Lesson 50: Pediatric Disorders

Scabies
Part 1: Integumentary Disorders Description
 This skin disorder is caused by infestation with Sarcoptes scabiei, the
Impetigo "itch mite."
Description  Infestation is transmitted by way of close personal contact with an
 This highly contagious bacterial infection of the skin is caused by infected person.
beta-hemolytic streptococci, Staphylococcus aureus, or both.  Because of close personal contact among members of these
 The most common sites are around the mouth, the hands, the neck, populations, scabies is endemic among schoolchildren and the
and the extremities. institutionalized.
 Assessment findings include:  Assessment findings include:
o Vesicles or pustules surrounded by edema and redness o Intense pruritus, especially at night
o Lesions weeping cloudy serous fluid o Pustules
o Honey-colored crusts o Burrows, which appear as fine grayish-red lines on the skin
o Pruritus and burning
Nursing Considerations
Nursing Considerations  A scabicide is applied topically (but lindane cream should not be
 Use contact precautions and stress the need for such precautions at used in children younger than age 2 because of the risk of
home. neurotoxicity and seizures).
 Soak the crusts and then wash them off with a warm, soapy wash  Apply the medication to the body and head (depending on age),
cloth three times a day, apply antibiotic ointment and allow to air avoiding the eyes and mouth; the medication must remain on the
dry; teach parents to perform this activity. child for 8 to 14 hours (depending on the medication prescribed) to
 Teach the parents to apply antibiotic ointments and explain that the be effective, so applying it at bedtime is recommended, it is washed
infection is communicable for 48 hours after antibiotic ointment off in the morning.
treatment is begun.  Household members and contacts of the infested child must be
 Explain that the infection is communicable for 48 hours after treated at same time as the child.
antibiotic ointment treatment is begun.  Stress the importance of frequent handwashing.
 Tell the parents that the child must use separate towels, linens, and  Explain to the parents that all clothing, bedding, and pillowcases
dishes. used by the child must be changed daily, washed in hot water with
 Explain to the parents that the child's linens and clothing should be detergent, dried in a hot dryer, and ironed before reuse.
washed separately with detergent in hot water.  Tell the parents to seal nonwashable toys and other items in plastic
bags for at least 4 days.
Pediculosis capitis Infestation (Head Lice)
Description Part 2: Oncological Disorders
 Lice live and reproduce only on human beings and are transmitted Nephroblastoma (Wilms Tumor)
by way of direct and indirect contact (e.g., sharing of brushes, hats, Description
towels, bedding).  This tumor of the kidney may present unilaterally and localized or
 The most common site of infestation is the occipital area; less bilaterally, sometimes with metastasis to other organs.
frequently, the eyebrows and eyelashes are affected.  Treatment is a combination of surgery (partial to total nephrectomy)
 Assessment findings include: and chemotherapy with or without radiation.
o Intense pruritus  Assessment findings include:
o Small, gray specks that may crawl very fast o Abdominal swelling or mass (firm, nontender, confined to one side,
o Nits, visible as tiny silver or gray specks resembling dandruff and deep within the flank)
o Abdominal pain
Nursing Considerations o Urine retention
 Use of a pediculicide shampoo will be prescribed and parents should o Hematuria
be taught to follow the directions on the prescription. o Hypertension
 Teach the parents to remove nits by back-combing the child's hair o Symptoms of lung involvement if metastasis has occurred
with a fine-tooth comb after loosining nits with a mixture of half
vinegar and half water 1 hour before back-combing; It is easier to Nursing Considerations
comb the child's hair for nit removal when the hair is damp rather Before Surgery
than wet or dry.  Monitor the client’s vital signs, particularly blood pressure.
 Tell the parents that bedding and clothing used by the child should  Avoid palpation of the abdomen, which could disrupt the tumor
be changed daily, laundered in hot water with detergent, and dried capsule, resulting in seeding elsewhere in the body.
in a hot dryer for 20 minutes.  Measure the client’s abdominal girth daily each morning.
 Instruct the parents that items that cannot be washed in hot water
should be dry cleaned or sealed in a plastic bag for 2 - 3 weeks. After Surgery
 Tell the parents to discard hairbrushes and combs or soak them in  Monitor the client's temperature for signs of infection; monitor the
hot water (greater than 140° F [60° C]) and to teach the child not to blood pressure for any changes.
share clothing, headwear, or brushes and combs.  Monitor for hemorrhage.
 Instruct the parents to vacuum furniture and carpets frequently.  Monitor intake and output, closely, particularly urine production.
 All contacts of the infested child should be examined.
 Monitor gastrointestinal activity, bowel sounds, stool production o Localized pain at the site (severe or dull) that may be attributed to
and for abdominal distention. trauma or the vague complaint of "growing pains"; often relieved
 Instruct the parents about signs of complications and the need to with a flexed position
avoid contact sports to prevent injury to the remaining kidney. o Palpable mass
o Limping, if weight-bearing limb is affected
Neuroblastoma o Progressively limited range of motion with curtailment of physical
Description activity by the child
 Neuroblastoma, an embryonal tumor found in children, arises from o Inability, depending on the site of the tumor, to hold heavy objects
the neural crest.
o Pathological fractures at the tumor site
 The abdomen is usually the primary site because the tumor cells (see
Nursing Considerations
image) arise from the adrenal gland or retroperitoneal sympathetic
chain; other sites include the head, neck, chest, and pelvis.
 Prepare the child and family for the prescribed treatment
modalities.
 Most presenting signs are caused by tumor compression of adjacent
normal tissue and organs.  Tell the child about phantom limb pain (burning, aching, or cramping
pain in the missing limb) and reassure the child that the condition is
 The prognosis is poor because of the frequency of invasiveness and
normal.
because in most cases a diagnosis is not made until after metastasis
has occurred.  Prepare the child for prosthetic fitting, as necessary, if surgery is
performed.
 Surgery is performed to remove as much of the tumor as possible
and to obtain biopsy specimens.
 Help the child deal with the problems of self-image.
 Radiation, commonly used in late-stage disease, provides palliation
Retinoblastona
for metastatic lesions in the bone, lung, liver, and brain.
Description
 Chemotherapy is the primary treatment for extensive local or
 Retinoblastoma is a rare, malignant tumor of the embryonic neural
disseminated disease.
retina.
 Assessment findings vary with the tumor site and degree of
 This tumor of the eye is found only in children.
invasiveness.
 A white reflection (leukocoria) is seen in one of the child's eyes
 Firm, nontender, irregular mass in the abdomen that
instead of the normal red color when a camera flash is reflected off
crosses the midline
the retina.
 Urinary frequency or urine retention resulting from
compression of the kidney, ureter, or bladder Nursing Considerations
 Lymphadenopathy, especially in the cervical and  Facilitate the educational process so families are informed of what
supraclavicular areas to expect, decreasing fear and anxiety.
 Bone pain, if skeletal involvement has occurred  Postoperative care of the enucleated orbit entails careful
 Supraorbital ecchymosis, periorbital edema, and observations for signs of infection, hemorrhage, and edema.
exophthalmos resulting from invasion of retrobulbar soft  The child will wear a patch over the socket for approximately 1 week
tissue postoperatively.
 Signs of respiratory impairment (thoracic lesion)
 Signs of neurological impairment (intracranial lesion) Ewing Sarcoma
 Paralysis resulting from spinal cord compression Description
 This bone tumor is most often located in the midshaft of a long
Nursing Considerations bone, especially the femur, ribs, and pelvic bones, or in the
 Before surgery, monitor the child for signs and symptoms related to vertebrae.
the location of the tumor.  Assessment findings include:
 After surgery, monitor the child for complications related to the o Pain
location of the surgery. o Swelling of soft tissue around the affected bone
o Fever
 Watch for complications related to chemotherapy or radiation, if it is
o Anorexia, malaise, fatigue, and weight loss if metastasis has
prescribed.
occurred
 Provide support to the parents and encourage them to express their o Neurological symptoms if a vertebral tumor is present
feelings; many parents suffer from guilt at not having recognized o Respiratory symptoms if a rib tumor is present
signs of disease earlier.
 Refer the parents to the appropriate community services Nursing Considerations
 Prepare the child for the administration of chemotherapy, surgical
Osteogenic Sarcoma (Osteosarcoma) resection of the tumor, and, possibly radiation.
Description
 Nursing care is similar to that for the child with osteosarcoma.
 This tumor is usually found in the metaphyses of long bones,
especially the legs; most cases occur in the femur.
 Symptoms in the earliest stage are almost always attributed to
extremity injury or normal growing pains.
 Treatment may include surgical resection with limb salvage to
remove affected tissue or amputation.
 Chemotherapy may be administered both before and after surgery.
 Assessment findings include:
 Part 3: Metabolic and Endocrine Disorders
Growth Hormone (GH) Deficiency
Fever Description
Description  Growth hormone (GH) deficiency results from inadequate
 Fever is the name given to an abnormally high body temperature. production or secretion of GH, causing poor growth and short
 A child's temperature may vary with activity, emotional stress, type stature.
and amount of clothing being worn, and environmental  Hypoglycemia may be a manifestation of GH deficiency.
temperature.  Signs/symptoms typical of GH deficiency include height less than 5th
 Assessment findings associated with fever provide important percentile for age and gender, diminished growth rate (less than 2
indications of its seriousness; findings include: standard deviations below the mean for age and gender), immature
o A temperature of 100.4° F (38.0° C) or higher or cherubic facies and delayed puberty.
o Flushed skin
o Diaphoresis Nursing Considerations
o Chills  Administer replacement therapy; synthetic growth hormone comes
o Restlessness or lethargy in a powdered form that must be diluted for administration or a
o temp 100.4F (38.0° C) premixed liquid form.
 Adminster synthetic growth hormone as a subcutaneous injection six
Nursing Considerations or seven times per week, usually at bedtime.
 Monitor the child’s temperature per agency policy.  Educate children and families about the proper dilution and
 Administer antipyretics (e.g., acetaminophen or ibuprofen) as administration of the growth hormone.
prescribed.  Remind the child and parents that growth hormone therapy is
 Do not administer aspirin (acetylsalicylic acid, ASA) unless continued until the child reaches an acceptable adult height or
prescribed, because it may precipitate the development of Reye radiographic evidence shows growth plate fusion.
syndrome.
 Retake the temperature 30 to 60 minutes after an antipyretic is Phenylketonuria
administered. Description
 Provide adequate fluid intake as tolerated and as prescribed.  This genetic disorder, also known as PKU, causes central nervous
 Monitor the child for dehydration and fluid and electrolyte system damage, the result of accumulation of a toxic level of
imbalances. phenylalanine in the blood (normal level is 1.2 to 3.4 mg/dL (72.6 to
 Instruct the parents in how to take the temperature, how to safely 205.8 mcmol/L) in newborns and 0.8 to 1.8 mg/dL (48.4 to 109.0
medicate the child, and when it is necessary to call the health care mcmol/L) thereafter).
provider.  All 50 U.S. states require routine screening of newborn infants for
PKU (PKU testing is universally offered but not required in any
Dehydration Canadian province or territory except Saskatchewan.)
Description  Assessment findings vary with the age of the child.
 Infants and children are more vulnerable to fluid-volume deficit than
are adults because more of a child’s body water is in the All Children
extracellular fluid compartment and because the organs that
conserve water are immature.
 Digestive problems and vomiting
 Causes include decreased fluid intake, diaphoresis, vomiting,
 Seizures
diarrhea, diabetic ketoacidosis, and extensive burns or other serious
injuries.  Musty odor of the urine
 Assessment findings depend on the severity of dehydration:  Mental retardation
o Dry skin and mucous membranes
o Loss of skin elasticity and turgor Older Children
o Tachycardia
o Sunken eyeballs and fontanels  Eczema
o Weight loss
 Hypertonia
o Decreased urine output and increased urine specific gravity
o Thirst  Hypopigmentation of the hair, skin, and irises
o Absence of tears  Hyperactivity
o Changes in the level of consciousness
Nursing Considerations
Nursing Considerations  The newborn should be screened for PKU (formula or breast feeding
 Monitor the child for signs of dehydration. should be started before specimen collection).
 Provide oral rehydration therapy with solutions, as prescribed, if the  The infant is rescreened by 14 days of age if the initial specimen was
child is able to tolerate fluids orally. collected before 48 hours of age.
 Administer intravenous fluids and electrolyte replacements, as
prescribed, if the child is unable to take sufficient fluids orally. If PKU Is Diagnosed
 Introduce a regular diet as prescribed when the child is rehydrated.  Restrict phenylalanine intake; high-protein foods (meats and dairy
 Provide instructions to the parents about the types and amounts of products) and grains are avoided.
fluid to be encouraged, signs of dehydration, and indications of the  Monitor physical, neurological, and intellectual development.
need to notify the health care provider.  Stress the importance of follow-up treatment to the parents.
 Part 4: Gastrointestinal Disorders Nursing Considerations
 Assess the child's ability to suck, swallow, handle normal secretions,
Vomiting and Diarrhea and breathe without distress.
Description  Modify feeding techniques; plan to use specialized feeding
 The major concerns with vomiting and diarrhea are aspiration, techniques, obturators, and special nipples and feeders.
dehydration, loss of fluid and electrolytes, and the development
of metabolic alkalosis (with vomiting) and metabolic acidosis (with
diarrhea).
 During assessment the nurse should be alert to:
o Signs of aspiration in a child who is vomiting
o The character of vomitus or stools
o Pain and abdominal cramping
o Signs of dehydration
o Signs of fluid and electrolyte imbalances
o Metabolic alkalosis or metabolic acidosis

Nursing Considerations
 Maintain a patent airway; position the child who is vomiting on the
side to prevent aspiration. 1, Mead Johnson bottle and nipple for cleft palate. 2a, Cleft palate
 Monitor the character, amount, and frequency of vomiting or nipple system with valve (2b) to regulate flow. 3a, Haberman feeder
diarrhea. with disc (3b) to control flow of milk. 4, Ross cleft palate assembly.
 Assess the force of vomiting; projectile vomiting is indicative of
pyloric stenosis or increased intracranial pressure.  Hold the child upright and direct formula to the side and back of the
 Assess the child for abdominal pain. mouth to prevent aspiration; feed small amounts gradually and burp
 Monitor intake and output and electrolyte levels and watch for signs the child frequently.
of dehydration.  Position the child on the side after feedings.
 Monitor skin integrity in a child with diarrhea.  Keep suctioning equipment and a bulb syringe at the bedside.
 Provide oral rehydration therapy as tolerated and as prescribed  Teach the parents special feeding and suctioning techniques.
(avoiding carbonated beverages and those containing high amounts  Teach the parents the ESSR (enlarge, stimulate sucking, swallow,
of sugar); start feedings slowly, giving small amounts of fluid at rest) method of feeding.
frequent intervals.  Enlarge the nipple.
 In cases of severe dehydration, the child is maintained on nothing-  Stimulate the suck reflex.
by-mouth (NPO) status to allow the gastrointestinal tract to rest,  Swallow.
with intravenous (IV) fluids and electrolyte replacements prescribed;  Rest to allow the child to finish swallowing what has been
if IV potassium is prescribed, ensure that the child has voided before placed in the mouth.
administration and monitor urinary output during administration  Teach the parents about removable orthopedic devices such as a
(potassium is excreted in the urine and hyperkalemia can result if Latham device which may be used before cleft palate surgery to
renal impairment occurs). expand and realign parts of the palate.
 Provide enteric isolation as required for the child with diarrhea.  Perform the appropriate interventions when surgical repair of the
 Instruct the parents to contact the health care provider if signs of cleft is performed.
dehydration or blood in the vomitus or stool are noted, or if forceful  Elbow restraints may be used (check agency procedures)
vomiting or abdominal pain occurs. to keep the child from touching the repair site; remove
restraints at least every 2 hours to assess skin integrity and
Cleft Lip and Palate permit exercise of the arms (never leave the child alone
Description when restraints have been removed).
 This congenital anomaly involves abnormal openings in the lip or  Avoid the use of oral suction and placement of objects in
palate (see image). the mouth (e.g., tongue depressor, thermometer, straw,
 Clefts may occur unilaterally or bilaterally; the defect is readily spoon, fork, pacifier).
apparent at birth.  Provide analgesics for pain as prescribed.
 Closure of cleft lip defects is performed usually by the age of 3 to 6  Instruct the parents in feeding techniques, care of the
months; cleft palate repair is performed sometime between 6 and surgical site, and signs of infection.
24 months of age.
 Encourage the parents to hold the child.
 Cleft lip ranges from a slight notch to complete separation from the
 Initiate the appropriate referrals for speech impairment or
floor of the nose.
language-based difficulties.
 Cleft palate includes nasal distortion, midline or bilateral cleft, and
 Take additional measures geared to the specific type of
variable extension from the uvula and soft and hard palates.
surgery:

Cleft Lip Repair

o A lip protector device (metal appliance or

adhesive strips) may be taped securely to the
cheeks to prevent trauma to the suture line.
 o Position the child on the side lateral to the repair  A gastrostomy tube may be placed; it is left open so that air entering
or on the back; avoid placing the child on the the stomach through the fistula can escape, minimizing the danger
abdomen to help prevent rubbing of the surgical of regurgitation.
site on the mattress.
o After feeding, cleanse the suture line of formula After Surgery
or serosanguineous drainage with a cotton-  Monitor the Infant's respiratory status.
tipped swab dipped in the prescribed solution  Care for the chest tube if one is in place.
(e.g., normal saline); apply antibiotic ointment as
 Inspect the surgical site and monitor the infant for signs of pain.
prescribed.
 Be alert for signs of anastomotic leaks (i.e., purulent chest drainage,
increased temperature, increased white blood cell count).
Cleft Palate Repair
 If a gastrostomy tube is present, it is attached to gravity drainage
until the infant can tolerate feedings (usually the 5th to 7th day after
o An older child is allowed to lie on his or her surgery).
abdomen.  Before oral feedings are resumed and the chest tube is removed, an
o Bottle, breast, or cup feeding is resumed. esophagogram may be performed to verify the integrity of the
o Oral packing may be secured to the palate esophageal anastomosis.
(removed in 2 to 3 days).
 Feedings through the gastrostomy tube may be prescribed until the
o Do not allow the child to brush the teeth.
anastomosis is healed.
o Instruct the parents not to offer hard foods (e.g.,
toast, cookies) to the child.  Before feeding, the gastrostomy tube is elevated and secured above
the level of the stomach to allow gastric secretions to pass to the
duodenum and permit swallowed air to escape through the
Part 4: Gastrointestinal Disorders gastrostomy tube.
 Monitor intake and output; weigh the infant daily and assess him or
Esophageal Atresia and Tracheoesophageal Fistula
her for signs of dehydration and
Description
fluid-volume excess.
 The gastrostomy tube may be removed before discharge or may be
maintained for supplemental feedings at home.
 If the infant is awaiting esophageal replacement, cervical
esophagostomy may be performed.
 Assess the site of cervical esophagostomy for redness, breakdown,
 Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are and exudate (continued discharge or saliva can cause skin
congenital malformations in which the esophagus terminates before breakdown); remove drainage frequently and apply a protective
it reaches the stomach and/or a fistula is present that forms an ointment, barrier dressing, or collection device.
unnatural connection between the esophagus and the trachea.  If the infant is awaiting esophageal replacement, nonnutritive
 Esophageal atresia and tracheoesophageal fistula can cause oral sucking is provided with the use of a pacifier; infants who are kept
intake to enter the lungs or a large amount of air to enter the from oral feedings for extended periods and have not received
stomach, which may result in choking, coughing, and severe frequent oral stimulation may have difficulty eating normally after
abdominal distention and, as a result, aspiration pneumonia and surgery, developing oral hypersensitivity and food aversion.
severe respiratory distress.  Instruct the parents in techniques of suctioning, gastrostomy tube
 Treatment includes maintenance of a patent airway, prevention of care and feedings, and skin site care as appropriate.
pneumonia, gastric or blind pouch decompression, supportive  Instruct the parents in the behaviors that indicate the need for
therapy, and surgical repair. suctioning, signs of respiratory distress, and signs of a constricted
 Assessment findings include: esophagus (e.g., poor feeding, dysphagia, drooling, regurgitation of
o The “3 C’s”: Coughing and choking during feedings and unexplained undigested food).
cyanosis
o Frothy saliva in the mouth and nose; drooling Hypertrophic Pyloric Stenosis
o Regurgitation and vomiting
o Abdominal distention
o Increased respiratory distress before or after feedings

Nursing Considerations
Before Surgery
 Keep the infant nothing by mouth (NPO); administer IV fluids as
prescribed.
 Perform suctioning of accumulated secretions from the mouth and
pharynx.
 A double-lumen catheter is placed in the upper esophageal pouch
and attached to intermittent or continuous low suction to keep the
pouch empty of secretions.
 The pouch is irrigated with normal saline solution as prescribed to
prevent clogging; maintain the infant in an upright position to
facilitate drainage and prevent aspiration of gastric secretions.
 Description Nursing Considerations
 Narrowing of the pyloric canal between the stomach and duodenum  Eliminate the offending dairy product and administer an enzyme
occurs as a result of hypertrophy of the circular muscles of the replacement, as prescribed, that predigests lactose in milk or
pylorus. supplements the body's own lactase.
 Assessment findings include:  In infants, soy-based formulas may be prescribed as a substitute for
o Projectile vomiting, usually after a feeding (vomitus contains gastric cow's-milk formula or human milk.
contents and may be tinged with blood but does not usually contain  If milk is permitted, limit it to one glass at a time and have the child
bile) drink it with other foods rather than alone.
o Hunger and irritability  Encourage consumption of small amounts of dairy foods—hard
o Peristaltic waves that are visible from left to right across the cheese, cottage cheese, and yogurt (which contains inactive lactase
epigastrium during or immediately after a feeding and immediately enzyme) instead of milk—each day to help colonic bacteria adapt to
before vomiting ingested lactose.
o An olive-shaped mass in the epigastrium just right of the umbilicus  Instruct the parents in the importance of calcium and vitamin D
o Dehydration supplements to prevent deficiency.
o Metabolic alkalosis
 Educate the parents about foods that contain lactose, including
o Failure to thrive
hidden sources.
Nursing Considerations
Celiac Disease
 Monitor the infant’s intake and output and weight. Description
 Watch for signs of dehydration and electrolyte imbalances.  Also known as gluten enteropathy or celiac sprue, this condition is
 Prepare for pyloromyotomy (an incision through the muscle fibers of an intolerance of gluten, the protein component of wheat, barley,
the pylorus, sometimes laparoscopically), if this procedure is rye, and oats.
prescribed.  Assessment findings include:
o Diarrhea (foul-smelling steatorrhea)
Before Surgery o Abdominal pain and distention
o Signs of malnutrition
 Monitor hydration status by weighing the child daily, o Muscle wasting, particularly in the buttocks and legs
tracking intake and output, and checking the urine for o Anorexia
specific gravity. o Anemia
 Correct fluid and electrolyte imbalances, administering IV o Behavioral changes (e.g., irritability, apathy)
fluids as prescribed for rehydration. o Signs of celiac crisis
 Maintain NPO status; a nasogastric tube may be placed for
 Precipitated by fasting, infection, or the ingestion of gluten
stomach decompression.  Causes profuse watery diarrhea and vomiting
 May lead to electrolyte imbalance, rapid dehydration, and
metabolic acidosis
After Surgery

Nursing Considerations
 Begin small, frequent feedings as prescribed; the amount
is gradually increased until a full feeding schedule has
 Educate the parents (and, when appropriate, the child) on the
gluten-free diet and discuss ways to eliminate wheat, rye, oats, and
resumed.
barley and substitute corn, rice, and millet as grain sources.
 Monitor intake and output.
 Encourage the use of mineral and vitamin supplements, including
 Feed the infant slowly, burping frequently; handle the
iron, folic acid, and fat-soluble vitamins A, D, E, and K.
infant as little as possible after feedings.
 Encourage the parents (and child, when appropriate) to read food
 Monitor the infant for abdominal distention.
labels carefully for hidden sources of gluten.
 Monitor the surgical wound and watch for signs of
 Instruct the parents (and child, when appropriate) in measures to
infection.
prevent celiac crisis.
 Instruct the parents in wound care and feeding.
Hirschsprung Disease
Lactose Intolerance
Description
 Inability to tolerate lactose as a result of an absence or deficiency of
lactase, an enzyme required for the digestion of lactose.
 Assessment findings include:
o Symptoms occurring after the ingestion of milk products
o Abdominal distention
o Crampy abdominal pain
o Excessive flatus
o Diarrhea
 Description Intussusception
 Also known as congenital aganglionosis or megacolon, this condition
results from the absence of ganglion cells in the rectum and upward
in the colon (confirmed by rectal biopsy) and causes mechanical
obstruction resulting from inadequate motility in an intestinal
segment.
 The most serious complication is enterocolitis; signs include fever,
severe prostration, gastrointestinal bleeding, and explosive watery
diarrhea.
 Assessment findings vary, depending on whether the affected
individual is an infant or an older child:

Newborn
o Failure to pass meconium stool
o Refusal to suck
o Abdominal distention
o Bile-stained vomitus

Child
o Failure to gain weight; delayed growth
o Abdominal distention Description
o Vomiting  One portion of the bowel telescopes into an adjacent portion,
o Constipation alternating with diarrhea obstructing the passage of intestinal contents.
o Foul-smelling ribbonlike stools  Assessment findings include:
o Colicky abdominal pain that causes the child to scream and draw the
Nursing Considerations knees to the abdomen
Medical Management o Vomiting of gastric contents
 Maintain a low-fiber, high-calorie, high-protein diet; parenteral o “Currant jelly” stools containing blood and mucus
nutrition may be necessary in extreme situations. o Hypoactive or hyperactive bowel sounds
 Administer stool softeners as prescribed. o Tender, distended abdomen, possibly with a palpable sausage-
 Administer daily rectal irrigations with normal saline solution as shaped mass in upper right quadrant
prescribed to promote adequate elimination and prevent
obstruction. Nursing Considerations
 Monitor child for signs of perforation and shock (e.g., fever,
Surgical Management increased heart rate, changes in level of consciousness or blood
 Initially, in the neonatal period, a temporary colostomy is created to pressure, respiratory distress); report these to the health care
relieve the obstruction and allow the normally innervated dilated provider immediately.
bowel to return to its normal size.  Administer IV fluids, nasogastric decompression, and antibiotic
 When the bowel returns to its normal size, complete surgical repair therapy as prescribed.
is performed with the use of a pull-through procedure to excise  Prepare the child for hydrostatic reduction, in which air or fluid is
portions of the bowel; at this time, the colostomy is closed. used to exert pressure on the involved area to reduce or eliminate
 Monitor hydration and fluid and electrolyte status; provide IV fluids the prolapse, as prescribed; the procedure is not performed if signs
as prescribed for hydration. of perforation or shock are present.
 Avoid taking the temperature rectally.  After hydrostatic reduction, monitor the child for the return of
 Monitor the child for respiratory distress associated with abdominal normal bowel sounds and the passage and characteristics of stool.
distention.  If surgery is required (in cases of unsuccessful hydrostatic reduction),
 Measure the abdominal girth. it may be done laparoscopically; postoperative care is similar to that
for any abdominal surgery.
 Assess the surgical site for redness, swelling, and drainage.
 Assess the stoma, if one is present, for bleeding or skin breakdown; Abdominal Wall Defects
the stoma should be red and moist.
 Assess the anal area for the presence of stool, redness, or discharge. Omphalocele
 Maintain NPO status as prescribed after surgery and until bowel Description
sounds return or flatus is passed, usually within 48 to 72 hours.  Abdominal contents herniated through the umbilical ring, usually
 Provide the parents with instructions regarding colostomy and skin with an intact peritoneal sac containing bowel or other abdominal
care. organs.
 Teach the parents about the appropriate diet and the need for  Rupture of the sac results in the evisceration of abdominal contents.
adequate fluid intake.
Nursing Considerations
 Immediately after birth, the sac is covered with sterile gauze soaked
in normal saline solution to prevent drying of abdominal contents; a
layer of plastic wrap is placed over the gauze to provide additional
protection against moisture loss.
 Check vital signs frequently (particularly temperature; the affected Incarcerated Hernia
infant loses heat through the sac).
 Before surgery, maintain NPO status, administer IV fluids as  A descended portion of the bowel becomes tightly caught
prescribed to maintain hydration and electrolyte balance, watch for in the hernial sac, compromising the blood supply and
signs of infection, and handle the infant carefully to prevent rupture sometimes resulting in complete intestinal obstruction and
of the sac. gangrene.
 After surgery, control pain, prevent infection, maintain fluid and  An incarcerated hernia is a medical emergency requiring
electrolyte balances, and ensure adequate nutrition. surgical repair.
 The affected infant demonstrates irritability, tenderness at
site, anorexia, abdominal distention, and difficulty
defecating.

Noncommunicating Hydrocele

 Residual peritoneal fluid is trapped with no

communication to the peritoneal cavity.
 Such hydroceles usually disappear by 1 year of age.

Communicating Hydrocele

 This type of hydrocele is associated with a hernia that

remains open from the scrotum to the abdominal cavity.
Gastroschisis  Assessment findings include a bulge in the inguinal area or
Description scrotum that increases with crying or straining and shrinks
 The intestine herniates lateral to the umbilical ring, with no when the child is at rest.
membrane covering the exposed bowel.

Nursing Considerations Nursing Considerations

 The exposed bowel is loosely covered in sterile saline solution– After Hernia Surgery
soaked pads and the abdomen wrapped loosely in a plastic drape;  Assess the wound for signs of infection (e.g., redness or drainage).
wrapping around the exposed bowel is contraindicated because if  Monitor the child’s intake and output and hydration status.
the exposed bowel expands, wrappings could exert pressure,  Advance the diet as tolerated.
resulting in necrosis.  Administer analgesics as prescribed.
 Before surgery, care is similar to that for omphalocele; surgery is
performed within hours of birth because no membrane covers the After Hydrocele Surgery
sac.  Provide ice bags and a scrotal support to relieve pain and swelling.
 After surgery, most infants experience prolonged ileus and  Explain the need to avoid tub bathing until the incision has healed.
require mechanical ventilation and parenteral nutrition; otherwise,
 Strenuous physical activity should be avoided.
care is similar to that for the infant with omphalocele.

Umbilical Hernia, Inguinal Hernia, and Hydrocele

Description
 A hernia is a protrusion of the bowel through an abnormal opening
in the abdominal wall; in children, a hernia most commonly occurs at
the umbilicus or through the inguinal canal.
 A hydrocele (see image) is the presence of abdominal fluid in the
scrotal sac.
 Assessment findings vary with the type of hernia or hydrocele.

Umbilical Hernia

 This soft swelling or protrusion around the umbilicus is

usually reducible with the finger.

Inguinal Hernia

 Painless, reducible inguinal swelling may disappear during

periods of rest and is most noticeable when the infant
cries or coughs.
 Imperforate Anus Nursing Considerations
Description  Stress the need for proper handwashing and standard precautions.
 The anus is incompletely developed or entirely absent.  Immunoglobulin provides passive immunity and may be effective
 The location of the anomaly (high or low) determines treatment. preexposure prophylaxis against HAV infection.
 Assessment findings include failure to pass meconium, absence  Hepatitis B immunoglobulin provides passive immunity and may be
or stenosis of the anorectal canal, and the presence of an anal effective in preventing infection after a one-time exposure (given
membrane or an external fistula to the perineum. immediately after exposure), such as an accidental needle puncture
or other contact of contaminated material with mucous membranes;
Nursing Considerations immunoglobulin should also be given to newborns whose mothers
 Watch for stool in the urine and vagina and report such findings are positive for hepatitis B surface antigen.
immediately.  Follow the recommendations of the Centers for Disease Control and
 A low anomaly may involve stenotic areas, or a membrane may Prevention for administration of the hepatitis A and B vaccines.
cover the anal opening; treatment includes incision of the  Hospitalization is required in the event of coagulopathy or fulminant
membrane followed by daily dilation performed by the parents. hepatitis; standard and enteric precautions are followed during
 A high anomaly necessitates colostomy in the neonatal period with hospitalization.
corrective surgery performed in stages over time.  The hospitalized child usually is not isolated unless he or she is
 After surgery, place the infant in a side-lying position with the legs fecally incontinent and items are likely to become contaminated
flexed or in a prone position to keep the hips elevated to reduce with feces.
edema and pressure on the surgical site.  Children are discouraged from sharing toys.
 Keep the surgical incision clean and dry; monitor it for redness,  Instruct the parents to disinfect diaper-changing surfaces thoroughly
swelling, and drainage. with a solution of 1/4 cup bleach in 1 gallon of water.
 Maintain NPO status and tend the nasogastric tube, if one is in place.  Maintain comfort and provide adequate rest and sleep.
 Maintain IV fluids until gastrointestinal motility returns.  Provide a low-fat, well-balanced diet to allow the liver to rest.
 Provide colostomy care if prescribed; a new colostomy stoma will be  Inform the parents that because HAV is not infectious 1 week after
red and edematous, but redness and swelling should decrease with the onset of jaundice, the child may return to school at that time if
time. he or she feels well enough.
 Teach the parents how to care for the colostomy.  Inform the parents that jaundice may appear worse before it
resolves.
Hepatitis  Caution the parents about administering any medications to the
Description child; explain the role of the liver in detoxification and excretion of
 Acute or chronic inflammation of the liver which may be caused by a medications in understandable terms.
virus, a medication, or another disease process; see Lesson 48 for  Educate the parents regarding the signs of worsening condition (e.g.,
detailed information on the disease, its presentation, and its changes in neurological status, bleeding, fluid retention).
treatment.
 Viral hepatitis has a variety of causative organisms, but the hepatitis Ingestion of Poisons
A and B viruses (HAV, HBV) are most common in children:
Lead Poisoning
HAV Description
o Incidence is highest among children younger than 15 years.  The affected child has an excessive accumulation of lead in the blood
o Affected children are often asymptomatic, but mild nausea, and other tissues.
vomiting, and diarrhea may occur.  Pathway of exposure may be food, air, or water.
o Infected children who are asymptomatic can still spread HAV to  Dust and soil contaminated with lead may be a source of exposure.
others.
 Lead enters the child's body through ingestion or inhalation or by
transmission through the placenta to an unborn child when the
HBV
mother is exposed; the most common routes of ingestion involve
o Most infection in children is acquired perinatally; a newborn is at risk
hand-to-mouth contact with contaminated objects such as loose
if the mother is infected with HBV or was a carrier of HBV during
paint chips, pottery, or ceramic ware coupled with the inhalation of
pregnancy.
lead dust in the environment.
o Possible routes of maternal-fetal (infant) transmission include
leakage of the virus across the placenta late in pregnancy or during  When lead enters the body, it affects the erythrocytes, bones and
labor; ingestion of amniotic fluid or maternal blood; and teeth, and organs and tissues, including those of the brain and
breastfeeding, especially if the mother has cracked nipples. nervous system; the most serious consequences are the effects on
o Severity in the infant varies from no liver disease to fulminant the central nervous system.
(severe, acute course) or chronic active disease.  Universal screening (for high-risk children) or targeted screening (in
o Members of specific groups—children with hemophilia or other low-risk children) is recommended; usually a blood lead level test
disorders requiring multiple blood transfusions, children or and an erythrocyte protoporphyrin test is done in the healthcare
adolescents involved in drug abuse, institutionalized children, clinic or pediatrician’s office.
preschool children in endemic areas, and children involved in  Universal screening: recommended for children 1 to 2 years old;
heterosexual activity or sexual activity with homosexual males—are children at high risk should be screened earlier.
at increased risk.  Targeted screening: A child at the age of 1 to 2 years (or a child
o HBV infection can result in a carrier state and lead to cirrhosis or between the ages of 3 and 6 years who has not been screened) may
hepatocellular carcinoma in adulthood. be targeted for screening if determined to be at risk.
 o First stage, first 24 hours: malaise, nausea and vomiting, sweating,
pallor, and weakness
o Second stage, latent period (24-48 hours) there is a rise in liver
enzymes (aspartate and alanine aminotransferase) and bilirubin;
right upper quadrant pain; prolonged prothrombin time
o Third stage, 3 - 7 days: jaundice, liver necrosis, signs of hepatic
failure can occur

Nursing Considerations
 N-acetyl cysteine is usually administered by nasogastric tube but
may be diluted in juice or soda to mask its offensive odor.
 Activated charcoal may be prescribed; it is not administered with N-
acetyl cysteine because it inactivates the antidote.

Acetylsalicylic Acid (ASA; Aspirin)

Description
 Toxicity occurs with acute aspirin ingestion at doses of 200 - 280
mg/kg.
 Long-term ingestion, a dosage of more than 100 mg/kg/day for 2
days or more, may be more serious than acute ingestion.
Lead Poisoning
 Assessment findings include:
Nursing Considerations
o Gastrointestinal effects: nausea and vomiting, thirst from
 Lead is removed from circulating blood and some organs and tissues dehydration
in a procedure called chelation. o CNS effects: hyperpnea, confusion, tinnitus, seizures, coma
 Chelation merely reduces the amount of lead in the body; it does o Renal effects: oliguria
not counteract the effects of lead. o Hematopoietic effects: bleeding tendencies
 Calcium disodium edetate and succimer, an oral preparation, are o Metabolic effects: diaphoresis, dehydration,
used for chelation; British antilewisite is used in conjunction with fever, hyponatremia, hypokalemia, dehydration, hypoglycemia
EDTA (administered IV or by way of the deep intramuscular route). Nursing Considerations
 British antilewisite is contraindicated in children with glucose-6-  Administer activated charcoal to decrease the absorption of
phosphate dehydrogenase (G6PD) deficiency or allergy to peanuts salicylate; administration early in the course of toxicity is important.
(the medication is prepared in a peanut oil solution) and should not  Administer IV fluids, sodium bicarbonate to correct metabolic
be given in conjunction with iron. acidosis, or electrolytes as prescribed.
 Ensure adequate urine output before administering the medications.  Other interventions include external cooling, anticonvulsants,
 Provide adequate hydration and monitor kidney function for vitamin K (if the child is bleeding), and oxygen.
nephrotoxicity when medication is given.  Prepare the child for dialysis as prescribed if he or she is
 Provide instructions to parents about safety from lead hazards, unresponsive to therapy.
medication administration, and the need for follow-up.
 Confirm that the child will be discharged to a home without lead Intestinal Parasites: Giardiasis and Pinworm
hazards. Giardiasis
Description
Ingestion of Poisons  Caused by a protozoal organism, giardiasis is prevalent among
General Principles of Emergency Treatment children in crowded environments such as classrooms and daycare
 Parents are advised to call the poison control center before initiating centers.
any intervention; instruct the parents to post the poison control  The affected child experiences abdominal cramps with intermittent
center telephone number near each phone in the house and to loose stools and constipation, plus anorexia and vomiting and failure
enter the number in their cell phone contact lists. to thrive.
 Treat the child first, not the poison; assess airway, breathing, and
circulation and initiate cardiopulmonary resuscitation, if necessary. Nursing Considerations
 Terminate exposure to the poison: Empty the victim's mouth, flush  Meticulous handwashing is crucial in preventing the spread of this
the eyes or skin, bring the victim of an inhalation injury into fresh air, parasite; stress its importance to the child and caregivers.
or dilute an ingested poison as directed to do so by the poison  Medications may be prescribed to eradicate the parasite.
control center.
 Identify the poison. Pinworm
 Administration of syrup of ipecac, to induce vomiting in the home Description
setting, is no longer recommended.  Pinworms (genus Enterobius) are universally present in temperate
climate zones.
Acetaminophen  Enterobiasis (pinworm infestation) is easily transmitted in crowded
Description environments.
 Toxicity occurs with acute aspirin ingestion at doses of 200 - 280  The affected child may experience intense perianal itching, poor
mg/kg. sleep, and bedwetting.
 The toxic dose in children is 150 mg/kg or more.
 Assessment findings vary with the time elapsed since ingestion:
 Nursing Considerations  Do not give the child straws, forks, or other sharp objects that can
 Perform a visual inspection of the anus, using a flashlight, 2 to 3 be placed in the mouth.
hours after the child falls asleep; the mature female pinworm leaves  Instruct the parents to notify the health care provider if bleeding,
the body to lay eggs. persistent earache, or fever occurs.
 In the tape test (the most common diagnostic test), a loop of  Instruct the parents to keep the child away from crowds until
transparent tape is placed firmly against the child’s perianal area healing has taken place.
overnight, then removed in the morning, placed in a plastic bag or
glass jar, and transported to the laboratory for analysis. Epiglottitis
 Medications may be prescribed to eradicate pinworms but are not Description
used in children younger than 2 years.  Bacterial croup results in inflammation of the epiglottis.
 All members of the family are treated for infestation.  Epiglottitis is considered an emergency because it can progress
 Teach the family and caregivers about the importance of meticulous rapidly to severe respiratory distress.
handwashing and about the need to wash all clothes and bed linens  Assessment findings include:
in hot water. o High fever
o Sore, red, inflamed throat
Part 5: Respiratory Disorders o Pain on swallowing
o Absence of spontaneous cough
Tonsillitis and Adenoiditis o Drooling
Description o Muffled voice
 Tonsillitis refers to inflammation and infection of the tonsils. o Retractions (see image) and inspiratory stridor
 Adenoiditis refers to inflammation and infection of the adenoids o Tripod positioning, in which the child supports the body with the
(see image). hands, thrusts the chin forward, and opens the mouth in an attempt
 Assessment findings in tonsillitis include: to widen the airway
o Persistent or recurrent sore throat
o Enlarged bright-red tonsils, sometimes covered with white exudate Nursing Considerations
o Difficulty swallowing  Maintain a patent airway.
o Unpleasant odor on the breath  Use the axillary, not oral, route to take the temperature.
o Fever  Monitor respiratory status and pulse oximetry readings.
o Cough  To prevent spasm of the epiglottis and airway occlusion, do not
 Assessment findings in adenoiditis include: attempt to visualize the posterior pharynx or to obtain a throat
o Nasal quality of speech culture specimen.
o Mouth breathing  Prepare the child for lateral neck films to confirm the diagnosis.
o Hearing difficulties  Keep the child from eating or drinking.
o Snoring or obstructive sleep apnea
 Do not leave the child unattended, do not force the child to lie
 In some cases the inflamed tissue is removed (i.e., tonsillectomy or
down, and do not restrain the child.
adenoidectomy).
 Administer intravenous (IV) fluids, antibiotics, analgesics, and
antipyretics as prescribed.
Nursing Considerations
Before Surgery  Provide cool mist oxygen therapy as prescribed.
 Watch for signs of active infection.  Provide high humidification to cool the airway and decrease
swelling.
 Assess the results of bleeding and clotting studies; the throat is very
vascular.  Have resuscitation equipment available and prepare for
endotracheal intubation or tracheotomy in the event of severe
 Inform the child that the throat will be sore after surgery and that he
respiratory distress.
or she will need to drink liquids.
 Ensure that the child is up to date with immunizations, including
 Assess the child for loose teeth to reduce the risk of aspiration
the Haemophilus influenzae type B (Hib) conjugate vaccine.
during surgery.
Laryngotracheobronchitis
After Surgery
Description
 Place the child in the prone position or side-lying position to
 This inflammation of the larynx, trachea, and bronchi is the most
facilitate drainage.
common type of croup.
 Have suction equipment available, but do not perform suctioning
 The condition may be viral or bacterial and may be preceded by an
unless the airway is obstructed.
upper respiratory infection.
 Watch for signs of hemorrhage (e.g., excessive swallowing,
 Assessment findings include:
restlessness, increased pulse rate, decreasing blood pressure,
o Fever, low-grade to high
vomiting of bright-red blood); if hemorrhage occurs, turn the child to
o Irritability and restlessness
the side and notify the health care provider.
o Hoarseness
 Discourage coughing or clearing of the throat.
o Seal bark
 Provide clear, cool noncitrus and noncarbonated fluids (e.g., crushed o Brassy cough
ice, ice pops). o Inspiratory stridor and suprasternal retractions
 Avoid milk products initially, because they coat the throat. o Use of accessory muscles for breathing
 Avoid red liquids, which will simulate the appearance of blood if the o Crackles and wheezing on lung auscultation
child vomits.
 Nursing Considerations  Ensure that nurses caring for infected children do not care for other
 Maintain a patent airway. high-risk children (e.g., those who are immunocompromised).
 Assess respiratory status.  Maintain oxygen saturation at 90 % or greater.
 Elevate the head of the bed and ensure bed rest.  Prevention measures include encouraging breastfeeding; avoiding
 Provide humidified oxygen in a cool mist tent for the hospitalized tobacco smoke exposure; using good handwashing technique; and
child. administering palivizumab, a monoclonal antibody, to high-risk
 Instruct the parents to use a cool air vaporizer or humidifier at infants (palivizumab is administered intramuscularly monthly for a 5-
home, have the child breathe in cool night air or air from an open month period, usually November to March).
freezer, or take the child to a cool basement or garage.
 Provide and encourage fluid intake; IV fluids may be prescribed to Asthma
maintain hydration status if the child is unable to take oral fluids. Description
 Administer analgesics as prescribed to reduce fever.  Chronic inflammatory disease of the airways, asthma is commonly
caused by physical or chemical irritants (e.g., foods, pollens, smoke,
 Avoid cough syrups and cold medicines, which may dry and thicken
animal dander, temperature changes, respiratory infection, activity,
secretions.
stress).
 Administer bronchodilators, if prescribed, to relax smooth muscle
 Allergic reaction in the airways can result in an immediate reaction
and relieve stridor.
involving obstruction or may precipitate a late bronchial obstructive
 Administer corticosteroids, if prescribed, for their antiinflammatory reaction several hours after the initial exposure (see image).
effect.
 Coughing in the absence of respiratory infection, especially at night,
 Administer nebulized epinephrine (racemic epinephrine) as is a common symptom.
prescribed for children with severe disease, stridor at rest,
 The child with asthma may experience status asthmaticus, in which
retractions, or difficulty breathing.
respiratory distress continues despite vigorous treatment measures;
 Administer antibiotics as prescribed, noting that they are not status asthmaticus is a medical emergency and may result in
indicated unless a bacterial infection is present. respiratory failure and death if left untreated.
 Heliox (mixture of helium and oxygen) may be prescribed because it  Assessment findings include:
reduces the work of breathing, reduces airway turbulence, and helps o Episodes of wheezing, breathlessness, dyspnea, chest tightness, and
relieve airway obstruction. cough, particularly at night or early in the morning
 Have resuscitation equipment available. o Itching localized to the front of the neck or over the upper part of
the back
Bronchiolitis and Respiratory Syncytial Virus o Exacerbations: episodes of progressively worsening shortness of
Description breath, cough, wheezing, chest tightness, decreased expiratory
 Bronchiolitis is an inflammation of the bronchioles that results in airflow caused by bronchospasm, mucosal edema, mucus plugging;
production of thick mucus that occludes bronchiole tubes and small trapping of air behind the occluded or narrow airways, sometimes
bronchi. resulting in hypoxemia
 Respiratory syncytial virus, or RSV, is a common cause of o Asthmatic episodes
bronchiolitis.  An episode begins with irritability, restlessness, headache,
 RSV, though not transmitted by way of the airborne route, is highly a tired feeling, or chest tightness.
communicable; it is usually transmitted by means of direct contact  Respiratory symptoms include a hacking, irritable,
with respiratory secretions (i.e., it can be transferred by the hands). nonproductive cough caused by bronchial edema.
 Assessment findings include:  Accumulated secretions stimulate the cough, which
o Upper respiratory infection symptoms (i.e., rhinorrhea, eye or ear becomes rattling and productive of frothy, clear,
drainage, low-grade fever) gelatinous sputum.
o Lethargy, poor feeding, and irritability in infants  The child may be pale or flushed; the lips may be a deep
o Pharyngitis dark red progressing to cyanosis (most often observed in
o Coughing the nail beds and skin and around the mouth).
o Sneezing  The child exhibits restlessness, apprehension, and
o Wheezing diaphoresis.
o Tachypnea, nasal flaring, and retractions as the disease progresses
 The younger child assumes a tripod sitting position, and an
older child sits upright with the shoulders hunched over,
Nursing Considerations
hands on the bed or chair, and arms braced to facilitate
 Maintain a patent airway. the use of the accessory muscles of breathing; the child
 Position the child at a 30- to 40-degree angle with the neck slightly refuses to lie down.
extended to maintain an open airway and reduce pressure on the  The child speaks in short, broken phrases.
diaphragm.
 Retractions are noted.
 Provide cool, humidified oxygen.
 Hyperresonance is detected on percussion of the chest.
 Encourage fluids; IV fluids may be necessary until the acute stage
 Breath sounds are coarse and loud, with crackles, coarse
has passed.
rhonchi, and inspiratory and expiratory wheezing;
 Periodic suctioning may be necessary; use of a bulb syringe expiration is prolonged.
(performed before feeding to promote comfort and adequate o Exercise-induced bronchospasm: cough, shortness of breath, chest
intake) may be effective. pain or tightness, wheezing, impaired endurance during exercise
 Isolate the affected child in a single room or place the child in a o Severe spasm or obstruction: inaudibility of breath sounds
room with another RSV-infected child. and crackles, ineffective cough (representing a lack of air movement)
 Maintain contact precautions.
 Nursing Considerations  Explain the importance of adequate fluid intake to liquefy
Management of the Acute Episode secretions.
 Assess airway patency.  Help the child develop an exercise program.
 Administer humidified oxygen with the use of nasal prongs or a face  Teach the child the procedures for prescribed respiratory treatments
mask as prescribed. and exercises.
 Administer quick-relief (rescue) medications as prescribed.  Encourage the parents to keep immunizations up to date.
 Short-acting beta2-agonists for bronchodilation  Tell the parents and child to inform other health care providers and
 Anticholinergics for relief of acute bronchospasm school personnel of the child’s asthma.
 Systemic corticosteroids, whose antiinflammatory action is  The child should be allowed to take control of self-care measures as
used to treat reversible airflow obstruction appropriate for his or her age.
 Monitor respiratory status, pulse oximetry readings, and color; be
alert to decreased wheezing or a silent chest, which may signal Cystic Fibrosis
inability to move air. Description
 Prepare the child for chest radiography.  This chronic multisystem genetic disorder is characterized by
 Prepare to obtain samples for testing of arterial blood gases and exocrine gland dysfunction.
serum electrolytes.  Mucus produced by the exocrine glands is abnormally thick, causing
obstruction of the small passageways of the affected organs.
Medications  The most common symptoms are pancreatic enzyme deficiency
 Quick-relief (rescue) medications are used to treat symptoms and caused by duct blockage, progressive chronic lung disease associated
exacerbations. with infection, and sweat gland dysfunction resulting in increased
 Long-term control (preventer) medications are used to achieve and sodium and chloride sweat concentrations.
maintain control of inflammation or achieve bronchodilation.  Increased amounts of sodium and chloride in both sweat and saliva
 Corticosteroids, which exert an antiinflammatory effect are the basis for one diagnostic test, the sweat chloride test.
 Antiallergics, which help prevent an adverse response on  Cystic fibrosis is progressive and incurable; respiratory failure is a
exposure to an allergen common cause of death.
 Nonsteroidal antiinflammatory drugs for their  Organ transplantation may be an option to increase the likelihood of
antiinflammatory action survival.
 Long-acting beta2-agonists for long-acting bronchodilation
 Leukotriene modifiers to prevent bronchospasm and
inflammatory cell infiltration
 If a metered-dose inhaler (MDI) is used to administer a
corticosteroid, a spacer device should be used to help prevent yeast
infections in the child’s mouth.

Chest Physiotherapy
 Physiotherapy includes breathing exercises and physical training but
is not recommended during acute exacerbations.

Allergen Control
 Measures should be taken to prevent and reduce exposure to
airborne and environmental allergens.
 Skin testing is performed to identify specific allergens.

Home Care Measures

 Instruct the parents and child in measures to eliminate or reduce
exposure to allergens.
 The child should avoid extremes of environmental temperature; in
cold temperatures, the child should breathe through the nose, not
the mouth, and cover the nose and mouth with a scarf.
 Instruct the child to avoid exposure to individuals with viral
respiratory infections.
 Teach the child to recognize early symptoms of an asthma attack.
 Instruct the child in the administration of prescribed medications.
 Teach the child to use a nebulizer, MDI (see image), or peak
expiratory flow meter.
 Encourage the child to cough effectively.
 Instruct the child in cleaning of the devices used for inhaled
medications; oral candidiasis may occur with use of aerosolized
corticosteroids.
 Encourage adequate rest, sleep, and a balanced diet.
 Assessment Findings: Respiratory System o The normal chloride concentration in sweat is less than 40 mEq/L (40
 Stagnation of mucus in the airway, leading to bacterial colonization mmol/L).
and destruction of lung tissue (see image) and resulting in o Chloride concentration greater than 60 mEq/L (60 mmol/L) is a
symptoms. positive result.
 Wheezing and dry, nonproductive cough o Chloride concentrations of 40 to 60 mEq/L (40-60 mmol/L) are highly
 Dyspnea suggestive of cystic fibrosis and require a repeat test.
 Cyanosis  Chest radiography reveals atelectasis and obstructive emphysema.
 Clubbing of the fingers and toes  Pulmonary function testing provides evidence of abnormal small
airway function.
 In stool fat and enzyme analysis, a 72-hour stool sample is collected
to check the fat and (trypsin) content (food intake is recorded during
collection).

Nursing Considerations
Respiratory System
 The goals of treatment include prevention and treatment of
pulmonary infection through improved aeration, removal of
secretions, and administration of antimicrobial medications.
 Chest physiotherapy (CPT; percussion and postural drainage) is
performed on awakening and in the evening (used more frequently
during pulmonary infection).
 CPT should not be performed immediately before or after a meal.
 Aerosol bronchodilator medications (administered before CPT when
the child has reactive airway disease or is wheezing) open the
bronchi for easier expectoration.
 Repeated episodes of bronchitis and pneumonia  The Flutter mucus clearance device (a small handheld plastic pipe
with a stainless-steel ball inside) facilitates the removal of mucus;
Assessment Findings: Gastrointestinal System store the device away from small children, because the steel ball
 Meconium ileus in the newborn poses a choking hazard.
 Intestinal obstruction (distal intestinal obstructive syndrome) caused  Handheld percussors and a special vest device provide high-
by thick intestinal secretions; signs include pain, abdominal frequency chest wall oscillation to help loosen secretions.
distention, and nausea and vomiting  Instruct the parents to avoid administering cough suppressants to
 Large, bulky, loose, frothy, foul-smelling stools the child, because they inhibit the expectoration of secretions and
 Deficiency of fat-soluble vitamins A, D, E, and K, resulting in easy thus promote infection.
bruising and anemia  Teach the child forced expiratory technique (huffing) to mobilize
 Malnutrition and growth failure; hypoalbuminemia caused by secretions.
diminished absorption of protein, resulting in generalized edema  Develop a physical exercise program with the aim of establishing a
 Rectal prolapse, the result of the large, bulky stools and lack of good habitual breathing pattern.
supportive fat pads around the rectum  Administer antibiotics as prescribed, prophylactically or when
pulmonary symptoms develop.
Assessment Findings: Integumentary System  Aerosolized antibiotics may be prescribed and are administered
 Abnormally high concentrations of sodium and chloride in sweat after CPT is performed, or IV antibiotics may be prescribed and
 Parents report that the infant tastes salty when kissed administered at home through a central venous access device.
 Dehydration and electrolyte imbalances, especially during  Administer oxygen as prescribed during acute episodes; monitor the
hyperthermic conditions child closely for oxygen narcosis (signs include nausea and vomiting,
malaise, fatigue, numbness and tingling of the extremities, and
Assessment Findings: Reproductive System substernal distress).
 Delayed puberty in girls  Hemoptysis of more than 300 mL in 24 hours in an older child (less in
a younger one) must be treated immediately.
 Inhibition of fertility by highly viscous cervical secretions, which act
as a plug and block entry of sperm  Hemoptysis may be controlled with bed rest, antibiotics, and vitamin
K; if it persists, the site of bleeding may be cauterized or subjected
 Sterilility in male subjects, a result of blockage of the vas deferens by
to embolization.
abnormal secretions or failure of duct structures to develop
normally
Gastrointestinal System
Description  The goal of treatment for pancreatic insufficiency is to replace
pancreatic enzymes; enzymes administered before all meals and
 Newborn screening, consisting of immunoreactive trypsinogen
snacks to ensure that they are mixed with food in the duodenum.
analysis and direct DNA analysis for mutant genes, is performed in
some U.S. states and in Canada.  Pancreatic enzymes may be mixed with pureed fruit and fed with a
spoon to the infant or young child.
 The quantitative sweat chloride test is used in older clients:
o Production of sweat is stimulated (pilocarpine iontophoresis), sweat  The dosage of pancreatic enzymes is adjusted to achieve
is collected, and electrolytes are measured (more than 50 mg of normal growth and a decrease in the number of stools to two or
sweat is needed). three per day.
 Enteric-coated pancreatic enzymes should not be crushed or Part 6: Cardiovascular Disorders
chewed.
 Pancreatic enzymes should not be given if nothing-by-mouth status Heart Failure
has been instituted. Description
 Encourage a balanced high-protein, high-calorie diet; multivitamins  In infants and children, inadequate cardiac output is most commonly
and vitamins A, D, E, and K supplements are also administered. caused by congenital heart defects that produce an excessive
 Assess weight and monitor the child for failure to thrive. volume or pressure load on the myocardium.
 Monitor the child for constipation and intestinal obstruction.  A combination of left- and right-side heart failure is usually present.
 Monitor the child for signs of gastroesophageal reflux and position  The goals of treatment are improved cardiac function, removal of
him or her upright after eating. accumulated fluid and sodium, decreased cardiac demand, improved
tissue oxygenation, and decreased oxygen consumption.
Home Care  Assessment findings (early signs) include:
 Explain the prescribed treatment measures and their importance to o Tachycardia, especially at rest and during slight exertion
the parents and child (as age appropriate). o Tachypnea
o Profuse scalp sweating, especially in infants
 Instruct the parents to make sure that immunizations are up to date.
o Fatigue and irritability
 Direct the parents to the Cystic Fibrosis Foundation. o Sudden weight gain
o Respiratory distress
Sudden Infant Death Syndrome
Description
 Known by many as SIDS, sudden infant death syndrome is the
unexpected death of an apparently healthy infant younger than 1
year in whom a thorough investigation of the death and a thorough
autopsy fail to demonstrate a conclusive cause of death.
 The cause is not known.
 SIDS is most common during the winter months.
 These deaths usually occur during sleep; sleep-related risk factors
include prone position, use of soft bedding, sleeping in a noninfant
bed such as a sofa, overheating (thermal stress), cosleeping, having a
mother who smoked cigarettes or abused substances during
pregnancy, and exposure to tobacco smoke after birth.
 SIDS is most common between the ages of 2 and 4 months.
 Incidence is higher among boys than girls.
 SIDS is more common among Native American infants, infants of
African extraction, and Hispanic infants than among those of other
racial backgrounds.
 Assessment findings in SIDS victims:
o Apneic, blue, lifeless
o Frothy blood-tinged fluid in the nose and mouth
o May be found in any position but typically huddled in the corner of a
disheveled bed with blankets over the head
o May be clutching the bedding
o May be found with a wet diaper full of stool
Nursing Considerations
Nursing Considerations  Watch for respiratory distress (count respirations for 1 full minute).
 Infants should be placed in the supine position for sleep.  Monitor the apical pulse (count pulse for 1 full minute) and monitor
 Parents must be taught about the risk factors for SIDS. the child for dysrhythmias.
 Teach the parents to monitor the infant for positional plagiocephaly  Monitor intake and output; weigh diapers.
caused by the supine sleeping position; signs include a flattened  Check the client’s weight daily to detect fluid retention; weight gain
posterior occiput and the development of a bald spot in the of 0.5 kg (1 lb) in 1 day is a result of fluid accumulation.
posterior occipital area.  Monitor the client for facial or peripheral edema, auscultate lung
 To help prevent positional plagiocephaly, teach the parents to sounds, and report abnormal findings.
change the infant’s head position during sleep, avoid keeping the  Elevate the head of the bed.
infant in infant seats and bouncers for prolonged periods, place the  Maintain a neutral thermal environment to prevent cold stress in
infant in a prone position while he or she is awake (monitoring the infants.
prone infant carefully).
 Administer cool humidified oxygen as prescribed; use an oxygen
 When SIDS does occur, the parents need a great deal of support as
hood for a young infant and a nasal cannula or face tent for an older
they grieve and mourn, especially because the event was sudden, infant or child.
unexpected, and unexplained.
 Provide rest; reduce environmental stimuli, organizing nursing
activities to permit uninterrupted sleep.
 Feed the child when he or she is hungry and soon after awakening
(crying exhausts a limited energy supply), accommodating the
 infant's sleep and wake patterns; the infant should be well rested  There are four types, described in greater detail on the screens that
before feeding. follow:
 Provide frequent small feedings, which are less tiring. o Atrial septal defect
 Administer sedation as prescribed during the acute stage to promote o Ventricular septal defect
rest. o Atrioventricular canal defect
 Administer digoxin as prescribed; monitor the child’s digoxin level o Patent ductus arteriosus
and watch for signs of digoxin toxicity, especially bradycardia and
vomiting. Atrial Septal Defect
 Check with the health care provider regarding guidelines for  This abnormal opening between the atria (see image, top) results in
withholding digoxin; generally it is withheld if the pulse is slower increased flow of oxygenated blood into the right side of the heart.
than 90 to 110 beats/min in an infant or young child or slower than  Defect closure during cardiac catheterization may be an option.
70 beats/min in an older child.  Open repair with cardiopulmonary bypass may be done; it is usually
 Note that infants rarely receive more than 1 mL (50 mcg, or 0.05 mg) performed before the child reaches school age.
of digoxin in one dose.
 Administer angiotensin-converting enzyme (ACE) inhibitors as Ventricular Septal Defect
prescribed; be alert for hypotension, renal dysfunction, and cough  This defect consists of an abnormal opening between the right and
when ACE inhibitors are administered. left ventricles (see image, bottom).
 Administer diuretics as prescribed; monitor laboratory results  Many ventricular septal defects close spontaneously during the first
for hypokalemia when furosemide or thiazide diuretics are being year of life in children with small or moderate defects.
administered.  Defect closure during cardiac catheterization may be an option.
 Administer potassium supplements and provide dietary sources of  Open repair with cardiopulmonary bypass may be necessary.
potassium as prescribed.
 Monitor serum electrolytes, particularly potassium. Atrioventricular Canal Defect
 Restrict fluids as prescribed in the acute stage; monitor the child for  This defect (see image, top), resulting from incomplete fusion of the
dehydration. endocardial cushions, is often seen in children with Down syndrome.
 Check with the health care provider regarding sodium restriction;  Management may include pulmonary artery banding for infants with
note that most infant formulas contain slightly more sodium than severe symptoms (palliative) or complete repair by means of
does breast milk. cardiopulmonary bypass.
 Instruct the parents in cardiopulmonary resuscitation (CPR).
 Educate the parents regarding the diagnosis and the administration Patent Ductus Arteriosus
of medications, especially digoxin.  The fetal ductus arteriosus (artery connecting aorta and pulmonary
 Administer as prescribed. artery) fails to close during the first weeks of life (see image,
bottom).
 Administer 1 hour before or 2 hours after feeding.
 A characteristic machinery-like murmur is audible on auscultation.
 Mark doses on a calendar.
 Widened pulse pressure and bounding pulses are present.
 Do not mix the medication with foods or fluids.
 Indomethacin (a prostaglandin inhibitor) is administered to close the
 If a dose is missed and more than 4 hours has elapsed,
defect in premature infants and some newborns.
withhold the dose and give the next dose at the scheduled
time; if less than 4 hours has elapsed, administer the  The defect may be closed during cardiac catheterization, or surgery
missed dose. may be required.
 If the child vomits, do not administer a second dose.
Cardiac Defects: Obstructive
 If more than two consecutive doses have been missed, Description
notify the health care provider; do not increase or double
 Blood exiting the heart meets an area of anatomic narrowing
the dose.
(stenosis), resulting in obstruction of flow.
 If the child has teeth, give water after administering the
 Affected infants and children exhibit signs of heart failure, although
medication; if possible, brush the teeth to prevent tooth
children with mild obstruction may be asymptomatic.
decay caused by the sweetened liquid.
 The three types of obstructive defects are discussed in greater detail
 If the child becomes ill, notify the health care provider.
on the screens that follow:
 Keep the medication in a locked cabinet. o Coarctation of the aorta
 Call the poison control center immediately if accidental o Aortic stenosis
overdose occurs. o Pulmonary stenosis

Cardiac Defects: Increased Pulmonary Blood Flow Coarctation of the Aorta

Description  Coarctation (see image, left) is localized narrowing near the insertion
 Intracardiac communication along the septum or an abnormal of the ductus arteriosus.
connection between the great arteries allows blood to flow from the  High blood pressure and bounding pulses in the arms, weak
high-pressure left side of heart to the low-pressure right side. femoral pulses (or absence of femoral pulses), and coolness of the
 The affected infant typically demonstrates signs and symptoms of legs may be present; the blood pressure is higher in the arms than in
heart failure. the legs.
 A characteristic murmur may be present, and signs and symptoms of  Headaches, dizziness, fainting, or epistaxis may result from
decreased cardiac output may be noted. hypertension.
 Resection of the coarcted portion with anastomosis of the aorta or
enlargement of the constricted section using a graft may be
required.

Aortic Stenosis
 Narrowing or stricture of the aortic valve (see image, middle) causes
resistance to blood flow in the left ventricle, decreased cardiac
output, left ventricular hypertrophy, and pulmonary vascular
congestion.
 Infants with severe defects demonstrate signs of decreased cardiac
output: faint pulses, hypotension, tachycardia, and poor feeding.
 Affected children show signs of exercise intolerance, chest pain, and
dizziness when standing for long periods. Tricuspid Atresia
 Dilation of the narrowed valve during cardiac catheterization or a  The tricuspid valve fails to develop, meaning that there is no
surgical aortic valvotomy may be performed; valve replacement may communication between the right atrium and right ventricle.
also be required.  Blood flows through an atrial septal defect or patent foramen ovale
to the left side of the heart
Pulmonary Stenosis and through a ventricular septal defect to the right ventricle and out
 The entrance to the pulmonary artery is narrowed (see image, right). to the lungs.
 Pulmonary atresia, marked by total fusion of commissures and no  Tricuspid atresia is often associated with pulmonary stenosis and
blood flow to the lungs, is the extreme form. transposition of the great arteries.
 Newborns with severe narrowing are cyanotic.  Mixing of unoxygenated and oxygenated blood in the left side of the
 Dilation of the narrowed valve may be performed during cardiac heart results in systemic desaturation, pulmonary obstruction, and
catheterization, or a surgical pulmonary valvotomy may be required. decreased pulmonary blood flow.
 Cyanosis, tachycardia, and dyspnea are seen in the affected
Cardiac Defects: Decreased Pulmonary Blood Flow newborn.
Description  Older children exhibit signs of chronic hypoxemia and clubbing.
 In such defects, an anatomic defect (atrial or ventricular septal  If the atrial septal defect is small, atrial septostomy is performed
defect) is present between the right and left sides of the heart, during cardiac catheterization; otherwise, surgery is necessary.
causing obstruction of pulmonary blood flow.
 Pressure on the right side of the heart increases, exceeding left-side
pressure, which allows desaturated blood to shuntfrom the right to
the left, resulting in desaturation on the left side of the heart and in
the systemic circulation.
 A characteristic murmur may be present.
 Hypoxemia and cyanosis are typical.
 This type of defect takes two different forms, discussed on the
screens that follow:
o Tetralogy of Fallot
o Tricuspid atresia

Tetralogy of Fallot
 This condition comprises four defects: ventricular septal defect,
pulmonary stenosis, overriding aorta, and right ventricular
hypertrophy.
 If pulmonary vascular resistance is higher than systemic resistance,
the shunt moves blood from right to left; if systemic resistance is Cardiac Defects: Mixed
higher than pulmonary resistance, blood is shunted from left to Description
right.  Fully saturated systemic blood flow mixes with desaturated blood
 The affected child may be acutely cyanotic at birth or may flow, causing desaturation of systemic blood flow.
experience mild cyanosis that worsens over the first year of life in  Pulmonary congestion, accompanied by decreased cardiac output,
tandem with the stenosis. results.
 Acute episodes of cyanosis and hypoxia (hypercyanotic spells), called  Signs of heart failure are present; the type and severity of symptoms
"blue spells" or "tet spells," occur when the infant's oxygen depend on the degree of desaturation.
requirements exceed blood supply (usually during crying or after
 There are four types of mixed defects, discussed in greater detail on
feeding).
the screens that follow:
 With increasing cyanosis, clubbing of fingers, squatting, and o Transposition of the great arteries/transposition of the great vessels
poor growth may be noted. o Total anomalous pulmonary venous connection
 Surgical interventions include the use of a palliative shunt and o Truncus arteriosus
complete surgical repair (usually performed during the first year of o Hypoplastic left heart syndrome
life).
 Transposition of the Great Arteries/Transposition of the Great Truncus Arteriosus
Vessels  Normal septation and division of the embryonic bulbar trunk into
 The pulmonary artery leaves the left ventricle and the aorta exits pulmonary artery and aorta fail, resulting in a single vessel that
from the right ventricle; there is no communication between the overrides both ventricles.
systemic and pulmonary circulations.  Blood from both ventricles mixes in the common great artery,
 Cyanosis is evident, and cardiomegaly becomes evident a few weeks causing desaturation and hypoxemia.
after birth.  Corrective surgery is performed during the first months of life.
 Prostaglandin E1 may be administered to temporarily increase blood
mixing if systemic and pulmonary mixing is inadequate.
 Balloon atrial septostomy may be performed during cardiac
catheterization, or surgery may be required.

Hypoplastic Left Heart Syndrome

 Underdevelopment of the left side of the heart results in a
hypoplastic left ventricle and aortic atresia.
 The syndrome is fatal in the first months of life without intervention.
 Surgery is necessary; heart transplantation during the newborn
Total Anomalous Pulmonary Venous Connection period may be considered.
 The pulmonary veins fail to join the left atrium.
 Mixed blood is returned to the right atrium and shunted from the
right to the left through an atrial septal defect.
 The right side of the heart hypertrophies; the left side may remain
small.
 Cyanosis worsens with pulmonary vein obstruction; once
obstruction occurs, the infant's condition deteriorates rapidly.
 Corrective surgery is performed in early infancy.

Cardiac Defects
Nursing Considerations
Basic Care
 Monitor vital signs closely.
 Monitor the child for nasal flaring and use of accessory muscles;
notify the health care provider if changes in respiratory status occur.
 Auscultate breath sounds for crackles and rhonchi.
 If respiratory effort is increased, place the child in a reverse
Trendelenburg position (elevate the head and upper body) to
decrease the work of breathing.
 Administer humidified oxygen as prescribed.
 Provide endotracheal tube and ventilator care if necessary and as
prescribed; restrain the hands of the intubated child.
 Monitor the child for hypercyanotic spells; if one occurs, place the to inform the dentist of the cardiac problem so that
infant in a knee-chest position, administer 100% oxygen by face antibiotics may be prescribed if they are necessary.
mask, and administer morphine sulfate and IV fluids as prescribed.  Instruct the parents to call the health care provider if
 Assess the child for signs of heart failure (e.g., fluid retention in the coughing, tachypnea, cyanosis, vomiting, diarrhea,
eyes, hands, feet, and chest). anorexia, pain, or fever occurs or any swelling, redness, or
 Assess the peripheral pulses. drainage is noted at the site of the incision.
 Monitor intake and output and notify the health care provider if
urine output decreases (weigh diapers, if necessary).
 Weigh the child daily.
 Maintain fluid restriction, if this is prescribed. Rheumatic Fever
 Provide adequate nutrition (high calorie requirements) as Description
prescribed.  This inflammatory autoimmune disease affects the connective
 Administer medications as prescribed. tissues of the heart, joints, subcutaneous tissues, and blood vessels
 Keep the child as free of stress as possible; plan interventions to of the central nervous system.
permit the most rest possible.  The most serious complication is rheumatic heart disease, which
 Prepare the parents and, if appropriate, the child for surgery. affects the cardiac valves, particularly the mitral valve.
 Familiarize the parents and child with hospital procedures and  Rheumatic fever appears 2 to 6 weeks after an untreated or partially
equipment. treated group A beta-hemolytic streptococcal infection of the upper
respiratory tract.
Postoperative Interventions  Diagnosis is based on a set of guidelines recommended by the
 Check the vital signs frequently. American Heart Association, known as the Jones criteria; these
criteria suggest that the presence of two major manifestations (e.g.,
 Notify the health care provider if fever occurs.
carditis and chorea) or one major and two minor manifestations
 Watch for signs of sepsis (e.g., fever, chills, diaphoresis, lethargy, (e.g., fever and arthralgia), with evidence of streptococcal infection,
altered level of consciousness). indicates a high probability of rheumatic fever.
 Maintain aseptic technique.  Assessment findings include:
 Monitor lines, tubes, and catheters and remove them promptly as o A low-grade fever that spikes late in the afternoon
prescribed when they are no longer needed to help prevent o Increased antistreptolysin O titer and sedimentation rate and the
infection. presence of C-reactive protein
 Assess the child for signs of discomfort (e.g., irritability; changes in o Aschoff bodies (hemorrhagic bullous lesions that cause swelling and
heart rate, respiratory rate, and blood pressure; inability to sleep). fragmentation in connective tissue) in the heart, blood vessels,
 Administer pain medications as prescribed, noting their brain, and serous surfaces of the joints and pleura
effectiveness.
 Administer antibiotics and antipyretics as prescribed.
 Encourage rest periods.
 Facilitate parent-child contact as soon as possible.
 Educate the parents in home care measures.
 Keep the child from playing outside for several weeks.
 Avoid activities in which the child could fall and be injured,
such as bike riding, for 2 to 4 weeks.
 Avoid crowds for 2 weeks after discharge.
 Follow a no-added-salt diet as prescribed.
 Do not add any new foods to the infant's diet; if an allergy
to the new food exists, the manifestations may be
interpreted as a postoperative complication.
 Do not apply creams, lotions, or powders to the incision
until completely healed.
 The child who has undergone cardiac surgery may
generally return to school the third week after discharge,
starting with half-days.
 The child should not participate in physical education for 2
months.
 Instruct the parents to discipline the child normally.
 Instruct the parents about the importance of the 2-week
follow-up.
 Avoid immunizations, invasive procedures, and dental
visits for 2 months; after this period has elapsed, the
immunization schedule and dental visits must be resumed.
 Advise the parents regarding the importance of a dental
visit every 6 months after age 3 years and explain the need
 Nursing Considerations  If the child develops the flu or chickenpox during treatment, he or
 Control joint pain and inflammation with the use of massage and she will need to stop taking aspirin because of the risk of Reye
alternating applications of heat and cold as prescribed. syndrome.
 Provide bed rest during the acute febrile phase.  Administer immunoglobulin IV as prescribed to shorten the duration
 Limit physical exercise in the child with carditis. of fever and reduce the risk of coronary artery lesions and
 Administer antibiotics (penicillin) as prescribed. aneurysms (IV immunoglobulin is a blood product, so blood
 Administer salicylates and antiinflammatory agents as prescribed; precautions are necessary).
these medications should not be instituted before the diagnosis is  Instruct the parents in the administration of prescribed medications,
confirmed, however, because they can mask polyarthritis. the need to monitor the child for bleeding or other complications,
 Initiate seizure precautions if the child is experiencing chorea. and the need for follow-up to detect cardiac complications.
 Instruct the parents in the importance of follow-up and the need for
Part 7: Renal and Urinary Disorders
antibiotic prophylaxis for dental work, in the event of infection, and
before invasive procedures.
Glomerulonephritis
 Urge the child to tell the parents if anyone at school contracts a Description
streptococcal throat infection.
 Glomerulonephritis is a group of disorders, most caused by an
immunological reaction.
Kawasaki Disease
Description  Immunological diseases
 Also known as mucocutaneous lymph node syndrome, Kawasaki  Autoimmune diseases
disease is an acute systemic inflammatory illness.  Streptococcal infection, group A beta-hemolytic
 The cause is unknown, but the disorder may be associated with an  History of pharyngitis or tonsillitis 2 to 3 weeks before
infection from a toxin or organism. onset of symptoms
 Cardiac involvement is the most serious complication; it may result  Destruction, inflammation, and sclerosis of the glomeruli of both
in the development of coronary aneurysms that can lead to kidneys occurs, with consequent loss of kidney function.
myocardial infarction.  Complications include kidney failure, hypertensive encephalopathy,
heart failure, and pulmonary edema.
Assessment findings vary with the stage of illness:  Assessment findings include:
Acute Stage o Periorbital and facial edema (more prominent in the morning)
 Fever o Anorexia
 Conjunctival hyperemia o Decreased urine output
 Red throat, inflamed mucous membranes, "strawberry tongue" (see o Cloudy brown urine (hematuria)
image) o Pallor
o Irritability
 Swollen hands and rash (see images)
o Lethargy
 Enlarged cervical lymph nodes o Headaches, abdominal or flank pain, and dysuria in the older child
o Hypertension
Subacute Stage o Proteinuria that produces persistent and excessive foam in the urine
 Cracked lips and fissures o Azotemia
 Desquamation of skin on the tips of fingers and toes o Increased blood urea nitrogen and creatinine levels
 Joint pain o Increased antistreptolysin O titer (used to diagnose disorders caused
 Thrombocytosis by streptococcal infections)
 Cardiac manifestations (greatest risk for coronary aneurysm during
this stage) Nursing Considerations
 Monitor the child’s vital signs, weight, intake and output, and urine
Convalescent Stage characteristics (assessing the weight for changes is useful in
 Normal appearance but signs of inflammation may be present determining fluid balance).
 Limit the child’s activity and take safety measures.
Nursing Considerations  Monitor the child for signs of complications.
 Check the child’s temperature frequently.  Administer diuretics, antihypertensives, and antibiotics as
 Assess heart sounds and rhythm. prescribed.
 Assess the extremities for edema, redness, and desquamation.  Initiate seizure precautions and administer anticonvulsants as
 Examine the eyes for conjunctivitis. prescribed for seizures associated with hypertensive
encephalopathy.
 Monitor the mucous membranes for inflammation.
 Educate the parents about the signs warranting health care provider
 Monitor intake and output.
notification (e.g., bleeding, signs of infection).
 Serve soft foods and liquids.
 Restrict fluids as prescribed.
 Weigh the child daily.
 Be aware of nutritional restrictions:
 Perform passive range-of-motion exercises to facilitate joint o Restrictions depend on the stage and severity of the disease,
movement. especially the extent of edema.
 Administer acetylsalicylic acid as prescribed for its antipyretic and o In uncomplicated cases, a regular diet is permitted but sodium is
antiplatelet effects (a standard part of therapy for Kawasaki restricted (no added salt).
disease); additional anticoagulation may be necessary if aneurysms
are present.
o Moderate sodium restriction is prescribed for the child with  Immunosuppressant therapy may be prescribed to reduce the risk of
hypertension or edema. relapse and induce long-term remission; this therapy may be
o Foods high in potassium are restricted during periods of oliguria. administered in conjunction with the corticosteroid.
o Protein is restricted if the child has severe azotemia resulting from  Diuretics may be prescribed to reduce edema.
prolonged oliguria.  Plasma expanders (e.g., salt-poor human albumin) may be
prescribed for the severely edematous child; furosemide is given
Nephrotic Syndrome intravenously after the albumin infusion to enhance diuresis and
Description decrease the chance of fluid overload.
 This kidney disorder is characterized by massive proteinuria,
 Educate the parents in urine testing for albumin, administration of
hypoalbuminemia, and edema. medications, side effects of medications, and general care of the
 The primary objective of therapeutic management is to reduce the child.
excretion of urinary protein, maintain protein-free urine, reduce  Teach the parents the signs of infection and stress the need for the
edema, prevent infection, and minimize complications. child to avoid contact with children with illnesses that may be
 Assessment findings include: infectious.
o Weight gain
o Periorbital and facial edema (most prominent in the morning) Hemolytic-Uremic Syndrome
o Leg, ankle, labial, or scrotal edema Description
o Decreased urine output  This disorder is thought to be associated with bacterial toxins,
o Dark, frothy urine chemicals, and viruses that cause acute kidney injury in children.
o Abdominal swelling (ascites)
 The syndrome occurs primarily in infants and small children 6
o Normal or slightly low blood pressure
months to 5 years old.
o Massive proteinuria
o Low serum protein level (hypoproteinemia)  Assessment findings include:
o Increased serum lipid levels o Proteinuria, hematuria, and urinary casts
o Increased blood urea nitrogen and serum creatinine levels
o Decreased hemoglobin and hematocrit levels
o Vomiting
o Irritability
o Lethargy
o Marked pallor
o Hemorrhagic manifestations (e.g., bruising, petechiae, jaundice,
bloody diarrhea)
o Oliguria or anuria
o Central nervous system involvement (e.g., seizures, stupor, coma)

Nursing Considerations
 Hemodialysis or peritoneal dialysis may be prescribed if a child is
anuric.
 Strict monitoring of fluid balance is necessary; fluid restrictions may
be prescribed if the child is anuric.
 Institute measures to prevent infection.
 Provide adequate nutrition.
 Other treatments include medications to treat manifestations and
the administration of blood products to treat severe anemia
(administered with caution to prevent fluid overload).

Cryptorchidism
Description
 One or both testes fail to descend through the inguinal canal into
Nursing Considerations the scrotal sac.
 Monitor vital signs and intake and output.  On assessment, the testes are not palpable or not easily guided into
the scrotum.
 Weigh the child daily.
 Monitor laboratory results for urine specific gravity and albumin. Nursing Considerations
 Monitor the child for edema; repositon the child every two hours;  Monitor the child during the first 12 months of life to determine
elevate edematous parts and maintain meticulous skin care. whether spontaneous descent has occurred.
 A regular diet without added salt is prescribed if the child is in  After 1 year, medical or surgical treatment may be instituted.
remission; sodium is restricted during periods of massive edema
 Human chorionic gonadotropin, a pituitary hormone that stimulates
(fluids may also be restricted).
the production of testosterone, may be prescribed for an older child.
 Corticosteroid therapy is prescribed as soon as the diagnosis has
 Surgical correction, if needed (if the testes do not descend
been confirmed; monitor the child taking corticosteroids closely for
spontaneously), consists of orchiopexy before the child's second
signs of infection.
birthday (preferably between 1 and 2 years of age).
 Monitor the child for bleeding and infection after surgery.
 Instruct the parents in postoperative home care measures, including  The bladder is covered loosely with sterile, nonadherent
infection and pain control and activity restrictions. clear plastic wrap or a sterile thin film dressing without
 Provide an opportunity for parental counseling if the parents are adhesive.
concerned about the future fertility of the child.  Petroleum jelly is avoided because it tends to dry out,
adhere to bladder mucosa, and damage delicate tissues
Hypospadias and Epispadias when the dressing is removed
Description  Monitor laboratory values and urinalysis results to check renal
 These congenital defects involve an abnormal situation of the function.
urethral orifice on the penis.  Administer antibiotics as prescribed.
 In hypospadias, the urethral orifice is located below the glans penis,  Provide emotional support to the parents; encourage verbalization
along the ventral surface. of fears and concerns.
 In epispadias, the urethral orifice is located on the dorsal surface of
penis; often occurs with exstrophy of the bladder. Part 8: Eye and Ear Disorders
 Both conditions can facilitate the entry of bacteria into the urinary
tract. Strabismus
Description
Nursing Considerations  In this condition, often called a "squint" or "lazy eye," the eyes are
 Surgery is performed before the child reaches the age of toilet not aligned as a result of a lack of coordination of the extraocular
training, preferably between 16 and 18 months. muscles.
 The newborn with epispadias or hypospadias should not be  Strabismus is most often caused by muscle imbalance or paralysis of
circumcised, because the foreskin may be used in surgical the extraocular muscles, but it may also result from a congenital
reconstruction. defect.
 Take the appropriate measures after the child has undergone  Amblyopia (reduced visual acuity) may occur if strabismus is not
surgery: treated early, because the brain receives two messages as a result of
o The child will have a pressure dressing and may have some type of the nonparallel visual axes; permanent loss of vision is possible.
urinary diversion or stent (used to maintain patency of the urethral  Strabismus is a normal finding in the young infant but should not be
opening) while the meatus heals. present after about the age of 4 months.
o Monitor the child’s vital signs.  Assessment findings include:
o Encourage fluid intake to maintain adequate urine output and stent o Crossed eyes
patency. o Squinting; child tilts the head or closes one eye to see
o Monitor intake and output; check urine for cloudiness or a foul odor. o Loss of binocular vision
o Notify the health care provider if there is no urinary drainage for 1 o Impairment of depth perception
hour; this may indicate kinks in the urinary diversion or obstruction o Frequent headaches
by sediment. o Diplopia
o Provide pain medication or medication to relieve bladder spasms o Photophobia
(anticholinergic) and administer antibiotics as prescribed.
o Instruct the parents in the care of the urinary diversion or stent, if Nursing Considerations
one is present.  Corrective lenses may be indicated.
o Instruct the parents to avoid giving the child tub baths until the  Instruct the parents in how to patch the “good” eye to strengthen
stent, if one is present, has been removed. the weak eye (occlusion therapy).
o Educate the parents in the need for fluid intake, proper medication
 Prepare the child for surgery to realign the weak muscles as
administration, signs and symptoms of infection, and the need for
prescribed if nonsurgical interventions are unsuccessful; surgery is
health care provider follow-up for dressing removal, approximately 4
usually performed before the age of 2 years.
days after surgery.
 Explain to the parents the importance of follow-up visits.
Bladder Exstrophy
Description Conjunctivitis
 This congenital anomaly is characterized by extrusion of the urinary
Description
bladder from the body through a defect in the lower abdominal wall.
 Inflammation of the conjunctiva; is also known as pinkeye.
 Treatment requires a series of reconstruction surgeries.
 Conjunctivitis is usually caused by an allergy, infection, or trauma.
 The initial surgery, for closure of the abdominal defect, is usually
performed during the first days of life.  Bacterial or viral conjunctivitis is extremely contagious.
 The goal of subsequent operations is to reconstruct the bladder and  Chlamydial conjunctivitis is rare in older children; if it is diagnosed in
genitalia and enable the child to achieve urinary continence. a child who is not sexually active, the child should be assessed for
sexual abuse.
 Assessment findings include an exposed bladder mucosa, a widened
symphysis pubis, and defects of the external genitalia.  Assessment findings include:
o Itching, burning, or scratchy eyes
Nursing Considerations o Redness
 Monitor the child’s urine output.
o Edema
o Discharge
 Watch for signs of urinary tract or wound infection.
 Maintain the integrity of the exposed bladder mucosa.
 Prevent the bladder tissue from drying, while allowing drainage of
urine, until surgical closure can be performed.
 Nursing Considerations  A surgical incision into the tympanic membrane,
 Instruct the parents (and, if appropriate, the child) in infection- sometimes with the use of a laser, is made to enable
control measures (e.g., good handwashing, no sharing of towels and drainage of purulent middle ear fluid.
washcloths).  Tympanoplasty tubes may be inserted into the middle ear
 Administer an antibiotic or antiviral eye drop or ointment as to promote continued drainage and to equalize pressure
prescribed if infection is present; severe infection may require and permit ventilation of the middle ear.
therapy with systemic antibiotics.  Instruct the parents and child to keep the ears dry.
 Instruct the parents to keep the child home from school or daycare  The child should wear earplugs while bathing,
until antibiotic eye drops have been administered for 24 hours. shampooing, and swimming (diving and submerging under
 Remove crusted material with a cotton ball soaked in warm water. water are not allowed).
 Explain the use of cool compresses to lessen irritation and  The parents may administer an analgesic such as
recommend the wearing of dark glasses if photophobia occurs. acetaminophen or ibuprofen to relieve discomfort after
 Instruct the child to avoid rubbing the eye to help prevent injury. insertion of tympanoplasty tubes
 Instruct a child who is wearing contact lenses to stop wearing them  Explain to the parents that the child should not blow his or
and to obtain new lenses to eliminate the chance of reinfection. her nose for 7 to 10 days after surgery.
 Explain to the adolescent client that eye makeup should be  Tell the parents that if the tubes fall out it is not an
discarded and replaced. emergency but that the health care provider should be
notified (describe the tubes—tiny, white, and
Otitis Media spool-shaped—so that they will recognize them if this does
Description occur).
 Infection of the middle ear—caused by blockage of the eustachian
tube, which prevents normal drainage—may be acute or chronic. Part 9: Neurological, Cognitive, and Psychosocial Disorders
 Otitis media is a common complication of acute respiratory
infection. Hydrocephalus
 Infants and children are more prone to otitis media than adults Description
because their eustachian tubes are shorter, wider, and straighter.  An imbalance of cerebrospinal fluid (CSF) absorption or production is
 Assessment findings include: caused by malformation, tumor, hemorrhage, infections, or trauma.
o Fever  Hydrocephalus results in head enlargement and increased
o Irritability and restlessness intracranial pressure (ICP).
o Rolling the head from side to side  Assessment findings vary with the age of the client:
o Pulling or rubbing of the ear
o Earache or pain Infant
o Signs of hearing loss o Increased head circumference
o Purulent ear drainage o Thin, widely separated cranial bones that produce a cracked-pot
o Red, opaque, bulging, or retracting tympanic membrane sound (Macewen sign) on percussion
o Tense, bulging, nonpulsating anterior fontanel
Nursing Considerations o Dilated scalp veins
 Encourage fluids and soft foods; chewing during the acute period o Frontal bossing
worsens pain. o Sunsetting eyes
 Provide local heat and have the child lie with the affected ear down.
 Instruct the parents in the appropriate procedure for cleaning Child
drainage from the ear, using sterile gauze or swabs. o Behavior changes (e.g., irritability, lethargy)
o Headache on awakening
 Teach the parents to administer analgesics or antipyretics (e.g.,
o Nausea and vomiting
acetaminophen or ibuprofen to ease fever and pain.
o Ataxia
 Instruct the parents in the administration of prescribed antibiotics, o Nystagmus
emphasizing that the prescribed treatment period is necessary to o High, shrill cry (late sign)
eradicate causative organisms. o Seizure activity (late sign)
 Inform the parents that screening for hearing loss may be necessary.
 If eardrops are prescribed, teach the parents to straighten the Nursing Considerations
auditory canal by pulling the pinna down and back in children  Surgery may be performed to shunt excess cerebrospinal fluid (CSF)
younger than age 3 and by pulling the pinna up and back in a child away from the brain
older than 3 years.  With a ventriculoperitoneal shunt, CSF drains into the
 Discuss with the parents various measures to help prevent otitis peritoneal cavity from the lateral ventricle.
media:  With an ventriculoatrial shunt, CSF drains into the right
o Feeding the infant in an upright position to help prevent reflux atrium of the heart from the lateral ventricle, bypassing
o Obtaining routine immunizations the obstruction; used in older children and in children with
o Breastfeeding for at least the first 6 months of life abdominal conditions.
o Avoiding exposure to tobacco smoke and allergens
 Shunt revision may be necessary as the child grows.
 If myringotomy is necessary, discuss the procedure and follow-up
 One alternative to shunt placement is endoscopic third
care with the parents.
ventriculostomy in which a small opening in the floor of
the third ventricle is made that allows CSF to bypass the
fourth ventricle and return to the circulation to be
 absorbed; this treatment may not be appropriate for some  Some associated cutaneous manifestations include skin
types of hydrocephalus. dimpling, dark tufts of hair, port-wine angiomatous nevi,
 After surgery, perform the appropriate interventions: or lipomas.
o Monitor the child’s vital and neurological signs.  The child may exhibit bowel and bladder sphincter
o Position the child on the side opposite the surgical site to prevent disturbances and progressive disturbances in gait.
pressure on the shunt valve. o Spina bifida cystica
o Keep the child flat as prescribed to help prevent rapid loss of
intracranial fluid.
 This defect results in incomplete closure of the vertebral
o Observe the child for signs of increased ICP; if increased ICP occurs,
and neural tubes, resulting in a sac-like protrusion in the
elevate the head of the bed to 15 to 30 degrees to enhance gravity
lumbar or sacral area, with varying degrees of nervous
flow through the shunt.
tissue involvement.
o Measure the infant’s head circumference.
o Monitor the child for signs of infection and assess dressings for  The two major forms of spina bifida cystic are meningocele
drainage. and myelomeningocele.
o Monitor intake and output.
o Provide comfort measures and administer medications as Meningocele
prescribed.
o Instruct the parents in how to recognize shunt infection or  The protrusion consists of meninges and a saclike cyst that
malfunction. contains CSF in the midline of the back, usually in the
 In an infant, irritability, a high shrill cry, lethargy, and poor lumbosacral area.
feeding may indicate shunt malfunction or infection.  The spinal cord is not involved.
 In a toddler, headache and a lack of appetite are the  Neurological deficits are usually not present.
earliest common signs.
 The older children may exhibit alterations in the level of
Myelomeningocele
consciousness.

 The protrusion contains meninges, CSF, nerve roots, and a

portion of the spinal cord.
 The sac (defect) is covered by a thin membrane that is
prone to leakage or rupture.
 Neurological deficits are evident.

Spina Bifida
Description
 This central nervous system defect occurs when the neural tube fails
to close during embryonic development.
 Associated deficits include sensorimotor disturbance, dislocated Nursing Considerations
hips, clubfoot, and hydrocephalus.  Evaluate the sac and measure the lesion.
 Assessment findings vary with the type of defect:  Conduct a neurological assessment.
o Spina bifida occulta
 Monitor the child for increased ICP, which could indicate developing
 The posterior vertebral arches fail to close in the hydrocephalus; measure the head circumference and assess the
lumbosacral area. anterior fontanel for fullness.
 In many cases there are no observable manifestations.
 Protect the sac; cover it with a sterile, moist (normal saline), o History of systemic viral illness 4 to 7 days before the onset of
nonadherent dressing to maintain the moisture of the sac and symptoms
contents. o Fever
 Change the dressing covering the sac on a regular schedule or o Nausea and vomiting
whenever it becomes soiled to reduce the risk of infection; diapering o Signs of altered hepatic function (e.g., lethargy)
may be contraindicated until the defect has been repaired. o Progressive neurological deterioration
 Use aseptic technique to help prevent infection.
Nursing Considerations
 Assess the sac for redness, clear or purulent drainage, abrasions,
irritation, and signs of infection.
 The goal of treatment is to maintain effective cerebral perfusion and
control the increasing intracranial pressure.
 Early signs of infection include increased temperature (axillary),
irritability, lethargy, and nuchal rigidity.  Provide rest and decrease stimulation in the environment.
 Place the infant in a prone position to minimize tension on the sac  Monitor the child for altered level of consciousness and signs of
and the risk of trauma; the head is turned to one side for feeding. increased ICP.
 Assess the infant for physical impairments such as joint deformities.  Monitor for signs of altered hepatic function and results of liver
function studies.
 Defect closure surgery is usually performed during infancy.
 Monitor intake and output.
 Administer antibiotics before and after surgery as prescribed to help
prevent infection.  Watch for signs of bleeding and impaired coagulation (e.g.,
prolonged bleeding time).
 Teach the parents and eventually the child about long-term home
care (e.g., positioning, diet and feeding, skin care, exercises, bladder
Near-Drowning
elimination and catheterization, bowel program, medications).
Description
 Monitor the child for latex allergy; the risk for allergy to latex and
 The term near-drowning is used to describe survival of at least 24
rubber products is high because of the frequent exposure to latex
hours after submersion in a fluid medium.
during care).
 Hypoxia and asphyxiation are the primary problems because they
Cerebral Palsy result in extensive cell damage (cerebral cells sustain irreversible
Description damage after 4 to 6 minutes of submersion); additional problems
include aspiration and hypothermia.
 Cerebral palsy is a chronic, nonprogressive disorder of posture and
movement; characterized by difficulty in controlling the muscles  Outcome predictions are based on the duration of submersion in
because of an abnormality in the extrapyramidal or pyramidal motor nonicy water:
system. o The outcome may be good if submersion lasted less than 5 minutes
and the child exhibits neurological responsiveness, reactive pupils,
 Co-morbidities such as cognitive, hearing, speech, and visual
and a normal cardiac rhythm.
impairments, as well as seizures, are common but vary widely from
o A child who was submerged for more than 10 minutes and does not
one affected child to another.
respond to cardiopulmonary life support measures within 25
 The damage to the motor system can occur prenatally, perinatally, minutes has an extremely poor prognosis (severe neurological
or postnatally. impairment or death).
 The most common clinical type is spastic cerebral palsy, which
represents an upper motor neuron type of muscle weakness. Nursing Considerations
Nursing Considerations  Provide ventilatory and circulatory support; if the child has had a
 Determine the need for special equipment for reading, writing, severe cerebral insult, endotracheal intubation and mechanical
eating, and mobility. ventilation may be required.
 Monitor the child's developmental level and cognitive abilities.  Monitor respiratory status, because respiratory compromise and
 Use the child's usual mode of communicating, such as flash cards cerebral edema may occur 24 hours after the incident.
and talking boards, to facilitate communication.  Be alert for symptoms of aspiration pneumonia.
 Administer prescribed medications to treat spasticity, pain and  Monitor neurological status closely; if spontaneous purposeful
secondary conditions (e.g., seizure disorder, chronic constipation, movement and normal brainstem function are not apparent 24
urinary tract infections, gastroesophageal reflux). hours after the event, the child most likely has sustained severe
 Monitor for infection or pump malfunction if intrathecal baclofen is neurological injury.
administered by an implanted pump to provide relief of spasticity.  Teach the parents to provide adequate supervision of infants and
 Reinforce the therapeutic plan and assist the family in devising and small children around water to help prevent such accidents
modifying equipment and activities to continue the therapy program
in the home. Autism
Description
Reye Syndrome  The term autism is often used to describe a severe form of an autism
Description spectrum disorder.
 In this disorder, acute encephalopathy follows a viral illness.  Symptoms are usually noticed by the parents by the time the child
 Reye syndrome is characterized pathologically by cerebral edema has reached 3 years of age.
and fatty changes in the liver.  The cause of the disorder is not specifically known; however, it has
 A definitive diagnosis is made by means of a liver biospy. been linked to a wide range of antepartum, intrapartum, and
 Aspirin should not be administered to children with a febrile illness postpartum conditions and exposure to hazardous chemicals;
or varicella or influenza because of its association with Reye genetic predisposition has also been linked to the disorder.
syndrome.
 Assessment findings include:
 The disorder is accompanied by intellectual and social behavioral o Poor attention span, shifting from one uncompleted activity to
deficits, and the child exhibits peculiar and bizarre characteristics in another
social interactions, communication, and behaviors. o Excessive talking and interruption or intrusion on others
o Engaging in physically dangerous activities without considering the
Social
possible consequences

• Abnormal comfort-seeking behaviors or a lack thereof Nursing Considerations

• Abnormal social play or a lack thereof  Provide parents with information about the disorder and treatment
plan; encourage parents to take advantage of support groups.
• Impairment in peer relationships
 Behavioral therapy is focused on preventing undesirable behavior.
• Lack of awareness of the existence or feelings of others  Maintain a consistent home and classroom environment.
• Abnormal imitation of others or a lack thereof  Discuss environmental and physical safety measures with the
Communication parents.
 Encourage the parents to seek appropriate classroom placement of
the child.
• Impaired or abnormal speech (e.g., monotone voice, echolalia) or
 Promote self-esteem on the part of the child.
a lack of speech  Stimulant medications may be prescribed; possible side effects
• Abnormal nonverbal communication (e.g., does not use gestures include appetite suppression and weight loss, nervousness, tics,
to communicate) insomnia, and increased blood pressure.
 Instruct the child and parents in proper medication administration
• Lack of imaginative play and the need for regular follow-up.
Behavior
Part 10 Musculoskeletal Disorders
• Persistent preoccupation or attachment to objects
Developmental Dysplasia of the Hip
• Restricted range of interests Description
• Self-injurious behaviors  In abnormalities of the hip, which may develop during fetal life,
infancy, or childhood, the head of the femur is seated improperly in
• Insistence on routine, with any environmental change producing
the acetabulum, or hip socket, of the pelvis.
marked distress  Assessment findings vary with the age of the child.
• Repetitive body movements (e.g., rocking, head-banging) Neonate

 Diagnosis is based on symptoms and the results of several screening

tools. • The ligaments around the hip exhibit laxity.
Infant
Nursing Considerations
 Determine the child's routines, habits, and preferences and maintain • The gluteal folds are unequal when the infant is prone and the
consistency as much as possible.
 Determine the specific ways in which the child communicates and legs are extended against the examining table (see
use these methods. image, A).
 Avoid placing demands on the child. • Abduction of the hip on the affected side is restricted when the
 Safety is a priority; implement safety precautions as necessary for
infant is placed supine with the knees and hips flexed
self-injurious behaviors such as head-banging.
 Initiate referrals to special programs as required. (image, B).
 Provide support to the parents and direct the parents to sources of • The limb on the affected side is shorter than the other; this is
community support. demonstrated with the Galeazzi (also known as Allis) test,

Attention Deficit–Hyperactivity Disorder in which the infant is laid supine and the knees are flexed
Description so that the feet are flat on the examination table. If the
 This developmental disorder, often referred to by its acronym, knees are not level, the infant may have hip malformation
ADHD, is characterized by developmentally inappropriate degrees of
(image, C).
inattention, overactivity, and impulsivity.
 Childhood problems connected to ADHD include lower-than-normal • The Ortolani sign—a “clunking” sensation that indicates a
intellectual development, minor physical abnormalities, sleep dislocated femoral head moving into the acetabulum—is
disturbances, behavioral or emotional disorders, and difficulty
elicited when the examiner abducts the thigh and applies
participating in social relationships.
 Early diagnosis, established on the basis of self-reports, parent and gentle pressure forward over the greater trochanter
teacher reports, and psychological assessments, is important. (image, D).
 Assessment findings include: • The Barlow sign—palpable movement of the femoral head out of
o Fidgeting with the hands or feet or squirming in a seat
o Easy distraction by external or internal stimuli the acetabulum—is elicited when the examiner adducts
o Difficulty following through on instructions the hips and applies gentle pressure down and back with
 the thumbs.  Talipes calcaneus: dorsiflexion in which the toes are higher
than the heel
Older Infant or Child
 Clubfoot may be unilateral or bilateral.
 The goal of treatment is to achieve a painless, stable plantigrade
• The affected leg is shorter than the other. (i.e., able to walk on the sole of the foot with the heel on the
• The head of the femur can be felt to move up and down in the ground) foot.
buttock when the extended thigh is pushed first toward  Clubfoot is classified on the positioning of the ankle and foot.
Nursing Considerations
the child's head and then pulled distally.  Treatment is begun as soon as possible after birth.
• The examiner elicits the Trendelenburg sign—a downward, rather  Manipulation and casting are performed weekly for about 8 to 12
than the normal upward, tilt of the pelvis—by having the weeks because of the rapid growth of early infancy; a splint is then
applied if casting and manipulation are successful.
child stand on one foot and then the other, holding on to a
 Surgical intervention may be necessary if normal alignment is not
support and bearing weight on the affected hip (image, E). achieved by about 6 to 12 weeks of age.
• Prominence of the greater trochanter is noted.  Monitor the infant for pain and assess the neurovascular status of
• Marked lordosis or a waddling gait is noted in bilateral the toes frequently.
 Instruct the parents in cast care and signs of neurovascular
dislocation. impairment requiring health care provider notification.
 Explain that long-term follow-up will be required at intervals until
the child reaches skeletal maturity.

Idiopathic Scoliosis
Description
 Scoliosis is the term given to three-dimensional spinal deformity,
usually involving lateral curvature, spinal rotation resulting in rib
asymmetry, and hypokyphosis of the thorax.
 Idiopathic scoliosis is usually diagnosed during the
preadolescent growth spurt; screenings are important when growth
spurts occur.
 Long-term monitoring is essential to detect any progression of the
curve.
 Assessment findings include:
o Asymmetry of the ribs and flanks when the child bends forward at
the waist and hangs the arms down toward the feet (Adams test)
o Asymmetrical hip height, rib positioning, and shoulder height (may
be noted when the examiner stands behind an undressed child)
o Leg-length discrepancy
 Radiographs are obtained to confirm the diagnosis.
Nursing Considerations
Nursing Considerations
 Between birth and 6 months of age, the hips may be splinted with
the use of a Pavlik harness (see image) to maintain flexion and  Monitor the progression of the curvatures.
abduction and external rotation; the harness is worn continuously  Surgical (i.e., spinal fusion, placement of an instrumentation system)
until the hip is stable, usually in 3 to 6 months. and nonsurgical (i.e., bracing; see image) interventions are used; the
 Between the ages of 6 and 18 months, gradual reduction by traction, type of treatment depends on the location and degree of the
followed by closed reduction or open reduction (if necessary) under curvatures, the age of the child, the amount of growth that is yet
general anesthesia, is performed; the child is then placed in a hip anticipated,
spica cast for 2 to 4 months until the hip is stable, after which a and any underlying disease processes.
flexion-abduction brace is applied for approximately 3 months.  Prepare the child and parents for the use of a brace, if one is
 In older children, surgical reduction and reconstruction is usually prescribed.
required.  Braces are not curative but may slow the progression of
 Instruct the parents regarding the proper care of a Pavlik harness, the curvature to allow skeletal growth and maturation.
spica cast, or abduction brace.  Braces are usually meant to be worn 16 to 23 hours a day.
 Inspect the skin for signs of redness or breakdown.
Congenital Clubfoot  Keep the skin clean and dry and avoid the use of lotions
Description and powders, which may cake, leading to skin breakdown.
 This term is used to describe a complex range of deformities of the  Advise the child to wear soft, nonirritating clothing under
ankle and foot that includes forefoot adduction, midfoot supination, the brace.
hindfoot varus, and ankle equinus.  Instruct the child in prescribed exercises to help maintain
 Talipes varus: inversion, or an outward bending and strengthen the spinal and abdominal muscles during
 Talipes valgus: eversion, or an inward bending treatment.
 Talipes equinus: plantarflexion in which the toes are lower  Encourage verbalization about body image and other
than the heel psychosocial issues.
 Prepare the child and parents for surgery, if it is prescribed. Part 11: Hematological Disorders
 Maintain proper alignment; avoid twisting movements.
 Use the log-roll procedure to maintain alignment while Sickle-Cell Anemia
turning the child. Description
 Assess the extremities for adequate neurovascular status.  Sickle cell anemia is the term given to a group of diseases, the
hemoglobinopathies, in which hemoglobin A is partly or completely
 Monitor the child for signs of superior mesenteric artery
replaced with abnormal sickle hemoglobin S.
syndrome (caused by mechanical changes in the position
of the abdominal contents during surgery) and notify the
 Hemoglobin S is sensitive to changes in the oxygen content of
health care provider if they occur; symptoms include the red blood cell (RBC).
emesis and abdominal distention similar to that which  Insufficient oxygen causes RBCs to assume a sickle shape, and the
occurs with intestinal obstruction or paralytic ileus. cells become rigid and clump together, obstructing capillary blood
 Instruct the parents and child in activity restrictions. flow.
 Explain to the child how to roll from a side-lying position to  Clinical manifestations occur primarily as a result of obstruction by
a sitting position and stress the need for the parents to sickled RBCs and increased RBC destruction.
assist with ambulation.  Situations that precipitate sickling include fever, dehydration, and
 Prepare the child for the use of a molded plastic orthosis emotional or physical stress; any condition that increases the need
(brace) to provide external stability of the spine when for oxygen or alters the transport of oxygen can result in sickle cell
activities are resumed. crisis (acute exacerbation).
 The potential for altered role performance, body image disturbance,  Sickle cell crises are acute exacerbations of the disease, which vary
fear, anger, and isolation exists in the child with a disabling condition considerably in severity and frequency; they include vasoocclusive
or one that requires the wearing of a body brace. crisis, splenic sequestration, and aplastic crisis.
 The sickling response is reversible under conditions of adequate
Marfan Syndrome oxygenation and hydration; after repeated sickling, however, the cell
Description remains permanently sickled.
 This disorder of connective tissue affects the skeletal and  A range of assessment findings are seen.
cardiovascular systems, as well as the eyes and skin. Vasoocclusive Crisis
 Marfan syndrome is caused by defects in the fibrillin-1 gene, which
serves as a building block for elastic tissue in the body.
• This complication, caused by stasis of blood, results in clumping
 The disorder may be inherited.
of RBCs in the microcirculation, ischemia, and infarction.
 There is no cure for Marfan syndrome.
 Assessment findings include: • Signs include fever, pain, and tissue engorgement.
o Tall, thin body structure: slender fingers, long arms and legs Splenic Sequestration
o Curvature of the spine
o Vision problems
• This life-threatening crisis is caused by the pooling of blood in the
o Cardiac problems
spleen.
Nursing Considerations • Signs include profound anemia, hypovolemia, and shock.
 Monitor the client for vision problems and stress the need for
Aplastic Crisis
regular vision examinations.
 Be alert for curvature of the spine, especially during adolescence.
 Cardiac medications may be prescribed to slow the heart rate and • Diminished production and increased destruction of RBCs is
thus decrease stress on the aorta. triggered by viral infection or depletion of folic acid.
 Explain to the parents that the child with Marfan syndrome should • Signs include profound anemia and pallor.
avoid participating in competitive athletics and contact sports to
help prevent injury to the heart. Nursing Considerations
 Instruct the parents to inform the dentist of the condition;  A multidisciplinary approach to care is needed; care is focused on
antibiotics should be taken before dental procedures to help prevent prevention (through prevention of exposure to infection and
endocarditis. maintenance of normal hydration) and treatment (oxygen,
 Surgical replacement of the aortic root and valve may be necessary. hydration, pain management, and bed rest) of the crisis.
 Maintain adequate hydration and blood flow with the intravenous
(IV) administration of normal saline solution as prescribed and with
oral fluids.
 Administer oxygen and blood transfusions as prescribed to increase
tissue perfusion.
 Administer analgesics as prescribed around the clock.
 Help the child assume a comfortable position with the extremities
extended to promote venous return; elevate the head of the bed no
more than 30 degrees, avoid putting strain on painful joints, and do
not raise the knee gatch of the bed.
 Encourage a high-calorie, high-protein diet with folic acid
supplementation.
 Administer antibiotics as prescribed to prevent infection.  Several possible causes exist, including chronic exposure to
 Monitor the child for signs of complications, including increasing myelotoxic agents, viruses, infection, autoimmune disorders, and
anemia, decreased perfusion, and shock (e.g., mental status allergic states.
changes, pallor, vital sign changes).  A definitive diagnosis is achieved with bone marrow aspiration
 Educate the child and parents about the early signs and symptoms of showing conversion of red bone marrow to fatty bone marrow.
crisis and measures to prevent crises.  Therapeutic management, focused on restoring function to the bone
 Ensure that the child receives pneumococcal and marrow, involves immunosuppressive therapy and bone marrow
meningococcal vaccines and an annual influenza vaccine because of transplantation, the treatment of choice if a suitable donor exists.
the child’s susceptibility to infection as a result of functional  Assessment findings include:
asplenia. o Pancytopenia (deficiency of erythrocytes, leukocytes, and
 Splenectomy may be necessary for children who experience thrombocytes)
recurrent splenic sequestration. o Petechiae, purpura
 Inform parents of the hereditary aspects of the disorder. o Bleeding
o Pallor
Iron-Deficiency Anemia o Weakness
Description o Tachycardia
 The body’s store of iron is depleted, resulting in a decreased supply o Fatigue
of iron for the manufacture of hemoglobin in RBCs.
Nursing Considerations
 This type of anemia commonly results from blood loss, increased
metabolic demands, syndromes of gastrointestinal malabsorption,  Prepare the child for bone marrow transplantation, if it is planned.
and dietary inadequacy.  Administer immunosuppressive medications as prescribed (e.g.,
 Assessment findings include: antilymphocyte globulin or antithymocyte globulin to suppress the
o Pallor autoimmune response, corticosteroids, and cyclosporine.
o Weakness and fatigue  Colony-stimulating factor may be prescribed to enhance bone
o Irritability marrow production.
o Low hemoglobin and hematocrit levels  Administer blood transfusions as prescribed and monitor the child
o RBCs that are microcytic and hypochromic for signs of transfusion reaction.
Nursing Considerations  Monitor the child for signs related to the disease and to
 Increase the child’s oral intake of iron. complications of the treatments and medications administered.
 Educate the child and parents on high-iron foods. Hemophilia
 Liver Description
 Meats  Hemophilia is the term used to describe a group of bleeding
disorders resulting from a deficiency of specific coagulation proteins.
 Egg yolks
 Identifying the specific coagulation deficiency is important because it
 Dark-green leafy vegetables
permits definitive treatment with the specific replacement agent;
 Breads and cereals; whole grains aggressive replacement therapy is initiated to prevent the chronic
 Kidney beans, legumes crippling effects of joint bleeding.
 Raisins  The most common types are factor VIII deficiency (hemophilia A or
 Dried fruits classic hemophilia) and factor IX deficiency (hemophilia B or
 Iron-enriched infant formula and cereal Christmas disease).
 Molasses  Hemophilia is transmitted as an X-linked recessive disorder (but may
 Prune juice also occur as a result of a gene mutation); carrier females pass on
 Tofu the defect to affected males; female offspring are rarely born with
the disorder but may be if they inherit an affected gene from the
 Teach the parents how to administer the iron supplement.
mother and are offspring of a father with hemophilia.
 Administer between meals for maximum absorption.
 Assessment findings include:
 Explain the need to give the supplement with a o Abnormal bleeding in response to trauma or surgery
multivitamin or fruit juice because vitamin C increases o Joint bleeding, resulting in pain, tenderness, swelling, and limited
absorption. range of motion
 Caution the parents against giving the supplement with o A tendency to bruise easily
milk or antacids, which decrease absorption. o Recurrent bleeding
 Teach the child and parents that liquid iron preparation o Normal results of tests that measure platelet function, but, often,
stains the teeth and should be taken through a straw. abnormal results of tests that measure clotting factor function
 Educate the child and parents about the side effects of
iron supplementation (e.g., black stools, constipation, foul Nursing Considerations
aftertaste).  The primary treatment is replacement of the missing clotting factor;
additional medications, such as agents to relieve pain or
Aplastic Anemia corticosteroids, may be prescribed, depending on the source of
Description bleeding from the disorder.
 Deficiency of circulating erythrocytes and all other formed elements  DDAVP (1-deamino-8-D-arginine vasopressin), a synthetic form of
of blood results from the arrested development of cells within the vasopressin, spurs production of plasma factor VIII and may be
bone marrow. prescribed to treat mild hemophilia.
 Monitor the child for bleeding and maintain bleeding precautions.
 Monitor the child for joint pain; immobilize the affected extremity if von Willebrand Disease
it occurs. Description
 Assess neurological status frequently; the child is at risk for  This hereditary bleeding disorder, which occurs in both males and
intracranial hemorrhage. females, is characterized by a deficiency of or a defect in a protein
 Monitor the urine for hematuria. called von Willebrand factor.
 Control joint bleeding by means of immobilization, elevation, and  Causes platelets to adhere to damaged endothelium; the von
application of ice; apply pressure (15 minutes) for superficial Willebrand factor protein also serves as a carrier protein for factor
bleeding. VIII.
 Instruct the child and parents in the signs of internal bleeding.  It is characterized by an increased tendency to bleed from mucous
 Explain to the parents how to control bleeding. membranes.
 Discuss with the parents activities for the child, emphasizing the  Assessment findings include:
avoidance of contact sports and the need for protective devices o Epistaxis
while the child learns to walk; assist in developing an appropriate o Bleeding gums
exercise plan. o Easy bruising
o Excessive menstrual bleeding
 Instruct the child to wear protective devices such as helmets and
knee and elbow pads when participating in sports such as bicycling
Nursing Considerations
and skating.
 Treatment and care are similar to the measures implemented for
Beta-Thalassemia Major hemophilia, including administration of clotting factors.
Description  Provide emotional support to the child and parents, especially if the
 Beta-thalassemia major is an autosomal recessive disorder child is experiencing an episode of bleeding.
characterized by the reduced production of one of the globin chains  The child with a bleeding disorder needs to wear a MedicAlert
in the synthesis of hemoglobin; both parents must be carriers to bracelet.
produce a child with the disorder.
 Incidence is highest among individuals of Mediterranean descent. Part 12: Infectious and Communicable Diseases
 The disease occurs in several types.
Rubeola (Measles)
 Thalassemia minor: asymptomatic silent carrier Description
 Thalassemia trait: produces mild microcytic anemia  The causative agent is the paramyxovirus.
 Thalassemia intermedia: manifests as splenomegaly and  The communicable period runs from 4 days before to 5 days after
moderate to severe anemia the rash appears, mainly during the prodromal stage (e.g., early
 Thalassemia major (a.k.a. Cooley anemia): results in severe symptoms that may mark the onset of the disease).
anemia requiring transfusion support to sustain life  Transmission occurs in airborne particles or by way of direct contact
 Assessment findings include: with infectious droplets; transplacental transmission is also possible.
o Frontal bossing  Assessment findings include:
o Maxillary prominence o Fever
o Wide-set eyes and a flattened nose o Malaise
o Greenish-yellow skin tone o The “three Cs”: coryza, cough, and conjunctivitis
o Hepatosplenomegaly o Red, erythematous maculopapular eruption, starting on the face and
o Severe anemia spreading downward to the feet; blanches easily with pressure and
o Microcytic, hypochromic RBCs gradually turns brownish (lasts 6 to 7 days)
o In some cases, desquamation
Nursing Considerations o Koplik spots: small red spots with a bluish white center and a red
 Treatment is supportive; the goal of therapy is to maintain a normal base, located on the buccal mucosa and lasting 3 days
hemoglobin level through the administration of blood transfusions. o Photophobia
 Bone marrow transplantation may be offered as an alternative
therapy. Nursing Considerations
 Splenectomy may be performed in a child with severe splenomegaly  Use airborne droplet precautions if the child is hospitalized.
who requires repeated transfusions; the procedure helps relieve  Restrict the child to quiet activities and bed rest.
abdominal pressure and may increase the life span of supplemental  Use a cool mist vaporizer for cough and coryza.
RBCs.
 Dim the lights if the child experiences photophobia.
 Administer blood transfusions as prescribed; monitor the child for
 Administer antipyretics for fever.
signs of transfusion reaction.
 Be alert for signs of iron overload; chelation therapy with deferasirox Roseola (Exanthema Subitum)
or deferoxamine may be prescribed to treat iron overload and to Description
prevent organ damage from the increased level of iron caused by
 The causative agent is Human herpesvirus type 6.
transfusion therapy.
 The incubation period is 5 to 15 days; the communicable period is
 If the child has undergone splenectomy, instruct the parents to
unknown but is thought to extend from the febrile stage to when
report any signs of infection because of the risk of sepsis.
the rash first appears.
 Ensure that the parents understand the importance of the
 The mode of transmission is unknown.
pneumococcal and meningococcal vaccines in addition to an annual
influenza vaccine and the regularly scheduled immunizations.
 The affected child exhibits a sudden high (>38.8° C [102° F]) fever of
3 to 5 days' duration after previously appearing well, followed by a
 Provide genetic counseling to the parents.
 rash of rose-pink macules that blanch with pressure; the rash o Slight fever, malaise, and anorexia, followed by a macular rash that
appears several hours to 2 days after the fever subsides and lasts 1 first appears on the trunk and scalp and spreads to the extremities
to 2 days. o Conversion of lesions to pustules, which begin to dry and develop a
crust
Nursing Considerations o In some cases, lesions on the mucous membranes of the mouth and
 Care is supportive in nature. the genital and rectal areas
Nursing Considerations
Rubella (German Measles)  In the hospital, ensure strict isolation (contact and droplet [airborne]
Description precautions).
 The causative agent is the rubella virus.  At home, isolate the infected child until the vesicles have dried.
 The communicable period is 7 days before to about 5 days after the  Provide supportive care.
rash appears.
 The virus is transmitted by way of the airborne route or through Pertussis (Whooping Cough)
direct contact with infectious droplets; indirectly, on articles freshly Description
contaminated with nasopharyngeal secretions, feces, or urine; or  The causative agent is Bordetella pertussis.
transplacentally.  The risk of spread is greatest during the catarrhal stage (when
 Assessment findings include: discharge from respiratory secretions occurs).
o Low-grade fever  Transmission occurs through direct contact, by way of droplet
o Malaise spread from an infected person, or by way of indirect contact with
o Pinkish-red maculopapular rash that begins on the face and spreads freshly contaminated articles.
to the entire body  Assessment findings include:
o In some cases, petechial spots on the soft palate o Symptoms of respiratory infection followed by increased severity of
cough, marked by a loud whooping inspiration
Nursing Considerations o In some cases, cyanosis, respiratory distress, and tongue protrusion
 Use airborne droplet precautions if the child is hospitalized. o Listlessness, irritability, anorexia
 Provide supportive treatment.
 Isolate the infected child from pregnant women. Nursing Considerations
 Isolate the child during the catarrhal stage; if the child is
Mumps hospitalized, institute airborne droplet precautions.
Description  Administer antimicrobial therapy as prescribed.
 The hallmark of mumps is marked parotid gland swelling.  Reduce exposure to environmental factors that cause coughing
 The causative agent is the paramyxovirus. spasms, (e.g., dust, smoke, sudden changes in temperature).
 The communicable period is immediately before and after parotid  Ensure adequate hydration and nutrition.
gland swelling begins.  Provide suction and humidified oxygen if these interventions are
 Transmission is made through direct contact or by way of droplet needed.
spread from an infected person.  Monitor cardiopulmonary status (using a monitor as prescribed) and
 Assessment findings include: oxygen saturation.
o Fever  Infants do not receive maternal immunity to pertussis.
o Headache and malaise
o Anorexia Diphtheria
o Jaw or ear pain aggravated by chewing, followed by parotid Description
glandular swelling  The causative agent is Corynebacterium diphtheriae.
o In some cases, orchitis  The communicable period varies but is known to last until virulent
bacilli are no longer present, as evidenced by three negative cultures
Nursing Considerations of discharge from the nose and nasopharynx, skin, and other lesions;
 Institute airborne droplet precautions. this is usually 2 weeks but may be as long as 4 weeks.
 Restrict the child to bed rest until parotid gland swelling has  Transmission occurs through direct contact with the infected person,
subsided. a carrier, or contaminated articles.
 Avoid foods that require chewing.  Assessment findings include:
 Apply hot or cold compresses as prescribed to the neck. o Low-grade fever, malaise, sore throat
 Apply warmth and local support with snug-fitting underpants to o Foul-smelling mucopurulent nasal discharge
relieve orchitis. o Gray membrane on the tonsils and pharynx
o Lymphadenitis (neck edema)
Chickenpox (Varicella)
Description Nursing Considerations
 The causative agent is the varicella-zoster virus.  Ensure strict isolation for the hospitalized child.
 The communicable period is 1 to 2 days before the onset of the rash  Administer diphtheria antitoxin as prescribed (after a skin or
to 6 days after the first crop of vesicles, when crusts have formed. conjunctival test to rule out sensitivity to horse serum).
 Transmission occurs through direct contact, droplet (airborne)  Restrict the child to bed rest.
spread, and contact with  Administer antibiotics as prescribed.
contaminated objects.  Provide suction and humidified oxygen as needed.
 Assessment findings include:  Provide tracheostomy care if a tracheostomy is necessary.
  The name Fifth disease was given to the disease because it was the
Poliomyelitis fifth childhood disease discovered in which a rash developed.
Description  The communicable period is uncertain but is believed to precede the
 The causative agent is an enterovirus. onset of symptoms in most children.
 The communicable period is unknown, but the virus is present in the  The mode of transmission is unknown but may involve respiratory
throat and feces shortly after infection and persists for about 1 week secretions and blood.
in the throat and 4 to 6 weeks in the feces.  Assessment findings (the most notable being the classic “slapped
 Transmission occurs through direct contact with an infected person face” rash, shown in the image) vary with the stage of illness.
and by way of the fecal-oral and oropharyngeal routes.  Before the rash, the child is asymptomatic or exhibits a
 Assessment findings include: mild fever, malaise, headache, and runny nose.
o Fever  Erythema of the face (slapped-cheek appearance)
o Malaise develops and disappears by 1 to 4 days.
o Anorexia  About 1 day after the rash appears on the face,
o Nausea maculopapular red spots appear, symmetrically distributed
o Headache on the extremities; the rash progresses from proximal to
o Sore throat distal surfaces and may last a week or more.
o Abdominal pain followed by soreness and stiffness of the trunk,
 The rash subsides but may reappear if the skin is irritated
neck, and limbs that may progress to central nervous system
by the sun, heat, cold, exercise, or friction.
paralysis

Nursing Considerations Nursing Considerations

 Enforce enteric precautions.  The child is not usually hospitalized unless an infection requiring
 Provide supportive treatment. intravenous antibiotics develops.
 Restrict the child to bedrest.  Pregnant women should avoid the infected individual.
 Monitor the child for indications of respiratory paralysis.  Provide supportive care.
 Arrange for physical therapy as prescribed.
Infectious Mononucleosis
Description
Scarlet Fever
Description  The causative agent is the Epstein-Barr virus.
 The causative agent is group A beta-hemolytic Streptococcus.  The communicable period is unknown.
 The communicable period begins about 10 days during the  Transmission occurs through direct intimate contact (oral
incubation period and clinical illness; during the first 2 weeks of the secretions), hence the nickname “kissing disease.”
carrier stage, although it may persist for months.  Assessment findings include:
 Transmission occurs through direct contact with an infected person o Fever
or droplets; indirect contact with contaminated articles, ingestion of o Sore throat
contaminated milk, or other foods can also spread the bacterium. o Malaise
 Assessment findings include:
o Headache
o Abrupt high fever, flushed cheeks, vomiting, headache, enlarged
o Fatigue
o Nausea
lymph nodes in the neck, malaise, abdominal pain
o A fine red sandpaperlike rash—developing in the axilla, groin, and
o Abdominal pain
o Lymphadenopathy
neck, then spreading to cover the entire body except the face—that
blanches with pressure (Schultz-Charlton reaction) except in areas of
o Hepatosplenomegaly
o Discrete macular rash, most prominent over the trunk, in some cases
deep creases and folds of the joints (Pastia sign)
o Desquamation, sheetlike sloughing of the skin on the palms and
Nursing Considerations
soles, appearing by weeks 1 to 3.
o Early on, a white, furry covering of the tongue with red projecting  Provide supportive care.
papillae (“white strawberry tongue”), replaced by the third to fifth  Monitor the child for signs of splenic rupture (e.g., abdominal pain,
day with a red, swollen tongue (“red strawberry tongue”). pain in the left upper quadrant and shoulder).

Nursing Considerations Rocky Mountain Spotted Fever

 Institute respiratory precautions until 24 hours after the initiation of Description
antibiotic therapy.  The causative agent is Rickettsia rickettsii.
 Provide supportive therapy.  Transmission occurs by way of the bite of an infected tick from a
 Restrict the child to bed rest. mammal, most often a wild rodent or dog.
 Encourage fluid intake.  Assessment findings include:
o Fever
 Monitor the child closely for signs of rheumatic fever (e.g., fever,
o Malaise
arthralgia), a complication of scarlet fever.
o Anorexia
o Vomiting
Erythema Infectiosum (Fifth Disease)
Description
o Headache
o Myalgia
 The causative agent is human parvovirus B19.
o Maculopapular or petechial rash, primarily on the extremities  Prepare to drain an infected skin site and obtain cultures
(ankles, wrists) but spreading in some cases to other areas, usually of the wound and wound drainage.
the palms and soles
 Prepare to obtain blood cultures, sputum cultures, and
Nursing Considerations urine cultures.
 Provide supportive care.  Prepare to administer antibiotics as prescribed.
 Administer antibiotics as prescribed.  Educate the parent and family about the causes and
 Teach the parents (and, when appropriate, the child) ways modes of transmission, signs and symptoms, and
to protect the child from tick bites. importance of prescribed treatment measures.
 Wear long-sleeved shirts, long pants tucked into long socks  Discuss prevention measures with the parents:
(socks should be pulled up over the pant legs), and a hat o Handwashing and good personal hygiene
when walking in tick-infested areas. o Avoiding sharing personal items
 Wear light-colored clothing to make ticks more visible if o Regular cleaning of shared equipment such as athletic
they do get onto the child.
equipment, whirlpools, or saunas
 Check children for the presence of ticks after they spend
o Thorough cleaning of cuts and other wounds
time in high-risk or known tick-infested areas.
 Encourage the child to follow paths rather than walking in
tall grass and shrub areas, where most ticks are found. Priority Points to Remember!
 Apply an insect repellent containing diethyltoluamide  Monitor a child with a neurological disorder for signs of
(DEET) and permethrin before entering areas where ticks increased intracranial pressure.
are found (use with caution in infants and small children).  Aspirin is not administered to a child with varicella or
 Keep the yard trimmed and free of accumulating leaves influenza because of its association with Reye syndrome;
and other brush. acetaminophen or ibuprofen is usually prescribed for the
 Apply tick repellent to dogs. pediatric client.
 Save any tick removed from the child’s body for later  Airway patency is the priority in a child experiencing a
identification.
seizure.
 Chlamydial conjunctivitis is rare in older children; if it is
Community-Acquired Methicillin-Resistant Staphylococcus
diagnosed in a child who is not sexually active, the child
aureus (MRSA)
Description should be assessed for sexual abuse.
 Staphylococcus aureus is a bacterium that is normally located on the  After tonsillectomy, monitor the child for signs of
skin or in the nose of a healthy person. hemorrhage; if hemorrhage occurs, turn the child to one
 Presence of the bacterium without symptoms is called colonization; side to help prevent aspiration of blood and notify the
when symptoms are present, it is considered an infection. health care provider.
 MRSA most often occurs in people who have been hospitalized or  To help prevent spasm of the epiglottis and airway
treated in a health care facility (hospital-acquired MRSA). occlusion, never attempt to visualize the posterior pharynx
 Community-acquired MRSA is an MRSA infection that occurs in a or to obtain a throat culture specimen in a child with
healthy person who has not been hospitalized or undergone a
epiglottitis.
medical procedure within the preceding year.
 Contact precautions are necessary for the child with
 Persons at risk for community-acquired MRSA include athletes,
prisoners, children in daycare, military recruits, persons who abuse respiratory syncytial virus infection.
intravenous drugs, persons living in crowded settings, persons with  Parents must be taught the guidelines for the
poor hygiene, persons who use contaminated items, persons who administration of digoxin.
get tattoos, and persons with compromised immune systems.  The major concerns when a child is vomiting or
 Community-associated MRSA is spread through person-to-person experiencing diarrhea are the risk of dehydration, the loss
contact, through contact with contaminated items, or through of fluid and electrolytes, and the development of
infection of a preexisting cut or wound that is not protected by a
dressing.
metabolic alkalosis (with vomiting) and metabolic acidosis
 The bacterium may enter the bloodstream through the cut or wound (with diarrhea).
and cause sepsis, cellulitis, endocarditis, osteomyelitis, septic  Proper handwashing and standard precautions can
arthritis, toxic shock syndrome, pneumonia, organ failure, and prevent the spread of viral hepatitis.
death.  In the event of a poisoning, parents are advised to call the
 Assessment findings include: poison control center before initiating any intervention.
o Skin infection: red, swollen area; warmth around the area; drainage  If poisoning occurs, treat the child first, not the poison;
of pus; pain at the site; fever
assess airway, breathing, and circulation and initiate
o Symptoms of more serious infection: chest pain, cough, fatigue,
chills, fever, malaise, headache, muscle aches, shortness of breath, cardiopulmonary resuscitation as necessary.
rash  The child with diabetes mellitus must be educated about
diet therapy, exercise, insulin administration, and
Nursing Considerations complications associated with the disorder.
 Assess skin lesions.  Nephrotic syndrome is a kidney disorder characterized by
massive proteinuria, hypoalbuminemia, and edema.
 Fractures in infancy are generally rare and warrant further
investigation to rule out child abuse.
 The most common opportunistic infection in children
infected with HIV is Pneumocystis jiroveci pneumonia.
 Bleeding is the primary concern in a child with hemophilia.
 In the child with leukemia, the priority nursing concern is
protecting the child from infection.
 Chickenpox (varicella) can be deadly to the
immunocompromised child because the child is unable to
fight the illness adequately.