER put anything in their mouth
- Place pillow under head
- Ensure safe environment
- Stay with child and reassure until fully awake
- Notify MD
- Document S&S
…After the seizure
- Stay with them until they’re fully awake.
- Check this VS
- Keep them in side lying position to prevent aspiration and to facilitate the drainage of oral secretions.
- Assess for any injuries and perform neurologic checks
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- Allow child to rest, they will be sleepy or post-ictal
- Reorient them and calm them
- Encourage them to describe the period before, during, and after seizure activity. Did they experience an aura?
What triggered episode? Document: S&S, onset, duration of seizure, apnea, cyanosis, LOC, incontinence.
CALL FOR THE DOCTOR AND RAPID RESPONSE ASSISTANCE IF…
- Evidence of injury after the seizure
- Patient has diabetes
- Pt is pregnant
- Seizures last > 5 minutes
- Pupils are not equal after seizure***
- Child vomits continuously 30 minutes after end of seizure
- Seizure occurred in water
- Patients first seizure?
- Status epilepticus occurs
CALL A CODE AND START CPR IF:
- The patient is unresponsive, stops breathing, barely breathing, gasping with < 10 breaths per minute
- The patient heart stops beating or less than 60 beats per minute with signs of poor perfusion
CARE MANAGEMENT
- Nurses are responsible for observing the seizure episode and accurately document the events, not diagnosing the
type of seizure that the patient had
- The nurse should describe only what is observed rather than trying to label a seizure
- Note the duration of the seizure with start and stop times
GOALS OF SEIZURE MANAGEMENT
- Control the seizures or reduce their frequency and severity
- Discover and correct the cause when possible
- Help the child live as normal live as possible
- If child has a history, ask them if they have an aura before an episode. That will let you/them know what to look for
so you can protect them from harm/implement precautions
STATUS EPILEPTICUS
- SE is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of
consciousness between any of them
- Requires immediate treatment to prevent loss of brain function, which may become permanent, because the brain
isn’t getting the blood/O2 flow it needs to stay perfused.
NURSING MANAGEMENT OF STATUS EPILEPTICUS
- ABC’s
- Monitor V/S
- Continuously monitor SpO2 and ABG results
- Administer Oxygen
- Obtain IV, preferably a central line because many anti-epileptic meds can be caustic to the vein
- Perform a stat EEG
- Intubation
- Sedation
- Give a loading dose IV of Lorazepam (Ativan) or Diazepam (Valium) followed by a continuous infusion of Dilantin
(Phenytoin)
HYDROCEPHALUS
- Imbalance in the production and absorption of CSF in the ventricular system
- Ventricles become dilated and compress the brain against the cranium, causing an increased ICP.
CAUSES
•Tumor
•Hemorrhage
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•Infection
•Congenital malformation
•Trauma
CLINICAL MANIFESTATIONS OF HYDROCEPHALUS IN INFANTS
- Large head
- Widened sutures
- Rapidly increasing FOC
- Full & bulging fontanels
- Irritability
- Vomiting
- High pitched cry
- Poor feeding
- Sun-setting sign (eyes with sclerae showing at top eye lid, eyes depressed and rotated downward due to the
increased pressure in the brain)
- Sluggish pupils
- …Note these are all signs of increased ICP. Again, infants can’t tell you they have a HA or are nauseated so it’s
important to pay attention to their VS and to use FLACC pain scale.
DIAGNOSTIC EVALUATION
- FOC- if it crosses the 1 percentile line on the head circumference chart within 2-4 weeks, that’s concerning.
- CT Scan
- MRI
- Also, look for any of the clinical manifestations listed above
THERAPEUTIC MANAGEMENT OF HYDROCEPHALUS
- Place a VP or a VA shunt in the ventricle and threading it into either the right atrium of the heart of the peritoneal
cavity of the abdomen. This will allow drainage of the backed-up CSF. It’s controlled by a one-way valve.
- Post-Op Nursing Care
- Positioning- initially patient will be in supine position for the first 12 hours. They can also be placed on the side if
that’s comfortable for them, but make sure it’s the uncooperative side. Then slowly start elevating HOB.
- Pain Management- narcotic or non-narcotic
- Monitor V/S
- GCS
- Skin integrity assessment at insertion site, which is at ventricle of head. If in their heart, we look at chest area.
And if a catheter is threaded to their abdominal area, assess that area for signs of redness, swelling, drainage,
tenderness. If it’s in the peritoneal area we also look for abdominal distention.
- Signs of infection
- Signs of malfunction- these are signs of increased ICP because if the valve gets kinked, then drainage is
backing up in the brain.
- Educate/Prepare for D/C
COMPLICATIONS OF VP SHUNTS
- Shunt infection:
- Greatest risk is 4-8 weeks after placement
- Meningitis
- Ventriculitis- inflammation of the ventricles, this is where the shunt is placed
- Remove shunt- and will get a culture to know how to treat
- Antibiotics for 7-10 days. So again, opt for that central or PICC line because these will be high dose antibiotics
- Shunt Malfunction:
- Kinking
- Plugging
- Separation or migration of tubing
- Mechanical obstruction…so pay attention to those signs of increased ICP and suspect shunt malfunction (fluid
is building up in their ventricles) if patient is irritable, complains of HA, vomiting, or has pupillary/VS changes.
- Remove shunt
- Replace shunt
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EXTERNAL VENTRICULAR DEVICE/ EVD
- If the patient does have to have their shunt removed, they may have had an EVD to drain the fluid until the shunt is
replaced. This allows you to obtain cultures form the CSF. You can also regulate the amount of drainage you’er
getting from the patient. Pay attention to patient’s position because if they move, you have to adjust your EVD.
Because it impact the amount of drainage coming from ventricles.
NURSING MANAGEMENT OF THE EXTERNAL VENTRICULAR DEVICE
- Must be knowledgeable about the equipment
- Assist MD with insertion
- Set up and replace equipment
- Maintain placement level- make sure it’s at level doctor prescribed
- Draw samples from port- clean with correct solution to prevent infection
- Interpret and monitor readings
- Document assessment findings
- Notify MD of changes/problems
- Change in color, amount of CSF drainage
- Behavioral changes in patient as signs of increased ICP
- Signs of infection at EVD insertion site
REYES SYNDROME
-
Is an extremely rare but serious illness that can affect the brain and liver
Occurs most commonly in kids recovering from a viral infection
Predominantly affects kids between 4 and 14 years old
Occurs most frequently when viral diseases are epidemic
Winter months or following an outbreak of chickenpox or influenza B…because again these are the times when
patients are medicated with some sort of salicylate.
Duration of illness depends on the severity of the disease
Stages 1-5 which can range from mild and self-limiting to, rarely, death within hours
Early detection, recognition and treatment are imperative
Should be treated as a medical emergency
ETIOLOGY
- Still not well understood and there’s no cure for this disease. It just has to run its course. You have to treat this
disease systematically depending on which stage it’s in.
- Studies have linked the use of aspirin/salicylates or aspirin-containing medications during viral disease as a factor
in the development of Reye’s syndrome
DIAGNOSIS
- Because there’s no test specific for Reye’s Syndrome, screening starts with blood and urine tests, as well as
testing for Fatty Acid oxidation disorders and other metabolic disorders
- Sometimes more invasive diagnostic tests are needed to evaluate other possible causes of liver problems and to
investigate any neurological abnormalities- Spinal tap
- Liver biopsy
- CT scan
- MRI
- Skin biopsy may be done to test for FA oxidation disorders or metabolic disorders
SIGNS AND SYMPTOMS OF REYE’S SYNDROME
- Frequent vomiting
- Lethargy or sleepiness
- In infants, diarrhea and rapid breathing
- Irritability or aggressive behavior
- Changes in vision
- Difficulty hearing
- Abnormal speech
- Alteration in LOC
- Fatty liver changes
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Hepatomegaly- due to swelling of the liver as a result of Reye’s Syndrome
Severe muscle weakness
Seizures
Loss of consciousness
…Because a lot of these symptoms sound like meningitis or increase ICP, it’s easy to misdiagnose this child. So we
need to pay close attention to their lab results especially their liver function tests.
MANAGEMENT OF REYES SYNDROME
- Supportive or symptomatic depending on which stage patient is in/No cure
- ABC’s
- Prepare patient/family for diagnostic tests
- Monitor V/S- they will be on continuous cardio-pulmonary monitor
- Strict I & O
- Monitor for signs of /Control ICP
- Because these patients are at risk for increased ICP, we’ll want to give them an osmotic diuretic like mannitol.
- Implement seizure precautions
- Because they’re at risk for seizures we may want to start them on prophylactic anti-seizure medications.
- Monitor Lab Studies
- We may also put them on vitamin K. They may also receive plasma and platelets due to bleeding from the liver
abnormalities, so pay close attention to PT, PTT, and INR values also.
- Nutritional support
- Monitor Fluid and Electrolytes and liver function tests
…It is important to catch Reye’s Syndrome within first 2 stages because it can progress quickly and the results can
be devastating if not treated in time.
SUPPORT AND EDUCATE FAMILY
- Many OTC medications contain salicylates
- Aspirin (salicylates) should not be used for kids or teenagers except on the advice of a doctor for certain
conditions. Yes the label does say it’s ok to give to kids > 2 years of age, but it is NOT recommended to give
especially when they have a viral infection, because it can cause severe damage to their brain and liver.
- NO ASPIRIN OR ASPIRIN CONTAINING PRODUCTS FOR CHILDREN OR ADOLESCENTS. Let the parents
know that if they see salicylate on the label, that this is Aspirin and it shouldn’t be give to their child!!!
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Fatemeh Sahrapour
MODULE: NURSING CARE OF THE CHILD WITH MUSCULOSKELETAL, ARTICULAR, AND
NEUROMUSCULAR DISORDERS
Readings:
Muscular/Articular Disorders
Perry: 1531-1552, 1556-1561, 1564-1567
Downs Syndrome
Perry: 1090-1092
Neuromuscular Disorders
Perry: 1571-1585, 1587-1592
Musculoskeletal Disorders
ATI 2013: 295-343
CARE OF THE CHILD WITH FRACTURES, TRACTION, AND CASTED EXTREMITIES
FRACTURES
- There are methods of treatment that are different in children than in adults. Fractures are rare in children and
warrant an investigation to make sure it’s not the result of abuse
- The distal forearm is the most frequently broken bone in childhood. Most often from sports injuries
- Common causes of fractures in children:
- increased mobility and desire for freedom but immature motor skills
- trauma or abuse
- bone disease
- birth injuries; the most common type of fracture caused by birth injury is clavicle injury and sometimes this is
intentionally done by MD to deliver an abnormally large baby or deliver rapidly one that is in distress
Types of Fractures
- Simple or closed: does not produce
a break in the skin
- Open or compound: fractured bone
protrudes through the skin
- Complicated: bone fragments have
damaged other organs or tissues
- Comminuted: small fragments of
bone are broken from fractured shaft
and lie in surrounding tissue.
- Greenstick: when a bone isn’t
-
-
broken all the way through, like a
twig that you snap and breaks on
one end but only bends on the other
Spiral: most often occurs in toddlers;
for ex. when they’re going down a
slide and get their foot stuck that
could cause a spiral fracture of tibia
Comminuted: a crush fracture
Transverse: a break straight through
Compound: bones stick through skin
Growth Plate (Epiphyseal Plate) Injuries
- Is the area of growing tissue near the ends of the long bones in children and adolescents
- Weakest point of long bones: the cartilage growth plate (epiphyseal plate)
- Each long bone has at least 2 growth plates; on at each end. The growth plate determines future length of mature
bone. When growth is complete, sometime in adolescence the growth plates close and are replaced by solid bone.
- The growth plates are frequent site of damage during trauma. And if they are injured, the injury may affect future
bone growth. Fractures considered minor in adults, may cause greater significant damage in the child if they affect
growth plates. Once growth plates close, because they’re now solid bone, they aren’t as vulnerable to fractures.
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- Treatment for fractures in the growth plate: may include open reduction and internal fixation (ORIF) to prevent
growth disturbances. This involves surgery where some type of a fixating devices like pins or a plate are placed.
- Growth plate fractures may not always be detected on X-ray. So make sure it’s evaluated by a pediatric orthopedist
if you suspect a fracture.
- Salter Harris classification system- is used to describe the degree of a fracture: I (transverse), II (through and
above the plate), III (fracture below plate), IV (fracture through metaphysis and epiphysis), V (crushing of physis)
Diagnosis and Management of Fractures
- Diagnostic evaluation
- Radiographs- only true way to diagnose a fracture is through x-ray
- History taking- from parent or child, pay special attention to how fracture occurred.
- Suspicion of fracture in a young child who refuses to walk or bear weight. Should be evaluated especially if child
has specific point of injury, is specific about where and how it happen, and if they hear a cracking sound and if
they have the inability to bear weight.
- Manifestation of Fractures- Pain, tenderness at the site (this is not specific because it could be strain, sprain or
fracture), decrease ROM, immobility, deformity of extremity, edema, crepitus (sound made when bone rubs
against bone), ecchymosis (bruising), inability to bear weight, muscle spasm
Goals of fracture management
- Reduction and immobilization- Reduction- repositioning of bones into normal alignment (a setting of bone). Reduction can be open or closed.
- Close: realigned bone without using an invasive procedure, although the setting of the bone may occur w/
anesthesia due to pain.
- Open: means needs an invasive procedure or surgery to realign the bone
- Retention or immobilization- is the application of a device or mechanism to maintain the alignment of the
bone until healing occurs, it can be with a cast, traction, plate, pin, or a combination of those.
- Restoring function
- Preventing deformity
Assessment of Fractures- The 6 Ps
- Pain and point of tenderness
- Pallor
- Pulselessness
- Paresthesia: sensation distal to the fracture site
- Paralysis: movement distal to the fracture site
- Pressure
Casting for Fractures
- Cast application techniques- Retention can be done through casting or traction.
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- When applying cast consider the age and skin, extremity of the child. Use age appropriate explanation of the
procedure beforehand, this should prepare the child and alleviate fears.
- Cast consists of layers or strips of clothes that may be impregnated with plaster of pares or a light-weight waterresistant material such as fiber glass that is more light weight but can be expensive.
- Children like to be given a choice regarding the color of the cast, give them these choices so that they have
some control and be able to participate.
- When applying, it can be helpful to provide distraction by talking about hobbies, pets, etc., also as the cast is
being applied reassure them it’s ok because they may feel heat or warmth from the application.
- Before cast is applied, area is applied with stocking net, important that all the bony prominences that will be
underneath cast are padded before cast is applied.
- As the cast is applied, the stocking net material can be pulled up and over the edge of the cast in order to
provide padding to those areas and protect the child’s skin, we don’t want the sharp edges to injure the child.
- Care management- Very important to let the cast dry completely and to dry from the inside out before we put any pressure in it, a
-
-
fan or cool air hair dryer may be helpful to get cast to dry if it’s very humid. Be very careful to not cause any
burn injuries that is why we use cool air.
- Drying time depends on the type of cast material used, if the cast is still wet, always use with the palms of the
hand and not fingers to avoid indentions. Indentions in the wet cast can create pressure areas.
Cast care at home- Parents need to be provided instruction to take care of cast at home like keeping the casted extremity elevated
for the first 24 hours to prevent swelling, observing extremities for swelling or discoloration, checking for
movement or sensation, be told as to what the provider has ordered as far as activity restrictions, not allowing
child to put anything inside cast, may get itchy and kids will try to scratch by putting things in there. Keep small
items away from young children because they may be curious and attempt to put things down the cast.
- Provide parents and children teaching on crutch walking if applicable.
Cast removalSkin care- Teach about hygiene because it’s important as well as how to pay special attention to skin care.
- Want to maintain child's skin integrity while they are in casts.
Cast Care—Assessment
- Unusual odor beneath the cast
- Tingling, burning, numbness of toes
- Drainage through cast to toes or fingers—this would be very alarming
- Swelling or inability to move toes or fingers
- Toes/fingers that are cold, blue or white (pallor)
- Sudden unexplained fever
- Pain that is not relieved by comfort measures
- Unusual pain or new pain that the child begins to experience
- Think about what is included in the neurovascular assessment—circulation, sensory, and motion!
Cast Care—Teaching
- “Petaling” the edges of the cast
- Especially when a child is in a spica cast, they have an opening that allows the child for urinary and bowel
elimination issues
- Petaling is when you apply transparent dressing to edge of the cast and another one to child’s perineum that
acts as a continuous water-proof bridge between the cast and the perineum in order to prevent leakage and
allows for observation of the skin in the area beneath dressing
- Drying of the cast- already talked about
- Prevention of swelling
- By making sure that the affected area is elevated
- For elbow cast—apply a sling, teach parent how to use it properly because it provides support for the arm or
hand and keeps it elevated and not in the dependent position to prevent swelling.
- Protecting the cast from damage- Cover it with water proof cover for bathing or swimming
- When to call doctor- teach parents when to notify doctor & importance of follow up care w/doctor for injury itself.
Spica Cast
- SPICA cast is used to immobilize the hips and thighs so that bones and tendons can heal properly.
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- There are several types. They can begin at the chest and extend down to
cover one or both legs.
- The doctor will decide which type of SPICA cast.
- The bar is a hip abductor to keep the legs abducted. That bar is not a handle,
-
-
it’s to keep the legs in a proper position to promote healing. Teach parents and
patient not to use the bar as handle.
There is an opening in the middle of the SPICA cast to allow elimination
needs.
They can pose specific challenge like eating, feeding, positioning, bathing
issues.
Make sure for infants that parents are aware and be using disposable diapers,
not cloth diapers, keep cast as dry as possible and the inside material as dry
as possible as well. For older children that are potty trained, they can use bed
side commode that’s adapted for use, petaling, and sometimes that
covering can be as simple as saran wrap to allow the bridge, for the
child to eliminate and keeping cast dry and moving that wetness of
urine away from cast itself.
Other issues are breastfeeding, one of the position that works is mom
can utilize the football hold, child’s head at the side next to the breast.
Traction for Fracture
- Traction is a pull or force that exerted on one part of the body
- In children, most balanced skeletal traction is applied to:
- Allow physiologic stability
- Align bone fragments
- Enable closer evaluation of the injured site
- Newer technology: orthopedic fixation devices that allow for mobility
Purpose of Traction
- Relieve fatigue in involved muscles
- Position distal and proximal bone ends
- Immobilize fracture site
- Prevent deformity
- Immobilize healing bone and prevent further injury
- Reduce muscle spasms
Types of Traction
- There are 2 ways we can apply traction:
- Skeletal Traction: Hardware is fixated to bone (top picture)
- Skin Traction: Applying dressing to skin and traction is applied through dressings (bottom picture)
Types of Traction (General)
- Traction is used less often now a days and more modern
methods have emerged, but you will still see it used specially for
certain types of fractures.
- Upper extremity (uncommon in children)
- Lower extremity
- Buck extension
- Used for comfort measures for hip fractures (immobilizes
hip before surgery can be completed and relieves
spasms). Pic with lady on bed.
- Bryant traction
- Used for developmental dysplasia of the hip, when the pelvic harness
isn’t working to keep the hips in place.
- Usually used for 2-3 weeks prior to surgery in order to loosen
muscles around the hip joint, then after surgery it’s usually replaced
with a Spica cast
- Russell traction
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- Balance suspension
- Gardner-Wells tongs
- Cervical (“halo” brace/traction or vest)
- Seen more frequently, applied and used for about 6-8 weeks before spinal
instrumentation with scoliosis. It can be used for issues other than scoliosis.
- Corrects curvatures that are greater than 80%. Those curvatures can be lessened
down to about 50-60%
- It is a continuous traction.
- Children can ambulate despite having screws in their head.
Traction Care
- Understand the purpose for ordering of traction: to maintain bone alignment? prevent muscle spasms? …because
this is going to be our outcome to measure
- Assessment of neurovascular status: make sure they don’t have any coldness, cyanosis, and pulselessness
- Maintain correct balance between traction pull and counter-action force
- Care of weights—NEVER adjust weights/tractions without a provider’s order
- Skin inspection: very easy for these patients to develop skin breakdown because they are immobilized.
- Pin care
- Developmental concerns: For instance, an infant who has hip dysplasia and has a spica cast, how are they going
to roll over, crawl, or lift their head up? Anything we can do to promote their development is very important.
Can Immobilization affect Development?
- Toddlers:
- Need exploration and the ability to imitate behaviors in order to develop a sense of autonomy.
- Help this by giving them different items of different textures to explore, and have them classify them.
- Anything to promote sense of exploration so that they can work to develop sense of autonomy.
- Preschoolers:
- Expression of initiative is evidenced by their need for vigorous physical activity. This is very hard for them to do
when they’re in traction. So, whatever they can do with their unaffected extremities is good.
- School-age:
- Sense of industry is influenced by physical achievement and competition. Maybe have competition with other
children on the unit or with parents or with board games. Or any game they can participate in that has simple
rules can help.
- Adolescence:
- Rely on mobility to achieve independence, one of the steps in creating their identity. Give them as much
independence as you can, that they can do.
- PROMOTE NORMAL DEVELOPMENT AS MUCH AS POSSIBLE DURING IMMOBILIZATION!!!
A Pneumonic for Providing Traction Care
- T: Temperature (look at temperature of affected extremity and that of body)
- R: Ropes hang freely on the traction?
- A: Alignment…is the alignment correct?
- C: Circulation check’s (6 P’s)
- T: Type and location of fracture
- I: Increase fluid intake so they don’t get dehydrated or constipated
- O: Overhead trapeze is there to help position them for comfort
- N: No weights ever on floor or bed
- VERY serious complication to look for is to look for COMPARTMENT SYNDROME!!!
- paresthesia, pain, pallor, paralysis, pulselessness, pressure . IT’S A MEDICAL EMERGENCY!!! MAKE SURE
TO CONTACT PROVIDER IMMEDIATELY if you see any one of these p listed. A patient can lose their limb from
compartment syndrome. Intervention needs to occur as quickly as possible. Usually provider will perform a
fasciotomy and cut open the tissue to let it heal from inside out. Elevate extremity to the level of the heart.
CARE OF THE CHILD WITH CONGENITAL MUSCULOSKELETAL DISORDERS
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
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- Refers to spectrum of disorders related to abnormal development of hip during fetal life, infancy, or childhood.
- Defined as condition where head of femur is improperly seated in the acetabulum of the pelvis
- Formerly called “congenital hip dysplasia” or “congenital dislocation of the hip”. Changed more accurately to reflect
the variety of hip abnormalities where there is shallow acetabulum subluxation or dislocation
- Incidence: 1.5 per 1000 live births. Girls are more commonly affected. 15-50% of babies born with DDH are born in
the breached position. Strong family history. The cause of it is not completely known or understood.
Theee Degrees of DDH
1. Acetabular dysplasia (preluxation)
- Mildest form
- Delay in development of acetabulum defined by inadequate development of baby’s acetabulum.
- Acetabulum is shallow and disk shaped rather than cup shaped, osseous hypoplasia (obliquely inclined
outward) of acetabular roof rather than normal horizontal orientation. Because of this the femoral head remains
in the acetabulum. Since the head remains in the acetabulum, it is the mildest form.
2. Subluxation
- The most common form of DDH
- Incomplete dislocation of hip, not complete dislocation, femoral head is in contact with acetabulum but it’s
partially displaced.
3. Dislocation
- Femoral head loses contact with acetabulum and is displaced posteriorly and superiorly over the rim so femoral
head actually slides completely out of socket
- Ligaments are elongated and taut
- Specialty organizations recommend that when we are swaddling infants, that infant’s hip be placed in slight flexion
and abduction during swaddling in order to decrease hip dysplasia in infants.
Clinical Manifestations of DDH
- Infant- In newborns DDH appears in a lax hip joint rather than an outright dislocation.
- Hip joint laxity
- Shortened limb on affected side
- Restricted abduction of hip on affected side
- Unequal gluteal folds when infant prone
- Positive Ortolani test result:
- Used to confirm the Barlow positive finding. In other words, to
confirm that the hip actually dislocated.
- Positive Barlow test result:
- Performed by adducting the hip bringing thigh to midline while
applying light pressure on the knee and directing force
posteriorly. If the hip dislocates easily with this maneuvre, then
the test is considered positive.
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- A: Asymmetry of the gluteal and the thigh folds when looking at the baby the thigh folds at the anterior view and
gluteal folds in the posterior view
- B&C: Demonstrate the limited hip abduction and flexion and also the shortening of the femur. One knee is shorter
than the other when they are flexed.
- D: Ortolani maneuver demonstrated, thighs are abducted to test for subluxation or dislocation. When provider does
maneuver they will feel the click as the hip slips back to socket. This maneuver is most reliably done on infants < 4
weeks of age. Ortalani & Barlow is done by physician or NP, we generally don’t do it but be familiar with maneuver.
Therapeutic Management of DDH
- Importance of early intervention, as soon as DDH is diagnosed, because it produces better outcome.
- Longer the delay in treatment the more severe, more difficult treatment, and less favorable the prognosis is.
- Goal is to obtain and maintain a stable hip joint and promote normal hip joint development.
- Birth to age 6 months- Pavlik harness for maintaining abduction and flexion of the hip for about
3-5 months (most widely used).
- Straps are checked and adjusted Q1-2 weeks due to rapid growth that
occurs for infants during this time.
- Pavlik harness: In the picture, there is one on each leg placed so that
legs are held in important position to keep it stabilized during course of
treatment. !
- Ages 6-24 months:
- Dislocation unrecognized until child begins to stand and walk
- Treatment is closed reduction under general anesthesia, then child is
placed in a hip spica cast for 2-4 months.
- If hips remain unstable, open reduction will need to be performed, which could be difficult.
- Older child:
- Operative reduction, which may include preoperative traction, or the performance of a tenotomy (surgical
division of tendon to release or lengthen that tendon for the contractive muscle), and possible a hip osteotomy
(surgical procedure where bones of hip joint are cut and reoriented and fixed back into a new position).
- So in an older child these more dramatic procedures may have to be performed in order to construct the
acetabular roof. Correction is very difficult after age 4 years, not advised after aged 6 years because severe
shortening of limb and muscle contracture. Important to check for DDH and start treatment ASAP if diagnosed.
Nursing Care
- Teach parents/caregivers to remove and apply harness appropriately –only remove for bathing and skin checks.
- Pavlik harness provides easily handling of infants, but usually parents are intimidated by the harness.
- Teach skin assessment, teach parent to always put a shirt or onesy underneath the harness chest straps and that
they put some type of long socks preferably up to knee to prevent straps from rubbing against skin.
- Have parents check 2-3 times a day for any red areas of those straps.
- Important to provide gentle massage underneath the straps to stimulate circulation.
- Avoid use of lotion, creams, or powder because they can irritate skin
- Place diapers underneath the straps
- Encourage cuddling infant to promote cognitive development and infant/caregiver bonding
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TALIPES EQUINOVARUS (CLUBFOOT)
- A congenital abnormality in which the foot and ankle is twisted out of its normal position
- Boys effected twice as much often girls, exact cause is unknown.
- Diagnostic evaluation: deformity is apparent and detected prenatally through US or at birth.
- Deformity is described according to the position of the ankle or foot
- Muscles, tendons, and bones are involved in the abnormality
- Talipes varus: inversion or bending inward (most common)
- Talipes valgus: eversion or bending out
- Talipes equinus: plantar flexion with toes lower than the heel
- Talipes calcaneus: dorsiflexion with toes higher than the heel
- Most cases are combination of these positions, with most commonly occurring being
the composite deformity tallpes equinovarus: foot pointed downward or inward in varying degrees of severity.
- Further be classified in three categories:
- Positional: mild or postural and may correct spontaneously or necessitate some passive exercising or possibly
serial casting. No bony abnormality but there could be tightening or shortening of soft tissues.
- Syndromic or teratologic: often associated with other congenital abnormalities, usually necessitates surgical
intervention, and with this there is a higher incidence of reoccurrence for these kids.
- Congenital: it’s usually idiopathic, there is bony abnormality involved and requires surgical procedure
Therapeutic Management
- Goal of care: stretch the tightened tendons and ligaments gently and return foot to maximal anatomical position
(correct position).
- Three stages of treatment:
- Correction of the deformity itself
- Maintenance of the correction until normal muscle balance is regained, and normal position is then achieved.
- Follow-up observation to avert possible recurrence
Serial Casting/Ponseti method (serial casting or serial manipulation, common treatment for clubfoot)
- Series of corrective casting and or use of splints and could even require surgical correction and series of cast to
gently guide that club foot into its normal anatomical position.
- Cast applied to hold foot in desired position.
- Usually begun right after birth, involves weekly manipulation and serial long
leg casts that allow gradual repositioning of the foot.
- Extremities are casted and changed every 1-2 weeks, until maximum
correction is achieved, usually in 6-10 weeks.
- Nursing Care- Cast care
- Skin Care
- Education of parents: It’s important that parents understand the overall treatment plan, importance of regular
cast changes and that they understand the role that they play and the overall effectiveness of therapy. We need
to reinforce and provide instructions of cast care and skin care. Make sure parents know how to assess for any
problems. Anything they can do to encourage normal growth and development.
- Parent Support- Important that parents understand their roles. Parents are trained and become active participants in the physical
therapy treatments and child’s stretching program.
- Nurses need to help the parents understand the time commitment involved in caring for these kids. This is a
very large commitment that parents have to follow through with physical therapy and doing it on consistent basis
as well as stretching program.
- Assess the parents’ ability to monitor the child adequately for complications and confirm they understand the
signs and symptoms of the complications that they might need to call the provider
Question
A parent asks why the infant must wear a Pavlik harness. What is the nurse’s best response? This treatment is to:
a. Provide comfort ad support
b. Shorten the limb on the affected side
c. Maintain the femur within the acetabulum
d. Provide outward displacement of the femoral head.
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OSTEOGENESIS IMPERFECTA (OI)
- Also known as “brittle bone disease”
- A group of heterogeneous inherited disorders of connective tissue. Patient’s with this often have a family history but
most cases are generally due to new mutations.
- Characterized by excessive fragility/fracture and defects of bones/bone deformity
- Defective periosteal bone formation and reduced cortical thickness of bones
- Hyperextensibility of ligaments
Classifications of Osteogenesis Imperfecta
- Most common osteoporosis syndrome in children or childhood but is very rare.
- There are at least 8 different types of OI and clinical features vary according to degree of bone fragility.
- Type 1
- Defect in Type I procollagen: Mutation on the genes that affect type 1 collagen (an important building block for
bones), results in bone mineralization, abnormal construction of bone, and the susceptibility of fractures.
- Most common, mild bone fragility and may see kids have blue tinged to sclera, teeth usually look normal and
may have some mild hearing loss.
- Type II
- Most lethal, results often in stillbirth or death in early infancy, it is a severe bone fragility with multiple fractures
that may occur at birth, autosomal recessive inheritance
- Type III
- Severe bone fragility (most cases), leading to severe progressive bone deformity, might have normal sclera, but
will see very marked growth failure. Most autosomal recessive inheritance, some may be autosomal dominant.
- Type IV
- A (mild to moderate bone fragility, normal sclera, short stature, variable deformities, autosomal dominant
inheritance) or B (same as A but with abnormal dentition/teeth called dentinogenesis imperfecta). Type 4B
represent about 6% of cases of OI.
- Type V
- Similar to Type IV may have hyperplastic callous and negative collagen mutation.
- Type VI
- Moderate to severe bone fragility
- Type VII and VIII
- Osteochondroplasia and short stature
Therapeutic Management
- Primarily supportive care
- Intravenous bisphosphonate therapy, may be on calcitonin, growth hormone. Regardless of treatment, fractures
occur. Children who suffer from multiple fractures or non-accidental trauma issues should be screened for OI.
- Rehabilitative approach for prevention of further complications:
- Positional contractures and deformities
- Muscle weakness and osteoporosis
- Misalignment of lower extremity joints
Nursing Implications
- Careful handling!!!! Changing a diaper or tying a tourniquet can cause a fracture because bones are so fragile
- Need to supported when turning, positioning, and moving them
- Education parents on limitations and planning suitable activities to promote optimum development and to protect
these kids from harm.
Clinical Features
- All have weak bones, susceptible to fractures (handle them carefully)
- Character from Malcolm in the Middle has Type IV OI
- These children also may have other issues going on, such as:
- Scoliosis
- Kyphosis
- Blue tint to sclera (type 1)
- Early hearing loss (type 1)
- Hypermobility in joints (all)
- Hypoplastic discolored teeth (type 4B)
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SCOLIOSIS
- Most common spinal deformity, It’s an abnormal curvature of the spine.
- Complex spinal deformity in three planes:
- Lateral curvature
- Spinal rotation, causing rib asymmetry
- Thoracic hypokyphosis
- May be congenital or develop during childhood. Multiple potential causes, although most cases are idiopathic.
- Becomes more noticeable after pre-adolescent growth spurt, clothes may be ill fitting.
- Hips are slightly higher than the other.
- School screenings at certain ages and grades, some controversy in whether we should do it or not. Important to
screen and catch as soon as possible.
Causes of Scoliosis
- Idiopathic Scoliosis- 80% of cases
- Infantile- (occurs at birth - 3 years), childhood or juvenile (starts at 4 years - 10 years), or adolescent (which is
diagnosed at 10 years or later when growth spurt occurs, and is the most common)
- Present in 2 – 4% of kids aged 10 – 16 years
- Progresses faster in girls (girls tend to need surgical treatment)
- Becomes noticeable after preadolescent growth spurt
- Multiple causes may exist for secondary scoliosis
- Neuro: Tethered cord, Cerebral Palsy, Muscular Dystrophy, spinal tumors
- MSK: DDH, leg-length discrepancy, OI
- Or may occur alone or in association with any of the above diseases but in most cases its usually idiopathic
Diagnostic Evaluation of Spinal Curvatures
- Diagnosis based on x-ray or observation.
- Assessment is performed by provider standing behind patient, patient should be undressed or in undergarments.
- Asymmetry of shoulder height, scapular or flank shaped shoulders, or hip height and alignment should all be noted.
Child bends forward and arms hanging, you’ll see asymmetry.
- Scoliometer is also used to measure the angle of trunk rotation
- Radiographs/x-ray to determine degree of curvature is definitive diagnosis, with the child standing
- Assessment findings:
- Trunk asymmetry, unevenness of shoulders, prominent scapula or uneven height of scapula, rib hump, uneven
hips. In addition to primary curve, compensatory curve often present that aligns head with gluteal cleft
Therapeutic Management of Spinal Curvatures
- Team approach to treatment (always!): orthopedist, neuro surgeon, PT, nurses, social workers
- Once diagnosed, children should be observe regularly by providers and receive routine x-rays for evaluation.
- Treatment decision is based on magnitude of curve, location, and type of curve.
- Other factors: Age and skeletal maturity and other underlying or contributing diseases. In deciding treatment,
will ask are growth plates closed? If curvature is to a certain degree, and the growth plates are still open, they
then expect the child to grow more. They also expect that the degree of curvature will also grow. Based on the
curvature, they decide if it should be treated or not. But if they know that the growth plates are closed, they can
be assured that the curvature won’t increase or grow anymore either. This can be factored in treatment decision.
- Sometimes scoliosis is treated with bracing or depending on severity may require a surgical fusion.
- Bracing is not curative but may slow curvature down in order to allow for skeletal maturity. Compliance in
wearing brace can be difficult because teens are very concern about appearance so that can make them feel
very awkward. The most common braces used: Boston, Wilmington, which are customized, pre-fabricated
plastic shells. Bracing is used for moderate curvature.
- Surgical intervention for severe curvature (instrumentation and fusion) is suggested in curves in growing children.
Greater than 30-40 degrees, require a spinal fusion. Spinal fusion involves realignment with in an internal fixation
and bony fusion of the realign spine. There are a variety of rods that may be used during surgical fusions (The two
that are most often used are the Harrington rods, Luque rods). Posterior spinal fusion is best choice for thoracic
curves. Anterior spinal fusion is the best treatment for lumbar curves.
- Exercise may be prescribed but really rarely of any value in managing scoliosis but can maintain and strengthen
abdominal muscles to provide support.
- Picture shows example of bracing, note designed that is actually made into a brace in the first picture. This can be
done to help teen to accept wearing of the brace. Because they do have to wear up to 16-18 hours a day
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depending on what the provider rights the order for. These
are custom molded to the individual.
Care Management of Spinal Curvatures
- Concerns of body image is the priority psychosocial
nursing diagnosis for the adolescent diagnosed with
scoliosis, due to wearing braces for long periods of time or
really wearing other types of device or engaging in other
types or therapy.
- Important to explain to parents and specifically to child the
expected benefit and result of wearing brace.
- Preoperative teaching for patient with spinal fusion- What to expect before surgery and after the surgery,
demonstrate use of incentive spirometer, coughing, deep breathing, and use of all of potential equipment they
may see and they may have. IE. Foleys, IVs, chest tube, oxygen mask.
- Let them beware of how to use PCA pump. Important to let them know how this is going to help with their pain.
- Demonstrate log rolling and how to assist them of bed.
- Postoperative care- Make sure child maintains airway, do neurovascular assessment of lower extremities, log rolling them every 2
hours, depending on providers and orders.
- Typically they will be out of bed and ambulating at least 4 times a day.
- Because most of the time we are talking about adolescents we want to encourage independence inADL, they
usually can start ambulating post-op 2-3 days.
- Family issues- Provide with resources and information on support groups. Family is encouraged to become
involved so that they will be comfortable caring for them at home.
CARE OF THE CHILD WITH OSTEOMYELITIS AND JUVENILE IDIOPATHIC RHEUMATOID ARTHRITIS
OSTEOMYELITIS
- Infection of the bone that can occur at any age. If in children, it’s most frequently seen in ages 10 years and
younger. Boys are more commonly affected, it more commonly occurs in foot, femur, tibia, and pelvis.
- May be caused by exogenous or hematogenous sources.
- Staphylococcus aureus is the most common causative organism. Group B Strep is the most common causative
organism when this occurs in neonates.
Signs/Symptoms
- To the right is an x-ray of osteomyelitis
- Begin abruptly & resemble symptoms of arthritis and leukemia.
Starts off with severe pain, fever, irritability, tenderness to the area,
limited ROM, swelling over area involved, and pain with movement.
Diagnostic Evaluation
- Include blood cultures. You're looking to identify organisms and
look for antibiotic susceptibility to see which antibiotic will work. It is
crucial to know which bacteria it is to treat.
- Bone cultures obtained from biopsy or aspirate. Bone biopsy rarely
indicated unless findings of other cultures are inconclusive.
- Supportive evidence of osteomyelitis is marked leukocytosis, elevated ESR and C-reactive protein.
- Radiographs/X-ray: may appear normal at first, may take 2 to three weeks for signs to become evident on X-ray.
- Bone scans can show areas where there is increase blood flow which can occur in early stages of infected bone
and that can be useful in locating multiple sites, but it is not a diagnostic test. MRI is definitive test and the most
sensitive diagnostic tool for diagnosing osteomyelitis.
Types of Osteomyelitis
- Acute hematogenous: Blood born infection that goes on to cause infection in bone
- Exogenous: Acquired directly from puncture wound, open fracture, surgical contamination, or from tissue infection
from adjacent wound. A way in which bone becomes infected from the outside.
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- Subacute: Has a longer course. May be caused by less virulent microbe that created a walled off type abscess
that typically in the tibia.
- Chronic: Progression of acute osteomyelitis, characterized by dead bone, bone loss, drainage as well as the
development of sinus tracts within the bone.
Therapeutic Management of Osteomyelitis
- Presentation: may be subacute, with walled-off abscess rather than spreading infection.
- IV antibiotics (ABX are priority; not pain)
- Prompt, vigorous intravenous antibiotics for extended period (3-4 weeks or up to several months)
- For S. aureus- Nafcillin, or clindamycin.
- Really important for you as nurse to go ahead and advocate for the use of PICC line as soon as osteomyelitis is
diagnosed because we are looking at IV antibiotic for 4 - 8 weeks.
- Educate parents on IV administration, typically because kids are sent home for home care with PICC lines. Make
sure parents know how to set those up and set up flushes. When they finish one dose, have to draw up flushes.
- Surgery may be necessary if there’s no response to specific ABX, if there’s a penetrating injury, or if the infection
spreads to the joint.
- Pain management because movement can cause severe discomfort. Make sure they’re positioned in a comfortable
position with affected bone or limb supported. No weight bearing. Long term pain medication may be administered.
- Monitor hematologic, renal, hepatic responses to treatment. Sometimes we have to make sure when using ABX
that we are checking their liver and kidney and see how they are responding.
JUVENILE IDIOPATHIC RHEUMATOID ARTHRITIS (JIA)
- Formerly known as “juvenile rheumatoid arthritis”. Also called “idiopathic arthritis of childhood”
- Only small amount of children have a positive Rheumatoid-factor, most (90%) of children have a negative R-factor
- Chronic autoimmune disease that causes inflammation in the joints and tissues.
- Cause is unknown but a couple of possible causes:
- Immunogenic susceptibility
- Environmental trigger, like a virus
- Occurs before age of 16 years, Peak onset is between 1-3 years of age
- Sometimes it can often go undiagnosed
- Actually a heterogeneous group of diseases, not just one disease- Systemic arthritis- It involves one or more joints. It is associated with at least 2 weeks of high fever, rash,
hepatosplenomegaly, pericarditis, pleuritis, serousitis (inflammation of serous tissues like the lining of the heart,
the lungs, and the abdomen), lymphadenopathy
- Oligoarthritic- Involves ≤ 4 joints, for the first 6 months
- Polyarthritic- Involves ≥ 5 joints in first 6 months with a negative R-factor or a positive R-factor
- Psoriatic- Enthesitis and undifferentiated where patient has psoriasis skin condition, nail pitting in their nail bed.
Enthesitis is related arthritis (inflammation on the site where tendons and ligaments enter into the bone) and
involves sacroiliac or lumbosacral pain or could also have acute anterior uveitis (inflammation in the interior
chamber of the eye). May also affect patient with inflammatory bowel disease.
- May also have undifferentiated arthritis where it fits > than one category or they may not fit in any categories.
Clinical Manifestations
- Rarely life threatening but may cause disability for patients.
- Symptoms come and go, and include chronic inflammation of synovium with joint
adhesion (which is increased intra-articular joint fluid)
- Includes destruction of cartilage as well as stiffness of joints as the disease progresses,
especially in the morning or after long periods of inactivity
- Swelling
- Loss of motion
- Areas that are warm to touch, but seldom red
- Joints can be tender to touch or may be painless
Diagnostic Evaluation
- No definitive diagnostic tests. Diagnosis is based on exclusion of other disease processes, and on clinical criteria
of American College of Rheumatology that includes: onset before age of 16, involves development of arthritis in
one or more joints for at least 6 weeks or more, ESR may be elevated but may not be.
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- The presence of antinuclear antibodies common, but not specific for juvenile idiopathic arthritis. Again, the RF is
positive in < 10% of cases.
- Leukocytosis is frequently present during exacerbations
Therapeutic Management
- No specific cure
- Goals of therapy:
- To control pain and relieve symptoms.
- Preserve function and ROM for joints involved, minimize effects of inflammation such as joint deformities.
- Promote normal growth and development
- Primarily outpatient care, but treatment for this can be exhausting & create difficulty for family and child.
Pharmacology
- Non-steroidal anti-inflammatory drugs (NSAIDS)- Are first line drugs for these kids: Ibuprofen, Indomethacin, and
Naproxen, These are effective and safe for use in children with few SE other than GI upset. Monitor for GI bleed.
- Corticosteroids- Can be given during a flare up, and always given at the lowest dose effective possible, and given
for the briefest time possible.
- Cytotoxic agents (methotrexate): May be given weekly. Sulfasalazine, Hydroxychloroquine, used in children when
NSAIDs alone have failed. Patient education is important about SE, discussing with teens possibility of birth
defects and importance of avoiding alcohol.
- Biologic agents- Slow-acting anti-rheumatic drugs: Etanercept, Cyclosporin. May be used in severe cases of JIA.
Care Management
- Remember goals of therapy are to relief of pain, preserve function, prevent deformities. Non-pharmacologic
therapy encouraged such as relaxation, distraction, etc.
- Physical therapy, occupational therapy which are individualized for each child. May receive PT several times a
week and exercising in the pool may be encouraged because it allows movement and support with less
gravitational pull.
- Opioids are usually avoided but may be used to provide short term pain relief
- Promotion of general health: well balance diet, adequate calories, and adequate rest in order to maintain growth
- Facilitating compliance
- Encouraging the use of heat and exercise.
- Use of hot packs with caution and not cause any thermal injuries.
- Use of warm baths before therapy will help with comfort and increase motion to get most effective therapy possible.
- Support child and family throughout the entire treatment.
- Physical limitations may interfere with self-care, child’s participation in school and activity and their ability to
engage in recreational activities, remember for children their job is school and it centers around school and peers.
- Family encouraged to maintain normal activities but also be able to work with & create adaptation for child with JIA.
CARE OF THE CHILD WITH CONGENITAL NEUROMUSCULAR DISORDERS
CEREBRAL PALSY (CP)
- “A group of permanent disorders of the development of movement and postures, causing activity limitations that
are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain”
- There are variable causes for this with 80% occurring from unknown factors, 12% of babies born weighing < 2000g
will develop CP. It manifests as a lack of movement or associative movement disorder. Can often be associated
with epilepsy, speech problems, issues with vision and cognitive dysfunction.
- Prognosis will depend on the type and severity of the condition. Those who have moderate impairment- 85% of
them will go on to achieve ambulation. About 30-50% with CP will develop cognitive impairments. Growth can be
affected, and their survival depends on any co-morbid conditions that they may be experiencing.
- CP is characterized by abnormal muscle tone and coordination
- Incidence: 2.4-3.6 per 1000 live births.
- Most common permanent physical disability in childhood
- Affected children: 15%-60% also have epilepsy
Causes
- Prenatal brain abnormalities— exact cause is unknown but can be genetic or other prenatal brain anomalies:
- Clotting disorder
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-
Gross abnormalities or malformation of the brain
Vascular occlusion
Laminar degeneration
Effects of low birth weight
Anoxia or Hypoxic infarction or hemorrhage
Perinatal ischemic stroke is also associated with CP. 80% of total cases of CP are related to perinatal neonatal
brain lesions or abnormal brain development.
Post natal factors can include bacterial meningitis, multiple birth (twins, triplets, etc.) usually from decrease
oxygenation baby may experience during birth, child abuse (shaken baby syndrome)
Types of Movement Disorders in CP
- Dependent on where brain damage occurs
- Spastic:
- Most common type, muscles appear stiff and movements are very stiff and jerky. Spasticity is a form of
hypertonia or increased muscle tone. When people without CP perform a movement some muscles will turn on
and some will turn off. But in people with spastic CP both groups of muscles will turn on at the same time and in
some instances the wrong group turns on making movement difficult or impossible.
- Dyskinetic:
- Have variable movement that are involuntary, that they are unable to control. Those uncontrolled movements
become very noticeable when they try to move. So those dyskinetic movements can be a twisting or repetitive
movement to the trunk or from extremities called dystonia. Slowed movements called athetosis/athetoid. Dance
like jerky irregular unpredictable movement called athetoid, which are involuntary jerky, slow wormlike
movements. Muscles involved are extremities, trunk, facial muscles, or tongue
- Ataxic:
- Wide based gait, rapid repetitive movement performed poorly
- Mixed:
- Combination of spastic and dyskinetic CP. May be labeled mixed when no specific motor pattern is dominant.
Diagnostic Evaluation
- Infants who are at risk:
- Require careful assessment during early infancy, this will include taking a good history and physical, talking to
parents, assessing for developmental milestone.
- Babies under 6 months of age; it includes if there is head lag when you pick them up, can assess or ask parent.
Ask if baby feel stiff when being picked up or feel floppy because as they get older they should not feel
completely floppy, a little is okay.
- When cradled in arms does child overextend the neck or the back or feel like they are pushing away from you?
- When child is picked up, do their legs get stiff or do they scissor/cross?
- Older than 6 months of age:
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Do they roll over in one direction or the other or both? If they don’t roll over it’s a concern.
If they can’t bring their hands together this is a concern as well.
Normal child should be able to put hands in mouth. Babies with CP have difficulties putting hands in mouth.
Do they reach out only with one hand and the other fisted, child without CP will reach with both hands.
Older than 10 months:
- Typically babies should be crawling, CP child will crawl in lop sided manner, may push off with one hand and leg
and drag with the other hand and leg. This should raise some flag for us.
- May scoot around on buttocks or hop on knees but cannot coordinate crawling on all fours.
Neurologic examination and history: primary means of diagnosis!
Neuroimaging- Used for diagnosis. MRI preferred over CAT scan.
Metabolic and genetic testing used if not able to identify structural abnormalities with MRI
Clinical Manifestations:
- Delayed gross motor development
- Abnormal motor performance
- Alterations in muscle tone
- Abnormal postures
- Reflex abnormalities
- Associated disabilities
- Look for poor head control after 3 months of age, should have head control by 3-4 months.
- Stiff rigid arms or legs, arching of the back, floppy body posture.
- By 8 months cannot sit without support would be a sign.
- By 3 months if hands remain clenched, would be a sign, if they are noticing that those hands are staying tightly
fisted after 3 months of age.
- Leg scissoring would be a sign.
- Persistent of primitive reflexes that they had as a newborn. For example, persistence of moro reflexes
- Seizures would be a sign.
- Behavioral signs: extreme irritability, crying, feeding difficulties, thrusting of tongues after 6 months of age, little
interest in their surrounding and excessive sleeping could be a sign of CP.
Goals of Therapy
- Early recognition, promotion of optimal development, to reach maximum potential. NOTE CP IS PERMANENT.
- To establish locomotion (ambulate as much as possible), communication, and self-help skills
- To achieve optimal appearance and integration of their motor functions
- To correct associated defects as effectively as possible
- To provide educational opportunities that are adapted to the child’s needs and capabilities
- To promote socialization experiences is essential for normal growth development of the child.
Therapeutic Management
- Each child is evaluated and managed on an individual basis, involves multidisciplinary
- Ankle-foot braces- May be worn, used to help reduce deformities or prevent them. We want to increase their ability to ambulate
and control the alignment of these effected muscle groups.
- Orthopedic surgery- To correct spastic deformities, can include tendon lengthening, releasing of spastic muscles, correction of hip
muscle spasticity, or muscle contractions
- Pharmacologic agents- To treat pain related to spasms and seizures, muscle spasms can be very painful
- Botulinum toxin A injections- Botox can be used to reduce the spasticity in specific targeted muscles.
- Dental hygiene- Regular dental visits are essential, proper brushing, flossing and fluoride is encouraged, brushing their teeth can
be a major ordeal if their facial muscles are involved.
- Physical/occupational therapy- Stretching, passive, active, and resistive movements to maintain & increase ROM, strength, & endurance.
Care Management
- Assisting the family in devising and modifying equipment and activities
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- Some kids may need gastrostomy tube and extra feedings to ensure that there is adequate weight gain, but at the
same time need to make sure that oral feeding are maintained in order to maintain oral motor skills.
- Medication administration though G-tube because jaw control is compromised. If meds are administered orally, it
-
can help to stabilize the child’s jaw by holding middle finger of non-dominant hand under the jaw with thumb placed
on bottom of lip and index finger placed along the jaw. This helps to kind of stabilize the child’s jaw in order to get it
open and control while child is trying to swallow medication. It can also be used with feeding.
Safety precautions- making sure they are not aspirating.
Recreational activities
Physical, speech & language, and occupational therapy (must utilized for these children)
Support for family
NEURAL TUBE DEFECTS
- Largest group of congenital anomalies
- Normally: the spinal cord and cauda equina are encased in a protective sheath of bone and meninges during
development
- Failure of neural tube closure during development: produces defects of varying degrees may involve entire
length of neural tube or be restricted to a small area.
- Incidence:
- 0.3 per 1000 births, number has very greatly decreased from what it used to be, which can be attributed with
mandatory fortification of food with folic acid
- Occurs more often in White and Hispanic children, studies have shown that it may be due to Hispanic diet. They
are less likely to take folic acid supplements and folic acid are known to help reduce neural tube defects.
- Supplements may not be as protective in overweight woman
according to some studies, this is important for Hispanic
women because they are one and half times more likely to
give birth to a baby with spina bifida or neural tube defects.
Types of Neural Tube Defects
- Anencephaly- Congenital malformation where both of the cerebral
hemispheres are absent, as seen in the middle diagram.
Condition is basically absences of brain. Condition is
incompatible with life, even if infant had some brain and is
able to control temperature, cardiac, and respiratory
function, the may live for a few hours to weeks but
eventually die from respiratory failure.
- Myelodysplasia- Any malformation of spinal canal and cord
- Failure of the bony spine to close is termed spina
bifida. There are 2 types of Spina bifida.
- Spina bifida occulta- Defect not visible externally, occurs most frequently
in lumbosacral area, not apparent unless other
associated manifestation or neuromuscular
disturbances.
- Mild form of SB that many people aren’t aware they
have it. Outer part of vertebrae are not completely
closed, the splits are so small that the spinal cord
does not protrude. The skin at site and lesion may
be normal or may have small hairs growing form it.
There may be a dimple in the skin or birth mark.
- Spina bifida cystica:
- Visible defect and usually occurs with external sac like protrusion. Two
major forms:
- Meningocele: encases meningeal and spinal fluid and no neural
elements involved
- Myelomeningocele: contains meninges, spinal fluid and nerves,
usually associated with varying degrees of neurological deficits.
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Pathophysiology of Neural Tube Defects
- Failure of the neural tube to close during the embryo’s early development (approximately 3-4 weeks after
conception). Some vertebrae and spinal cord do not fully formed and remain unfused and open. If opening is large
enough then can cause some spinal cord to protrude through opening of those bones. There may not be a fluid
filled sac that surrounds the spinal cord. May be a genetic component here. Degree of neurologic dysfunction the
child will experience depends on where the sac protrudes through vertebrae, what the level of defect is, and
amount of nerve tissues involved.
- Multifactorial causes can include: drugs, radiation, maternal malnutrition, chemical exposure, genetic mutation
- Additional causative factors- Maternal obesity: mothers who are overweight tend to get higher risk
- Maternal diabetes mellitus
- Low vitamin B12 level (low maternal levels)
Prenatal Detection of Neural Tube Defects
- Diagnosis is made from clinical manifestation but its important to know that prenatal detection is possible through:
- Elevated alpha-fetoprotein level in amniotic fluid at16-18 Weeks of gestation (optimal time to do this test)
- Uterine ultrasonography
- Chorionic villus sampling (cvs) is another method of prenatal dignosis– you can do first. Not recommended
before 10 weeks of gestation because the cvs carries certain risk with it
Clinical manifestations
- Hydrocephalus which is frequently associate with children with spina bifida (it occurs in 80-90% of these children),
or flaccid paralysis of lower extremities, absence of deep tendon reflexes, lack of respond to pain or to pain,
presence of constant urinary dribbling.
- Mortality is 10-15% in babies who are born with it. But also, about 70% of these infants go on to demonstrate
normal intelligence levels.
Therapeutic Management of Neural Tube Defects
- Postnatal care- Preventing infection, performing neurological assessment, observing for abnormalities, and dealing with the
impact that it might have on patient and family. Make sure that we do early closure of meningocele, typically
within first 24-72 hours is recommended. Closing it early offers favorable outcome for patient. If sac is leaking
then closure is recommended even earlier (within first 24 hours or birth).
- Shunt- Procedures may be performed and it may provide some relief from progressive hydrocephalus.
- Early surgical closer of myelomeningocele sac, pre-fetal birth surgery…meaning in utero, can reduce need
for placement of shunt.
- Can show improvement of mental and motor function.
- Orthopedic considerations- Includes prevention of joint contracture, correction of existing of deformities if possible, prevention or
minimization of motor and sensory deficit, we want best possible function of lower extremities. Skin care is
important associated with uses of braces, walking devices, or wheel chairs that these kids often use.
- Management of genitourinary function
- Myelomeningocele is a common cause of neurogenic bladder which is lack of bladder control due to nerve
innervation that causes them to have lack of bladder control.
- Goal is to preserve renal function and manage the urinary incontinence. This predisposes child to UTI because
the bladder does not completely empty. So sometimes taken care of clean intermittent catheterization. Teach
parents how to do it and eventually taught to child when they are older.
- Medication like Ditropan, Detrol can be given to help.
- Surgical procedures- Vasectomy- bladder is surgical brought out to the abdominal wall to allow continuous drainage.
- Appendovasacotomy aka Mitrofanoff- where catheterizable channel is created from appendix, ureter, or
bowel, so catheter can be inserted through the channel. This is usually done when kids gets older around 10
years of age because they are old enough to use this to perform a self-catheterization, and this fosters
independence in children.
- Latex allergy- Risk for latex allergy is highest for children with spina bifida.
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- We always place these kids o latex precautions. It can be found in many items and foods: bananas, kiwis,
-
avocado and nuts. Make sure to identify these kids for everyone to know not to use latex products. Advocate for
having Epipen.
Bowel control- some degree of fecal continence may be achieve with regular bowel habits, aka bowel training,
and can help with constipation and impaction
Prognosis: depends on extend of neurologic deficit and early surgical repair, preventing infection and correcting
hydrocephalus. Many are intelligent and will achieve independence. Remember coordinated care is important.
Emergent Nursing Care
- Every effort is prevent trauma to the membranous cyst, usually baby is placed in incubator or warmer to maintain
temperature. Avoid rectal temps on these kids because bowel sphincter function is affected. Doing a rectal
temperature can cause irritation or prolapse. So never take rectal temp.
- Before surgical closure, myelomeningocele is prevented from drying out by covering it with a sterile moist nonadherent dressing, usually sterile normal saline. When changing dressing check for leaks, abrasions, irritations,
signs of infection. Sac must be carefully clean if soiled/contaminated. Possible to get fecal on it, make sure to clean
- Look for signs of ICP: irritability, lethargy. Assess q2hours. Monitor FOC, done through every 2 hours,
- Keep baby prone, no clothing or covering because don’t want to irritate membranous cyst of spinal lesion.
- Turn head and reposition q2hours
Post-op Care
- Monitor VS, I&O, providing nourishment through OG, NG, or placed on TPN if needed, or may be able to actually
take oral feeds, its just depending on child.
- Position prone initially after surgery, you don’t’ want to put pressure on surgical site. Side lying may be allowed.
- Close observation for any CSF leakage.
- Surgical closure site- look for signs of Infection, monitor for pain.
- Ventriculoperitoneal (VP) Shunt: FOC measurements, signs of increased ICP, be careful with positioning of head
- Bladder Surgery: look for signs of infection, make sure that vesicostomy is healthy and no unusual drainage or
odor. Site looks healthy with regard to color, similar if you think about colostomy. Want a pink color, no bleeding.
- Orthopedic Surgeries to prevent any deformities that may be associated with spina bifida. Be aware of associated
problems related to orthopedic surgeries.
Prevention of Neural Tube Defects
- CDC says 50-70% can be prevented through daily consumption by woman during childbearing ages.
- Women of childbearing age
- Supplementation: folic acid, 0.4 mg/day- should begin before conception
- Prevents 50%-70% of all cases
- Food that naturally have folate: Green leafy vegetable and citrus. Fortified foods like rice, grits, pasta, bread
- Within at least 1-2 months prior to getting pregnant it’s important to get them to take supplement if they
haven't done so before.
- If history of neural tube defects: 4 mg/day
- Cereal grains fortified with folic acid contains 100% of folic acid, as required by U.S. Food and Drug
Administration since 1998, when we started seeing a decrease in spina bifida cases
DUCHENNE MUSCULAR DYSTROPHY
- Also called “pseudo-hypertrophic muscular dystrophy”
- Most severe and most common of muscular dystrophies in childhood
- X-linked recessive inheritance pattern; one third of cases result from fresh mutations and mother is not a carrier
- Incidence: 1 per 3600 male births
Characteristics
- Most kids reach their appropriate early developmental milestones but evidence begins to occur in early childhood
(onset between ages 3 and 5 years)
- Difficulty in running, climbing stairs, riding the bike …are the first things that are noted. A progressive of muscle
weakness, wasting, and contracture then begins
- Hypertrophic calf muscles occur in most patients due to enlargement from fatty infiltration occurs. Those muscles
may feel firm or woody.
- Progressive generalized weakness occurs up to and through adolescence
- Death from respiratory or cardiac failure between ages of 15 up till age of 30.
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Diagnostic Evaluation
- Prenatal diagnosis is possible as early as 12 weeks of gestation
- Made through PCR where they look for dystrophic chain gene mutation
- Confirmation of diagnosis by electromyelography (EMG), muscle biopsy (would reveal fatty fibrous tissue that
gradually replaces muscle, protein dystrophin is low in muscles of these patients), & serum enzyme measurement
- Positive family history and display of the usual characteristics of the disease
Clinical Manifestations
- First sign you will see is delayed walking, tired easily, & has difficulty running, climbing, riding a bike, etc.
- Waddling gait (as a result from weakness from gluteus medius and maximus muscles), frequent falls, Gower sign
(characteristic sign of rising up from squatting or sitting position from the floor)
- Lordosis from weaken pelvic muscles
- Progressive symmetric muscle wasting that occurs
- Enlarged or hypertrophic muscles, especially in thighs and upper arms
- Profound muscular atrophy in later stages
- Mild to moderate mental impairment
- Obesity is common, may actually contribute to premature loss of ambulation and the other reason why it’s common
in these kids is that, these children who are restricted because of dystrophy, they have restricted physical activity
and become bored and end up consuming more calories. Something to be aware, diets need close monitoring.
- Deficiency of distrophin isoforms in brain tissue is what causes cognitive mental impairment
Therapeutic Management
- No effective treatment established
- Primary goal: maintain function in unaffected muscles (ambulation and independence as long as possible)
- Keep child as active as possible via: ROM exercises, bracing, performance of activities of daily living, surgical
release of contractures as needed
- Maintain vital lung capacity, sometimes may have surgery to release any muscle contracture deformities, we want
to help them in their performance of ADLs
- Make sure kids are getting pneumococcal and influenza vaccine because they are at risk for respiratory infection.
Everyone around them should get vaccinated as well. Contact with anyone with respiratory infection should be
avoided. They do develop abnormal breathing patterns which causes inadequate oxygenation. Long-term
ventilation may be required.
- Genetic counseling for family
Care Management
- Multidisciplinary team helps child and family cope with chronic, progressive, debilitating disease
- Design program to foster independence and maintain activity as long as possible
- Teach child self-help skills
- Provide appropriate health care assistance as child’s needs intensify (e.g., home health, skilled nursing facility,
respite care for family)
- Make sure we are taking care of their skin and family as well because they can be immobilized or with assistive
devices that can cause problem for their skin. We want to try to make sure they are maintaining some sort of bowel
and bladder functioning and protect them from respiratory infections. Talk to parents about possible diet monitoring
to preventing obesity.
CARE OF THE CHILD WITH ACQUIRED NEUROMUSCULAR DISORDERS AND DOWN’S SYNDROME
GUILLAIN-BARRE SYNDROME
- Also called “infectious polyneuritis”
- Acute demyelinating polyneuropathy with progressive flaccid paralysis
- The hallmark of Guillain-Barre is acute peripheral motor weakness. It often occurs after 10 days after a nonspecific
viral infection. It has on a very rare occasion been reported after administration of certain vaccines; usually the
influenza vaccine.
- Children less often affected than adults. Occurrence in children most often between ages 4 and 10 years
- It is a very rare disorder where the child’s own immune system begins to damage their nerve cells, causing muscle
weakness, which then leads to paralysis.
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- Can cause symptoms that can last for a few weeks. Most people fully recover but some people may be left with
serious nerve damage. In rare occasions people have died from this disease, usually if the death occurs due to
difficulty breathing.
Pathophysiology of acquired neuromuscular disorders
- Immune-mediated disease
- Often associated with viral or bacterial infection or administration of vaccines
- CDC says that if a person develops Gullian-Barre within 6 weeks of receiving a vaccine, we should not
vaccinate those people for influenza in the future. Since they cannot be vaccinated then other people around
them need to be vaccinated to protect them from influenza.
- It has been associated with infectious mononucleosis, measles, mumps, gastroenteritis [esp. the one caused by
campylobacter jejuni], cytomegalovirus, Epstein barr virus, h. pylori, and lyme disease.
- There’s inflammation and edema in spinal and cranial nerves: progresses to impair nerve conduction and then
produces partial or complete paralysis of muscles innervated by involved nerves
Diagnostic Evaluation
- Based on paralytic manifestation, electromyelographic findings, or both
- CSF analysis: may have increased protein concentration; other lab test results may be within normal limits
- Symmetric nature of paralysis helps differentiate from other diagnosis
Clinical Manifestations
- Very rapid onset
- Typically begins with flu like symptoms
- Initially: muscle tenderness, sore throat, paresthesia, muscle weakness (caused by neuromuscular involvement)
- The weakness progresses to paralysis: may be ascending or descending; usually rapidly ascends from lower
extremities; may involve trunk, arms, and face
- Flaccid paralysis with areflexia which is a loss of reflexes
- Intercostal and phrenic nerve involvement
- Breathlessness and vocalization and shallow and irregular respirations may be noted
- In many patients: urinary incontinence or retention and constipation
- Recovery of function usually begins 2-4 weeks after the progression stops
Therapeutic Management
- Treatment: symptomatic
- Patients are hospitalized in the acute phase due to respiratory involvement that may require ventilation assistance
or even the use of a temporary tracheostomy tube
- Treatment is aggressive in the acute stage
- Possibly IV steroids, intravenous immune globulin, and plasmapheresis
- Better outcomes are associated with the younger age. Early diagnosis is important because death can occur from
respiratory failure.
- Respiratory support
- Medications to prevent complications
- Phases
- Acute: when the symptoms begin until when new symptoms stop appearing; may last for as long as 4 weeks
- Plateau: symptoms remain constant without deterioration and may last from several days up to a few weeks
- Recovery: patient begins to improve and progress on to their optimal recovery period
- Most patients may make a full recovery in several weeks but it can take up to several months to recover
Course and Prognosis
- Better outcomes are associated with younger ages; most patients have complete recovery
- In most patients, muscle function begins to return 2 days to 2 weeks after onset of symptoms, but period to
complete recovery is prolonged
- Most deaths caused by respiratory failure
Care Management
- Supportive care
- Observation for early signs of respiratory distress/difficulty swallowing
- May require an NPO status, NG/G tube feeding
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- Make sure the patient is maintain an open airway with suctioning; postural changes to prevent pneumonia;
monitoring O2 status
- It is common to have urinary retention. So temporary urinary catheterization. Provide foley care and monitor I&O
- Prevention of complications
- Prevent muscle or joint contractures so nurses or PT may provide passive ROM
- Pain management: Neurontin may be used for these patients
- Physical therapy: passive ROM in the acute phase. Later in the recovery phase: active therapy may be indicated
- Support for child and family
DOWN’S SYNDROME
- It is the most common chromosomal abnormality
- There is decreased muscle tone, which can begin to compromise respiratory expansion. The underdeveloped
nasal bone also causes inadequate drainage of mucus.
- Associated with the extra chromosome 21, which is why they call it Trisomy 21.
- Approximately 3-4% are caused by a translocation of chromosomes 15, 21, or 22. These are associated with
advanced maternal age [>35 years].
- The degree of cognitive and physical development is related to the percentage of cells with the abnormal
chromosomal make-up.
- Physical features associated with DS: separated saggital sutures, the brachycephaly [short head], flat occiput
[back of the head is flat], inner epicanthical folds of the eye, speckling of the iris [called Brushfield spots], small
nose with the depressed nasal bridge, small ears [often have conductive hearing loss], high arched palate,
protruding tongue, delayed eruption of teeth, excess neck skin folds [can be detected in prenatal ultrasound], neck
laxity, very short broad neck, pectus excavatum (sunken chest), pectus carinatum (pigeon chest), congenital heart
defects, rounded protruding abdomens, umbilical hernias, small penis, cryptorchidism, bulbous vulva, broad short
hands with stubby fingers and transverse palmar crease, plantar crease between the big and the second toe,
broad short feet with stubby toes, short stature, hyperflexibility, muscle weakness, hypertonia, atlantoaxial
instability, dry cracked fissuring of skin, and mottling of the skin.
Brushfield spots
- White dots ringing the iris- here you see the white dots within blue iris
- Suggestive of Down’s Syndrome
Considerations
- Speech, OT, PT: to promote this child’s optimal development
- At higher risk for: strabismus, leukemia, cardiac defects, obesity, and
respiratory infections, hearing and vision losses, and hypothyroidism
- Atlantoaxial instability
- Increased mobility at articulation of 1st and 2nd cervical vertebrae
- Causes are not well understood but it may be an abnormality of the ligament which maintains that articulation
there; it could also be from bony abnormalities of the cervical vertebrae…or it could be both
- Approximately 15% of children with Down Syndrome may have this
- Most of the time it is something that is asymptomatic. Some who have normal x-rays may have abnormal followup x-rays, and some who have abnormal x-rays may have normal follow-up x-rays. All children with Down
Syndrome who want to participate in sports should have cervical spine x-rays to check for this. Repeated x-rays
are not indicated for children with DS who have had previously normal neck x-rays because it’s not very
common to go from normal to abnormal. Children who do not have this instability should be encouraged to
participate in any sports that they want to engage in.
- Hypotonicity of the muscles as well as hyperextensibility of the joints can complicate positioning of these children
- The limp, flaccid extremity resembles posture of a ragdoll so holding the infant can be very difficult.
- Extended body position can also promote heat loss so parents should be encouraged to swaddle or cover the
infant before picking them up.
- Decreased muscle tone compromises the respiratory expansion and also affects gastric motility, which then
predisposes the child to constipation. So increase fiber and fluid to prevent the constipation.
- Give the family reassurance and resources and tell them about support groups.
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Fatemeh Sahrapour
MODULE: EMERGENCY CARE OF THE INFANT AND CHILD
Readings:
Respiratory Emergency
Perry:
1242-1243
Pediatric Emergencies
ATI 2013: 477-491
EMERGENCY CARE OF THE PEDIATRIC POPULATION AND DISASTER PREPAREDNESS: PART 1
Pediatric Respiratory Emergencies
- # 1 reason for pediatric hospital admissions
- # 1 cause of death during the first year of life with the exception of congenital abnormalities
How do you recognize a child who is in respiratory distress/failure simply by looking at a child?
- Appearance- The child’s overall appearance reflects the adequacy of oxygenation, ventilation and perfusion.
Before you even put your hands on the child, there is a lot you can tell by looking at them. If you notice they are
anxious, look from a distance (least invasive to most invasive). Appearance is the single most important factor in
assessment. There are very few false negatives. You will rarely see kids who are sick look well You can see:
- Alert or listless? LOC/GCS
- Color or circulation
- Should be pink, pink means good perfusion, what you expect
- Pale or white is a sign of lack of O2, poor perfusion from vasoconstriction because the blood is being
shunted to the vital organs away from the extremities. Hands and feet are cold. What comes after that? Blue.
- Blue is cyanosis- meaning that all compensatory mechanisms have failed.
- Eye contact
- Are they looking at you?
- Are they looking past you?
- Glass eyed?
- Speech or cry
- If you’re doing something and they don’t respond, it’s very concerning
- Normal, high pitched, weak, are they even crying?
- Consolable, inconsolable?
- Motor activity, are they limp or flaccid?
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Distractibility
Consolable
Work of breathing- nasal flaring and retractions
RR increased OR decreased RR
- If their pulse is < 60/minute and there are signs
of poor perfusion like pallor, mottling of the skin,
cyanosis despite the support of oxygenation and
ventilation you will start chest compressions.
Because cardiac output in infancy and childhood
largely depends on HR, profound bradycardia
with poor perfusion is an indication for chest
compressions. This is because cardiac arrest is
imminent and beginning CPR prior to full cardiac
arrest results in improved survival. So absolute
HR at which chest compressions should be
initiated isn’t clear, but the AHA recommends that
providing chest compressions for a HR < 60/min,
with signs of poor perfusion is appropriate.
Tachycardia
Restlessness
Agitation
Altered/lowered LOC
Causes of Pulmonary/Cardiac Arrest in Children
- Respiratory- BPD, Croup, Pneumonia, Bronchiolitis, Apnea, Asthma, Submersion, Aspiration, Epiglottis, Smoke
inhalation, Suffocation, Anaphylaxis
- Infectious- Meningitis, Septic shock
- CV- Congestive heart disease, arrhythmia, myocarditis, pericarditis, hypovolemic shock
- Traumatic- MVA, fall
- CNS diseases- hemorrhage, cerebral edema, shaken baby syndrome, hydrocephalus with shunt malfunction,
seizures, and tumors
…Respiratory diseases and SIDS = 1/3 - 2/3 of all pediatric arrests! Respiratory distress can lead to cardiac failure,
so we need to react quickly!
Respiratory Distress
- We can still help them!
- Airway open and maintainable
- Tachypnea
- Increased respiratory efforts
- Grunting
- Retractions- substernal and intercostal
- Nasal flaring
- Abnormal airway sound (stridor, wheezing)
- Tachycardia
- Pale to cool skin
- Change in mental status (anxiety, agitation)/GCS
Respiratory Failure
- This is what we are trying to prevent!
- Airway not maintainable
- Nasal cannula or facemask will not correct this
- Need ET
- Bradypnea
- Apnea
- Decreased or no respiratory effort
- Poor to absent distal air movement
- Bradycardia
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Cyanotic
Stupor
Coma
Flaccid muscle tone
Unresponsive
If signs of respiratory distress are not addressed and managed immediately the child will rapidly progress into
respiratory failure, shock, and respiratory/cardiac arrest!
What is Cardiac Arrest?
- aka cardio-pulmonary arrest or circulatory arrest. It’s an abrupt cessation of normal circulation of the blood due to
failure of the heart to contract effectively during a systole…cardiovascular collapse an impending shock.
- Cessation of clinically detectable cardiac mechanical activity
- Characterized by: unresponsiveness, apnea, absence of detectable central pulses
- So it’s a decreased respiratory reserve + an increased O2 demand = increased respiratory failure —> patient dying
…when a pediatric patient experiences cardio-pulmonary arrest, First Obtain History & a Thorough Physical Exam
- Age
- Recent illness
- Previous medical problems
- Current meds, recent trauma
- Time of day of incident
- Location of child during incident
- Access to toxins/medicines/poisons
- Access to potential foreign bodies
- Length of downtime. This can affect recovery
- Was CPR initiated and for how long?
-
Overall appearance (congenital defects, “special needs”)
A,B,C’s
Vital signs- get our baseline
Sp02
LOC/GCS
Tracheal deviation? This could indicate a pneumothorax, meaning there’s air in chest cavity outside lungs
Subcutaneous air/crepitus
Pupillary response? Is it sluggish, fixed, and dilated?
Evidence of trauma? including retinal hemorrhages, also log roll patient to check for injuries to back
Surgical scars, (especially sternal meaning they’ve had cardiac surgery, scalp meaning brain surgery, etc.)
Findings suggesting prolonged time since death include: rigor mortis, dependent lividity (pooling of blood into
extremities such that the hands/feet are purple), and corneal clouding
BLS Principles
- A-B-C-s….Maslow's Hierarchy of Needs
- C-A-B pneumonic for CPR. New guidelines from the
AHA. Chest compressions, Airway, Breathing.
- The new guidelines apply to adults, children, and
infants, but excludes new borns.
- Most recent guidelines emphasize effective CPR—it
improves victims’ chances of survival from sudden
cardiac arrest 3-4-fold. Effective CPR prolongs
presence of VF (v-fib), & improve chances that a shock
will terminate this lethal rhythm. Why do we want v-fib?
We need electrical activity to shock the heart.
- “Push hard—push fast” for compression to ventilation
ratio of 30:2 or 100 compressions/minute.
- In many cases there’s a reserve of O2 left in patient’s blood and lungs from that last breath they took, so we can
take advantage of that last breath they took and do chest compressions until help arrives.
- Reminders:
- Don’t just focus on monitor, but on patient & assessment!
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Infant < 1 year: palpate pulse at the brachial artery
Infants > 1 year of age to adolescence: palpate pulse at the carotid artery
HR < 60 Beats per minute/poor perfusion = Compress
< 10 Breaths per minute/ gasping/apneic= Bag-mask-ventilation, rescue breaths
Remember to push to the beat of the song “Staying alive” by the BeeGees
What do we do first?
- Assess for unresponsiveness, by gently stimulating them
- check for breathing. Is there a rise and fall of their chest?
- quickly check for pulse. Is it < 60 bpm with signs of poor perfusion?
- Call for help
- push code button
- call for code cart
- Witnessed arrest/unresponsiveness, call for help (by first pushing code button & then calling for a code cart),
then begin compressions! If we didn’t witness patient become unresponsive/Non-witnessed arrest (since we
don’t know how long they’ve been down), initiate chest compressions (if HR < 60 bpm) & continue with rescue
breaths (if RR < 10 breaths/min or are only gasping) at least for 5 cycles or 2 minutes, then call for help!
- Position for CPR
- hard flat surface, backboard, CPR lever
- No pulse, poor perfusion, HR< 60 BPM begin chest compressions
- Rescue breaths if not breathing or only gasping
- Gasping breaths isn’t enough for perfusion
- Slow breaths aren’t enough for perfusion
- We have to help them.
Circulation: Chest Compressions Review
- Chest compressions first: Applies to adults, children, and infants only. Not Newborns! Neonatal cardiac arrest is
predominantly afixial in nature, so the ABC resuscitation sequence with a 3:1 compression:ventilation ratio has
been maintained, except when the etiology is clearly cardiac.
- Compression to ventilation ratio for infants and
children- 30:2 for single rescuer
- 15:2 for 2 HCP rescuers
- Need to know for lab – count out loud!
- Infants < 1 year of age: Use 2 thumbs-handsencircling-the-chest technique, mid-sternum or 2
fingers mid-sternum just below nipple line.
Compress the chest about 1.5 inches. By
yourself – use two thumbs. With other people –
use two fingers (on same hand)
- Children 1-8 years: Use the heel of one hand to
compress the lower ½ of the sternum. Compress
about 2 inches
- Children > 8 years: Use adult method of
compressions, two hands at a depth of 2 inches
- Techniques- Lab – know the age of the patient to know the technique!
- Arms straight, bent over – gives good force
- Have ribs been broken during CPR? Yes. But we want them
to breathe.
- C – Effective Compression: Push HARD AND FAST
- Rate = 100/min, sing to the song “Staying Alive”
- Depth = 1 1/2 to 2 inches depending on age
- Always allow for complete chest recoil
- Compressions must NOT be interrupted except for
ventilation
- Re-evaluate after 5 cycles or 2 minutes
- Know that the rhythm on the strip will not be accurate
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A – Maintain Patent Airway
- Most common cause of upper airway obstruction is posterior displacement of the tongue
- Airway may be placed to move tongue (?)
- Use head tilt/chin lift. Don’t do if suspect cervical spine injury
- Use jaw thrust maneuver if possibility of cervical spine trauma
- Open mouth, visually inspect and suction
- Vomitus or foreign material may obstruct the airway. Clear that out
- You may see nasopharnygeal or oropharnygeal airways used/placed (in the unconscious patient only)
- POSITION POSITION POSITION! Position helps with visualization and ventilation.
- See how in the “sniffing” position there’s a towel under patient’s neck to get better visualization of airway, and nose
is angle up like he’s sniffing. For older child you can also use a towel behind neck to extend it for a good chin lift.
B – Breathing to Compression Ratio
- Starts rescue breathing even if patient has a palpable pulse > 60 bpm, but there’s inadequate breathing of < 10
breaths/minute and continue until spontaneous breathing resumes. And since HR is > 60 bpm, then we don’t need
to do chest compressions. But if their HR is at < 60 bpm, then do chest compressions in addition to the bag/mask
ventilation. Reassess pulse every 2 minutes.
- Rescue Breathing by Lone provider and Lone Healthcare
Provider = 30 : 2
- Just breathing? Do rescue breaths at a rate of 12 – 20
breaths/min (1 breath/approx. 1 every 3 – 5 sec)
- Two Rescuers = 15 : 2
- Just breathing? Do rescue breaths at a rate of 10 – 12
breaths/min (1breath/approx. 1 every 3 – 10 sec)
- Bag/mask = ventilate to see chest rise and fall
- Use C&E Technique – Form a “C” to create a good seal
around patient’s mouth and nose. Form an “E” under patient’s
chin to get a good chin lift.
Placement of an Artificial Airway
- During resuscitation if patient isn’t able to maintain their
airway, then we will place an artificial airway for them until the patient can breathe on their own again.
Types of Artificial Airways
- ET tubes
- preferred because it allows greatest control of airway
- ET tube is directly inserted into trachea all the way
down to the carina of the bronchi.
- Can suction fluids/secretions through them
- Can prevent aspiration
- LMA (Laryngeo-Mask Airway)
- Inserted directly into pharynx, and doesn’t go as far
down as an ET tube.
- Mostly used when patient is trapped in a sitting position.
Also when there’s suspected trauma to cervical spine or
head tilt/chin lift position isn’t possible. Also when
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intubation with an ET tube is unsuccessful.
- Easier to insert causing less pain than ET tubes, buy you some time
- Cannot suction through them
- Do not prevent aspiration
- Physicians need a blade to intubate
- L- shaped blade- Miller
- Curved blade – MaCintosh
- Your responsibility as a nurse is asking MD what size ET tube he wants or looking at your code sheet to see
what size a child gets based on many factors like swelling, age, weight, etc. You’ll also give him a stylet to be
placed in ET tube before insertion. Also ask him what type and size blade and endoscope he wants.
Artificial Airway Established
- Once an advanced airway is in place, chest compressions can be continuous (at a rate of at least 100/min) and no
longer cycled with ventilations
- Rescue breaths can then be provided at about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute)
- ABGs will be drawn – this is how we know what to set the ventilator to
- Excessive ventilation should be avoided
- NGT placed to decompress the stomach, prevent aspiration, and get excessive air out of their tummies. Your job is
to secure tube and pay attention to where it is based on markings/doesn’t move, etc.
- We document patient’s size, depth of ET tube, and that it’s secured.
C- Circulation: Vascular Access
- Establish this EARLY!
- A small gauge IV is better than no IV at all!
- Like it to be more central rather than distal. Sites can be in scalp,
heel, antecubital, and last resort is intra-osseous (which is placed if IV
is unsuccessful after 2 attempts)
- Memorize colors of needles
- Yellow = 24
- Blue = 22
- Pink = 20
- Green = 18
- Grey = 16
- It’s difficult in infants and children because shock, hypothermia,
vasoconstriction are often present in resuscitative situation. that may ultimately result in vascular collapse
Intra-osseous (IO) Needle Placement in Children
- Used in emergency situations only when IV access not available or not feasible
- Can use on any age child (except a preterm neonate!)
- Placement is the proximal medial aspect of the tibia
- Remember the marrow of these long bones have a rich network of vessels that drain into the central venous canal
and ultimately into the central circulation. Thus, the marrow functions as a non-collapsable venous access route,
whereas peripheral veins do collapse because of vasoconstriction. So this approach is important in patients in
shock or cardiac arrest where the blood is shunted to the core due to a compensatory peripheral vasoconstriction.
- Takes a few seconds to enter central circulation, not as fast as an IV route (drip or push). So push hard to get fluid
in there quickly.
- Can give any IV solution or meds through this site, as well as draw labs.
- KNOW: when they can be used and what we can use them for…
- Used for
- Fluids
- Blood draws
- Meds
- NOT LONG TERM. Used in an emergency situation. Remove as soon as IV or central line access is achieved.
The goal is to remove it within 3-4 hours. It can be left in place for up to 76-92 hours.
- IO are associated with fewer complications. It can be implemented with less delay, requires less skill for
placement,. But complications do include: extraversion of fluid when needle is misplaced, compartment syndrome,
infection, pain, fracture.
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Cntral Line
- The picture above is of a triple lumen catheter. It has 3 distinct exit points, so there are 3 catheters that merge to
inside of one, so they never mix. It’s important to know what medication/fluid should go through which port. Each
catheter/lumen is a different size.
Remember IVFs
- Provide volume replacement
- Administer/replace electrolytes
- Treat/prevent dehydration
- Maintain homeostasis
Most Commonly Used IVF in Pediatric Population
- 0.9% Normal Saline: called Normal Saline or NS
- 20mL/kg bolus
- Lactated Ringers: called LR
- 5% Dextrose in Water: called D5W
- 5% Dextrose and 0.9% Normal Saline: called D5NS
- 5% Dextrose and 0.45% Normal Saline: called D5 half NS
- If your patient has potassium added to their IVF it will be indicated RED writing. Pay close attention to this!
IV Fluid Rate Formula for Pediatrics
- Although it is the physicians’ responsibility to calculate and order the fluid requirements for patients, Registered
Nurses are responsible for double checking the order for accuracy.
- Need to Memorize Formula:
- 100 ml for the first 10 kg (100 x 10 = 1000 mL)
- 50 ml for each kg 11-20 (50 x 10 = 500 mL)
- 20 ml per kg for each additional kg > 20
- Or 421 rule
- 4 cc/kg/hour for the first 10 kg
- 2 cc /kg/hour for the second 10 kg
- 1cc/kg/hour for each additional kg >20.
…If it’s within a few cc’s, that’s ok
QuestionCalculate the hourly maintenance fluid rate for a child who
weighs 25 kg…
…Hourly rate = 67 cc/hour
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Drug Therapy
- This is the next-to-last line of treatment…not the first!
- The majority of pediatric resuscitations will NOT require a lot of drugs (the resuscitator might, tho’!)
- Pediatric drug doses are based on pt. weight
- Some medications in the crash cart will tell you the dosages
IV Medication Administration
- ALWAYS be sure to look at concentration of medication prior to drawing up the medication
- In order for the mg to equal mL the concentration of the medication HAS to be 1 mg : 1 mL. If not, then you’ll have
to do your calculation to find out how many mL you will draw up.
- In a code situation the person drawing up the drug has a HUGE role in assuring pt. safety! Check, Double Check
and Triple Check name/concentration/route/dose of the medication.
- In a code situation when pulling up the medication, you will show it to another person and say: 0.1 mg Epi drawn
up. You’ll then pass it to the patient who’s delivering the med during the code. They will say: 0.1 mg Epi given now.
The person documenting the code will then document: 0.1 mg Epi given at _____ time.
Question
A code has been called on your unit for a 7 year old female weighing 25 kg’s who is bradycardic with poor perfusion.
CPR is currently in progress. Your role during this code is to draw up the medications. The Dr. orders 0.01 mg/kg of
IV Epinephrine to be given stat. A pediatric crash cart is already in the patients room. What do you do next?
- Grab Epinephrine. There are 2 concentrations of epinephrine: 1:10,000 and 1:1000 Ask what concentration the Dr.
wants, then verify the correct ampule.
- Calculate dosage!
- 0.01mg/kg x 25 = 0.25 mg is your dose
- Next look at concentration of med. Epinephrine 1:10,000 is 0.1mg/ mL. Then do ratio and proportion: 0.1 mg in
1 mL, 0.25 mg over x mL = 2.5 mL
- Draw up medication, repeat dose back to dr., hand it off to person who is administering medication, they’ll say dose
given, charter to document medication, time /dose /route
Question
A 2 year old patient arrives in your ER in respiratory distress, she’s pale, has nasal flaring, substernal/intercostal
retractions and appears listless. You immediately connect her up to the cardiopulmonary monitor and here are their
vital signs: HR 50, RR 6 and shallow, SPo2 85% on RA, B/P 80/50,Temp 102.5 axillary, with capillary refill >4
seconds . What would you do next?
- Call a code on patient/Call for help. Have someone bring you a crash cart.
- Initiate compressions and respirations immediately! Poor perfusion, RR, HR…
- Establish an IV line. We need to find her weight. If parents aren’t sure, use Broselow tape to measure patient from
head to heel and that will let us know what color patient falls in and which drawer to select. Needs 20 mL/kg bolus
- Temperature does eventually need to be addressed. Infection, meningitis…
- May initiate isolation if child is irritable, fever, and has a rash
Specific Drugs Used During a Code
- Epinephrine: ↑ HR, contractility, & BP
- Atropine: ↑ HR
- Amiodarone & Lidocaine: (anti-arrthymics) converts V. Fib, pulseless V Tach or V. Tach with pulse. Amiodarone
can also be used for some atrial tachyarrthymias
- Dextrose: reverses hypoglycemia
- Sodium Bicarbonate: reverses metabolic acidosis (must be adequately ventilated before use!)
- Naloxone/Narcan: reverses opiate narcotic depression
- Adenosine: converts paroxysmal SVT. You have to push it quickly, and it will momentarily stop the HR
- Dopamine: improves BP
- Dobutamine: ↑ contractility of heart
- Drugs that can be given per endotracheal tube:
- “L. E. A. N.” lidocaine, epi, atropine, naloxone
- [Epi per ETT is given at “high dose” of 0.1 mg/kg of the 1:1,000 solution!]
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Indications for Oxygen
- CAN administer more than 2L in an emergency situation!
- An acute or emergency situation
- Child in respiratory distress:
- dyspnea
- tachypnea
- apnea
- pallor
- cyanosis
- use of accessory muscles, and nasal flaring
Oxygen
- The target percentage % of O2 saturation of Hb (SaO2 or SpO2) is
- 95-97% children/adults
- 91-95% for all neonates (premature or term less than 28 days of age)
- > 60% cyanotic Heart disease
- KNOW VALUES FOR LAB!
- Abnormal O2 saturations:
- 85-89% indicates moderate to severe hypoxia
- Below 85% indicates severe to life-threatening hypoxemia( may require intubation and mechanical ventilation)
- Remember that sometimes you can position them first to see if that helps O2, and if they require suction do that.
Try it first, then you can tweak oxygen and maybe give them less.
Oxygen Delivery Systems
- Blow-by- Keep their heads midline – can get creative and tape it to their chest or somewhere close.
- May be either a narrow oxygen catheter with small perforations though which oxygen can flow or corrugated
oxygen tubing
- Used when: the child will not tolerate other means of oxygen therapy, low oxygen concentrations with
humidification are needed, if they’re vomiting, or have facial injuries
- The concentration of oxygen delivery varies according to the flow rate and proximity to the face
- Can be used for young infants
- Nasal Cannula- Low flow
- High flow
- Liter percentages:
- 1 L/min = 24%
- 2 L/min = 28%
- 3 L/min = 32%
- 4 L/min = 36%
- 5 L/min = 40%
- 6 L/min = 44%
- Nasal cannula is used to deliver low-flow, low concentration oxygen
- It does not provide humidified oxygen (you have to add humidification)
- A flow rate set higher than 6L/min will irritate the nasopharynx without improving the child’s oxygenation
- Can deliver up to 44% oxygen with a flow rate of 1 to 6 L/min
- Correct placement of nasal prongs
- Masks- Agitated and refuse face mask…hand the tube to mom and she can hold it towards baby’s face
- Bag has to be full! If not full, turn up your liter flow
- The size of the mask is important when administering oxygen
- The mask should extend from the bridge of the nose to the cleft of the chin
- It should fit snugly on the face but put no pressure on the eyes to avoid stimulating a vagal response
- Two types of face masks:
- Simple face mask: 30% to 60% oxygen with a flow rate of 6-10 L/min when a tight seal is maintained on face
- Non-rebreather: 60%-90% oxygen with a flow rate of 12-15 L/min, when a tight seal is maintained on face
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EMERGENCY CARE OF THE PEDIATRIC POPULATION AND DISASTER PREPAREDNESS: PART 2
Most Common Dysrhythmias in Pediatric Resuscitations
- Bradycardia; Asystole; & Pulseless electrical activity (PEA)
- Child comes in with asystole: do not administer shock because there is no electrical activity! Continue CPR and
figure out underlying cause.
- PEA- previously referred to as electro-mechanical dissociation. It is a clinical condition characterized by
unresponsiveness and the lack of palpable pulse in the presence of an organized cardiac electrical activity.
Some situations that cause sudden changes in preload, afterload, or contractility often result in PEA. Most
common cause of PEA in children is hypovolemia. Rx with a rapid fluid bolus of 20 cc/kg of NS IV.
- Key point in Rx of PEA and asystole is to determine reversible causes: (PAT2H4)
- P = pneumothorax (tension)
- A = acidosis (severe)
- T2 = toxic ingestion, tamponade (cardiac)
- H4 = hypovolemia, hypoxia (severe, hyper/hypokalemia and hypothermia)
- VF & VT are not common in children, but may be seen in adolescents with drug ODs
- VF is an abnormal heart rhythm and is seen in sudden cardiac arrest. This rhythm is caused by an abnormal
and very fast electrical activity in heart. VF is chaotic and unorganized. The heart quivers and can’t effectively
pump blood. VF is usually short-lived and it will deteriorate to asystole if not treated properly and promptly. The
only effective treatment for VF is an electrical shock called defibrillation, which is an electrical current applied to
the chest. This electrical current passes through the heart with the goal of stopping the VF and giving an
opportunity for heart’s normal electrical system to take over. This current that the defibrillation provides helps the
heart reorganize electrical activity so it can pump blood again. So there’s a defibrillator and an automated
external defibrillator which does the same thing, they both do the same thing.
Defibrillators & AEDs
- Generally use defibrillators over AEDs (automated external defibrillator). AEDs come in various sizes. They give
you verbal instructions of how to apply pads and will set amount of Joules according to patient’s rhythm.
Defibrillators are manual and you’ll adjust this according to Broslowe tape of instructions or your code sheet.
- You have pedi pads (used in kids ages 1-8 years) and adult pads that differ in size
- If you don’t have pedi pads, it’s ok to use adult pads just ensure pads do not touch each other. If it looks like they’re
going to touch each other, then place one on center of child’s chest and one on center of their back. Don’t ever cut
defibrillator pads to fit a child.
- Remember chest hair can get in the way. Make sure to push firmly on each pad to get them to stick to chest skin. If
too hairy, can shave chest with a razor that’s provided in AED kit.
- Ensure they don’t have a pacemaker. Look to make sure they don’t have a large lump under the skin in the upper
chest area. If they do – move pad over at least an inch away from the pace maker.
- Medicinal patches are common – don’t put AED pad on top of a patch. Can move patch to another site with gloves.
- Make sure everything is clear before activating it.
- Don’t use in water. If the patient is in water, make sure you pull them out of water. If their chest is in water, wipe
their chest down to make sure it’s completely dry before you apply the pads.
Treatment for Dysrhythmias ***Don’t need to memorize all this, but at least know that these are some of treatments***
- Bradycardia: oxygenation/ventilation; f/u with Epinephrine, Atropine and transcutaneous pacing
- V. Tach (hemodynamically stable): Amiodarone or Lidocaine or Procainamide
- Unstable tachydysrhythmia: Immediate synchronized cardioversion for PSVT. If IV access available—give
Adenosine before cardioversion. Recall: Adenosine must be given quickly and stops the heart momentarily.
- VF or pulseless VT:
- Immediate defibrillation, Epinephrine, intubation
- Consider Amiodarone, Lidocaine, or Magnesium sulfate
- Asystole and PEA:
- Doesn’t have a rhythm, we want to establish some type of rhythm/electrical activity!
- Remember we can’t do an AED on someone who has no pulse. We need to have some sort of electrical
activity for AED to fire.
- Not a shockable rhythm so continue CPR
- Intubation
- Epinephrine – first line drug
- Determine cause, and reverse it.
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Putting it All Together
- The nurse’s role in a resuscitation:
- Patient assessment—determine need for resuscitation, e.g. are the monitor electrodes attached?
- Does it look like a duck? RR < 10? HR < 60? with signs of poor perfusion.
- Start CPR and call the code or vise-versa
- Breathing really fast and stop breathing? Call for help, start CPR.
- If you witnessed it, you know when they took their last breath. You have time to call for help first.
- If you didn’t witness it, you don’t know when they went down…So immediately start compressing for at least 2
minutes, then you can call for help.
“Roles” in a resuscitation:
- Team Leader: oversees the entire process; monitors effectiveness of resuscitation; orders drugs, treatments, labs,
etc. The doctor is the one that runs the code, NOT the nurse.
- Team Member: each has a specific job to do: Compressions, BMV, starting IVs, drawing up, labeling & giving
meds; “go-fer”: labs, equipment, recorder, CHARTING events accurately (!); keeping family members informed.
Anytime an order is given, you’ll repeat it back to physician for confirmation and so that every team member hears.
Make sure there is someone whose role is to JUST document on the code sheet
Nursing Interventions to Support the Family
- During the arrest, support is aimed at keeping family informed of child’s status, assuring them that all is being done
- Nurses must consider needs, fears and concerns of family members
- Family should be able to be present during code
All patients should receive CPR unless…
- The patient has a valid DNAR order
- The patient has signs of irreversible death: rigor mortis, decapitation, or dependent lividity
- No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy for
such conditions, such as progressive septic or cardiogenic shock
- Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants with —confirmed
gestation < 23 weeks or birthweight < 400 g —Anencephaly or Confirmed Trisomy 13 or 1
When Should We Stop CPR?
- When normal pulse established
- When normal respiratory rate established
- If obvious signs of death are apparent
- If asystole persist for > 20 minutes in the absence of a reversible cause
Termination of Resuscitation
- Neonate:
- Termination in the neonate occurs with parent agreement: Withhold resuscitation for conditions associated with
high mortality and poor outcome:
- Such as gestation, BW, or congenital anomalies
- Uncertain prognosis with borderline survival and high morbidity rate, plus “burden to the child” is high
- Resuscitation of extremely immature or extremely low birth-weight infants or infants with certain
chromosomal or anatomical defects is unlikely to result in survival or survival without extreme disability.
- Discontinue resuscitation: Infants with no signs of life after 10 minutes of continuous and adequate resuscitative
efforts (as per practitioner order)
- Child:
- Guidelines for resuscitation termination in children are unreliable
- Depends on situation, diagnosis and parental wishes
- Children can survive prolonged efforts if:
- the collapse was witnessed
- bystander performed immediate CPR
- early professional treatment are initiated
Organ Donation and The Gift of Life
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- Every day, more than 75 people across the country receive lifesaving organ transplants, and countless others
-
receive lifesaving tissue transplants
Many more receive the gift of sight through cornea donation
There is a critical shortage of organs across the country
More than 120,000 individuals are waiting for a lifesaving transplant. Of those, more than 11,000 are Texans
Every 11 minutes, a new person is added to the national organ transplant waiting list
Every day 18 people die waiting for a lifesaving transplant
An individual donor can save up to eight lives through organ donation and tissue donation
Skin is used to treat burn patients and individuals with cancer; bone can be used to treat orthopedic injuries and
cancer patients
There is a process for asking a family if they’re willing to donate the organs of their family member…
Transplantable Organs
- Heart
- Kidneys
- Lungs
- Liver
- Pancreas
- Intestine
Transplantable Tissue Includes
- Skin
- Bone
- Heart
- Valves
- Veins
- Corneas
Post Resuscitation Care
- Gift of Life will come in with orders of what meds to keep them on and will keep the organs perfused and
oxygenated until transplant.
- Maintain
- Normal ventilation (do not hyperventilate)
- Temperature
- Glucose
- Manage post-ischemic myocardial dysfunction
- Medications- Dopamine, Dobutamine,Epinephrine
- Monitor labs
- Treat post-arrest cardiogenic shock and septic shock aggressively
- Fluids
- Inotropes
- Pressors
Disaster: What is the Plan?
- Do you have a personal plan?
- Where will you go?
- What’s the escape route?
- Who will pick up the children or pets?
- Where is the meeting place?
- Where is emergency travel kit?
- Make sure you have extra supplies of medication to take with you.
- Do you have a professional plan?
- Know your facilities policy and procedure for emergency/disaster situations
- Protocols
- Escape routes
- Form of communication, chain of command?
- Patient evacuation procedures?
- Do you have a community plan?
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Map of city?
Escape routes?
Shelter in place sites?
Neighbors in need? elderly? those with physical and mental disabilities?
What are your Responsibilities as a nurse when disaster strikes?
- Be professionally and personally prepared. Know that you will be called upon and make arrangement with family
for absence.
- Be aware of ethical issues you may encounter, when you face patient care decisions.
- Protect the patient, get them transported to a safer area, crowd control, and triage (for ER nurses)
Weapons of Mass Destruction
- Chemical
- Radiological
- Biological
- Nuclear
- Explosive or Enhanced conventional weapons
Disaster preparedness
- Why is it important to know what your patient was exposed to?…so we can triage…
- Is it contagious?
- Precautions?
- Who has a better natural resistance to aerosolized biologic or chemical agents – a child or an adult?
- An adult
- Why?
- Children, especially babies are vulnerable. They’re curious, small, and have sensitive skin that needs extra
protection. Aerosols are coming down to the ground – where children are. PLUS, they breathe faster.
- Who will require more resources – children or adults? …again, children!
- Why do you think the availability of drug formulations are limited for the pediatric population?
- Because they aren’t FDA approved. There’s limited testing done on infants and children, since it requires
authorization from parents who are often reluctant to have their child test an unknown drug.
- Do you think children are desirable targets for terrorist attacks?
- YES. Schools especially because they know that our children are our most precious asset and such an attack
would psychologically cripple the population. Also, schools are totally defenseless and unprepared.
- Tend to gather in large groups
- Have natural curiosity and seek out objects of interest
- They evoke extreme emotional reaction by rescuers and the public
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Fatemeh Sahrapour
MODULE: CARE OF CHILD WITH ENDOCRINE DISORDERS
Readings:
Endocrine Disorders
Perry:
1461-1470, 1474-1492
Endocrine Disorders
ATI 2013
PEDIATRIC HORMONAL IMBALANCES - PART 1
Network of six glands
- Pituitary - pea sized gland at base of cranium
- Hypothalamus – in brain around pituitary
- Thyroid - 2 large lateral lobes below larynx
- Parathyroid - 4 or 5 small bodies on thyroid
- Adrenal - cap like glands on top of kidneys
- Pancreas - Islets of Langerhans
- Ovaries/Testes - Female pelvis/or male scrotum
- Certain diseases are associated with each of these glands and
these glands secrete hormones into the bloodstream that carry into
target organs or tissues. Most hormones exert their influences
through interactions with receptors of target cells of specific tissues.
Components of Endocrine System
- Cells- send a chemical messages by the means of the hormones
- Target Cells or End Organs- receive that chemical message
- Environment- is defined as through which the chemical is
transported such as blood, lymph, or ECF
- The endocrine system controls or regulates metabolic processes governing energy production, growth, fluid and
electrolyte balance, response to stress, and sexual reproduction.
- Hormone Types
- Hormones are a complex chemical substance produced and secreted into body fluids by a cell or a group of
cells that exert a physiological controlling effect on other cells.
- Local Hormones create the effect near the point of secretion. For instance, acetylcholine is released at the
parasympathetic of skeletal nerve endings mediates the synaptic activity of the nervous system.
- General Hormones are produced in one organ or part of the body and carried through the blood stream to a
distant part of the body where they initiate or regulate physiological activity of an organ for a group of cells.
What Does the Endocrine System Do?
- Allows for differentiation of fetal reproductive and central nervous systems. In other words, it determines the sex.
- Regulation of the pace of growth and development of the CNS throughout childhood and adolescence.
- Coordination of the male and female reproductive systems enabling sexual reproduction.
- Maintenance of an optimal level of hormones for body functioning.
- Maintenance of homeostasis in the presence of a constantly changing external environment.
Endocrine System
- The endocrine system is the least developed system at birth
- Hormonal control is lacking until 12-18 months of age. Therefore, infants may exhibit imbalances in the
concentration of fluids, electrolytes, amino acids and trace substances. The normal hormonal levels are related to
age and stage of puberty.
- Most endocrine malfunctions are present at birth. They are either observed at birth or detected within the first year
of life. If they are not diagnosed and treated early these conditions can lead to delayed growth and development,
mental retardation, and occasionally death.
- Treatment usually consists of a supplementation of what is missing such as what hormone is missing or an
adjustment of levels of dietary control.
- Most of these patients are treated on an outpatient basis.
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Fatemeh Sahrapour
Diagnostic Tests in General
- Laboratory Screening
- Thyroid function tests (TSH and T4 total)
- Growth hormone - The growth hormone is a time specific test. The child is made NPO and an agent such as
insulin is given which is a known stimulate of GH release; however, this study is not done with the insulin much
any longer.
- Blood glucose tests - timed blood tests to diagnose problems such as diabetes mellitus; serial blood draws
- CBC, Serum chemistries, urine studies
- Radiology Screening
- CT, MRI, X-ray for bone age and density
- Accurate Ht/Wt measurements- is an important time to make sure that these are up-to-date and done carefully
- Genetic studies
Disorders of Pituitary Function
Growth Hormone Deficiency – Hypopituitarism
- It is a disorder caused by a decreased activity of the pituitary gland. It is an inadequate production of the secretion
of the growth hormone (GH) which results in poor growth and short stature.
- It can be an isolated event or there could be an underlying cause of hypopituitarism such as brain tumors or cranial
irradiation.
- Some of the diseases or manifestations that you will see are things like Turner’s syndrome, Renal disease, or
Prader Willi disease.
- Turner Syndrome
- Chromosomal disorder
- Females are affected
- Short stature, short neck, webbed feature
- 1 X chromosome is missing from the cells
- Prader Willi
- Chromosome 15
- Morbidly obese
- Cognitive involvement
- 1 in 3,500 school-age children are afflicted with this and that could be a result of a genetic mutation or deletion
Release of GH from pituitary is controlled by:
- The Hypothalamus secretes releasing and inhibitory factors
- The GH stimulates the growth of all body tissues, the synthesis of proteins in the liver; among them, the insulin like
growth factors, IGF, promotes glucose utilization by the cells and cell proliferation.
- Infection, infarction of the pituitary gland, CNS disease, tumor of the pituitary gland or the hypothalamus, and
psychosocial deprivation may cause hypopituitarism, GH disease, or even a chromosomal mutation.
- A growth hormone deficiency is a result of the failure of the pituitary or the hypothalamus to produce sufficient GH.
Usually, children with GHD are deficient in other hormones. For instance, hypopituitarism is when a child lacks
more than 1 hormone produced by the pituitary gland.
Causes
- Infection or infarction of the pituitary gland sometimes related to sickle cell disease
- CNS disease
- Pituitary or hypothalamus tumors
- Pyschosocial drawfism or psychosocial deprivation causing dwarfism. All of these will act by interfering with the
production or the release of the GH. Psychosocial dwarfism is the emotional deprivation that could also effect the
actions of the pituitary by causing suppression of the production of the pituitary hormones. The child is seen as
withdrawn, will have bizarre eating habits, polydipsia, gorges, and vomits. By removing the child from this
environment and providing normal dietary intake, the pituitary secretion is restored and catch up height is
observed. This is seen in orphanages in the past or underdeveloped countries.
- Dominant or recessive inheritance.
- It could be something that doesn’t happen or malformed during fetal development
- ½ cases have unknown causes
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Manifestations for infant
- Normal weight and length at birth
- Neonatal jaundice
- Delay of the closure of the anterior fontanel
- By age 1, the infant’s height is in < 5% for one’s age and sex. Grow at a rate of < 5cm per year
- Hypoglycemia which might lead seizures
- Micropenis with undescended testicles
- Pale optic discs in the eyes
Manifestations for child
- Immature/cherubic facies which are angel/youthful facial features
- High pitched voice
- Delayed puberty
- Delayed dentition
- Hypoglycemia
- Overweight
- Ripply abdominal fat
- Delayed skeletal maturation
- Delayed sexual maturation
Diagnosis
- Monitor the growth measurement over time and look to see if he/she falls off the chart, which he or she WILL.
- Do an initial screening such as a thyroid function test or to see if the IGF 1 levels are low.
- CBC and bone age x-rays are also done.
- Pay attention to the Somatomedin-C which is an indirect measurement of GH level.
- An MRI of the brain is done to rule out a pituitary lesion or abnormality.
- You need to rule out the familial short statue of a parent or a family member to see if the patient also has a
constitutional growth delay such as skeletal dysplasia or psychosocial dwarfism.
- A Stimulation test with insulin, arginine, clinidine, or glucagon is also done. Once the levels are drawn, you will
need 2 positive tests for diagnosis. These medications or substances will help stimulate the release of the growth
hormone; however, these are not done so much anymore.
Treatment- Depends on the cause
- Replacement therapy- Up until 1984, patients were treated with GH derived from human cadaver pituitaries until they reported of
Creutzfeldt-Jakob disease, a virus, found in these patients. This disease is progressive and fatal and is a
neurological disorder. You are unable to test for it and someone is unable to give blood if they’ve received
human GH.
- In 1985 the synthetic GH was produced and was very expensive of $30,000 a year (2004); however, it’s partially
covered by insurance.
- It is administered subcutaneous up to 3 times a week or daily until the bone plates close or the patient reaches
his/her predicted final height. Side effects are rare, but there could be an increased of ICP, so any headache
needs to be worked up. Early diagnosis and treatment are important to ensure obtainment of maximum adult
height potential.
- Testosterone injections needed for some boys and estrogen needed for some girls to stimulate puberty.
- Growth monitoringNursing Care
- Do an assessment of the entire family
- Provide psychosocial adjustment support because they might need financial assistance, as therapy is expensive
and only partially covered by insurance. Some of the side effects of the medication that we need to let the parents
know about side effects is that there may be an increased of BG levels and local infection.
- Compliance with medication regime is an issue such as rotating the sites and giving them at consistent time of day
- Education- Let them know that it is just temporary
- Keep a growth chart at home allows them to see what’s going on and to take some responsibility for that
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- Proper med administration on how to give an injection is done here. Teach that they need to give an injection at
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bedtime, which closely approximates physiological release of GH. The physiological GH is released 45-90
minutes after falling asleep.
Provide accurate height and weight measurements for these kids and follow them.
Children might have academic problems resulting from learning disabilities and from below average intelligence.
Teasing at school may happen because the child is short.
We need to encourage the child to participate in sports such as swimming, martial arts, and gymnastics.
The child may also grow at a slower rate with treatment resulting in self-esteem issues.
Counseling may be needed for the child.
Hyperpituitarism
- Excessive secretion of the GH
- Excess GH increases the growth rate in the child
- Hyperpituitarism is rare
Causes
- It can be caused by a pituitary adenoma or a tumor of the hypothalamus
- The child can grow up to 7 or 8 feet in height when over secretion occurs before the closure of the epiphyseal
plates = Gigantism
- Excessive growth diagnosis is often delayed because people value being tall. However, when the height exceeds
the parental height that is when you need to consider evaluation.
- Acromegaly occurs with a hyper secretion of the GH after the epiphyseal closes. Acromegaly causes an increase
-
of facial features such as a prominent super overdo ridge, a prominent jaw, and generally enlarged facial features.
These facial changes are secondary to the elevated GH levels.
This could be stressful for girls because they become so tall affecting their muscle and organ growth making them
look large for their age. This can also cause an increased strain on the organs leading to cardiomegaly or diabetes
due to a strain on the pancreas. This can also cause hypogonadism and/or a visual loss.
Diagnosis
- Shows an increased level of IGF-1, which is an insulin-like growth factor
- A bone scan is done to see if the epiphyseal plates have begun to fuse
- X-rays are also done to look for any tumors
- Assessment of the child: large feet, hands, facial features
Treat the cause
- Removal of tumor- Radiation therapy
- Oral administration of Bromocriptine or Somanavert
- Bromocriptine is a dopamine agonist that suppresses the secretion of the GH
- Somanavert is a new drug which blocks the action of the excessive growth hormone
Precocious Puberty
- Normal puberty is controlled by the pituitary
- Girls – 8-13 years of age (10-12)
- Boys – 9½-14 years of age (11-14)
- Precocious puberty is a hyper function of the pituitary
- Girls – before before 7, 6 in AA)
- Boys – before 9 or 10
- The official definition has not changed. However recent studies are showing that onset of puberty is occurring
earlier especially in girls (PP occurs more frequently in girls). Manifestations of sexual development before age 9 or
10 years in boys or 8 or 9 (but evaluate at 6-7 years in girls) are considered precocious and should be investigated.
- The child will appear taller than his or her peers, but will reach skeletal maturity and the closure of the epiphyseal
plates early resulting in an overall short stature later on.
- Cause not usually found in 80-90% of girls and 50% of boys. Speculated causes:
- It may result from a disorder in the gonad, the adrenal glands, or the hypothalamic pituitary gonadal access.
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- The premature activation of the access produces early maturation and development of the gonads, the
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secretion of sex hormones, and the development of secondary sex characteristics such as a mature sperm or
ova. This is an early acceleration of a normal course.
Other types of PP, there is no early secretion of the gonadotropin. It’s an early overproduction of the sex
hormones caused by a tumor, ovaries, testes, or adrenal glands. So we’re getting exogenous sources of
androgens or estrogens.
Many commercials female products such as facial creams or hair products contain estrogen hormones or
placental extracts. Some shampoos made specifically for African Americans contain hormones that are readily
absorbed into the body that can even lead to some of the precocious puberty that we are seeing.
CNS abnormalities such as tumors, surgery, inflammation, hydrocephalus, cysts
Androgel, Android, (skin to skin contact) are testosterone products
Another common link is the positive correlation between obesity and precious puberty.
Only other gland that makes steroid hormones is the adrenal gland
- World's youngest mother in recorded medical history
- Lina Medina, at 5.5 years of age, seven and a half months into pregnancy. On May 14,
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-
1939, Medina gave birth to a boy by caesarean section necessitated by her small pelvis performed by Dr. Lozada, Dr. Busalleu, with Dr. Colareta providing anesthesia.
Medina's son weighed 2.7 kg at birth and was named Gerardo after her doctor (Dr.
Gerardo Lozada). Gerardo was raised believing that Medina was his sister, but found out
that she was his mother. He grew up healthy but died in 1979 at the age of 40 of a bone
marrow disease.
The image was taken by Edmundo Escomel, a physician-researcher. La Presse Medicale.
"La Plus Jeune Mère du Monde." 47(43): 875, 1939 (31 May 1939).
- Treat the cause if it’s pseudopuberty
- LHRH – Luteinizing hormone-releasing hormone can slow down the pituitary secretion that consists of:
- Monthly IM or daily SQ injections are given
- The LHRH regulates the pituitary secretions
- It can slow the prepubertal growth to normal rates
- You want to discontinue LHRH at the appropriate chronological time
- Be sure to dress the child for their age. Regard the child at their chronological age. The child is fertile; however,
sexual interest is at the chronological age not the developmental level. You need to be aware, but not prevent if
they are not sexually active. You need to be aware that if they are put on birth control such as estrogen it will
initiate the epiphyseal closures resulting in stunted linear growth.
Case Study
- 2.7 year old boy
- Bothersome Feautures- progressive pubic hair for 6
months, penile enlargement for 6 months, frequent
penile erection, aggressive behavior and bad temper
- Physical Exam- Weight 17.1 Kg (97th %tile) & height
39.3” (96th %tile), Skin: no skin rashes, Pubic hair:
Tanner stage: 2 ,male pattern, Testes: pre pubertal,
descended, 2 cc in volume no masses, Genitalia:
Male, scrotum and penis enlarged, tanner stage 3
- Lab Imaging- adrenal US: normal adrenal glands, bone
age (consistent with 2-3 yo), testosterone level 1,080.
- Found that: A father uses a nightly testosterone gel at
night on skin. He was then playing with child/baby
causing some gel to be absorbed though babies skin.
Diabetes Insipidus
- Rare disorder of the posterior pituitary gland
- It is characterized by the deficiency of the ADH or vasopressin
- There are 2 forms of DI:
- True or central form is the actual ADH deficiency
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- Familial or nephrogenic DI in which the kidneys are unable to respond to the ADH that are present. This is an Xlinked transmission.
- DI is the inability to concentrate urine due to the deficiency of vasopressin or ADH (antidiuretic hormone)
- ADH facilitates the concentration of the urine by stimulating the reabsorption of the water from the distal renal
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tubule from the kidney. When the ADH is inadequate, the tubules do not reabsorb the water leading to polyuria,
which is the passage of a large volume of urine in a given time.
This can be a familial or idiopathic, which are considered as primary causes
Examples of secondary causes include: result of head trauma, tumors or infection in the area of the hypothalamus.
Meningitis, encephalitis, or vascular anomalies such as an aneurism can occur.
Craniopharyngioma is a tumor involving the hypothalamus which can also be a cause of DI
Head trauma or surgical resection can also lead to DI. This is something that we watch for if the child just had any
kind of cranial surgery and is put into the PICU. The intake and output will be closely recorded and we will monitor
for any signs of DI.
- Normally: Hypothalamus —> ADH —> pituitary —> blood —> kidneys —> distal tubules
- A low serum osmolality means that there is less solute and more water. A decrease in ADH slows down the
reabsorption in the water and makes the urine less concentrated, making more urine.
- Looking at the normal function and compensatory action, the hypothalamus releases ADH to the pituitary which
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will then go to the blood, the kidneys, and then the distal tubules causing an increase reabsorption of free water
to concentrate the urine and decrease the urinary output.
- Osmoreceptors in the pituitary react to serum osmolality.
- A low serum osmolality leads to a decrease in ADH production leads to an increase in urine output,
normalizing osmolality.
- High osmolality can lead to an increase of ADH production, which can then lead to water retention and
decrease urine output.
In DI:
- There is a deficiency of ADH; therefore, the body is unable to conserve water causing an increase in volume of
dilute urine, which is then voided. A loss of free water leads to an increase of serum Na concentration. If the
child has an intact thirst center then he or she may be able to compensate for the large fluid loss by increase
his/her oral fluid intake. If he/she is unable to drink enough then he/she will result in a high serum sodium level.
Manifestations
- Polyuria, which is an increase in urine volume, and polydipsia, which is an increase in thirst..are the cardinal signs.
- For an older child, he/she may have an excessive urination and insatiable thirst. The child will do a little more than
drink and void. The first sign of this may be enuresis.
- In an infant, he/she may be irritable, which can be relieved with feeding water, not milk. Prone to dehydration,
electrolyte imbalance, hyperthermia, and circulatory collapse.
- Nocturia may also occur with a Na level >150 mEq/L and a urine specific gravity < 1.005
- All of these children with DI are usually dehydrated. However, this isn’t a serious problem in older children because
they are able to voluntarily drink enough water, but if the patient is unconscious such as after a trauma or
anesthesia then it may become life threatening due to the absent voluntary demand for fluid.
- Careful monitoring of the urine volume, blood concentrations, and IV fluid replacement are all essential to prevent
dehydration. Watch for this in the PICU after any type of head surgery. Urine cannot be concentrated, so no matter
how dehydrated the child becomes, dehydration will usually precipitate the diagnosis. The serum sodium
concentrations and osmolality will increase rapidly to pathological levels.
Diagnostic Test
- The water deprivation test is a test in which you leave the child without any water and then you draw frequent
blood lab levels.
- Often times you put a heplock in so you can get those levels.
- If a child continues to have DI then he/she will continue to have a large amount of dilute urine, and a low
specific gravity, and an increased serum sodium level.
- 4-7 hour procedure
- Normal response: is decreased urine output with a high urine specific gravity and no change in Na level.
- Abnormal response: Dilute urine, low specific gravity, increased sodium level
- This test is done in the hospital with frequent monitoring of the Na, Hct, osmolality, urine output and osmolality,
weight before, during and after the test.
- A weight loss of 3-5% indicates significant dehydration that requires termination of the test.
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- Small children require close observation during fluid deprivation to prevent them from drinking even from toilet
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bowls, plants, or mop buckets. Often times, the health care team will need to turn off the water in the commodes
and the sinks as well.
- If the test is positive then a vasopressin injection is given which can alleviate polyuria and polydipsia.
If the patient is unresponsive to this, then it can indicate that the patient has nephrotic or nephrogenic DI.
A way to differentiate between DI from other causes of polyuria or polydispa such as from diabetes mellitus is done
through a CAT scan or MRI.
Treatment
- Treatment is life long in some cases or until the cause for DI goes away
- Fluid balance
- Synthetic vasopressin (DDAVP) 0.05 - 0.2 mL intranasally, SQ, IM, or oral.
- Concentrations vary by the different route:
- If given intranasally, it is done by a squirt or through a soft flexible tube with premarked doses twice a day. To be
effective, this DDAVP needs to be mixed thoroughly with the oil by holding it under warm water for 10-15
minutes and shaking it vigorously before having it drawn up in the syringe. If it is not done, then the oil may be
injected without the ADH. The intranasally route can be given by a tube or a metered spray twice a day.
- SQ injections will last 48-72 hours, but require frequent injections, so every 2-3 days. You will see the effect
within 8-20 hours. Watch for signs of overdose such as water intoxication.
Question: How do you think vasopressin works with someone who has a nephrogenic DI?
- In nephrogenic DI, they will not respond to vasopressin, but instead they will be treated with diuretics, high
fluid intake, and with a salt and protein restricted diet.
Nursing Care
- Doing an assessment and looking at their weight, I & O, and electrolyte monitoring
- Educating on what symptoms to watch for
- DDAVP administration
- Teaching symptoms of excessive or insufficient DDAVP
- Teaching symptoms of hyper and hyponatremia
- Urine measurement and specific gravity teaching
- Medical Alert bracelet
- Child should be given free access to water and restroom, so teachers need to be aware of this
- Teach the child how to care for himself
SIADH Syndrome of Inappropriate Antidiuretic Hormone
- Opposite of DI
- This is an excessive production or release of ADH/vasopressin at the posterior pituitary gland.
- It causes the filtered water to be reabsorbed in the kidneys back to central circulation.
- It is caused by a disorder of the CNS including infections such as meningitis, head trauma, brain tumors.
- After a brain tumor surgery, initially the patient will gets DI, then SIADH, then will probably return back to DI
- SIADH is transient and will resolve when the underlying condition is corrected
- SIADH is an increase of ADH that causes the kidneys to reabsorb too much free water leading to a decreased
output of concentrated urine, an increased fluid circulatory volume, and a decreased serum Na.
- Remember that the normal Na level is 135-145
- If the child is below 125, the child may become symptomatic and experience:
- Anorexia
- Nausea
- Weakness
- Weight gain
- Confusion
- Irritability
- This leads to:
- Water retention
- Decreased serum sodium due to hemo dilution
- Extracelluar fluid volume expansion
SIADH Manifestations
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Decreased urinary output
Increased urine specific gravity where the urine is MORE concentrated
Fluid retention (expanded circulatory volume), but with no edema
Weight gain
Increased BP
Hypotonicity
Increased urine osmolality
Hyponatremia
Hypochloremia
Serum osmolarity
Urine spec. gravity is > 1.030
- Nursing alert!!! Stupor and seizures may occur because of the decreased sodium level.
Seizure precautions are initiated.
SIADH Treatment
- Fluid restriction to correct hyponatremia
- Correct the underlying cause
- Severe hyponatremia, so an IV NaCl with slow careful monitoring of hypertonic saline
- Someone with chronic SIADH will consist of lithium and demeclocycline treatment, which block the action of ADH
at the renal collecting tubules
SIADH Nursing Care
- Assessment of recognizing the symptoms especially with PICU patients
- Accurate I&O
- Daily weights
- Signs and symptoms of fluid volume overload
- Children with SIADH develop an expanded circulatory volume, but do not form edema, which is an excess of both
water and sodium. Be aware of the fluid and what it contains. Irrigate all of the tubes with NaCl, not water, to
prevent the pulling of NaCl thus creating a greater imbalance.
Thyroid Function Disorders
Congenital Hypothyroidism
- This is a condition present from birth where the thyroid gland does not produce enough thyroid hormones to meet
the metabolic needs of the baby.
- This is usually caused by a spontaneous gene mutation, an autosomal recessive genetic transmission of an
enzyme, or from iron deficiency
- Untreated hypothyroidism can lead to mental retardation, which is irreversible, and delayed growth
- This occurs in 1:4000 births: where girls > boys, and also > in Hispanic infants.
- This is part of the mandatory newborn screenings that is present in all 50 states: This is done within the first 24-48
hours or before discharge as part of the concurrent screening for other metabolic defects. This early screening
could result in an over diagnosis of giving false positives, but that’s preferable to missing the diagnosis.
- Elevated TSH levels indicate that the disease originated in the thyroid and NOT the pituitary.
- If the T4 Is low and TSH level is high then the synthetic thyroid hormone, Synthroid, will be prescribed.
- Low T4 (<6) and high TSH (>60) at age 3-6 days is abnormal
- 90% sporadic, 10% hereditary
Manifestations: Few clinical signs the first week of life
- Prolonged jaundice, lethargy, constipation – everything is slowed down
- Feeding problems, cold to touch, skin mottling, bradycardia causing a small metabolic
rate
- Umbilical hernia
- Hypotonia/slow reflexes
- Large tongue
- Thick lips
- Dull appearance
- Short trunk and neck
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Large fontanel
Distended abdomen
Hoarse cry
Excessive sleeping
- Sometimes this may be referred as Cretinism. Rarely, is this seen today because early
screening allows treatment to be started right away.
Treatment
- Lifelong thyroid hormone replacement will be started immediately to control the signs and symptoms and
reestablish mental and physical growth
- Synthetic levothyroxine sodium (Synthroid or Levothroid) is given, which is a single oral dose (3-6 mcg/kg/day
- Routine T4 levels drawn and bone scans done
- Prognosis is good when there is a compliance with treatment. If the child is diagnosed before 3 months of age,
then optimal mental development will occur. There may be some mild delays, but he/she will play catch up by the
6th grade.
Nursing Care
- Good newborn assessment
- Routine follow-up assessment:
- Looking at his/her growth/development milestones
- Accurate height and weight
- Measuring the head circumference
- Parental teaching
- Medication administration and compliance. Teach about how it’s given and when it should be given. The
medication can be dissolved in small amounts of water and can be given by a syringe or in the nipple of the
bottle with a little bit of fluid and not the milk.
- Never put it in the whole bottle in case it’s not completed. Sometimes you can mix it in a spoon full of cereal or
baby food. If he/she vomits within 1 hour of taking the medication, DO repeat the dose, that’s how serious it is.
- Teach the parents to watch for s/s of hypothyroidism and or getting too much medication leading to
hyperthyroidism.
- Teach that frequently missed doses can lead to developmental delays and poor growth
- Teach parents how to take a pulse and how to hold the dose if greater than said by the practitioner and to then
contact the practitioner.
- Genetic counseling will be done if the cause is genetic
- Teach to dress the child appropriately due to the tendency of the child to be cold
- Teach to increase fruits and bulk to help towards constipation
- Make sure the child has a medical alert bracelet
Acquired Hypothyroidism
- Much like congenital hypothyroidism
- Inadequate thyroid hormone to meet metabolic needs of body
- Acquired after 2-3 years of age
- This is reversible
Causes
- Hashimoto’s thyroiditis associated with a goiter
- Surgical thyroidectomy
- Radiation therapy for any type of malignancies
- Excessive iodine ingestion because too much iodine could destroy the thyroid tissue
- Iodine meds
- It could also be caused from a isolated thyroid stimulating hormone deficiency
- A goiter can sometimes be present, which is an enlargement of the thyroid gland under the larynx. It can occur in
areas where iodine deficiency is severe.
- If at birth, this goiter can cause respiratory distress, so we as nurses want to prepare for ER ventilation such as
to have supplemental oxygen ready and a tracheostomy tube set.
- Hyper extension of the neck facilitates the breathing if there is a large goiter. Assessment is important.
- It is normal for some enlargement of the thyroid to happen during adolescence.
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- If congenital, it is caused by iodine or anti-thyroid drugs during pregnancy.
- If it is acquired, it can be caused by a decrease of iodine, tumor, or inflammation.
Manifestations
- Goiter (enlarged gland)
- Dry, thick skin and course hair
- Hair loss
- Tiredness/fatigue
- Cold intolerance
- Constipation
- Weight gain
- Decreased growth
- Irregular menses
- Edema of the face, eyes and hands
- High TSH
- Low T4
Treatment
- Thyroid hormone replacement (Levothyroxine), which is the same dose as patients with congenital hypothyroidism
Nursing Care
- Teach about medication administration and compliance
- Do an assessment of the Goiter to see if it is decreasing in size
- Do a growth/development assessment
- Look at height and weight
- Denver Development
- School performance
Hyperthyroidism or Graves’ Disease
- This is an excessive thyroid hormone that is being produced because of an enlarged thyroid gland
- Increased metabolism
- Hyperthyroidism is seen mostly in 6-15 year olds.
- There is a higher incidence with girls
- This could be caused by an autoimmune response to TSH receptors which is the
stimulating thyroid to secrete more T3 & T4
- The patient will have a high T4 and low TSH
- This is an autoimmune disorder in which the body produces antibodies that attack cells of
the thyroid gland. This is a high familiar incidence. The immunoglobulin is produced by the
B-lymphocytes that stimulates the over secretion of thyroid hormones.
Example: An infant diagnosed with hyperthyroidism had a history of poor feeding at 3 months
of age. Note that infant currently has a dull face, peri orbital edema, and large tongue.
Manifestations
- Goiter
- Weight loss
- Increased appetite
- Diarrhea
- Nervousness
- Increased perspiration
- Tremors
- Overheated/fatigued during physical education
- Heat intolerance
- Increased heart rate
- Exophthalmos, which is the protruding of the eyeballs
- Wide eyed
- Staring expression
- Increased blinking
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Absence of the wrinkling of the forehead when looking upward
Lid lag
Lack of convergence
Declining performance in school
Muscle weakness
Difficulty sleeping and relaxing
The child may not be able to cover the cornea with his eyelid
Behavioral problems
Blurred vision and loss of visual acuity
Poor attention span
Enlarged thyroid gland will be up to 3-4 times normal; this is known as a goiter.
All these signs prompt the parents to take the child to the doctor.
Treatment
- The goal is to inhibit the excessive secretions of the thyroid hormone
- We give an antithyroid drug therapy, which can block the production of the thyroid hormone by the thyroid gland
- Propyl-thiouracil or methimazole is also given 3 times a day.
- The improvement is noted in the first 2 weeks.
- Patient will have an initial tx course of 1-2 years that may be followed by a complete remission of disorder.
- Those who relapse may benefit from a 2nd course of this therapy, but may also undergo a surgical intervention.
- Radioactive iodine may be linked to thyroid cancer.
- The thyroid takes up the iodine and destroys the thyroid tissue, which can lead to hypothyroidism.
- The patient may also undergo surgery to remove thyroid gland.
Thyrotoxicosis is a thyroid crisis or storm. It may occur from a sudden release of the hormone. It is unusual in
children, but can be very life threatening. Patient will have acute onset of severe irritability and restless with signs of:
- Vomiting
- Diarrhea
- Hyperthermia
- Hypertension
- Tachycardia
- It can progress to:
- Delirium
- Coma
- Death
- It may be precipitated by acute infection, surgical emergencies or a discontinuation of the anti-thyroid therapy.
- Additional treatment besides the anti thyroid drugs is the administration of beta-adrenergic blocking agents, such
as Propranolol to provide relief from adrenergic hyper responsiveness that produces the reaction.
Nursing Care
- Do an assessment for compliance – Are they taking their meds and taking it the right way?
- Education of child and parents
- The child will be on life long medication if the he/she had radiation or surgery
- Medication administration and compliance
- Teach that the medications can cause an increase risk of neutropenia and hepatotoxicity
- If the child has a fever/sore throat he/she needs to see a doctor because neutropenia and leukopenia
- Teach that the child should limit contact sports
- Provide rest periods because they are easily fatigue
- Teach about the side affects of meds such as:
- Skin rash
- Pruritus
- Gastric intolerance
- May promote increase calorie intake providing 5-6 meals per day due to an increased in metabolic rate
- The child may have a heat intolerance and may want to be cooled
- Hygiene teaching may need to be done due to increase sweating
Adrenal Function Disorders: Cushing Syndrome
- Adrenal cortical hyper function
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Excessive circulating free cortisol in the blood
Uncommon in children
Due to malignant adrenal tumor
Usually comes from prolonged steroid therapy that produces a cushingoid appearance such as:
- Moon face
- Chubby cheeks
- Double chin
Can also occur from pituitary, adrenal problems, tumor, or food causing
an over production of ACT which stimulates the cortisol secretion
Cortisol inhibits the action of the GH
Manifestations
- Excessive hair growth
- Moon face
- Pendulous abdomen
- Poor wound healing
- Temporal fat
- Red cheeks
- Ecchymoses
- Red abdominal striae
- Bruises
- Weight gain
- Hypertension
Labs
- Decreased K
- Decreased PO4/Phosphate
- Tests:
- An adrenal suppression test is used for the initial screening of children with suspected adrenal cortical
hyperfunction.
- If the test reveals that the adrenal cortisol output is not suppressed over night after a dose of dexamethasone,
then they are positive.
- A MRI and CT are also used to detect any type of tumor.
Treatment
- Radiation or drug therapy
- Wean the patient off of steroids
- Bilateral adrenalectomy with replacement therapy
- Children who require cortisol replacement therapy need to take their meds early in the morning every other day
because this mimics the normal pattern of the cortisol secretion.
- A medical alert bracelet is important
PEDIATRIC HORMONAL IMBALANCES - PART 2
Pancreatic Function Disorders
Diabetes Mellitus
- Most common metabolic disease in children
- Disorder of carbohydrate, protein, and fat metabolism
- Type 1 is most common
- Occurs from 10-15 yrs of age in girls and 12-14 in boys
- Type 1 is insulin deficiency
- Type 2 is insulin resistance. Type 2 is contracted usually as an adult and associated with overweight but there is an
increasing incidence with adolescents getting T2DM. Diet, exercise and oral hypoglycemics are used to treat Type
2 insulin resistant DM
Etiology
- Genetic Factors
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- Not really inherited. Child inherits a susceptibility to the disease rather than the disease itself. Presence of HLA.
HLA is human Leukocyte Antigen. It is the loci on short arm of the chromosome. It has to do with compatibility.
- Autoimmune Mechanisms
- Presence of HLA causes defect in immune system making it susceptible to a trigger event such as a dietary
-
source, a virus, bacteria or a chemical irritant. Gradually it destroys beta cells; without beta cells no insulin can
be produced.
Environmental
- Viruses or chemicals damage the insulin producing beta cells
Pathophysiology
- Insulin
- Used to transport glucose into the cells so carbohydrates become energy
- Prevents outflow of glucose from the liver to the general circulation
- This is when 90% of beta cell in islets of Langerhans are destroyed
- The remaining are unable to maintain normal blood glucose level
- Lack of insulin causes results in a↑ blood glucose level and ↓ glucose level inside cells
- When renal threshold for glucose is exceeded, glycosuria occurs. Up to 1000 calories per day can be lost in urine.
- When no glucose is available to the cells, free fatty acids provide alternate source of energy, which are
metabolized by the liver producing acetyl coenzyme A (CoA). Ketone bodies are byproducts of CoA metabolism
and accumulate in the body resulting in ketoacidosis.
Clinical Manifestations
- Hyperglycemia
- Glycosuria
- Polyuria
- Polydipsia
- Glucogenesis
- Polyphagia
- Ketoacidosis
Complications
- The microvascular complications, because the
protein in the blood becomes deposited in the
basement membranes, which can cause:
- Nephropathy
- Retinopathy
- Neuropathy
- Heart Disease
- Peripheral Vascular Disease
- This results from the hyperglycemic effects from the blood vessels.
Manifestations
- Polyphagia
- Polyuria
- Polydipsia
- Weight loss
- Enuresis
- Irritability
- Shortened attention span
- Fatigue
- Blurred vision
- Poor wound healing
- Flushed skin
- Headache
- Frequent infections
- Hyperglycemia
- Dry Skin
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Fatemeh Sahrapour
Diagnostic Tests
- Serum glucose levels
- Fasting >126 would be indicative of DM
- Random > 200 would be indicative of DM
- Urine test strips to determine ketonuria
- Hemoglobin A1C is a longer term index of a patient’s average blood glucose level. An increase occurs about 3
weeks after a sustained elevation in blood glucose. So it takes about 4 weeks to show. And a decrease in A1C also
after a decrease in blood glucose. Good control is around 7%, fair control is 10%, and poor control is 13-20%. It’s
used to assess diabetic control. Less than 7.5% is good for a diabetic.
Therapeutic Management
- Balancing of things that will raise blood sugar with things that will lower blood sugar
- Will raise blood sugar!!!
- Food – especially carbohydrate
- Stress due to adrenalin and cortisol
- Physical-infection, illness
- Emotional – worry, excitement
- Growth due to growth hormone
- Certain medications (hormones, steroids)
- Menstrual cycle due to estrogen
- Will lower blood sugar!!!
- Insulin – only hormone to decrease blood sugar
- Exercise but most effective in well controlled state
- Alcohol due to blocked glycogen breakdown in liver,
SO…Eat before drinking
- Insulin is composed of a series of amino acids.
- Animal insulin is different from human insulin but only one in pork amino acid or 3 in beef amino acids. Human
insulin is made by recombinant DNA [genetic engineering] using E. coli or yeast.
- Pork or Human Insulin (preferred)
- It is available in rapid, short, intermediate and long acting preparations
- It comes in 100 units/cc concentration
- The dosage is based on capillary blood glucose levels
- In kids usually we try for a twice-daily insulin regimen or the use of insulin pump [constant pulse of insulin]. An
insulin pulse requires a site change every 48 – 72 hours.
- Goal of insulin therapy is to maintain near normal levels of less than a 126 mg/dL and a Hgb- A1C of 7% or less.
Insulin Types
Type
Name
Onset
Peak
Duration
Rapid Acting
Humalog/Lispro
Novolog
Apidra/glulisine
15-30 minutes
10-20 minutes
15-30 minutes
.5-2.5 hours
1-3 hours
.5-2.5 hours
5 hours
3-5 hours
5 hours
Cannot mix with other
Insulins
Short Acting
Regular/Humulin R
30-60 minutes
2-4 hours
5-8 hours
Can be given IV
Intermediate Acting
NPH/Humulin N
Ultralente
Novoin-N
1-2 hours
2-4 hours
2-6 hours
2-8 hours
6-14 hours
4-14 hours
14-24 hours
18-20 hours
14-20 hours
Long-Acting
Lantus
Levemir
1.5 hours
.8-2 hours
None
None
20-24 hours
Inject 1-2/day
Up to 24 hours
Inject 1-2/day
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Therapeutic Management: Insulin
- Mixing insulin in same syringe
- Regular insulin can clinically and practically be mixed with any insulin however it’s action may be blunted by mixing
with Lente or Ultralente.
- NPH cannot be mixed with any lente type insulin.
- Humulin BR, which is pump insulin, cannot be miced with any insulin.
- When mixing insulin, the regular insulin should be drawn into the syringe first.
- IV administered insulin
- Only Regular insulin (also new Apidra) may be given IV. NO other insulin can be given IV!!
- It requires a special line priming because the insulin attaches to the plastic polymers of the IV bags and tubing.
- When preparing a solution containing insulin, inject the insulin into the bag, and then run the mixed fluid through
the tubing. This allows the insulin to begin filling the receptors along the way. So essentially you are going to
prime the bag and the tubing and run about 30-50 ml out of the tubing into the sink before you give it to the
patient so you can ensure that the patient is really getting insulin and not just the fluid without the insulin
because the insulin is clinging to the plastic.
- Insulin works rapidly and clears the blood stream in about 30 minutes.
- Abrupt discontinuation of IV insulin will cause blood sugars to rise after 5 – 30 minutes, this is important.
- When you discontinue the IV insulin (turn the pump off), be sure to give a SQ dose of insulin to keep the blood
glucose levels stable.
- Insulin Pumps
- Usually use regular insulin. Humulin BR is buffered regular insulin designated to withstand the movement
through pump tubing. Regular is most often used. It’s worn on a belt or a shoulder harness. The needle and
catheter are changed every 48 – 72 hours. New insulin Apidra can be used in pumps. Lispro can also be used,
it is rapid acting.
- Insulin Program:
- Plan of 4 things
- Always available in basal amounts
- Available in larger amounts at meal times
- Less insulin between 2-3 a.m.
- More insulin between 4-7a.m.
- Most are treated with 2 injections per day
- A typical program would be 30 minutes before breakfast NPH and regular, 30 min before supper NPH and
regular. When would peaks occur? NPH in 6-12 hours. Regular in 30 minutes.
- Insulin absorption: how well is insulin taken out from the subcutaneous tissue is determined by:
1. The condition of the site
2. The temperature of the insulin [injected cold insulin is painful and is absorbed more slowly]
3. The location of the site. Insulin given over exercising muscle is absorbed more quickly. The fastest in the
abdomen and shortest in duration. The slowest absorption is the leg or buttocks but the longest duration.
Therapeutic Management (Continued)
- Monitoring
- SBGM (self blood glucose monitoring) is taught and used.
- Insulin dosage based on reading
- Urine testing no longer routine
- Research indicates that normalization of blood sugar levels may prevent long-term complications. We want it to
be between 80-120 mg/dL.
- Nutrition is a big part of management.
- Need consistent intake and timing of food especially CHOs which should be limited and kept constant in amount
consumed and time consumed from day to day (fruits, breads, milks).
- Fruits are simple carbohydrates and raise blood sugar quickly but the effect is not sustained.
- Starches are complex CHOs; they raise the blood glucose more slowly but have a more sustained effect.
- Certain vegetables fall into this category, such as potatoes, beans, pasta, corn, rice and peas.
- Milk is also complex carbohydrate. It can raise blood glucose still more slowly and last even longer, mainly
due to the effect of protein and fat in the milk. Protein will eventually breakdown releasing some glucose.
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Protein is planned in the diet in moderate amounts.
Time is regulated according to insulin type
Extra food is needed for extra energy
The exchange system consists of 6 basic food groups.
Should allow calories for optimal growth
It should be simplified for ease in understanding and for optimizing compliance
- Exercise plays a big part.
- Vigorous exercise should be preceded by a carbohydrate snack.
- A simple sugar should be made available at all times during exercise.
- Exercise is not indicated if DM is poorly controlled, meaning the blood glucose is over 240 with positive ketones.
- In such a state, the child is insulin depleted and exercise would be an added stress resulting in even further
gluconeogenesis and ketogenesis due to adrenaline.
- Hypoglycemia control:
- Physical activity is associated with increased insulin sensitivity. Regular exercise and fitness improve metabolic
control with a lower insulin use. The child must have adequate caloric intake to prevent hypoglycemia.
- Illness Management:
- Do not omit insulin during illness, although the amount may change. Supplemental Lispro or Regular for
hyperglycemia during illness. Watch the fluid balance. If the child vomits more than one time, let the HCP know.
- Surgery may require alterations in the insulin needs of the child. The stress of surgery will increase the blood
glucose levels. Regular insulin is usually needed during this time.
- Transplantation can be seen as a cure.
- Islet cell or whole pancreas transplantation. Viable insulin producing cells have been injected into portal veins,
where they are transported to the liver to produce two-thirds of the insulin.
Diabetes Dilemmas
- Hypoglycemia – mild
- Brain symptoms:
- Consist of headaches, hunger, confusion, dizziness, diplopia, mood changes, and behavioral changes.
- Adrenalin symptoms:
- Can include shakiness, pallor, tachycardia, dilated pupils, cold and clammy types of feelings.
- Treatment:
- Stop the exercise, check the blood glucose level, give milk or fruit juice or a carbonated beverage, candy, a
fruit exchange, or anything that is a high sugar.
- Wait 10-15 minutes to check effect and then recheck blood sugar. Repeat fruit exchange is still symptomatic.
- Give a starch and a protein if the next meal or snack is more than an hour away.
- Hypoglycemia – severe
- Symptoms:
- Unconscious, extreme confusion, combativeness and/or seizures.
- Treatment:
- Call for help. Give a sticky food exchange such as honey or gel or syrup into the side of the mouth. Give
glucagon by subcutaneous injection.
- Check blood glucose during treatment. Be careful, as gel on your finger will alter any BG test result.
- Following recovery, the child may eat a snack of complex carbohydrates to replenish the glycogen stores.
- Following a severe reaction, symptoms may include: N/V, and severe headache. No memory of the event.
- Somogyi Effect or Rebound:
- During hypoglycemia, the body responds to the stress by secreting anti insulin hormones, which are counter-
regulatory [such as adrenaline or cortisol or growth hormone].
These hormones release stored glycogen in the liver where it is converted to glucose.
Blood glucose goes up, often too high, resulting in rebound hyperglycemia.
Rebound refers to the hyperglycemia followed by hypoglycemia.
Prevention of rebound requires increase in the amount of food or decreasing the insulin.
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- Dawn Phenomenon:
- This is an increase in blood sugar between 4 and 7 am. We need to increase the insulin at the bedtime. It’s the
big problem during puberty due to the release of cortisol, growth hormone and other stimulants.
- Hyperglycemia:
- Common symptoms include:
- Polyuria, polydipsia, and polyphagia.
- The blood sugar in over 240 mg/dl. This requires a urine ketone check.
- Persistent hyperglycemia necessitates an insulin change or evaluation of food intake. Hyperglycemia creates an
osmotic diuresis and dehydration.
- Oral fluids must be encouraged.
- Exercise may still continue if the child is not keotic or ketotic or spilling ketones in the urine. Hyperglycemia can
also be caused by: illness, growth, emotional upset, or missed insulin doses.
- Things such as school exams or menses can also cause it. Treat by adjusting the insulin or by food intake.
- Diabetic Ketoacidosis/DKA
- Signs:
- Dehydration [because of osmotic diuresis which causes a decrease in the electrolytes especially K, Na, Cl,
Ph, and Mg]. Serum pH and bicarbonate reflect degrees of acidosis.
Weight loss
Tachycardia
Flushed ears and cheeks
Kussmaul respirations
Acetone breath
Decreased level of consciousness
Hypotension
Hyperglycemia, glycosuria (increase glucose in urine)
Blood glucose > 300
Ketosis in serum
Acidosis: pH < 7.3 and H2CO3 < 15
Pediatric emergency!!!
- The priority is to get venous access.
- Also weigh, measure, put on a cardiac monitor, and get labs.
Treatment:
- Start with treating dehydration. Fluid bolus for volume expansion, usually the initial IV is NS.
- To decrease the risk of cerebral edema, replace the deficit over 24 – 48 hours.
- Serum potassium levels may initially be normal but check again after fluid bolus and insulin has been started.
- Fluid and insulin cause a rapid return of potassium to the cells and can severely deplete serum potassium
levels. Start potassium replacement after the child has voided.
- You need to make sure that the child has kidney functionality.
- Insulin therapy is used to decrease the serum glucose levels.
- Not to exceed 100mg/dl/hr… usually 0.1U/kg/hr of insulin is given.
- Faster than this could lead to cerebral edema.
- You want the blood sugar to fall 50-100mg/dl/hr.
- When the blood glucose level gets to 250 – 300, you begin to add dextrose to the fluid, either 5% or 10%.
- We want the goal to be a 120-240
- Fluid and electrolyte balancing is important.
- Give potassium after you know the level and after the first void to determine the kidney functionality.
- Monitor T waves as changes indicate hypokalemia or hyperkalemia [elevated T waves, shortened QT
interval].
If NOT treated:
- Acidosis
- Coma
- Death
Nursing Considerations:
- Patient and Parent teaching is essential
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Fatemeh Sahrapour
- Nutrition & meal planning: They need to learn the labels. They need to measure the amounts. They need to
-
get a list of fast food restaurants with calories and fats listed. They want to avoid high fats, carbs, and sugar.
Choose a plain hamburger over a double cheeseburger. Use sugar substitutes moderately.
- Insulin & Injection technique: Open bottles can be stored at room temperature or refrigerated. The injection
technique and rotation pattern need to be taught. Giving 4-6 injections per site before you change the site.
Remember that sites over active muscles absorb faster.
- Blood glucose monitoring
- Record keeping
- S&S and treatment of hyper or hypoglycemia
- Family support is important. This is a disease that does not go away.
- Proper hygiene: Caution children to not let anyone else use their lancet or their lancet device or their needle
or syringe. Teach methods to minimize the pain of blood glucose testing, such as holding the finger under
warm water to stimulate blood flow to the area, puncture the finger on the side as it has less nerve endings.
An alternative site may be forearm. Apply Emla to the site to be punctured, especially when first starting out.
Nursing Diagnosis:
- Risk for injury related to insulin deficiency
- Risk for injury related to hypoglycemia
- Knowledge deficit related to care of a child with newly diagnoses DM
- Altered family process related to management of a chronic disease
Child Development and DM
COGNITIVE DEVELOPMENT
Birth - 2 year
Sensorimotor
PATTERNS OF LEARNING
STRATEGIES
Exploration
Use of senses
Developing trust
Parent Education
Relaxation
Plan
5 year old
Pre-conceptual
Use of hunches
Magical thinking
Short attention span
Feltboard, Movies, Pretend
Games, Puppets, Drawings,
Therapeutic play
6-11 year old
Competitive games, Rules
Worksheets, Films
12 year - Adult
Abstract thinking
Interest in details
Can form theories
Abstract thinking
Interest in details
Can form theories
Can think of possible choices like an adult
Debates
Challenging games
Group discussion
Problem solving
TASK ACCOMPLISHMENTS FOR THE CHILD WITH DIABETES
AGE
DIET
INSULIN
TESTING
<5 years old
Helps pick foods
based on food
preferences
Gathers supplies
Picks injection site
Pinches up skin
Wipes skin
Gathers supplies
Collects urine
Watches parent
Observes test
Pushes
6-7 years old
Can tell if food has
no sugar, some
sugar, or lots of
sugar
Pushes plunger in after
parent gives the injection
Performs finger stick
Can do ketone test
Records results
Needs reminding
Needs supervision
8-9 years old
Selects foods based
on exchanges
Gives own shots
Can draw one insulin
Does own BG test
Rotates sites
Measures mixed insulin doses
Looks for patterns in test results
10-13 years old Knows meal plan
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Fatemeh Sahrapour
14+ years old
Plans meals &
snacks
Makes adjustments
in insulin or
exercise to cover
food intake
Skills more accurate
Less supervision required
Suggests insulin dose changes based on
test patterns
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Fatemeh Sahrapour
MODULE: CARE OF CHILD WITH CARDIAC DISORDERS
Readings:
Cardiovascular Dysfunction
Perry:
1318-1351, 1353-1360
Cardiac Content
ATI 2013
MURMURS, CYANOSIS, AND CARDIAC ANOMALIES - PART 1
Utero
- In utero, oxygenation is provided by the placenta, not the lungs
- After birth, the fetal connections close and the lungs begin to take over oxygenation
- The heart develops in the first 3 weeks and fetal circulation by 8 weeks
- Therefore, congenital lesions develop in 3-8weeks of age in utero (cardiac defects)
- The heart starts out as a simple tube and grows into a complex organ.
- One end of the tube is arterial and one end is venous.
- The middle part of the tube widens, folds, and bulges into 4 chambers by the 3rd week of fetal life (heart beat).
- Heart starts to beat at the 4th & 5th wk; atrium & ventricles (i.e. all 4 chambers) are developed.
- Lungs are not expanded and air (gas exchange) is not used during utero, therefore connections must close by birth
- Openings that need to close by birth, all of which help to bypass the lungs:
- Foramen ovale (atria)
- Ductus venosus (shunts blood from belly button to vena cava)
- Ductus arteriosus (aortic arch) this is the most common one that does not close
- In the fetal circulation, we have some things that are not found after the child is born.
- One of them is the ductus venosus, the other is foraminal valley, and the other is ductus arteriosus. These help
to bypass the lungs.
- These open so that oxygen is exchanged while the baby is in utero.
- The fetus doesn’t rely on the lungs for oxygenation; it relies on the umbilicus (the blood).
- The blood goes from the placenta to the umbilical cord, which then goes up the fetal abdomen, goes to the liver,
where it divides into two.
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- The liver and the one vena cava through the ductus venosus, which then goes into the atrium through the
-
foramen ovale, to the left atrium, then to the left ventricle, to the heart, the upper body getting oxygenated rich
blood to the highest level of the body causing encephalocoele developmental head to rump.
The Foramen Ovale allows blood from the right atrium to the left atrium.
The Ductus Venosus shunts the blood from the umbilicus to the inferior vena cava.
The Ductus Arteriosus takes blood from the pulmonary artery and puts it into the aorta.
Fetal Hgb carries 20-30% more O2 than maternal Hgb. Fetal Hgb concentration is 50% greater than maternal
Hgb. Fetal HR is 110-160 bpm; so greater cardiac output per minute than the adult.
Changes After Birth
- There is no longer a placenta so the blood needs the lungs for oxygenation
- The pulmonary vascular resistance decreases causing vasodilation in the pulmonary vascular bed.
- The pulmonary blood flow increases
- The systemic vascular resistance increases
- The blood flow through the ductus arteriosus becomes primarily left to right
- The foramen ovale closes.
- This is the opening between the atria.
- The ductus arteriosus, which allows blood between the pulmonary artery and aorta, shunting blood away from
pulmonary circulation when its in-utero, now closes.
- With the baby’s first breath, lungs inflate reducing PVR to blood flow. The pulmonary artery pressure drops
this causes pressure in the right atrium to decrease. Blood flow to the left side of the heart increases the
pressure in the left atrium. This leads to closure of the feremenal valley. The baby crying may cause temporary
reversal with mild cyanosis. Pressure of the pulmonary artery causes promotes closure of the ductus arteriosus.
Also, decrease in the circulating Prostaglandin E causes this to close. Usually this happens within the first few
hours and permanently within the first 3 weeks as it then changes to a ligament, unless the baby is premature or
it is needed to stay open due to other cardiac defects. If it is open then you hear a murmur. These things all
happen within the first few days after birth. The BP is low in these early days.
And This is the Way it Should Work!
- Superior Vena Cava (SVC)-venous return from the upper body
- Inferior Vena Cava (IVC)- venous return from the lower body
- Right Atrium (RA)- saturation of 70-75%, Central Venous
Pressure (CVP)-pressure 2-6 mm; thin walled, low pressure
collecting chamber for all systemic venous return
- Superior vena cava and inferior vena cava empties into RA
- Tricuspid Valve
- Anterior artioventricular valve
- Has 3 leaflets- anterior, septal, and posterior
- Each leaflet is attached to chordae tendonae which are in
turn attached to the papillary muscle in the RV
- Valve opens passively in diastole because the pressure in
the relaxed, empty ventricle is lower than in the full RA
- Blood then goes through the tricuspid valve as it leads the
-
-
-
right atrium and goes into the right ventricle. This valve is
open when the atrium is filling as the pressure in the
ventricle is less.
Right Ventricle (RV)
- Most anterior of all the chambers
- Receives blood from the right atrium during diastole
- Thick walled muscle
Pulmonary Valve (PV)
- Semilunar valve with 3 leaflets
- Opens during systole when the ventricle contracts
- Leaflets close passively when ventricular pressure drops
Pulmonary Artery (PA)
- Divides into left and right branches
- Low resistance pathway to pulmonary circulation from the
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right (venous) side of the heart
- Pressure 20-30mm systolic, 10-15mm mean; 0-5mm diastolic
- Pulmonary Veins
- 2 that enter separately into the left atrium
- Bringing back oxygenated blood from the pulmonary circulation
- Lung-oxygen is picked up by the blood
- From the lung the blood goes into the pulmonary veins to the left atrium
- Left Atrium
- Chamber for the pulmonary venous return; saturation 95-100%; Pressure is 5-10mm
- Mitral Valve (MV)
- Atrioventricular valve with 2 leaflets (septal and posterior)
- Each leaflet is attached to chordate tendonae that connects to the papillary muscles of the left ventricle
- Opens passively in diastole
- From the left atrium, it goes to the mitral valve, into the left ventricle as blood comes the atrium down to the
ventricle with the pressure
- Left Ventricle (LV)
- Receives blood from the LA, thin walled at birth, then thickens
- Saturation 95-100%; pressure 60-140mm systolic and 0-10 mm diastolic
- From the left ventricle it goes out through the aortic valve to the aorta
- Aortic Valve (AV)- Semilunar valve like the PV with 3 leaflets
- Leaflets are thicker than the pulmonary valves
- Aorta
- High resistance pathway that carries blood to the systemic arterial circulation
- Thick wall and small lumen
- Divided into ascending aorta, aortic arch, and descending aorta
- Vessels that come off the arch are the brachiocephalic, left common carotid, and the left subclavian
- Saturation is 95-100%
Compensation
- Infants have a limited ability to increase their stroke volume to compensate for increase demands
- Leads to tachycardia
- Heart rate is primary compensatory mechanism for children when metabolic demands increase (i.e. temp)
- Tachycardia may decrease cardiac output by decreasing filling time
- Bradycardia has a profound effect on cardiac output
There are two major groups of cardiac problems:
- The first are CONGENITAL cardiac defects. These are anatomical disorders that are present at birth. 6 in 1000 live
births will have a congenital cardiac defect
- ACQUIRED heart disorders is the second major group - these are issues that happen after birth, the components
that develop in-utero during the 4th of gestation until about the 8th week, and then the heart begins to mature.
- DiGeorge syndrome (a disorder caused by a defect in chromosome 22) may be signs you can see at birth. Some
may develop later. These include bluish skin, seizures, twitching, learning delays, developmental delays, and
failure to gain weight. There are heart defect issues and facial issues.
Etiology of Congenital Defects
- Etiologies of most defects are unknown.
- Some genetic predisposition interacting with environmental triggers
- Chromosomal abnormalities account for almost 10% (Downs, Turner, DiGeorge among others).
- Environmental or adverse maternal conditions account for 2%-4%.
- Maternal diabetes, phenylketonuria
- Rubella and other viruses
- Maternal ingestion of alcohol, anticonvulsants, lithium, etc.
- Family History
- Heart disease are usually dx at birth or in the first 4 to 6 weeks of age and greater than half the cases. The
incidences are 2 times greater than pre-term babies.
- Genetics make up 24% of the cases with up to 8% having chromosomal defects.
- Sudden Death
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-
-
Diabetes
Heart Disease, Hypertension, Hyperlipidemia
Congenital heart defects
Family members with cardiac risk factors
Babies may have a family history so we must interview and check with the family when a child comes in
Incidence of Defects
- Approximately 5-8 per 1000 live births in United States
- Approximately 2-3 per 1000 will be symptomatic during 1st year and need treatment
- About 40,000 new cases of congenital heart disease per year in the U.S.
- There are more than 35 recognized heart defects with VSD is the most common
- 85% of children with CHD will become adults
Nursing History- Infant
- How is the infant/child feeding? Get diaphoretic or cyanotic around the mouth or extremities when they eat?
- Weight loss or failure to gain weight.
- How are they breathing? (Persistent, peaceful tachypnea RR>60). Cyanosis, pale color?
- History of low birth weight related to UGR
- Pregnancy history; what meds mother took before and during pregnancy
- Be sure you aren’t implying any blame on the mother when you’re asking questions!
Nursing History—Older Children
- Do they tire easily?
- Syncope?
- Recurrent respiratory problems that do not get better including asthma
- Poor weight gain
- Palpitations
- Lower extremity swelling
- Clubbing of the fingers
- Chest pain-rare that this is a cardiac condition in children
Physical Assessment
- Nutrition-how long does it take your child to eat?
- Color
- Chest & chest deformities
- Unusual pulsations
- Respiratory excursion
- Clubbing of fingers— which may be seen as early as 3 months, especially in the thumbnail.
- COULD BE DUE TO HYPOXIA AND THE PRESENCE OF RIGHT TO LEFT INTRA-CARDIAC SHUNT AND AN
INCREASE HEMOGLOBIN AND HEMATOCRIT
- Cyanosis can be more easily seen in lighter skin babies. Children with darker skin, check their nail beds, mucous
membranes, palms, and soles.
- Palpate pulses:
- Chest for apical pulses, heaves, and thrills. Heart rate and rhythm
- The apical impulses in children’s < 4 years of age should be in the 4th intercostal space, mid-clavicular line
- Children 4 to 7 years of age, midclavicular line
- Children greater than 7 years of age is the 5th intercostal space, right mid-clavicular line
- Abdomen (enlarged spleen and/or liver)
- Peripheral pulses, femoral pulses: coarctation of the aorta may indicate weaker pulses and blood pressures in
the lower extremities
- Heart rate and rhythm
- Character of heart sounds
Diagnostic Tests
- Chest X Ray—check to see the size of the heart
- ECG—checking the rhythm
- Holter monitor—Used for an extended amount of time and activated when there is an abnormal rhythm
- Echocardiography—blood flow
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- Cardiac catheterization—Injecting dye into the femoral artery and watching it go up to the heart while visualizing
with a ultrasound
- Exercise stress test
- Cardiac MRI
Heart Sounds
- S1- beginning systole, loudest at apex and best heard over the mitral and tricuspid areas.
- Closure of the AV valves
- S2- Loudest at the base.
- Closure of the semilunar valves, best heard over the pulmonic and aortic areas
- S3- Normal in some children and young adults.
- Best heard over mitral area.
- S4- not usually good to hear
What Is A Murmur?
- A sound that is produced by vibrations within the heart chambers or in the major arteries from the back and forth
flow of blood
- May be detected in 50%-90% of children at some point in their lifetime
- May be innocent- (Stills) or pathologic
- Kid could grow out of it
- Most pathologic murmurs are diastolic in nature, except venous hum
- Are rated on a scale of 1-6 with grade 1 and 2 barely audible
Heart Defects
- This isn’t a true classification because cyanotic diseases can become cyanotic and vice versa
- Acyanotic—can be from:
- Increased pulmonary blood flow
- Atrial septal defect- Hole btw two atria
- Ventricular septal defect- Hole btw two ventricles
- Patent ductus arterious- Didn’t close at the right time
- Atrialventricular canal
- Obstruction to blood flow from ventricles
- Coarctation of the aorta
- Aortic stenosis
- Pulmonic stenosis
- Cyanotic— can be from:
- Decrease pulmonary blood flow
- Tetralogy of Fallot- the right ventricle is connected to the left ventricle via VSD (ventricular septal defect)
- Tricuspid atresia- underdeveloped right ventricle
- Mixed blood flow
- Transposition of the great arteries- Aorta connecting to the pulmonary artery
- Total anomalous pulmonary venous return- Pulmonary veins connecting to the superior vena cava
- Truncus arteriousus- Pulmonary veins connecting to the aorta
- Hypoplastic left heart syndrome
Patent Ductus Arteriosus (PDA)—Defect of Increased Pulmonary Blood Flow
- The PDA connects the aorta with pulmonary artery. This usually is closed off upon birth within the first 48 hours.
- Failure of the fetal ductus arteriosus to close within the first weeks of life. This makes a reversal in blood flow due
to the increased aortic pressure.
- 2nd most common CHD. It accounts for 12% of all cardiac defects.
- After birth the pulmonary vascular resistance decreases. The pulmonary artery pressure is low, and the aortic
pressure is high. Blood shunts from the aorta to the PA. The amount of shunt is dependent on the size of the PDA,
systemic resistance, and pulmonary resistance. This includes left to right shunting.
- At risk for endocarditis and pulmonary vascular obstruction disease
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- Failure to close leads to continued blood flow from left to Right shunt (aorta to pulmonary artery). Oxygenated
blood is getting re-oxygenated again. Blood doesn’t get out systemically and this increases the work load of the left
heart. Pulmonary vascular congestion can occur and right ventricular hypertrophy can occur.
Clinical Signs- May be asymptomatic or show signs of CHF, presence of a murmur, bounding pulses and widening pulse pressure
- Frequent URI’s
- These children may become diaphoretic while eating and they may tire while eating
PDA Treatment- Indomethacin soon after birth
- A prostaglandin inhibitor—the prostaglandin is what keeps it open. We don't want it open! Its supposed to be
closed by the first day of life. This is especially done in pre-term babies. They have prostaglandin E that’s still
circulating in their system keeping that open.
- If you do give Indomethacin, can give up to 3 doses and watch for necrotizing enterocolitis, GI bleed, and renal
flow.
- Surgical division or ligation- if the medicine doesn’t work (video-assisted thorascopic surgery to place a clip on the
ductus is being done as well)
- Use of coils in the cath lab
- Antibiotics post op for any of these procedures
- Ibuprofen—not as effective as indomethacin in low-birth weight babies and babies less than 27 weeks gestation
- There’s a low risk of mortality with theses babies.
Atrial Septal Defect (ASD)—Defect of Increased Pulmonary Blood Flow
- An abnormal opening between the atria, allowing blood from the higher pressure left atrium to flow into the lower
pressure right atrium. Left —> Right
- 10-12% of CHD
- More common in females
Clinical Signs- May be asymptomatic
- May have fatigue, shortness of breath on exertion, may develop CHF and respiratory infections
- Presence of a murmur (2nd intercostal space in systole and may be accompanied by a thrill)
- Dysrhythmias, pulmonary vascular disease and emboli formation later in life
- If an ASD is undetected, it can lead into a formation of emboli, which can then lead to a stroke, and this is from
chronically increased pulmonary blood flow.
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- Treatment
- Use of Dacron patch for closure of moderate to large, open bypass before school, and possible mitral valve
-
replacement (via median sternotomy, bypass and aortic clamping). Surgical interventions need to be careful of
where the SA or AV node is for conduction purposes.
Small defects may be closed in the cath lab- Patient will receive low doses of aspirin for 6 months after closure
Or it may close on its own before 4 years of life
Ventricular Septal Defect (VSD)—Increased Pulmonary Blood Flow
- Abnormal opening between the right and left ventricles. This is a Left to Right shunt.
- 20%-60% are thought to close spontaneously during the first year of life
- Most common CHD
- 15-20% of all CHD
Clinical Signs
- A small VSD may be asymptomatic and may close with
normal growth and development
- CHF is common, presence of a murmur, at risk for
endocarditis, and pulmonary vascular disease
- These children may also have increase respiratory
infections and poor weight gain (delay in growth and
development), and fatigue
VSD Treatment
- May close on own during 1st year of life
- If asymptomatic, wait for closure which could take up to
school age. Manage the child with Digoxin and Lasix as needed and observe for signs of pulmonary HTN,
prophylactically treat with antibiotics, and may use Captopril if needed for after load reduction.
- If symptomatic (such as having HF, FTT, aortic involvement, etc.)- surgical closure – open or cath can be done at
any time. A medium sternotomy with bypass and aortic clamping might be done. The hole can be closed with the
patch or stitches. The child is put on antibiotics to help prevent bacterial endocarditis.
Tetralogy of Fallot (TET)—Decreased Pulmonary Blood Flow
- 4 defects:
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A. Ventricular septal defect- opening in the ventricles- The VSD is usually large and unrestricted, which allows
for equal systolic pressure in both ventricles
B. Pulmonic stenosis (PS)- may be infundibular, valvular, supra-ventricular, or any combination thereof, the
degree of stenosis determines the degree of cyanosis. pulmonary valve may be normal or hypo-plastic.
C. Overriding aorta- aorta mixes with right and left ventricle, blood mixes together, usually straddles the VSD
and the degree of overriding aorta does vary.
D. Right ventricular hypertrophy- right ventricle muscle is enlarged, results from high ventricular pressure
Manifestations:
- Decrease pulmonary blood flow-depending
on degree of PS. This may help to protect
lungs from over-circulation from large VSD.
- High pressure in the RV due to outflow
tract obstruction causing shunt of blood
through VSD to LV
- Some blood flow may be from RV to aortadepends on the degree of overriding.
- Some infants may be cyanotic at birth,
others may have mild cyanosis that
progresses over the first year of life
- Most common cyanotic HD: 10% of CHD.
- If cyanotic at birth, will administer
prostaglandin to increase pulmonary blood
flow and surgery to keep the PDA open to
allow more mixture of blood.
- Presence of a murmur
- Presence of “tet” spells
- Have episodes of cyanosis or hypoxia because the infant’s O2 requirements exceed the blood supply usually
during crying or after feeding.
- Use calm approach. Give O2, morphine. Place in knee to chest position
- MORPHINE→ DECREASE DEFIBRILLATION, SPASMING ON VENTRICLES OF THE HEART
- Possible neurological complications and dehydration may occur as well ( may cause strokes)
- These children may have cyanosis, poor weight gain, and short stature
- May see an older child playing in the playground, and then immediately squats down. This is to prevent an episode
of “tet” spells.
TET Treatment- Palliative shunt (Blalock Taussig)- provides blood flow to the pulmonary arteries from the left or right subclavian
artery via a tube graft until correction of TET can be done.
- Complete surgical repair by putting child on bypass with aortic clamping
- Risk of dysrhythmias (heart block most common), sudden death, CHF
- Just know that there is a shunt that can get the oxygen he needs just long enough for him to be able to get the
repairs done.
Tricuspid Atresia—Decreased Pulmonary Blood Flow
- Failure of the tricuspid valve to develop. There is no
communication between the R atrium and the R ventricle.
- Cyanosis in newborn period, tachycardia and dysrhythmia
- Older children may have signs of chronic hypoxemia &
bleeding
- Blood flows through the ASD or patent ovale to the left side
of the heart and allows blood to get to the lungs
- It allows the mixing of the blood in the left side of the heart
Treatment
- Risk for endocarditis, brain abscess and stroke
- Newborns may be given continuous infusion of
prostaglandin E until surgical intervention arranged so the
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foramenal valley and ductus arteriosis can stay open
A pulmonary to systemic artery shunt is placed to increase the blood flow
Shunt – Glenn shunt- is the 2nd stage when the child is 4-9 months of age.
Then a modified Fontaine procedure is the final correction.
Complications of these surgeries include: dysrhythmias, systemic venous hypertension pleural and pericardial
effusion, ventricular dysfunction.
Obstruction Disorder: Coarctation of the Aorta
- Narrowing of the aorta usually is distal to the origin of the left subclavian artery, thereby the head and upper body is
affected. There is a decreased pressure to the lower body.
- Most common site is at the ductus
- Aortic narrowing increases resistance to aortic flow
- Increase left ventricular pressure and work load (after load)
- Blood flow to lower part of body is going to be decreased
-
Accounts for 8-10% of CHD
Often associated with other defects (VSD most common)
More common in whites, males
1/3 of girls born with Turners
Some familial cases reported
Different degree's of this anomaly
Clinical Manifestations
- Neonates with a closed PDA will have increased after load
of the LV
- Neonates with an open PDA will have increased pulmonary
blood flow and volume overload to the left side of the heart.
- Older children will have increased blood flow to the upper body and decrease blood flow to the lower body.
Increase after load to the left ventricle.
- The renal arteries receive decreasing flow
- Renin released, causing HTN in the ascending aorta
- Development of collateral circulation to the lower body
- Difference in extremity BP and pulse. The upper part of body will be hypertensive with bounding pulses while the
lower extremity will have lower BP with faint pulses. Must report a 10 mmHg difference in BP in infants. Most
deteriorate rapidly with HTN. They will be treated for their cyanosis. They may need mechanical ventilation and
anon tropic med support before surgery can do this.
- Decrease systemic perfusion
- Need supportive care before correction -usually
Treatment
- Surgical repair- may be emergent or electively done at 2-4 years of age. Surgery is treatment of choice for babies
less than 6 months of age and could be used for all patients. Surgery is done via a left thoracotomy with aortic
cross clamping.
- An end-to end anastomosis is usually done with the stenosed area being excised
- Balloon Angioplasty - common
- Antibiotic prophylaxis
Complications
- CVA/Stroke- monitor for this as part of your assessment
- Bleeding
- Lower extremity paralysis
- Hypertension that may last for a few weeks or months after surgery- if so, this is treated with nipride (HTN may
cause bleeding)
- Chylothorax
- Is caused from a type of lymph fluid called chyle that leaks into the thoracic space through their chest tube
- This accumulates in the chest cavity or the thoracic space, this often occurs after a thoracotomy
- It is treated by draining it, often with a chest tube
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- Ways to stop production of chyle is to give them a fat restricted diet and supplement with medium chain TGAs to
-
decrease that chyle production. Chyle is made of long fatty acid chains. Once chyle production decreases, it
closes the thoracic duct.
Recoarctation (later in life)
Transposition of the Great Vessels—Mixed Defects
- Pulmonary artery leaves the left ventricle
- Aorta exits from the right ventricle
- Results in no communication between the systemic and pulmonary circulation
- May be severely cyanotic and depressed at birth
- May have symptoms of CHF, murmur, cardiomegaly
- Child may need a septal defect or a PDA to
make the blood communicate. He also
may have a patent foramen ovale or VSD
Treatment
- Intracardiac mixing with prostaglandin E (to
keep PDA open)
- May have a cardiac cath to increase
mixing
- Surgery performed w/in 1st weeks of life
- A later surgery, you risk of dysrhythmia and
ventricular dysfunction later in life.
- Surgery may require multiple surgeries
before it can be corrected.
Impact on the Family
- Adjustment to a child with special needs.
They may be in shock, denial, angry
- How does this affect the parent-infant interaction?
- Protective?
- Discipline?
- We want these children to be as normal as possible regarding their social interaction AND NOT PART OF A
BUBBLE.
- So, yes indeed, there must be discipline and boundaries set upon what they can and cannot do. You do want to
be protective, but you also want to allow them to be a child
- MOST REQUIRE INITIAL SURGICAL INTERVENTION AND THEN LATER ON, ONGOING SX INTERVENTION.
Helping Families to Cope
- Listen—be present
- Educate
- Remember the stage of development!
- Support groups
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CARE OF CHILD WITH CARDIOVASCULAR DISORDER - PART 2
- Mnemonic to help remember order of auscultation
- Cardiac Electrode Placement
- Right side of chest above heart level (white)
- Abdomen – grounding lead (green or red)
- Left side of chest (black)
Cardiac Catheterization
- Catheter inserted through a peripheral blood vessel into the heart
- Through a large needle inserted either in a vein or an artery. Usually femoral artery.
- Fluoroscopy
- Used to help guide the catheter
- Contrast media (Dye)
- Injected when catheter is in heart chambers (up and around heart chambers). Films are taken for an
angiography. Measurements are done for different pressure readings. Pressure readings can be obtained from
different parts of heart
- Three types:
- Diagnostic: Catheter enters femoral vein or artery, up circulatory system then to heart (right atrium for right side
of heart, through artery and aorta, then to left side of heart) and look for abnormal pulses or identity any
structural problems.
- Interventional /Therapeutic: might have balloon on end. Dacron patch. Ream out stenosis. Ability to alter the
anatomy.
- Electrophysiology studies: Record heart impulses or destroy parts of heart generating abnormal conduction
Nursing Considerations
- Often an outpatient procedure unless child is already in NICU or PICU.
- Risks include:
- Hemorrhage from insertion site, N&V: side effect from the dye or anesthetic agent used, low-grade fever due to
foreign object being inserted, loss of pulse at cath insertion site could be from clot or hematoma or from a tear,
dysrhythmias – insertion of foreign object into heart could interrupt normal conduction
- Pre-op:
- Assess for allergies to contrast, ht & wt so know length of catheter needed to get to the heart, mark pulses (dp,
pt) – pedal and tibial - so we know where to mark and palpate post-procedure, baseline spO2 level, monitor for
infection, NPO 4-6hrs prior to catheterization.
- Prepare the child and/or parents by description of the cath room. Explain what they need to have done:
earphone might be used by older children to help distract them***, oral or IV sedation might be used, let
them know he/she might need an IV start if doesn’t already
- Post Op Considerations:
- Following cath- general post-op care
- Return directly to the room if inpatient or holding unit if outpatient
- Cardiac monitor and pulse oximetry initial hrs
- Most important nursing responsibility:
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- Assess – the 5 P’s* (pain, pallor, pulseless, paresthesia, paralysis, pressure), pulses distal to insertion site
-
(might be weak first few hours post procedure due to edema and inflammation, but should normalize/
increase gradually), fluids (prevent dehydration since have been NPO and might have lost blood; dextrose IV
fluid in for a while; dye is diuretic)
Temp and color of extremity – look at dressing for any type of bleeding. Put pressure right above insertion site if
bleeding. If bleeding – apply pressure 1 inch above site
VS – BP and pulse for 1 min for dysrhythmia or bradycardia, hypotension indicates hemorrhage.
BG for hypoglycemia- give dextrose IV fluid due to NPO status.
Lie flat after procedure: in mother’s lap with straight legs, sitting in bed, sitting in chair with propped legs. For a
venous access: lies flat for 4-6 hrs, for arterial access: lies flat for 6-8 hrs.
Remove pressure dressing day after surgery. Can shower, but no baths for a few days. Observe site. No
strenuous exercise allowed. Might be given ibuprofen or Tylenol for pain. Important to have f/u appointment.
Congestive Heart Failure (CHF)
- Often a consequence of congenital heart diseases we discussed in part 1
- Inability of the heart to pump an adequate amount of blood into systemic circulation to meet body’s demands
- Mostly occurs secondary to structure anomalies – such as septal defects causing increased blood volume in heart
and pressure. Failure where contractility is impaired such as myopathy or dysrhythmias
- Can also occur due to excessive demands as in sepsis and severe anemia
Pathophysiology- Left-sided Failure
- Left ventricle unable to pump blood into circulation
- Increased left atrial pressure
- Lungs congested with blood -- pulmonary edema
- Right-sided Failure
- Right ventricle unable to pump blood effectively into pulmonary artery
- Increased right atrial pressure & systemic venous circulation – hepatosplenomegaly, with edema
- Decreased blood flow to kidneys continues to stimulate Na & H2O reabsorption, causing fluid overload and
increased workload on heart, which can lead to congestion.
Signs & Symptoms of CHF- Clinical S/S are different in adults between the R and L side, but usually not easily differentiated in children
- Each side of the heart depends on the other for adequate functioning
- Failure to treat underlying cause results in heart muscle damage - leading to a decrease in Cardiac Output. This
affects many body systems.
- Three groups for symptoms:
- Impaired myocardial function: tachycardia, sweating, pale, decreased urinary output, weakness,
restlessness, anorexia, extremities that are pale and cool to touch, cardial megaly
- Pulmonary congestion: crackles, tachypnea, dyspnea, retractions, nasal flaring, cyanosis, grunting, wheezing
- Systemic venous congestion: wt gain from edema, hepatomegaly, periorbital edema, peripheral edema,
ascites, neck vein distension
- Clinical presentation varies among different children
- Early Signs & Symptoms:
- Tachycardia during rest and slight exertion
- Tachypnea
- Profuse scalp sweating, infants
- Fatigue, irritability
- Sudden weight gain
- Respiratory distress
- Be alert or parent statements such as:
- “The baby drinks a small amount and the stops and then wants to eat again real soon.”
- “The baby seems to perspire a lot during feeding”
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- “The baby is more comfortable when sitting up or on my shoulder than when flat.”
- “My baby has episodes of rapid breathing and grunting.”
- “Difficulty feeding” and “easily tired” are classic signs
CHF Goals of Treatment- Treat the underlying cause whenever possible.
- Want to:
- INCREASE CARDIAC FUNCTION by increasing contractility and decreasing afterload.
- Remove accumulated fluids and Na to decrease cardiac demands
- Improve tissue oxygenation to decrease O2 consumption
So how are we going to care for these children?
- Varying degrees of treatment for each one: NICU, Infant, and young children, etc.
- Nurse has responsibility to TEACH the parents or caregiver for discharge, so they can take care of them so they
can grow and until they’re large enough for surgery
Treatment of CHF
- Goal #1: Improve cardiac function
- Lanoxin (Digoxin) -- understand how it works
- Improves contractibility. Helps bundle fibers work in sync together
- Increases cardiac output, decreases heart size, decreases venous pressure, relieves edema
- Edema: results from back flow of blood in heart. When ventricles not able to push blood out, it causes
preload (blood before ventricles) to back up, thereby casing edema as blood stagnates in lower half of body.
- Used due to rapid onset; can be given PO or IV
- Elixir, calculated in mcg
- 0.05 mg/mL
- High potential for error and overdose. Requires check with another RN.
- Infants rarely receive > 1 mL of medication. Anything higher than 1 mL is a red flag!!
- Digitalization can be done initially– where ECG monitoring is done while IV or oral Digoxin given over 24
-
-
hr period, several doses given over 24 hrs and maintenance given usually twice/day. This is to reach the
body’s threshold or need for Dig.
- Therapeutic level – ***0.8 - 2.0 mcg/L***
- Monitor serum K: fall in K enhances effect of Digoxin. Can lead to Dig toxicity.
- Side effects: GI (N/V, anorexia) and Cardiac (bradycardiac and dysrhythmia)
Nursing Care:
- Watch for toxicity (GI and Cardiac signs)
- GI signs: N/V, anorexia; Cardiac signs: bradycardia and dysrhythmias
- Correct dosing
- Administration: Available in 0.05 mg/ml. Be very careful with calculation. Requires double check by
another RN. Infants rarely get more than 1 ml of Digoxin. Red flag if calculated to be >1 ml
Parental Teaching:
- Checking apical pulse prior to administration for full minute. If infant or young child: hold Dig when apical
pulse is < 90-110**. Older children: hold if apical rate is < 70***. Dig ultimately slows down heart rate, so
do not want HR to go below these numbers. Remember in adults, the number is 60 bpm. A medical order
is written based on the child for what the HR needs to be to hold Dig. Also hold if apical pulse taken is
significantly lower than previous apical pulse rate and let physician know.
- Observe the parents as they administer the med, usually 2 doses/day every 12 hrs
- Usually given twice a day. Every 12 hrs. Usually an hour before or 2 hours after eating – best on empty
stomach. Do not mix with food or liquid in case all of it is not taken. Small dose, make sure every spec of
it is given. Absorbed very quickly. If child vomits after administration, DON’T re-administer. If overdosed,
call Poison Control right away
- Antidote: Digibind or Digiband. Look at EKG strip to see if there’s an increase in PR interval, which
indicates Dig toxicity
- Goal #2: Afterload Reduction
- ACE Inhibitors – Captopril & Enalapril
- Capoten & Vasotec (assess for hypotension, cough, renal functionality)
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- Blocks angiotensin 1 conversion to angiotensin 2: vasodilation occurs, blocks aldosterone secretion
(therefore keeps potassium: causing hyperkalemia)
- Reduces afterload of heart, making it easier to pump
- Reduces preload of heart by preventing volume expansion from fluid retention and decreases hypokalemia
- Sparing K and excreting Na
- Beta-Blockers
- Blocks alpha and beta adrenergic receptors, causing decreased HR and BP and vasodilation. Good
response shown in adults, used selectively in children
- Side effects: dizziness, headache, and hypotension
- CRT: Cardiac Resynchronization Therapy can be used
- Is relatively new; used for severe ventricular dysfunction
- Nursing Care
- Monitor for hypotension, dizziness
- Monitor electrolytes and renal function: PAY ATTENTION TO Potassium!
- Goal #3: Remove Accumulated Fluid/Sodium
- Diuretics – Lasix, thiazides, Aldactone
- Lasix (get rid of Potassium, need Potassium supplement), thiazides (get rid of Potassium, need Potassium
supplement), Aldactone (spares potassium)
- Fluid restriction
- this is rarely needed as these children self regulate. It’s hard to get them to drink with CHF.
- Na restricted diets usually not used in kids because of negative effects on appetite
- If must be used, be sure to check their trays: no added salt diet (is more realistic) and potato chips
- Nursing Care
- Wt – same time, same amount of clothes, same scale each day
- Monitor electrolytes, dehydration status
- Give med same time each day – early in day so they won’t wet bed or void at night
- Potassium rich food due to the K losing diuretics
- IE. bananas, oranges, green leafy vegetables, whole grain
- Might need Potassium supplement elixir. Potassium supplement: super salty (tastes horrible), administer
with orange or grape juice to hide taste
- Be careful of dehydration. Children who are cyanotic and have polycythemia can have blood clots, keep
them hydrated
- Goal #4: Decrease Cardiac Demands
- Cardiac workload reduced through decreasing metabolic needs
- Limiting physical activity
- Treat existing infection
- Body temperature preservation- not having the stress of becoming cold
- Decrease work of breathing- by placing them in a semi Fowler’s position
- Medication to sedate an irritable child as needed
- Provide rest
- Nursing Care
- Rest
- Cluster care to minimize interruption and provide uninterrupted sleep, parents can stay for holding and
-
-
rocking; change linen only when necessary; bathe only when necessary; feed only when they’re hungry,
not when they’re crying (sign of hunger: sucking on fist)
Conserve energy for small feedings
- Q 3 hours
- Planned with sleeping periods
- Gavage when necessary to allow rest: putting feeding tube in
- Lavage = take out
Decrease anxiety
- Plan with older children: school at home
- Sedate infant to facilitate sleep as necessary
Temperature regulation
- Hyper and hypo thermia- need more O2
- Be aware of children getting cool humified O2 so they don’t get too cold
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- Treat infection promptly
- Skin Care
- If edematous (which they are)– change positions frequently and watch for skin tears
- Nutritional Status Maintenance
- Metabolic need greater d/t
- Poor cardiac function
- Increased heart and respiratory rates so they’re often fatigued.
- Nursing Care
- Rested to eat: feed when first wake up and about q3h
- Easy to suck nipple: enlarged slit or has a hole and soft
- Stimulate on jaw or cheek to get to suck
- Timing: don’t do >30 min as can be more tiring and use up more calories than taking in
- Gavage what they would not take within 30 min or if tachypnic (RR >70-80/min, usually temporary)
- Caloric density might need to be increased, can’t tolerate as much fluid. Add corn oil or MCT (medium
-
chain triglycerides) oil or polycose to formula. Normal formula: 20 calories/oz. Increase to 30 calories/oz,
adding slowly at rate of 2 calories/oz/day to avoid irritation of GI tract.
Can supplement breast milk with high-calorie formula or add calories to breast milk
Normal healthy newborn feeding goal: 108 kcal/kg/day. Cardiac Disease baby: up to 120 kcal/kg/day
- Goal #5: Reduce Resp. Distress and Improvement in Tissue O2
- Improve myocardial function
- Lessening tissue oxygen demands
- Use cool humidified O2 to increase the amount of available O2 during inspiration. O2 is a vasodilator,
-
decreases pulmonary vascular resistance, O2 is a drug and requires an MD order; It can be given via hood,
tent, nasal cannula, or mask
Nursing Care
- Assessment: 1 full min after administering for any respiratory distress signs, which can worsen congestive
heart failure. Assess rate and ease of breathing, saturation, and color
- Positioning to maximize chest expansion: infant seat, hold at 45 degree angle, several pillows for the older
kids to sleep with, loose clothes and diaper, safety restraint low on abdomen
- Infection control: infection is worse on child with CHF. Encourage good hand washing to everyone entering
room and to family. Start on antibiotics as soon as show signs of infection
- O2 Administration
Hypoxemia -- Hypoxia
- Hypoxemia: Altered oxygen tension (pressure) less than normal and identification by decreased arterial saturation
levels; decreased PaO2
- Hypoxia: Reduction in tissue oxygenation from low O2 saturation
- Cyanosis in children with heart defects due to desaturated venous blood entering systemic circulation without
passing through lungs
- Sats are usually 80-85%, in presence of deoxygenated hemoglobin
Chronic Hypoxemia- occurs over time
- Two changes occur over time to try to compensate
- A) Polycythemia –
- increased RBCs, blood viscosity, crowds clotting factors; can develop a CVA, developmental delays
- B) Clubbing –
- thickening and flattening of tips of fingers and toes.
- All the shunting of blood from the R to the L allows air in venous system to go directly to brain.
- IV lines need filters, need to be primed and checked for no air bubbles
- Child will be squatting to get oxygenated blood back to heart when going through hypercyanotic spells
- Hypercyanotic Spells (TET spells): infundibular venous spasm decreasing pulmonary blood flow, increases right to
left blood flow or shunting; occurs when communication between the ventricle and/or obstruction of pulmonary
blood flow is decreased. Child becomes acutely cyanotic and hyper apneic b/c of this. Happens when baby is
primarily >2 months of age and in first year of life often when blood draw is done or IV started.
- Risk for neurological involvement
- CVA, abscess, development delays (G&D)
- Will need fluid to decrease risk of CVA
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- Treat TET: morphine subQ or IV to decrease infundibular venous spasm, oxygen via face mask, Knee to chest
position helps as it reduces system venous return, and calm them down
Nursing Care- Family Focus
- The diagnosis of heart disease affects the whole family – Family Focus
- Goal is to help family adjust to the disorder: Initially shock, then anxiety/fear
- Educate family about disorder, they are scared
- Help family cope with the effects of the disorder. The more they know, the more prepared they are, the better they
can take care of their child
- Prepare child and family for any upcoming surgery
- Family might go through an initial period of shock when first find out, then anxiety and fear as they fear their child
may die. Oftentimes, need to help the family treat the child as normal as possible, with limit setting and discipline
and allow normal socialization and play. Parents might need help to learn how to manage
Preparing for Surgery
- Introduce child to environment: see where they’re going to be such as OR, Recovery Room, PICU
- Familiarize with equipment and procedures: show machines they’ll be hooked up to and how they can write and
communicate, familiarize family to equipment so they won’t be so scared walking in to so many tube and IV
connections.
- Post-op care delivered by ICU nurses
- Observe Vital signs very frequently
- Maintain respiratory status
- Monitor fluids – elevated BUN and creatinine. Signs of renal failure - < 1ml/kg/hr
Surgical Interventions
- Open heart surgeries
- Closed heart procedures
- Staged procedures- Oftentimes, need more than 1 surgery to fix heart condition
- Prepare child and family for procedures
Shunt Procedures
- Temporary measures until corrective interventions can be done
- Modified Blalick-Taussig: Subclavian artery to pulmonary artery shunt
- Central Shunt: Ascending aorta to main pulmonary aorta
- Bidirectional Glenn Procedure: Superior vena cava to the side of right pulmonary artery and both go to lungs
- Aspirin often given prophylactically to prevent clots and thrombus
Postoperative Care for the Child
- Monitor vital signs and Arterial/Venous pressures
- Intra-arterial monitoring of BP
- Intracardiac monitoring
- Respiratory needs such as intubation, off ET tube as quickly as possible, suction might be needed
Chest tube: increased output first 12-24 hrs post-op then begin to taper down and color begins to clear up, usually
removed day 1- 3, does hurt when removed so pre-medicate child, cover hole with petroleum gauze right away and
tape as if sealing it (do not want air to go back into pleural space)
- Rest, comfort and pain management: pain meds (morphine, epidural morphine, etc.) and non-pharm methods
(extra pillows, parents at bedside, favorite teddy bear, turning position, etc.). After tube comes out, can be on oral
pain meds.
- Thoracic insertions usually more painful than sternal. Child should be on continuous IV opioids and PCA if old
enough. Some might require a paralyzing agent to conserve energy. Epidural morphine is also being used. After
tube removal, can begin to wean to oral pain meds. Always plan for discharge,
- Fluid management: I&O, Input includes ice chips and IV flushes; watch for renal failure: notify MD if < 1mL/kg/hr,
check BUN and Cr, daily weights
- Progression of activity: up and walking post-op day 2 usually after tubes removal
- Emotional Support
- Discharge planning
Postoperative Complications
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Can be due to excessive pulmonary blood flow or fluid overload causing possible cardiac changes and CHF
Dysrhythmias due to electrolyte imbalance (watch K level), or interfered SA or AV node from surgical intervention
Watch for cardiac tamponade, cardiac infusion, and restricted function of heart
Hypoxia due to respiratory difficulty or inadequate pulmonary blood flow
Decreased cardiac output syndrome and peripheral perfusion: due to hyperthermia or left ventricle unable to
maintain circulation, can treat with Dopamine. Use assistive devices such as ECHMO is the medications fail. If
ECHMO fails, then he’ll need a transplant.
Pulmonary changes: pneumothorax, pulm. edema, and pleural effusion
Neurologic changes: cerebral edema, brain damage d/t hypoxia, seizures and infection
Hema changes: look at Hgb, Hct; might have RBC hemolysis, might have renal tubular necrosis, clotting issues
after prolonged heparin, anemia
Prognosis is good. Ventricular function return 2-3 days with meds and ventilator
Acquired Cardiovascular Disorders
- Bacterial endocarditis
- Rheumatic fever
- Hyperlipidemia
- Cardiac dysrhythmias
- Cardiomyopathy
- Hypertension
- Kawasaki Disease
Bacterial Endocarditis (KNOW!)
- Infection in the valve in the endocardium (inner lining of heart), grows and might break off, might go to adjunct
tissues or valves or kidneys or spleen or cerebral nervous system. Usually sequelae from sepsis in children with
cardiac disease or congenital anomalies
- aka BE, IE (Infective Endocarditis), or SBE (Subacute bacterial endocarditis)
- Streptococci, Staphylococci, Candida, Gram (-) bacteria
- May enter at any site, but most common is in heart (can come from dental procedures, UTI, catheters, venous
lines, and surgeries)
- Treated with high-dose antibiotics (penicillin, ampicillin, methocillin, moxicillin, streptomycin, gentamycin. Will need
blood cultures to evaluate effectiveness.
- 2-8 wks of antibiotics. If not successful, can develop CHF and damage to valves. If they do have valvular damage,
then continue IV therapy and give IV antibiotics at home.
- Fungal infections: amphoTerrible/Amphotericin
- Prophylaxis: for dental work and other high risk procedures (bronchoscopy, cystoscopy, tonsillectomy, etc.)
- New guidelines on p.1345
- Educate parents to report: malaise, fever, and anorexia. & teach to take all medications
Rheumatic Fever (RF) & Rheumatic Heart Disease
- Rheumatic Fever is inflammatory disease occurs after group A Strep such as upper respiratory involvement
- ß-hemolytic streptococcal pharyngitis (2-3 weeks after strep throat)
- Infrequently seen in U.S.; big problem in Third World
- Often in children not taking antibiotics post-strep throat or all antibiotics course
- Manifestations listed on p. 1345
- Self-limiting
- Affects joints, skin, brain, serous surfaces, and heart
- Rheumatic heart disease
- Most common complication of RF
- Damage to valves as result of RF
Clinical Manifestations of RF
- Need 2 majors OR 1 Major and 2 minors for diagnosis
- Major Criteria
- Carditis involving endocardium, pericardium, or myocardium; most commonly involving mitral valve
- Polyarthritis- is reversible; does migrate, especially in large joints such as knees, elbows, hips, shoulders, and
wrists; they appear red and swollen
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- Erythema marginatum: rash usually on trunk in proximal portion of extremities; red macula with clear center and
wavy well demarcated border
- Subcutaneous nodules: small, non-tender nodules which appear over bony prominences such as hands, feet,
-
elbows, scalp, scapulae, vertebrae; persist indefinitely after onset of the disease and resolve with no swelling
and resulting damage
- Chorea: irregular movements or jerky movements
Minor Criteria
- Arthralgia
- Fever
- ↑ESR
- Prolonged PR interval
Prevention of RHD so it doesn’t lead to CHF
- Full treatment of streptococcal tonsillitis/ pharyngitis
- Treatment of recurrent RF: take antibiotics or prevent getting strep
- Ongoing and continued antibiotics and prophylaxis, and salicylate for inflammation and pain. Could be monthly IM
injections or PO doses; could be daily doses or given 5 years after last episode or 18 years or up to adulthood
every day if no valve involvement or to age 40 if there is valve involvement
- Bed rest for the acute phase and prevent and treat. Get respiratory and throat cultures for sore throat
- Goals of therapy: get rid of strep, prevent cardiac damage, manage symptoms, and prevent reoccurrence
Kawasaki Disease (KNOW!)
- Acute systemic vasculitis
- Usually children <5 yrs old
- Not contagious. Unknown etiology
- Greatest risk of heart problems
- Risk for cardiac sequelae
- Heart muscle inflamed, around the heart there is potential for coronary artery aneurysm to be formed (look at
“Kawasaki Disease” picture). Inflammation of arterioles, venules and capillaries
- Risk for coronary artery aneurysms
Diagnosis
- Prolonged temp up to 4-5 days that is unresponsive to antibiotics
- Sore, red eyes which are not weepy
- Red lips, might be cracked
- Red tongue or red mouth (aka. Strawberry tongue)
- Redness and peeling on hands and feet
- Swollen hands and fingers
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Rash all over body
Swollen glands in neck
Cough, diarrhea, sore joints, and sore neck
Not happy babies; HARD to console
- Acute Phase: High fever, abrupt onset, unresponsive to antibiotics and
antipyretics (Tylenol doesn’t affect their
temperature), very irritable
- Subacute Phase:
- Resolution of fever, still very irritable
- Risk for aneurysm (child will need ECHO
to watch for development of aneurysm
because one of the sequelae of
Kawasaki’s is potential for the
development of aneurysms)
- Convalescent Phase: All but lab results
normal, 6-8 weeks to normalize
Treatment
- IV IgG:
- High dose, to reduce duration of fever and reduce risk of coronary artery abnormality
- Needs to be given in first 10 days of disease
- A single large dose of 2g/kg infused over 10-12 hrs
- Monitor infusion same way as you would when giving blood transfusion: for anaphylaxis, AE, etc.
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- ASA (not Tylenol!)
- High dose initially: 80-100 mg/kg/day in divided doses/6 hours for fever and inflammation, until fever is gone
- Then 3-5 mg/kg/day—After fever is gone, you continue to give Aspirin as an anti-platelet agent, given until
platelet count is back to normal
- Prophylactic aspirin for life (indefinitely) if develop coronary artery abnormality, or Plavix or Lovenox
- Coumadin for children with giant aneurysm > 8mm in size
Nursing Care
- Careful monitoring: cardiac status, I&O, weight, fluid with care due to myocarditis, watch for signs of CHF
- Gamma globulin administration: monitor just like blood products with the frequent VS checks
- Symptom relief: cool cloths, loose clothing, mouth and lip care, popsicle will help with lips and tongue
- Irritability management: quiet environment, parents can comfort, could last up to 2 months - normal
- Parent teaching of expectations: expected peeling of hands and feet at 2-3 weeks of dx – is painless
- Might see arthritis for a few weeks, stiff in the morning
- Might need to know how to do CPR at home depending on cardiac involvement
- Live vaccines deferred for 11 months b/c of gamma globulin and antibody formation
Hyperlipidemia
- Identify kids at risk and treat early
- Obesity is becoming common in our society
- Get fasting blood draw and look for an increased LDL in blood. This is a risk factor because it carries cholesterol
to the cells. Want it to be < 110. LDL: “Lousy”
- Increased HDL helps as it carries cholesterol to liver —> bile —> to be excreted. HDL: “Happy”
- Look at excessive lipids and fats. High lipids and cholesterol leads to atherosclerosis or fatty plaques
Treatment = start with dietary
- Eat more whole grains, fruits, vegetables. Restrict intake of cholesterol and fats.
- Increase exercise up to 60 min/day minimally
- If no response to diet —> Rx
- Colestipol (Colestid)
- Cholestyramine (Questran): not well-tolerated in children b/c of nasty side effects
- Statins: increase enzyme ability to have cholesterol synthesis; only recently approved for children but not used
often due to SE: muscle pain, digestion issues, memory loss
Pharmacological Meds Used with CV Disorders -- Those You Need to KNOW!!
- IV IgG
- Digoxin (Lanoxin)
- ACE inhibitors
- ASA, NSAIDs
- Lasix
- Spironolactone (Aldactone)
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MODULE: CARE OF CHILD WITH HEMATOLOGY/ONCOLOGY DISORDERS
Readings:
Hematological Disorders
Perry: 1362-1385
Neoplastic Disorders
Perry: 1408-1409, 1102-1104, 1561-1564, 1436-1438
Review
218-233, Perry: 1388-1390 (AIDS & transfusion therapy)
ANEMIA, SICKLE CELL, HEMOPHILIA - PART 1
Assessment of Hematologic Function
- Complete blood count
- What might you see in a hematologic condition?
- RBC, HCT, and Hgb would be decreased
- Normal ranges:
- Hgb: 11.5-15.5
- HCT: 35-45%
- Platelets: 140-400,000
- WBCs: 4.5-13.5. In WBC differential we’re looking for shanks and bands. Bands are immature neutrophils.
- History and assessment findings.
- Skin for bruising, petechiae, pallor
- Child’s energy and activity level, decreased
- Growth patterns, slowed down or tapered off
Anemia
- It’s not a disease—it's a symptom!
- The most common hematologic disorder of childhood
- Decrease in number of RBCs and/or hemoglobin concentration below normal for age
- Decreased oxygen-carrying capacity of blood and decreased amount of O2 available to tissues
- If it develops slowly, the child learns to adapt and it might not be noticeable right away
Classification of Anemias
- Etiology and physiology
- RBC and/or Hgb depletion such as in Iron deficiency anemia
- Morphology (shape)
- Characteristic changes in RBC size, shape, and/or color such as in Sickle cell anemia
Effects of Anemia on Circulatory System
- May see these things – What is the cause?
- Hemodilution- Fewer red blood cells, more fluid in the blood stream. The blood is diluted
- Decreased peripheral resistance- Less cells, less volume, less viscosity
- Increased cardiac circulation and turbulence
- The heart is trying to compensate
- …which may be indicated by hearing a murmur
- Increased cardiac work may lead to cardiac failure
- Cyanosis- A late sign, because of the ability of the child to compensate
- Growth retardation- due to the decreased cell metabolism
Therapeutic Management
- Treat underlying cause
- Transfusion after hemorrhage if needed
- Nutritional intervention for deficiency anemias (IE. iron)
- Supportive care
- IV fluids to replace intravascular volume
- Oxygen
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- Bed rest
- Often times the child is lethargic, fatigued, weak and needs rest
- You CANNOT put the child on strict bed rest
Nursing Considerations
- Prepare child and family for laboratory tests
- The child will be poked a lot for blood labs… prepare them by letting them know
- EMLA, child life (IE. let the child poke the doll)
- Decrease oxygen demands
- Play games, puzzles, etc. “Less stressful” activities, give O2 as needed
- Prevent complications
- Monitor them for infection and educate them on preventing techniques such as good hand washing, how to
assess temperature, and look for leukocytosis
- Support family
Iron Deficiency Anemia
- Anemia caused by inadequate supply or loss of iron
- RBCs are decreased in number, hypochromic, microcytic, and malformed. The membrane changes may
predispose to hemolysis causing further loss of RBCs.
Incidence
- Most prevalent nutritional disorder in US and the common mineral disturbance
- Most often see in 6-24 months
- Pre-term infants & adolescents are at risk
- Pre-term have a reduced Iron supply. Iron stores from the mother are done in the last trimester, so pre-term
babies don't acquire their mother’s storage into their livers
- Adolescents are in the rapid growth stage, and don't get enough iron (poor eating habits)
- Lower socioeconomic status
Etiology
- Decreased supply of iron
- Impaired absorption of iron
- Blood loss
- Increased body’s need for iron due to growth
- Affected synthesis of Hgb
- Caused by inadequate supply of dietary iron
- Most iron is transferred from mom during the last trimester, and is stored in liver, bone marrow and spleen. Fetal
supplies are available up until 4 months of age in full-term baby as it’s stored. There are less in premature baby.
- Maternal iron stores are adequate for 4 months in a full term infant.
- Maternal iron stores are adequate for 1 month in pre-term/multiple birth infants. These babies must be
supplemented after 1 month of age. They will usually get 2mg/kg/day of Fe (double of the full term baby)
- A diet consisting mainly of cow's milk (due to a diet of cow’s milk after age 1 and after age 2 years. This
happens because there is a perception that milk is the perfect food. These babies are called “milk babies” and
are usually toddlers, overweight because of the excessive amount of milk that is ingested), which is low in
absorbable iron, may lead to iron deficiency anemia. Cow’s milk alone does not contain enough iron
- The baby’s gut cannot handle the milk protein, which can cause them to bleed
- If a baby is exclusively breast fed after 4 months, they will need iron supplementation. Start them off with Iron
fortified rice cereal with 1mg/kg/day. Formula is already fortified with Iron.
- Vegetarian diets
- An assessment that needs to be done, to make sure the mother is consuming enough iron, vitamin B12 and
vitamin D. Good sources of Iron include: meat, shellfish, legumes, and foods rich in vitamin C to absorb Fe.
Manifestations
- Listlessness- Lack of energy
- Pallor (porcelain-like skin)
- Beware of chubby, pale infants with poor muscle development
- Prone to infection
- Impaired cognitive, behavioral skills, and often social problems- that may not reverse after correction
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- Pica- eating non-food items, odd cravings (IE. soil, paint, etc)
- Irritability
Diagnosis
- CBC, Reticulocyte Count, Peripheral Smear
- RBC— normal, microcytic, hypochromic
- Hgb↓
- Reticulocytes: normal or ↓
- Hct ↓
- SIC↓
- MCV↓
- TIBC ↑
- See normal RBCs vs Iron deficiency RBCs to the right
Prevention & Management
- Breast milk has very little of Iron.
- Baby needs 1mg/kg/day supplement at 4 months age until formula or iron fortified foods can be started.
- Babies who are fed formula should have iron-fortified infant formula for first 12 months
- Iron-fortified cereal started at 4-6 months of age.
- Special needs of premature infants- Ferrous sulfate drops 2mg/kg/day to breast-fed pre-term infants after 1 mo. of age, given until they’re 12
months. Iron fortified cereal will give them this. But until they can start eating the cereal they must be
supplemented.
- Limit amount of milk/formula to no more than 1 L/day = 24 oz.
- Babies under 12 months of age shouldn’t be given cow’s milk as it increases bleeding from an allergic reaction or
causes GI mucous damage due to the lack of heme protein.
- Infants 6-12 months of age require 11 mg/kg/day of Iron and this can be accomplished with their diet, but will need
to be supplemented if their diet is poor
- A toddler age 1-3 years needs 7 mg/day. Again if the diet is poor, need to supplement.
- Adolescents at risk due to rapid growth and poor eating habits
Therapeutic Management of Iron Def. Anemia
- Ferrous iron supplement (is what’s given at 4 months). It is more readily absorbed than ferric acid.
- Give them Vitamin C (IE. orange juice)- The acid facilitates absorption in the duodenum
- Give between meals (an empty stomach is an acidic environment) & Do not give with milk (Again it’s absorbed
better in an acidic environment. Milk also binds Fe and decreases absorption). If they can’t handle it on an empty
stomach give with juice.
- Stool changes- Tarry, green stool (This can be a good assessment question to evaluate compliance)
- Teeth stain in the older child (How can this be prevented?)
- Give them a straw or a syringe
- Have the wash their mouth or brush their teeth afterwards
- If they’re very deficient and need supplementation readily, they may need IM or IV Iron
- IM: Z-track method to make sure all the iron gets into the muscle. Don’t massage afterward
- They might even need a blood transfusion in severe cases for supplementation.
- Diet – iron rich foods. Being overweight as an infant or toddler isn’t a healthy sign as many believe.
- Evaluate the labs after administration of iron—you’ll typically see a rise in RBC counts after 5-10 days of
administration. A substantial increase occurs in 1 month.
Side effects of Iron Def. Anemia
- Rare in infants
- Nausea, gastric upset, diarrhea, constipation, anorexia
- If vomiting and diarrhea does occur, give with meals (but not with milk) and gradually increase the doses
Education
- Limit quantity of milk
- When to introduce solids (4-6 months)
- Overweight doesn't mean good health
- Give between meals, ÷ doses, w/citrus fruit/juice
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- Use straw and brush teeth after iron given
- Don't give iron with tea—because the tannin in tea form an insoluble complex with iron from foods other than meat.
Herbal teas may adversely affect Iron absorption.
- Stools will turn tarry green or black
- Keep out of reach of children
- Foods high in iron
- Red meats
- Liver
- Whole grains
- Green leafy veggies
- Peanuts
- Potatoes
Sickle Cell Anemia
- Inherited autosomal recessive defect in the hemoglobin synthesis
- HgbA is normal; SCA contain mostly HgbS differs by one amino acid.
- When the hemoglobin-S loses its oxygen, it becomes sickle or recent shaped and have
difficulty passing through small blood vessels. This causes the RBCs to clump together
- 8% or 1/400 of AAs are carriers of the trait; a carrier can live a normal life with minimal
health issues. If both parents have the trait, each offspring will have a 1/4 chance of
getting it. If one parent has the disease and the other parent is normal, all the kids
will have the trait. If one parent has the trait and the other has the disease, then
there’s a 50% chance that child will have trait or the disease.
- Mom:Disease (SS); Dad: Trait (SA)
SA/SS
S
S
S
SS
SS
A
SA
SA
Manifestations
- Usually they’re symptom free for the first several months up to a year because of the protection they get from the
HgbF (fetal hemoglobin). This prevents sickling of the cells
- The symptoms we see occur due to increased obstruction or increased RBC destruction
- Normal RBCs have a lifespan of 120 days The sickle RBCs containing mostly the Hgb-S have a lifespan of 15 days
Pathology
- Partial or complete replacement of normal Hgb with abnormal hemoglobin S (HgbS)
- Hemoglobin in the RBCs takes on an elongated “sickle” shape causing clumping
- Sickled cells are rigid and obstruct capillary blood flow; blood viscosity is increased
- Hypoxia occurs causing ischemia and infarction
- Diagnosis is done by a Hgb electrophoresis blood test
- Newborn screening is now done in order to detect it early (before 3 months) which prevents infection from
occurring (can start them on prophylactic antibiotics), therefore preventing a crisis (a period of exacerbation)
Sickle Cell Crisis
- Periods of exacerbation in a child with SCD
- Precipitating factors- Anything that increases body’s need for oxygen or alters transport of oxygen—
- Trauma
- Infection, fever
- Cold weather
- Physical and emotional stress
- Increased blood viscosity due to dehydration—DON'T LET KIDS GET DEHYDRATED
- Hypoxia- From high altitude, poorly pressurized airplanes, hypoventilation, vasoconstriction due to hypothermia
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- Oxygenated Hgb-S has the same shape as Hgb-B. When Hgb-S loses its O2 it becomes insoluble in
-
intracellular fluid and crystallizes into rod-like structures. Clusters of rods from polymers that bind erythrocyte
into the crescent shape.
All children with sickle cell disease are given antibiotics for prophylaxis (Penicillin) at 2 months -5 years to prevent
Strep and Pneumonia infection. A splenectomy is done in a history or Pneumonia or if child is a high risk child.
- 5 Types of Sickle Cell Crisis
- Vaso-occlusive [VOC] thrombotic crisis
- Most common type of crisis—very painful
- They’ll have stasis of blood with clumping of cells in microcirculation which leads to → ischemia → infarction
- Signs: fever, pain, tissue engorgement
- Dactylitis – swelling of hand/feet in toddler – often times an early sign of a vaso-occlusive event
- Splenic sequestration crisis
- Life threatening—death can occur within hours
- Blood pools (sickling) in the spleen and liver, the blood cannot leave because it is occluded
- You’ll be able to see the spleen getting bigger in the abdomen
- Signs: Profound anemia, hypovolemia, and shock
- Aplastic or hyperhemolytic crisis
- Diminished production and increased destruction of RBCs
- Triggered by viral infection or depletion of folic acid
- Signs: profound anemia, pallor
- Acute Chest Syndrome
- Pulmonary infiltrate—crisis in the chest. Capillaries in the lungs become occluded
- These patients will be in the ICU, with:
- Oxygen, deep breathing, blood transfusion, antibiotics—SUPPORTIVE CARE
- Signs: chest pain, fever, cough, wheezing, tachypnea, hypoxia
- Cerebral Vascular Accident (stroke)
- Sickled cells that block major vessels to brain- can be sudden and severe
- Results in infarction
- Signs include neurological impairment
Systems Affected
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Goals of Therapy & Nursing Management of Sickle Cell Anemia
- Treat medical emergencies
- Rest – maybe passive range of motion on unaffected extremities
- Careful multi-system assessment
- Abdominal assessment—looking for the swelling of the spleen
- Monitor for chest syndrome—SOB, CP, back pain, tachyacrdia, tachypnea, coughing, fever, low O2 sats
- Monitor for CVA—headaches, and change in behavior or LOC
- Observe for presence of inflammation or possible infection
- Antibiotics – treat aggressively
- Carefully monitor for signs of shock
- Hydration/ I&O/ VS for shock/wt. measurements
- Monitor for Priapism- Continuous or intermittent painful erection that wont subside
- Keep elevated, ice packs to groin area, aspiration of corpus cavemosum
- Oxygen therapy- if child is hypoxic. This does not fix or reverse the sickling, but it does help prevent further sickling
- Hydration – oral and IV- Need PO and IV hydration asap in order to help un-clump the RBCs
- Electrolyte replacement – hypokalemia
- If hypoxia is present it can cause metabolic acidosis which leads to increased sickling. Monitor for met. acidosis
- The destruction of RBCs releases K
- Assess, treat pain and prevent pain
- Heat helps with pain. Cold doesn’t as it causes increased clumping
- PCA pumps give the child a sense of control
- IV narcotics also given. For mild pain, start NSAIDs adding Codeine or progressing to IV if control is needed.
- Demerol (narcotic given short term works wonders) restrictions
- Long term administration leads to the break down of the metabolite nomeperidine, which causes seizures
and loss of pain control
- GOLD STANDARD: Morphine
- Do not hold pain meds, give them around-the-clock pain relief
- Monitor reticulocyte count regularly to evaluate bone marrow function
Sickle Cell Treatment
- Rx— ongoing research. There’s not a lot that can be done other than manage and prevent. But we can reduce SC
episode by increasing the production of fetal Hgb-F with is normal and not sickle-shaped. Hydroxyuria is being
used to help do this. Hydroxyuria treatment has recently been approved for use in children < 18 years
- Splenectomy
- Treatment for splenic sequestration, where blood is pooling in spleen and liver
- They will need to be on long term antibiotics, because they’re more susceptible to infefction
- Bone marrow transplant/stem cell transplant. HSCT – Hematopoietic stem cell transplantation – is being looked at
as only possible cure
- Methylpredisolone is effective in short-term use to help with pain control during a crisis.
- Blood/RBC transfusion as needed to reduce ischemia. Done often if there’s a high risk for strokes.
- Frequent transfusions increase Hemosiderosis (an increase Fe levels in the tissues) Iron can build up, and so
we treat with Iron chelation: Deferoxamine/Vitamin C given IV or subQ to bind with the excess Iron and be
excreted in the kidneys
Ongoing Nursing Management
- Monitor child’s growth—watch for failure to thrive
- Keep accurate growth charts; review/ compare. Physical and sexual maturation is a commonly delayed
- Immunizations: Pneumococcal and meningococcal vaccines and yearly influenza vaccine must be given and are
especially important for children who don’t have a spleen.
- Possible prophylactic antibiotics from 2 months—5 years
- Patient/Family Education- what to look for such as signs of infection and dehydration
- Prevent conditions for sickling- Keep hydrated – how? Particular/specific instructions/keep log of intake at home
Psychosocial Needs of Sickle Cell Anemia
- Coping mechanisms
- Support with genetic counseling
- Financial needs
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- Caregiver role strain
- Living with chronic illness in the family
Sickle Cell Prognosis
- No cure (except possibly bone marrow transplants) Supportive care/prevent sickling episodes
- Frequent bacterial infections may occur due to immunocompromise.
- Bacterial infection - leading cause of death in young children with sickle cell disease < 5 years of age and this is
why they’re often put on prophylactic antibiotics
- Strokes in 5%-10% of children with disease- Can result in neurodevelopmental delay, mental retardation
- Newborn Screening – most states
Aplastic Anemia
- Is bone marrow failure where all formed elements of the blood are simultaneously depressed aka
“pancytopenia” (Fanconi syndrome): leukopenia, anemia, and thrombocytopenia
- Hypoplastic anemia: profound depression of RBCs but normal WBCs and platelets
- Very poor prognosis and its rapidly fatal
- Confirm diagnosis of either by a bone marrow aspirate
Goal of management
- Recognition of underlying cause
- Treat by restoring function
- Immunosuppressive therapy (ALG- anti-lymphocyte globulin, ATG- anti-thymocyte globulin)
- Administered through a central line over 4 days for 12-16 hours a day
- These children will of ten times need Tylenol and steroids prophylactically to decrease SE of hypersensitivity,
fever, and chills.
- Oral cyclosporin (used in organ transplants) for those that don’t respond to ALG or ATG
- May have to give a colony stimulating factor
- Lastly, a bone marrow transplant for severe cases- The best treatment; has to be a matched donor. It’s best to
do stem cell transplantation before multiple transfusions are given. Have to watch the children very carefully for
infection. Irradiate the blood products they’re given because we want to give them leukocyte poor blood to
decrease risk for infection. Nursing care of these children is similar to those with cancer.
- The bad news: these children often die
Hemophilia
- What is it? – Hereditary disorder that results in deficiencies of anti-hemophilic factor, specific clotting factors. The
most common is Factor 8 or 9 deficiency.
- Rarely occurs in girls, females are carriers. X-linked recessive transmitted to sons only. Daughters of an affected
man will be a carrier.
- Two types:
- Hemophilia A
- “Classic hemophilia”
- Deficiency of factor VIII (8)
- Accounts for 80% of cases of hemophilia
- Occurrence: 1 in 5000 in males only.
- Degree of bleeding depends on the amount of clotting factors and severity of injury
- Up to a third of cases have no family history, where disease is caused from a new mutation.
- Hemophilia B
- Also known as Christmas disease
- Caused by deficiency of factor IX (9)
- Accounts for 15% of cases of hemophilia
- Affects mostly boys
- von Willebrand disease
- Affects both boys and girls
- Factor VIII deficiency and protein deficiency
Manifestations of Hemophilia
- Bleeding tendencies range from mild to severe. The platelet plug forms but the fibrin doesn’t solidify.
- Symptoms may not occur until 6 months of age since the child is being mostly carried around during this time.
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- Mobility leads to injuries from falls and accidents
Hemarthrosis- Bleeding into joint spaces of knee, ankle, elbow leading to impaired mobility
Ecchymosis = bruising
Epistaxis
Bleeding after procedures
- Minor trauma, tooth extraction, minor surgeries
- Large subcutaneous and intramuscular hemorrhages may occur
- Bleeding into neck, chest, mouth may compromise airway
Diagnosis- based on history, labs, and exams
- decreased factor 8 or 9
- DNA testing to confirm
- Can be through amniocentesis
- Child will have a normal platelet, pT, and fibrinogen count, the pTT is what is prolonged
Medical Management of Hemophilia
- DDAVP
- Increases the production of factor 8 (therefore, its good for hemophilia A only and not type B)
- IV infusion- The parent is trained to give it at home through a butterfly ~3x/week
- Causes 2-4 X increase in factor VIII activity
- Used for mild hemophilia
- Replace missing clotting factors
- Cautious use of NSAIDS – inhibit platelet function
- Steroids could cause hematuria.
- Transfusions:
- With factor 8 from pooled plasma or engineered recombinant
- At home with prompt intervention to reduce complications
- Following major or minor hemorrhages
- Can also be given prophylactically up to 3x/week
- Age 2-3 parents are taught how to do it, and between 8-10 years of age the child can do it.
Prognosis of Hemophilia
- No cure
- HIV exposure 1979-1985.Ryan White case.
- Historically most children die by 5years. Now mild to moderate hemophilia patients live near normal lives
- Gene therapy for future
- Infused carrier organisms act on target cells to promote manufacture of deficient clotting factor
Nursing Care: Goals & Interventions
- Prevent bleeding
- Assessment, avoid or decrease use of BP cuff
- Close supervision and safe environment
- Dental procedures in controlled situation with water pick, sponge, or a soft bristle tooth brush
- Shave only with electric razor
- Superficial bleeding—apply pressure for at least 15 minutes + ice to vasoconstrict. If significant bleeding occurs,
and/or transfuse factor 8 or 9
- Avoid IM injections or aspirations. Use subQ if you must.
- Do a venipuncture if you need blood, avoid heel and finger pricks since IV doesn’t destroy as many capillaries
- Support to family
- Insurance, care after 26 years
- Treatment can cost $60-$150,000/year (2013)
- Need to wear a medical bracelet
- Need to avoid contact sports
- Genetic Counseling- so that parents will know if they’re likely to pass it on to their other children.
Managing Hemarthrosis
- During bleeding episodes, elevate and immobilize joint (RICE)- Rest, ice, constriction, elevation
- apply pressure for at least 15 minutes if bleeding occurs. Ice – promote vasoconstriction
- Analgesics- if needed
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- ROM after bleeding stops to prevent contractures- PT
- Avoid obesity to minimize joint stress
Idiopathic Thrombocytopenic Purpura (ITP)
- Acquired hemorrhagic disorder characterized by
- Thrombocytopenia: ↑ destruction of platelets in spleen, but the bone marrow is producing the platelets just fine
- Purpura: discoloration caused by petechiae beneath the skin
- Normal bone marrow
- Usually happens between 2-10 years of age
- Could be autoimmune
- Acute self-limiting- Often follows URI or other infection
- Chronic (> 6 months duration)
Diagnostic evaluation
- Platelet count less than 20,000. Normal is 150-400,000.
- Therapeutic management
- Rest, prednisone, IV Ig (gamma globulin), monitoring vital signs, prophylactic antibiotics
- Prognosis – usually self-limiting
- Nursing considerations
- Supportive
- Therapy affects
- Activity
- Tylenol for pain
- No contact sports
ONCOLOGY - PART 2
Neoplastic Disorders
- Leading cause of death from disease in children past infancy
- Leukemia’s (1/3 of all childhood cancers) are most common, brain cancer is the 2nd most common, and typically it
doesn't metastasize outside brain. Osteosarcoma and Ewing’s is the next most common and rapidly metastasizes
- 4th leading cause of death during childhood (after accidents)
- Almost half of all childhood cancers involve blood or blood-forming organs
Nursing Considerations for Child with Cancer
- Assessment
- Look for increased signs of tiredness, night sweating, pain, bruising, headache, decreased appetite
- Nursing diagnosis
- Planning
- Implementation
- Prepare child and family for procedures (bone marrow aspirates, spinal taps, labs)
- Pain management
- Prevent complication of myelosuppression
Causes of Cancer
- Alteration of cellular growth in response to external and internal stimuli
- External factor (chemical) – genetic mutation
- Immune system – gene abnormalities
- Chromosomal abnormalities
- Emphasis is now on long term sequelae of interventions and timely interventions
- Recurrence – can be after treatment or years later and often a new malignancy different from the first
General Treatment
- One can come before the other; it depends on the cancer, size of the tumor, etc.
- Chemotherapy
- Surgery
- Radiation
- Then; if no luck with chemo/surgery/radiation-
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Bone Marrow Transplant
Stem Cell Transplant
Biological Response Modifiers
Target Cell Therapy - gene therapy
Chemotherapy
- Anti-neoplastic – kills cells. Good cells, bad cells, all cells. Non selective destruction of rapidly dividing cells
- Usually given in combination of drugs to hit cells at all phases of the cell cycle
- Drug resistance- different combinations of drugs are used
- Can be given by all routes: IM, IV, subQ, PO, IT (thecal), or even via cath to be directly placed on affected site
- Usually hospitalized for first therapy- since design on children isn’t as well researched
- Outpatient chemo is given often
- Sometimes even at home
- Affect multiple systems- all rapidly dividing cells; hair, mouth, GI tract
- Nadir score
- The time that the drug will cause the greatest suppression; neutrophil count will be the lowest. This is when you
want to protect child. For example, don’t take them to crowded places.
- Usually within 7-10 days post infusion
- Increased Susceptibility to Infection
- At time of diagnosis and relapse- their WBC is very low
- During immunosuppressive therapy
- After prolonged antibiotic therapy that predisposes to the growth of resistant organism
- Want ANC (Absolute Neutrophil Count) >500 before back to school
- Looks at segs and bands multiplied by WBC counts
- So if WBC is 1000, Segs 15% and bands 5%
- 15% + 5% = 20%
- 0.20 x 1000 = 200 ANC
- Infection Control
- Environment- Clean house, clean bathrooms, hand hygiene
- Diet high in protein and calories
- Visitor restriction, especially in Nadir time
- Watch for hemorrhage
- Limited invasive procedures
- No rectal temps, IMs, fingersticks, etc.
- Limit contact sports and activities
- Watch for temp and skin breakdown
- The most skin breakdown will be stomatitis (mouth) and bottom
- Vaccines are held when they’re in this immunocompromised state
- Managing Problems of Drug Toxicity
- Nausea/vomiting
- Prevent it!!! Zofran (Ondansetron) is the gold standard
- Dexamethasone can also be given as an anti-emetic
- 2nd generation anti-emetic Aloxi (palonosetron) it good for 72 hours!
- Anorexia- they just don’t feel like eating
- Let them eat what they want. This isn’t the time to tell them what not to eat because they won’t otherwise eat
- Alternative is NG tube or IV TPN
- Taste buds will change; things will taste metallic and everything will seem extra cold (IE. cold soda in the
-
mouth will be painful and everything will feel cold on their hands) this usually happens during the infusion
and a couple hours afterwards.
Mouth care- mucous ulcerations
- Soft toothbrushes
- Saline mouth washes
- Stay away from lemon glycerine swabs
- Milk of magnesia dries up the mucosa
- Hydrogen peroxide breaks down proteins
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- Can administer, but be careful with viscous Lidocaine because if it gets back in the throat their gag reflex is
altered and they won’t be able to swallow, it can be a choking risk
- Neuropathy- You’ll see foot drop or loss of sensation in fingers and feet
- Vincristine is notorious for inducing neuropathy
- Hemorrhagic cystitis- Bleeding in the bladder
- Antidotes are given after chemo infusion to help excrete the metabolites of the drug. IE. Mesna
- Alopecia- They need to protect their head! Wear hats when out in the sun
- Mood changes- drug induced depression, irritability
- Moon face- from the steroids
- Constipation
- Managing Chemotherapeutic Agents
- “Vesicants”- is an agent that causes blistering or sclerosis (tissue becomes hard from overgrowth of fibrous
tissue) even in minute amounts
- Extravasation- is the accidental administration of intravenously (IV) infused medications into the extravascular
-
space/tissue around infusion sites, either by leakage (e.g., because of brittle veins in very elderly patients),
previous venipuncture (such as from blood drawn for laboratory tests prior to therapy), or direct leakage from
mispositioned venous access devices.
Risk for anaphylaxis
Tumor Lysis Syndrome
- Chemotherapy rapidly destroys cells and puts all the metabolites into circulation
- The patient becomes hyperuricemic- Many times patient receives Allopurinol for this
Second Malignancies
Surgery
- Biopsy
- Removal of solid tumor or biopsy
- May get chemo or radiation to debulk and then surgery to remove
- Placement of CVC device. Can be a central line (aren’t seen as often
anymore) or a Port-a-Cath
- Chemotherapy must be given into a large vein with fast moving blood so that
it doesn't get stagnant and chemotherapy gets into major circulation fast
- Port-a-Cath (Intravenous Access Device)
- Child can go swimming, take a bath,
with no fear of it coming out. They can
do all this with a central line too but
need s a protective dressing first
- 90 degree Huber needle access
- The port is in subQ tissue and is
flushed once a week
- Nothing is showing from the outside
Radiation
- Curative or palliative or prevention
- Total body before transplants
- Affects rapidly dividing cells – nonselective
- Side effects similar to chemo – increased fatigue
- Brain radiation—have to be very careful about it because
its still growing rapidly in babies less than 3 years of age
- Protect skin that’s being radiated from sun, heat, cold.
Sometimes tattooed
Bone Marrow or Stem Cell
- High dose of chemo to destroy own marrow
- Infuse healthy marrow or stem cells IV. The bone marrow
aspirate isn’t put in to the bone but given as an IV.
- Before you can have this done- your body is zapped. You
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don't have any cell lines (0 counts), and you are kept in isolation. It replaces all of your cell lines. This will also
change your blood type! It’s better to get a transplant done sooner than later because if you’re getting transfusions
then body will develop all sorts of antibodies. It’s hard then to match those antibodies than to match cells.
- Syngeneic – identical twin
- Autologous – own marrow
- Allogeneic – donor who matches
Side effect –
- Rejection, graft vs host disease so we give them anti-rejection medication
- Swelling and petechiae rash
Anti-rejection medications—a life long process
Patients are in reverse isolation. Protecting child from us. Air is being forced out. They’re in positive pressure room
Patient will get a lot of supportive care. Don’t let live plant and flowers come into room that harbor bacteria, etc.
Biologic Response Modifiers
- Naturally occurring substances that influence immunize system function
- Helps to minimize the BM suppression
Target Cell Therapy
- Gene Therapy
- Antibodies that are tumor specific to certain cancers
- Produces in response to antigens from cancer cells
Nursing Diagnoses
- Risk for injury related to malignant process, treatment
- Risk for fluid volume deficit related to nausea, vomiting
- Altered nutrition
- Impaired skin integrity
- Altered family processes
- Fear related to diagnosis, procedures, treatments
- Pain
- Impaired physical mobility
- Altered mucosal membranes
- Risk for infections
- Anticipatory Grieving
- Growth & Development
Late Effects of Cancer and Its Treatment
- General intelligence, academic performance, memory and attention span
- Vision & Hearing loss
- Short stature & loss of bone growth
- Gonadal dysfunction
- Hypothyroidism
- Scoliosis, kyphosis, asymmetry
- LVD, CHF, CAD, arrythmia, risk of sudden death
- Interstitial pneumonitis & pulmonary fibrosis
Psychosocial issues
- affects whole family: parents, child, sibling(s)
- stressors: dx, relapse, off therapy, death
- finances, time away from work, school, home
- Create Normalcy
- School: re-entry program
- Discipline needs to be carried out just as in a child that doesn’t have cancer!
- Routines & rituals. Can have rest periods, but still need to do chores!
Leukemia
- Stem cell or blast cell leukemia
- Definition: Unrestricted proliferation of immature WBCs in blood forming tissues of body. Not a tumor.
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Morphology
- Acute lymphoid leukemia (ALL)
- The most common in children and easiest to cure in children, but not in adults.
- You can give child multiple rounds of chemotherapy and if then it still fails then, you do a transplant
- Acute non-lymphoid (myelogenous) leukemia (ANLL or AML)
- Outcomes aren’t good in children, but are better in adults.
- If they don’t respond to the first or second round of therapy, we go ahead and do a transplant because it’s such
a difficult cancer to beat.
Consequences of Leukemia
- What does it cause and why?
- Anemia
- Infection
- Bleeding tendencies
- Spleen, liver, and lymph glands show marked infiltration, enlargement, and fibrosis
- CNS – increased ICP- Lumbar punctures needed and IT meds, primarily Methyltrexate, to prevent CNS disease
- Bone pain
- Bone Marrow aspirate – definitive diagnosis (GOLD STANDARD)
Therapeutic Management
- Chemotherapeutic agents
- Cranial irradiation (in some cases)
- Normal Blood
Leukemic Blood
- Four Phases of Therapy- Do a lot of supportive therapy, prevention of SE, etc.
- Induction therapy: First 4-6 weeks.
- CNS prophylactic therapy: intrathecal chemotherapy if there’s a high chance of it metastasizing to brain. So
it’s done even if spinal fluid doesn’t show cancer cells.
- Intensification (consolidation) therapy: eradicate residual leukemic cells & prevent resistant leukemic clones
- Maintenance therapy: to preserve remission
- Re-induction: with alternative drugs as needed if relapse
- Hematopoietic Stem Cell Transplantation (HSCT)
- Donors may be relatives or non-relatives
- Antigen-matched or mismatched
- Peripheral stem cells may be used
- Stem cells from umbilical cord blood
- Significant risk of morbidity and mortality
- Graft vs. host disease (GVHD)
- Overwhelming infection
- Severe organ damage
- Cure after HSCT: up to 60%-70%
- Prognosis-
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- If relapse after HSCT: dismal prognosis
- Identified factors upon initial prognosis for determining prognosis
- Initial WBC count- normal?
- Age at time of diagnosis- if leukemia is diagnosed at 2-9 years, child has best prognosis
- Type of cell involved- AML vs ALL?
- Gender- girls have a better chance of having a longer life than boys
- Karyotype analysis to determine prognosis and longevity
- Late Effects
Lymphomas
- Hodgkin disease- More prevalent in 15-19 yrs of age
- Non-Hodgkin lymphoma (NHL)- More prevalent in children <14 yrs of age
- Hodgkin Disease- Neoplastic disease originating in lymphoid system
- Often metastasizes to spleen, liver, bone marrow, lungs, and other tissues
- Different histologic types
- Most common in boys, adolescents, and young adults
Classifications of Hodgkin Disease
- Classification A: asymptomatic- has a better prognosis
- Classification B: temperature of 38°C or higher for three consecutive days, night sweats, unexplained wt loss
of 10% or more over previous 6 months
Four Stages of Hodgkin Disease
- Accurate staging is basis for treatment and prognosis
- Ann Arbor staging
- Stage I – involvement of single node
- Stage II – 2 or more nodal regions on same side of diaphragm
- Stage III – lymph node involvement on both side of diaphragm with spleen usually
- Stage IV – disseminated spread extra-lymphatic
-
Therapeutic Management
Radiation- again fatigue as a big SE
Chemotherapy (alone or with radiation)
Prognosis – excellent for early stage. Risk for sterility of consider sperm banking
Nursing considerations – same as discussed
- Non-Hodgkin Disease:
- Approximately 60% of pediatric lymphomas are NHL
Clinical appearance
- Disease usually diffuse rather than nodular
- Cell type undifferentiated or poorly differentiated
- Dissemination occurs early, often, and rapidly
- Mediastinal involvement and invasion of meninges
-
Diagnostic evaluation- can see and palpate an enlarged gland
Therapeutic management- chemo and radiation
Prognosis- is good. relapsing after 2 years is rare
Nursing consideration- same as discussed above
Wilms Tumor
- Renal tumor
- Usually children <5 yrs of age
- Presents with abdominal swelling or mass, fatigue, weight loss
- Surgery and chemo and radiation depending on mets
- Survival is good, though secondary tumors may occur
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- Protection of remaining kidney considered as the affected kidney is removed.
- Nursing Considerations- DON’T palpate. If you touch it, it will spread!
CNS Tumors
- Brain tumors and neuroblastoma are derived from neural tissue
- Account for approximately 20% of childhood cancers
- Tumors are difficult to treat and result in poor survival rates
Brain Tumors
- Most common solid tumors in children, but 2nd most common cancer
- 60% occur in posterior third of brain- Primarily in cerebellum or brainstem
- 40% occur in anterior 2/3 of brain- Mainly in cerebrum
Diagnostic Evaluation
- Signs and symptoms are related to anatomic location, size, and child’s age
- Presenting clinical signs
- Neurologic evaluation- LOC, weakness on one side or the other, behavioral changes, VS changes, seizures
- MRI, CT, EEG, LP
- Histologic diagnosis via surgery- biopsy to determine what type of cancer it is and how it will be treated.
Therapeutic Management
- Depends on type of tumor
- Surgery
- Radiotherapy- remember not always done especially in cases if child is < 3 years
- Chemotherapy- water soluble agent is needed to cross the BBB
- Prognosis - poor
Nursing Considerations
- Obtain baseline database
- Prepare child and family for diagnostic and operative procedures
- Considerations related to body image
- Post-operative care- don’t want to lie patient in certain position
- Support child and family
- Promote return to optimum functioning
Neuroblastoma
- Most common malignant extracranial solid tumor of childhood
- Majority of tumors develop in adrenal gland or retroperitoneal sympathetic chain – abdominal area
- Other sites: head, neck, chest, pelvis
- Metastasis may have already occurred before diagnosis is made – Silent tumor
Diagnostic Evaluation of Neuroblastoma
- Objective is to locate primary site + sites of metastasis
- Signs and symptoms depend on location and stage of disease
- Radiologic studies, bone marrow evaluation
- IVP to evaluate renal involvement
Therapeutic Management of Neuroblastoma
- Clinical staging to establish treatment plan
- Surgery to remove tumor and obtain biopsies (staging done)
- Radiation, chemotherapy
Prognosis for Neuroblastoma
- Survival rates with all stages grouped together
- 75% of <1 yr age
- 50% of >1 yr age
- In general, younger at diagnosis = better prognosis
- May have spontaneous regression as embryonic cells mature and with development of active immune system
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Bone Tumors
- Osteosarcoma and Ewing sarcoma account for 85% of all primary malignant bone tumors in children
- Occur more commonly in males, with highest incidence during accelerated growth rate of adolescence
Diagnosis of Bone Tumors
- Rule out trauma or infection first, will usually have pain in the area
- Definitive diagnosis based on radiologic studies (CT scans, bone scans) and bone biopsy
- MRI to evaluate neurovascular and soft tissue extension
- Labs: elevated alkaline phosphatase with some bone tumors
Osteogenic Sarcoma/Osteosarcoma
- Most frequent malignant bone tumor type in children
- Peak incidence age 10-25 yrs
- Most primary tumor sites are in metaphysis of long bones, especially legs
- >50% occur in distal femur
- Other sites: humerus, tibia, pelvis, jaw
Therapeutic Management
- Traditional approach: radical surgical resection or amputation of affected area
- Limb-salvage procedures: resection of bone with prosthetic replacement of affected area
- Chemotherapy accompanying surgical treatment
Nursing Considerations
- Preoperative preparation is crucial
- Support during adjustment to concept of amputation, surgical resection
- Body image concerns—issues of adolescents
- Pain management- Phantom limb pain
Ewing Sarcoma
- Second most common malignant bone tumor in children and adolescents, rare in age >30 yrs
- Arises in bone marrow especially in
- Femur, tibia, ulna, humerus
- Vertebrae, pelvis, scapula, ribs, and skull
Treatment of Ewing Sarcoma
- Radiation most common first approach
- Chemotherapy as adjunct to radiation
- Surgical resection in some cases—usually able to preserve affected limb
- Prognosis best if no metastasis at time of diagnosis; distal lesions have best potential for cure
Nursing Consideration for Ewing Sarcoma
- Assisting family in dealing with diagnosis of malignancy
- Managing complications of radiation and chemotherapy
- Nutritional concerns throughout treatment regimen
Rhabdomyosarcoma
- Soft tissue tumor
- Malignant neoplasm originating from undifferentiated cells in muscle, tendon, bursa, and fascia or in fibrous,
connective, lymphatic, or vascular tissue
- Name reflects tissue of origin
- Myosarcoma (myo—muscle)
- Rhabdomyosarcoma (rhabdo—striated muscle)
Potential Sites of Rhabdomyosarcoma
- Eye Orbit- common
- Nasopharynx
- Paranasal sinuses
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- Middle ear
- Retroperitoneal area
- Perineum
Tumor Treatment and Prognosis
- Highly malignant and frequent metastasis
- Complete removal of tumor if possible
- Radiation therapy for most tumors
- Chemotherapy to shrink tumor may precede radiation therapy
- Long-term chemotherapy (1-2 yrs)
- Prognosis-improving
Blood Transfusion Therapy
- Verify identity of recipient and verification of donor’s blood group
- Monitor VS
- Use appropriate filter
- Use blood within 30 minutes of arrival
- Infuse over 4 hours maximum
Transfusion Reactions
- Hemolytic: the most severe, but rare
- Febrile reactions: fever, chills
- Allergic reaction: urticaria, pruritis, laryngeal edema
- Air emboli: may occur when blood is transfused under pressure
- Hypothermia
- Electrolyte disturbances: hyperkalemia from massive transfusions or pt with renal problems
Nursing Responsibilities
- Identify donor and recipient blood types and groups before transfusing
- Transfuse slowly for first 15-20 minutes
- Observe carefully for patient response
- Stop transfusion immediately if signs/symptoms of transfusion reaction; notify practitioner
Delayed Reactions to Blood Transfusion
- Transmission of infection
- Hepatitis, HIV, malaria, syphilis, other
- Blood banks test vigorously and discard units of infected blood
- Delayed hemolytic reaction
- Destruction of RBCs and fever 5-10 days after transfusion
- Observe for posttransfusion anemia
Family Concerns
- Difficult decision for HTSC transplant
- Child faces death without transplant
- Preparing child for transplant places child at great risk
- No “rescue” procedure if complications follow HTSC transplants
- Nursing considerations
Apheresis
- Definition: removal of blood from an individual; separation of the blood into its components
- Nursing considerations
Hematopoietic Stem Cell Transplantation (HSCT)
- Used to establish healthy cells in both malignant and nonmalignant disease
- Ablative therapy: high-dose combination chemo (with or without radiation) to eradicate unhealthy cells and
suppress immune system to prevent rejection of transplanted marrow
- Stem cells harvested from bone marrow, peripheral blood, or umbilical vein of placenta
- Stem cells given to patient by IV transfusion
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- Newly transfused stem cells repopulate ablative bone marrow
Allogeneic Bone Marrow Transplant (BMT)
- Involves matching histocompatible donor with recipient
- Limited by presence of suitable marrow donor
Umbilical Cord Blood Stem Cell Transplantation
- Rich source of hematopoietc stem cells for use in children with cancers
- Stem cells found with high frequency in circulation of newborns
- Benefit of umbilical cord blood is blood’s relative immunodeficiency at birth, allowing for partially matched unrelated
cord blood transplants to be successful
Autologous BMT
- Uses patient’s own marrow collected from disease-free tissue, frozen and sometimes treated to remove malignant
cells
- Has been used to treat neuroblastoma, Hodgkin disease, NHL, Wilms' tumor, rhabdomyosarcoma, and Ewing
sarcoma
Peripheral Stem Cell Transplants (PSCT)
- A type of autologous transplant
- Different type of collection from patient
- Stimulate production of high number of stem cells then collect stem cells by an “apheresis” machine
- Stem cells separated from whole blood
- Remaining blood cells and plasma returned to patient after apheresis
- Stem cells frozen for later transfusion to patient
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MODULE: CRITICAL CARE AND END OF LIFE
Readings:
Emergency Admission/Critical Care
Perry: 1125-1129
Care of the Dying Child
Perry: 1068-1081
Chronic Child Care
Perry: 1051-1068
Death and Dying
ATI: 97-105
END OF LIFE CARE - PART 1
Why do Children Die?
- Infants
- Congenital Anomalies
- Factors related to prematurity and low birth weight
- Sudden Infant Death
- Syndrome Respiratory Distress
- Children ages 1-4
- Accidents
- Congenital malformations
- Assault (homicide)
- Malignant neoplasms
- Diseases of the Heart
- Children ages 5-14
- Accidents (MVA and others)
- Malignant Neoplasms
- Congenital Anomalies
- Homicide/Assault (firearms)
- Suicide
- Influenza and Pneumonia
- Heart Disease
- Chronic Low Respiratory Disease
- Teens ages 15-24
- Accidents (MVA and others)
- Homicide/Assault (firearms)
- Suicide
- Malignant Neoplasms
- Heart Disease
- Influenza and Pneumonia
What Affects a Child’s Concept of Death?
- Age, cognitive developmental stage
- Prior experience with loss-death, illness/injury, family separation, moving
- Family’s emotion and how they deal with loss/death
- Communication within the family
- Child’s personality and life experience
Children’s Concepts and Reactions to their Death and Death of Others
- Infants (ages birth- 12 months)
- Trust VS Mistrust
- Death has little significance to children under 6 months
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- Loss of parent-child attachment and trust impacts infant
- Prolonged separation affects growth and development (physical, emotional, and social)
- Care Management
- Encourage parents to stay near to child
- Support care providers
- Provide consistency within the family
- Toddlers (ages 1-3)
- Autonomy VS Shame and Doubt
- Egocentric; think about things concerning them
- Cannot comprehend death—they think they’re still alive
- Reacts to parents anxiety and sadness
- Affected more by changes in lifestyle (the pain and uncomfortable feeling), than death
- Care Management
- Maintain normal environment, routine
- Provide ritual
- Be verbally affectionate/ reassuring
- If loss of parent, provide consistent care giver
- Preschoolers
- Initiative VS Guilt
- Magical Thinking - May believe their thoughts caused death – they feel very guilty; as if they caused the death
- Death may be seen as a departure-sleep
- Death seen as temporary and reversible
- Do not really understand the inevitability of death
- May revert to earlier develop-mental stages, giggling, laughing
- They have very limited coping- they hold it in denial
- Care Management
- Encourage parents to stay as near as possible with child
- Help parents deal with their feelings, so they can meet the needs of their child
- Encourage consistent caregiver if a parent has died
- Primary nursing
- Don’t ever lie to the patient. If you don't know the answer—tell them you don't know
- AVOID: “God has taken Grandpa” “Mom has gone to sleep” “You can always get another pet”
- Reassure and explain – use concrete words
- Tolerate the regressive behaviors
- School Age
- Industry VS Inferiority
- Associate misdeeds/bad thoughts as causing death & feel guilt/responsibility for loss—just like the preschooler,
-
they think its their fault
Fear mutilation and punishment they associate with death
Can comprehend logical explanations; death = concrete; curious
Personify death as the devil or a monster
By age 9-10—They begin to understand that death is inevitable, universal, and irreversible. Begins to
understand finality.
They have a great fear of the unknown
They have a difficult time understanding abstract things—IE. Heaven and spirituality
They’re interested in post-death services
They’re very concerned with “What’s going to happen to me?” “Who’s going to pick me up from school? Who’s
going to take me to practice?”
This can all be a delayed process, doesn't necessarily happen right away.
Care Management
- Child control over their body (Industry)
- Prepare them for the post-death processes (IE. the funeral/burial, etc.)
- Encourage talking about their feelings
- Provide outlets for their aggression
- Encourage parents to answer questions honestly
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- Care for the parents
- Encourage parents to share their sorrow with their child
- Allow for privacy
- Adolescents
- Identity VS Role Confusion
- Sees death as an interruption/an enemy
- Mature understanding of death
- Influenced by only some magical thinking; some feelings of guilt and shame
- Still coping with transition from childhood to adulthood
- Difficulty coping with death
- Least likely to accept death, especially their own
- They worry more about their physical appearance than their own prognosis
- They criticize funeral rights as unnecessary/barbaric, and money making
- They are much more concerned about today than tomorrow (present instead of the future)
- They alienate themselves from their parents and possibly their friends as well
- They may need to be told its okay to grieve
- They feel like they need to escape—acting out: speeding, sexually promiscuous, etc.
- Care Management
- Avoid alliances
- Allow some self control and independence
- Answer questions honestly -treat as mature individuals
- Respect need for solitude
- If they are ill, work with their parents to understand their child’s reaction to being ill and reaction to present
crisis
How to Talk to a Child about Dying
- Be honest. Remember the child’s age-brief age appropriate explanations.
- Avoid: “Its God’s will” “Baby brother is with God now” Don't ever tell the child “they’re going to sleep” whether its
regarding death, or anesthesia pre-op.
- Best if happens over time
- Let them and encourage them to ask questions remembering that you may not know the answers (and that is
okay)
- Be sure to tell the patient that some sicknesses can cause death; old age can cause death, accidents, etc.
- Don't lie to the child or keep any secrets! They will usually figure it out and they will be angry for not being told the
truth or for the truth being kept from them. BE HONEST.
- Listen
- Accept their feelings and them
- Let the child participate in their care—let them voice their opinion
How Do We Help Them Express Themselves?
- Colors, blank paper
- Paint
- Puppets
- Music
- Writing/journaling
- Books
- Play therapy
Care Need to Think About
- Palliative Care
- Treatment that wont cure, but will keep you comfortable
- Hospice Care
- EOL. May or may not have medical treatment. You give them what they need to live the last parts of their lives
the best they can.
- IE. A pain schedule, nursing equipment needed in the home, etc.
- Pain Management and Child Comfort
- One of the BIGGEST fears amongst dying patients
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Fatemeh Sahrapour
- Need to help the parent understand they wont overdose the child (with all the pain medications), and that
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addiction is not something we need to worry about at this time
Providing normalcy as long as they can
Needs of Siblings
DNR Status or Plan
Difficult Decisions—often times involves social workers, Chaplin, etc.
Home Care
Care for the Dying Child
- Involve the parents – how do they wish to have the child communicated to? Include them in the care
- Children very perceptive – help parents to understand importance of honesty
- Involve others – social work, chaplain, etc.
- School age child – ask how much they want to know, and who do they want to tell them? Give them time to
process their thoughts
- Involved siblings when you can. They often time feel really left out
Fears During the Dying Process
- Of pain
- Side effects of medications
- Addiction – not something worried about. Can build up a tolerance of the pain med where more is needed
- Of dying alone
- Final hours respiratory change – let parents know what to expect
- Irregular breathing, secretions in the chest
- Withdrawing of life support- Let them know what to expect
- Funeral arrangements
Care Providers
- What do we do, what helps, what does not help?
- Need to focus on our feelings, not generalizations
- Our next speakers will address some of these topics
- Focus on feelings – not generalizations
- Allow family to do what they need to do, to stay with child, to hold, cry, etc.
- Understand grieving process
- Refer to special groups for assistance
- Take care of self
END OF LIFE CARE - PART 2
Words Matter: The art of communication in the clinical setting
Communication is…
- A process by which we assign and convey meaning
- In an attempt to create shared understanding.
- This process requires a vast repertoire of skills in intrapersonal and interpersonal processing
- Listening
- Observing
- Speaking
- Questioning
- Analyzing
- Evaluating
- It is through communication that collaboration and cooperation occur
Facts
- Communication is:
- A core clinical skill essential to professional competence.
- An art that takes practice
- A process of human engagement; it is not a business transaction
- A partnership involving at least two people; thus, at least 50% of a conversation is in your control
Fatemeh Sahrapour
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- Article in Journal of Urban Health states” “Studies indicate that good physician-pt/fam communication can improve
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diagnostic accuracy and treatment adherence, increase satisfaction and fulfillment of both pt/fam and MD, reduce
risk of malpractice suits” and aid in alleviating psychological, emotional, and spiritual distress…
Studies in 1997, 2002, 2004, and 2005 prove that: “Communication is most commonly discussed challenge and
perhaps the most important component of effective care for pts and fams”
Never the same person, context, content, variables are abstract, invisible, and constantly changing
This doesn’t let you off the hook, it just states that even when you are on you’re a-game, miscommunication can
happen
Basic Communication Needs
- To feel respected
- To exchange information (give and/or receive)
- To be heard and feel understood
- To accomplish something (create plan, clarify, learn)
- To adjust emotional distance
- Can you think of other things that you need when you are communicating with your pts/fams?
- Can you think of other things they might need from you?
Common Communication Scenarios in Clinical Setting
- Delivering difficult news
- Engaging a complex or “difficult” family
- Deciding on end-of-life care goals
- Discussing quality of life issues
- Reframing expectations
- Preparing for complications ahead
What are Barriers to Communication?
- Emotions
- Time limitations
- Comprehension abilities
- Language and cultural differences
- www.blogs.utmb.edu/pastoralcare
- Perceptions of reality
- Impenetrable religious language
- Values
Communication “Be’s”
- Be human
- Be authentic, honest (no false hope, no exaggerating)
- Be clear and direct (no jargon, no superfluous info)
- Be compassionate (appreciate the circumstance of the other)
- Be willing to collaborate with family—goals for patient’s care
- Be aware of your own emotions
- Be at eye level in the conversation—for the entire conversation
- Be both focused and flexible
- Be attentive to what is being said and what is not being said (non-verbal cues)
- Be committed to establishing rapport
- Be reminded that you are part of a team—be aware of the people resources available to you
- Be gracious and forgiving (to self and others)
- Be okay with silence
Options when Effective Communication isn’t Happening
- Explore new ways of communicating
- Ask family how they communicate best—find a point person to help
- Utilize other members of the team who have different communication styles
- If possible, take a break and reconvene
- Grace yourself, grace them, and do the best you can
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Back-Pocket Phrases
- “If I’ve hears you right, you seem to be saying...”
- “I wish that I had other news to give you but...”
- Working as a team, partnership, depending on and trusting each other
- Art of negotiation, give and take
- Interest in emotion
- Fire a warning shot so fam is not caught-off guard about content of discussion
- Assessing clarity and comprehension
- Affirming emotional exchange as helpful
- “I want to be sure that what we have talked about is clear.”(Assesses understanding)
- “Are you familiar with _______ procedure? What do you understand of ______________ procedure?”
- “Do you have thoughts about where things are going with your child’s illness/condition?”
- “I’m happy to answer that and give you as much information as I can, but do you mind telling me what made you
ask that question?”
- “What do you hope for (your child in) the future?”
- “What concerns do you have at the moment?”
- “Doctors sometimes forget and use words that may not be understood. Please stop me if I begin to do this.”
Chaplain is...to Patients
- Congregational/Community connection
- Comfort
- Communication
- Cultural information
Chaplain is...to Staff:
- Peer/Team Member
- Encourager
- Resource
- Bereavement Support
- Goals for Communication
- Give information
- Hear other person’s needs, thoughts
- Gain additional insights and ideas
- Remain in conversation/relationship
- Perhaps alter opinion/perspective
- Sometimes come to a decision or conclusion
Goals for Communication
- Give information
- Hear other person’s needs, thoughts
- Gain additional insights and ideas
- Remain in conversation/relationship
- Perhaps alter opinion/perspective
- Sometimes come to a decision or conclusion
- Patient/Family centered communication can improve outcomes such as psychosocial adjustment, patient
satisfaction and treatment adherence, thus contributing to better overall quality of life.
Conversation Tool
- AMEN
- Affirm the patient’s belief/feeling
- Meet the patient or family member where they are
- Educate from your role as a medical provider
- No Matter What...assure the patient/family that you are committed to them.
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Sounds like…
- “thanks, but we are hoping for a miracle and fully expect it to happen.”
- I, too, am hopeful.
- I join you in praying/hoping for a miracle.
- My job is to assist with providing you with medical information as we hope. There are some issues that need
addressing as we wait….
- No matter what happens , I will be with you every step of the way.
Continue Conversation
- Normalizes religious language by framing it in concept of hope.
- When we say but… patient/family are dismissed and provider tries to compete with God
- Hope is assurance that medical team is committed to the patient, regardless of the outcome. Hope becomes the
way to reframe the conversation as well as continue the conversation.
Child Life Perspective
- Offer parents lasting keepsakes- impressions kit, silver charms of child’s fingerprint