Chapter 16 Nursing Care of the Child with An Alteration in Intracranial Regulation/Neurologic

Disorder
 Differences in Anatomy and Physiology of the Neurologic System of Children
o First 3 to 4 weeks’ gestation
 Infection, trauma, teratogens, and malnutrition can cause physical defects and may
affect normal CNS development.
o Birth
 Cranial bones well developed, but not fused: increased risk for fracture.
 Brain is highly vascular: increased risk for hemorrhage.
o Child
 Spinal cord is mobile: high risk for cervical spine injury.
o If something is wrong with neuro, it will be detrimental to growth and development
o Preemies are at risk for brain problems
o Myelination is going to occur which helps gross motor and fine motor skills
 Proportions of Head to Body Height in Newborn, Child and Adult

o
o In a baby, the head is a quarter of the body while in an adult it is 1/8 of the body
o Assessment of the growth trend of the head is important in detecting potential neurological
conditions
 Types of Neurologic Disorders in Children
o Structural disorders
o Seizure disorders
o Infectious disorders
o Trauma to the neurologic system
o Blood flow disruption disorders
o Chronic disorders
o It is important to check LOC first followed by vital signs
 Common Types of Structural Defects
o Neural tube defects
 Majority of the congenital anomalies of the CNS
 Folic acid supplementation can decrease the incidence of NTDs
o Anencephaly
 Defect in brain development resulting in small or brain hemispheres, skull and scalp
o Microcephaly
 Smaller than normal head circumference
 May be congenital or acquired and develop in the first few years of life
 Caused by abnormal development during gestation or follow intrauterine infections
such as rubella, toxoplasmosis and cytomegalovirus

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 o Arnold–Chiari malformation
 Usually associated with hydrocephalus and myelomeningocele resulting from the
cerebellum, medulla oblongata and fourth ventricle displacing into the cervical canal
resulting in an obstruction of the CSF and causing hydrocephalus
o Hydrocephalus
 Larger than normal head circumference
 Results when there is an obstruction in the ventricular system and the venous
channels
o Intracranial arteriovenous malformation
 Caused by an abnormal development of blood vessels and can occur in brain,
brainstem or spinal cord
o Craniosynostosis
 Premature closure of the cranial sutures which can inhibit brain growth and a
distorted skull appearance will be evident
 Hydroencephalus and increased ICP are more likely to appear
o Extra Notes
 Some patients with hydrocephalus can look normal, while others will have the
typical large head
 Children with shunt are more likely to have developmental problems
 Spongy fontanel sign of increased ICP
 Depressed fontanel is a sign of dehydration
 Intracranial AVM can occur anywhere in the brain, brainstem or spinal cord and if it
hemorrhages, it can lead to neuro problems or death
 Past Medical History Findings Related to Neurologic Disease in Children
o Prematurity
o Difficult birth: ask mom to tell you about the birth.
o Infection during pregnancy
o Falls
o Recent trauma
 Common Signs and Symptoms Related to Neurologic Disease in Children
o Nausea, vomiting: is an early indicator of incr. ICP
 Brain tumor sign: vomiting early in the morning. Then the pt is not able to walk
o Headaches (early morning, frequent, or persistent)
o Changes in gait
o Loss of motor function
o Visual disturbances: seeing flutters
o Changes in level of consciousness (LOC) or confusion: earliest indicators
o Increased irritability lethargy: late signs
o Altered muscle tone: meningitis or lethargy
 Measure head circumference until age 3
o LOC earliest indicator of improvement or degradation
o NEED TO KNOW PEDIATRIC GCS
 5 Different LOC states (pg 476)
o Full consciousness – defined as a state in which the child is awake and alert, is oriented to
time place and person and exhibits age-appropriate behaviors
o Confusion – defined as a state in which disorientation exists. The child may be alert but
responds inappropriately to questions
 Ex: kids may ask where there mom is, but mom is there.

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 o Obtunded – defined as a state in which the child has limited responses to the environment
and falls asleep unless stimulation is provided
o Stupor – exists when the child only responds to vigorous stimulation
 Painful stimulation
o Coma – defines a state in which the child cannot be aroused even with painful stimuli
 Prenatal Risk Factors for Neurologic Disorders
o Prematurity
o Maternal drug or alcohol use during pregnancy
 Common for baby to have a drug withdrawal
 Start w/ morphine then get weaned off to methadone
o Maternal infection during pregnancy
o Maternal ingestion of teratogens
o Fetal malnutrition in utero
 Risk Factors for Birth Trauma
o Multiple deliveries
o Large-for-date infants
o Infants with extreme prematurity
o Infants with a large fetal head: maybe from fetal alcohol symptoms
o Infants with congenital anomalies
 Common Laboratory and Diagnostic Tests
o Lumbar puncture (LP)#1 go to!, CSF analysis
 Withdrawal of CSF from the subarachnoid space for analysis
o Intracranial pressure (ICP) measurements
 Sensing device place in the head used to monitor ICP resulting from
hydroencephalus, acute head trauma, and brain tumors
 Ventricular catheter allows for draining of CSF to reduce ICP
o Electroencephalogram (EEG)
 Measures electrical activity of the brain to diagnose brain seizures and brain death
o Head and neck radiograph
 Radiographic image of the head and neck to detect skull and spinal fractures
o Ultrasound
o Fluoroscopy
 X-ray of vertebral blood vessels to assess for vessel defects or space-occupying
lesions
o Computed tomography (CT), magnetic resonance imaging (MRI), positron emission
tomography (PET), and single photon emission computed tomography (SPECT)
 Other Procedures and Treatments for Neurologic Disorders
o Ventricular shunt placement
 Catheter is placed in the ventricle to pass the CSF to the peritoneal cavity, atrium of
the heart, or pleural spaces
 Commonly used in hydrocephalus or increase ICP
 Rovisions:
o Hyperventilation
 Used to decrease PaCO2 which will result in vasoconstriction and therefore decrease
ICP
o Physical, Occupational, or Speech Therapies (PT/OT/ST)

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  Therapies are used to improve motor function and ability of children with neurologic
disorders
 Used for head injury, or intellectual disability
o External ventricular drainage (EVD)
 A catheter is temporarily placed in the ventricle and CSF is drained in a closed
system to an external reservoir
 Commonly used with shunt infections until CSF is sterile and shunt can be replaced
 EVD direct access to spinal cord and so child with be in ICU
o Ventricular tap
 Go into the shunt To reduce accumulation of CSF and decrease ICP
o Vagal nerve stimulator
 A nerve stimulator is implanted and a lead wire running under the skin is wrapped
around the vagus nerve and is programmed to stimulate at certain intervals
 Used for short and long term seizure management in children older than 12 years old
o Ketogenic diet
 Diet involving a high intake of fats, adequate protein and very low intake of carbs
 Used for prevention, control and reduction of seizures
 Inspection and Observation of a Child With a Neurologic Disorder
o Level of consciousness (LOC)
o Vital signs
 Baby check the reflexes
 Do neuro test
 Sunsetting: eyes point downwards. Seen in a pt w/ a shunt
 Review decerebrate (hands and feet turn out) and decorticate ( coming into the core)
o Head, face, and neck
o Cranial nerve function
o Motor function
o Reflexes
o Sensory function
o Increased intracranial pressure (ICP)
o Chart 16.1
 Medications Used to Treat Neurologic Disorders
o Antibiotics
 Treatment of bacterial meningitis and shunt infections
 Kill and prevent growth of bacteria
o Anticonvulsants
 Decrease hyperexcitability of nerves
 Treatment and prevention of seizures
o Benzodiazepines
 Minor sedative that prevents or stops seizures by slowing down the CNS, making
abnormal electrical activity unlikely
 Ex: xanax
o Analgesics
 Block pain impulse in response to inhibition of prostaglandin synthesis
 Narcotic analgesics act on receptors in the brain to alter perception of pain. Used to
treat pain. Used to help avoid increase in ICP
 Propohyl and ketamine: it helps with pain. Fast acting, acts for about 10 min.
children have shaking eyes.

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 o Osmotic diuretics
 Increase plasma osmolality, therefore inducing diffusion back into plasma and
extravascular space/reduces ICP
o Corticosteroids
 Suppress inflammation and normal immune response/reduce cerebral edema
 Common Types of Seizures
o Febrile seizure: does not need an intervention unless it lasts longer than 5 minutes.
Check temperature and blood sugar.
o Kids w/ seizures longer than 5 min get diastat (diazepam- anxiolytic, sedative).
o Parents need to change medications when child going to growth spurt. Stress and not
going enough sleep can increase the risk of seizures.
o Need to know where they were, what were doing before the seizure, what did it look like
and how long did it last, and what happened before and after.
o Infantile spasms:
o Absence
 Brief interruption in consciousness without loss of postural control
 Staring off into space
 May have hand gestures, blinking and chewing
o Tonic-clonic
 Begins with LOC change, stiffening and then jerking. They will have that time frame
where the mind is not there.
o Myoclonic
 Single jerk of one or more muscles, lasting seconds
 Consciousness usually is preserved
o Atonic
 Sudden loss of muscle tone (drop attack)
o Simple partial
 Seizure that occurs in one part of the brain
o Complex partial
 May begin with a focal seizure without impaired consciousness and then progress
o Status epilepticus
 Febrile seizures are the most common type seen in children less than 5 years
 Commonly occurs early in the course of epilepsy and can be life threatening
o Extra Notes
 If child just had a seizure, then pain will be done via FLACC scale
 Status epilepticus is an emergency as it happens for longer than 5 mins
 Diazepam used in febrile seizures going on for more than 5 mins
 Febrile seizures depend more on how quickly their fever goes up instead of how high
the fever can go
 Febrile seizures usually do not have permanent brain damage
 Febrile seizures are usually related to a viral illness
 Seizures have to be within 24 hours apart to be considered a seizure
 Seizure meds cannot be abruptly stopped and must be weaned off
 Weaning off doesn’t occur unless seizure free for at least two years
 Have suction and oxygen at the bedside, padding of the hand rails.
 Ativan is the go to drug. They can also be on phenobartibal are the drug they are on
at home. They have to have their labs checked continually and be compliant
 Types of Infectious Disorders of the Neurologic System

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 o Bacterial meningitis
 Infection of the meninges, the lining that surrounds the brain and spinal cord
 Can occur as secondary infection of upper respiratory infections, sinus infections or
ear infections or direct introduction through LP, skull fracture or severe head injury
 Hib vaccine has reduced incidences of this
 Sensitive to light, neck pain, and vomiting are big signs

o Aseptic meningitis (viral)
 Most common type of meningitis and majority of children infected are less than 5
years
 Causative organism is usually a virus especially enteroviruses
o Encephalitis
 Inflammation of the brain that may also include an inflammation of the meninges
 Caused by protozoan, bacterial, fungal or viral invasion
 Swelling of the bain
o Reye syndrome (rare)
 Affects children less than 15 years
 Reaction triggered by the use of salicylates or salicylate-containing products to treat
a viral infection
o Extra Notes:
 Bacterial meningitis usually seen after sepsis
 Child can deteriorate in 24 hours with meningitis and gold standard for testing is
lumbar puncture
 If known for sure that it is viral, then antibiotics will not be given
 Reye syndrome caused by aspirin
 Encephalitis is inflammation of brain caused by virus, bacteria or fungal can come
from herpes or vector born. Can cause brain damage if not treated quickly. Can even
by caused by chemo.
 Intracranial Pressure (ICP)
o CNS has a dynamic balance of fluid (called CSF) that bathes the brain and spinal cord at a
specific pressure called intracranial pressure (ICP).
o Elevated ICP is a sign of a neurologic disorder.
o Possible causes: head trauma, birth trauma, hydrocephalus, infection, brain tumors.
o Try and limit pain such as preventing crying because it will increase ICP
o Child will have a shrill cry which is common and parents will know the difference
 Early Versus Late Signs of Increased Intracranial Pressure

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 o Know this chart!
o Vomiting and headache are big ones especially with babies since they can’t say that they
aren’t feeling well
o Shunt patients have heart rate all over the place and will be on pulse ox to monitor pulse
o Main late sign is bradycardia and posturing
o Brain damage w/ repeated concussions
o Shunt malformation or infection will need to be on a pulse O2 and it can get really low.
o Seizures from bulging fontanelle
 Hydrocephalus
o Caused by an imbalance in the production and absorption of CSF.
o May see signs of ICP including increase in head size and loss of developmental milestones or
changes in personality in older children.
o May require surgical intervention to relieve pressure with a ventricular shunt (temporary or
permanent).
o Prepare parents for surgery, babies will have a shrill cry due to increase in irritability from
malformation or infection.
 Parents know to look for sunset eyes.
o Sometimes it is seen in utero. Can have surgery before the baby is born
 Signs and Symptoms of Shunt Infection
o Elevated vital signs
o Poor feeding
o Vomiting
o Decreased responsiveness
o Seizure activity
o Signs of local inflammation along the shunt tract/ see infection on the shunt
o Kids will grow so the shunt will need multiple revisions
 Common Causes of Head Trauma in Children
o Falls
o Motor vehicle accidents
o Sports injuries
o Pedestrian and bicycle accidents
o Child abuse: shaking baby syndrome. Coup to coup injury.
 Causes of Nonaccidental Head Trauma
o Violent shaking: shaken baby syndrome (SBS)

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 o Blows to the head
o Intentional cranial impacts against the wall, furniture, or the floor
o Seen if there is no prenatal care, younger parents who get aggravated from baby
o Extra Notes:
 SBS occurs because of knocking against the skull back and forth
 Concussion in kids under a year gets CT scan but if over a year, they will have
questions asked as well such as if they were vomiting or have been eating or drinking
before they get a CT
 After concussion they will be on brain rest so no studying or playing games etc.
 If head injury, adult has to be with child every 24 hours and wake them up every few
hours to observe them and make sure everything is okay
 Parent has to wake up every 2 hours to check on the child w/ a concussion.
 If they haven’t vomited just check on the child.
 If there is an injury, stabilize the neck.
 Common Head Injuries Seen in Children (Table 16.6)
o Skull fractures – a break in the bone surrounding the brain
o Linear skull fracture – a simple break in the skull that follows relatively straight line
o Depressed skull fractures – the bone is locally broken and pushed inward, causing pressure on
the brain
o Diastatic skull fracture – a fracture through the skull sutures
o Compound skull fracture – a laceration of the skin and splintering of the bone
o Basilar skull fracture – a fracture of the bones that form the base of the skull
o Concussion – a type of traumatic brain injury that is caused by a bump, blow, jolt, jarring, or
shaking and results in disruption or malfunction of the electrical activities of the brain
o Contusion – bruising of cerebral tissue
o Subdural hematoma – collection of blood between the dura and cerebrum
o Epidural hematoma – collection of blood located outside the dura but within the skull
 Acute Stroke in Children
o Ischemic or hemorrhagic types.
o Risk factors in children are different than in adults.
o Will see same signs and symptoms as in adults.
 Weakness on one side or hemiplegia
 Facial droop
 Slurred speech
 Speech deficits
o Usually rare in kids except for sickle cell anemia children
 Blood transfusions helps child w/ stroke
 Managing Disturbed Sensory Perception
o Assess for changes in sensory perception.
o Monitor child for risk of injury secondary to changes in sensory perception.
o Notify physician or nurse practitioner of changes in sensory perception.
o Assist child to learn to use adaptive methods to live with permanent changes in sensory
perception (i.e., use of eyeglasses) and maximize the use of intact senses.
o Provide familiar sounds (voices, music).
 Pediatric Glasgow Coma Scale
o Objective measure of child’s LOC by assigning numerical values to the presence of
developmentally appropriate clues (eye-opening, verbal response, and motor response).

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 o Memorize this for the exam

o
 Closed Head Injuries
o Brain injury graded on severity (mild, moderate, severe) based on symptoms.
o May occur with an accident or intentional injury.
o Nonpenetrating injury to head.
o Normal behavior before the injury, may or may not lose consciousness.
o Skull fx does not get any interventions, but just watching them while in the hospital. Watch
out for bleeding to see changes in LOC
 Promoting Child and Family Teaching
o Assess child’s and family’s willingness to learn.
o Provide family with time to adjust to diagnosis.
o Repeat information.
o Teach in short sessions.
o Gear teaching to a level of understanding of the child and family.
o Provide reinforcement and rewards.
o Use multiple modes of learning involving many senses.
o Near drownings can cause a lot of injuries such as long-term neuro effects
 Defined as an incident in which a child has suffered a submersion injury and has
survived for at least 24 hours
 Near drownings in children younger than 1 years old can occur in bathtubs, toilets or
buckets
 Children between 1 – 4 years are more likely to drown in residential swimming pools

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For children older than 15, drowning occurs in oceans or lakes

Chapter 14: Pain Management in Children

**peptic ulcers caused by h.pylori treated with triple therapy***

Pain Transmission in the Nervous System

 Transduction
o Nociceptors (specialized nerve cell endings) are activated when exposed to noxious stimuli.
 Mechanical, chemical, or thermal
 Putting hand on the stove, ouch
 Transmission
o Stimuli are converted to electrical impulses and relayed to spinal cord and brain by afferent nerve
fibers and unmyelinated small C fibers.
o Neurotransmitters facilitate transmission process to the brain.
o Brain tells your body to remove the hand from the stove
 Perception
o Nerve fibers divide in the dorsal horn of the spinal cord, cross to the opposite side, and rise
upward to the thalamus.
o Thalamus quickly sends a message to somatosensory cortex of the brain where impulse is
interpreted as pain.
 A-delta fibers lead to sharp, stabbing, local pain.
 C fibers lead to diffuse, dull, burning or aching pain.
 Pain threshold is the point where a person feels the lowest intensity of painful stimulus.
 Modulation
o Neuromodulators modulate the pain sensation.
 Naturally occurring examples include serotonin, endorphins, enkephalins, and
dynorphins.
 Pharmacologic treatments can interrupt or modulate the perception of pain.
o Flight or fight response. Use endorphins for strength u
o Pain sensation can be modified peripherally (at the site) or centrally (in the brain).

Classifications of Pain
 Duration
o Acute: tissue damage(sore throat, appendicitis) or chronic- not protective (cancer)
o Kids in chronic pain cannot grow or meet milestones as fast as normal.
 Etiology
o Nociceptive: stimulus that damages the tissue (stabbing, chemical burns) or neuropathic:
peripheral or CNS(tingling, spasms) Vincristine: tx for leukemia, but causes neuropathic pain.
Kids will walk on their tippy toes. Vincristine also causes constipation
 Source/location
o Somatic: superficial (organs-sharp stab pain, paper cut) or visceral: deep pain(kidney failure,
ulcerative colitis, skin-arm cut, nausea, vomiting diaphoresis, )

Factors Influencing Pain

 Age
 Gender
 Cognitive level
 Temperament
 Previous pain experiences
 Family and cultural background-how parent responds to pain-the child will follow

Myths and Misconceptions About Children and PainNOT TRUE

 Newborns don’t feel pain.

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  Exposure to pain at an early age has little or no effect later.
 Infants and small children have little memory of pain.
 Intensity of the child’s reaction to pain indicates intensity of pain.
 A child who is sleeping or playing is not in pain.
 Children are truthful when asked if they are in pain.
 Children learn to adapt to pain and painful procedures.
 Children are more prone to addiction to narcotic analgesics.

Indicators of Pain in Infants

 Behavioral
o Facial expressions, body movements, crying, increased irritability, refusal to move injured body
part, interrupted sleep
 Physiologic
o Changes in heart rate (may be  in preemies), respiratory rate, oxygen saturation levels, vagal
tone, plantar or palmar sweating

Using Age-Appropriate Language to Assess Pain in Older Children

 Toddlers are likely to understand words such as “owie” or “boo-boo”.
 Preschoolers may need to be coaxed to discuss their pain as they feel it is something to be expected.
 School-aged children can usually report type, location, and severity because of their well-developed
language skills.
 Teens concern about body image and fear of losing control may result in denying pain or refusing
medication.

Factors Affecting Children’s Responses to Pain

 Type of pain
 Extent of pain
 Age/developmental level
 Cultural/family norms surrounding expression of pain

Key Principles of Pain Assessment (QUESTT)

 Question the child.
 Use a reliable and valid pain scale.
 Evaluate the child’s behavior and physiologic changes to establish a baseline and determine the
effectiveness of the intervention.
 Secure the parent’s involvement.
 Take the cause of pain into account when intervening.
 Take action.

Health History Data Related to Pain Assessment

 Location, quality, severity, and onset of the pain, as well as the circumstances in which the child
experiences the pain.
 Ask questions about chronic pain.
 Conditions, if any, that preceded the onset of pain and conditions that followed the onset of pain.
 Any measures that increase or decrease the pain.
 Any associated symptoms, such as weight loss, fever, vomiting, or diarrhea, that may indicate a current
illness.
 Any recent trauma, including any interventions that were used in an attempt to relieve the pain.

Pediatric Pain Assessment Tools

 FACES pain rating scale (ages 3+, emoticon-like faces)
 Oucher pain rating scale (ages 3+, actual photos of children, must know number values)
 Poker chip tool (uses 1 to 4 poker chips to describe pain)

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  Word-graphic rating scale (ages 8 to 15, child selects pain rating)
 Visual analog and numeric scales (ages 3+, scales of 0–10)
 Adolescent pediatric pain tool (ages 8 to 15, measures pain location, intensity and quality)

Pediatric Physiologic and Behavioral Pain Assessment Tools

 Neonatal infant pain scale (NIPS)
 Riley infant pain scale
 Pain observation scale for young children
 CRIES scale for neonatal postoperative pain assessment
 FLACC behavioral scale for postoperative pain in young children9most used, esp in children who cant talk)
 NUMERIC,

Pain Management Guide for Children

 Individualize interventions based on the amount of pain experienced and the child’s characteristics, such as
developmental level, temperament, previous pain experience, and coping strategies.
 Use nonpharmacologic and pharmacologic approaches to ease or eliminate the pain.
 Teach the child and family about pain-relief interventions and techniques and discuss with the child and
family expectations of pain management.
 Using different techniques helps the most.

Techniques for Pain Management

 Nonpharmacologic
o Relaxation, distraction, guided imagery, massage
 Pharmacologic
o Analgesics, patient-controlled analgesia, local analgesia, epidural analgesia, conscious sedation
(used for deformities to put a bone back into place)

Behavioral-Cognitive Pain Management Strategies

 Relaxation
 Distraction
 Imagery
 Biofeedback
 Thought stopping
 Positive self-talk

Biophysical Interventions for Pain Management

 Nonnutritive sucking with sucrose (infants or toddlers)
 Heat and cold applications
 Massage and pressure

Factors Affecting the Choice of Pharmacologic Interventions for Pain

 Drug being administered.
 The child’s status.
 The type, intensity, and location of the pain.
 Any factors that may be influencing the child’s pain.
 Morphine will cause resp. depression. They always should be on a monitor. They also cause nausea, and
itching. Also give Benadryl and Zofran. Also give Toradol instead of Tylenol.
Medications Used for Pain Management
 Analgesics
o Nonopioid (Tylenol, Motrin: works better and quicker) and opioids
 Anesthetics: Dilaudid goes on a pump.
 Sedatives: Ativan. Versed w/ ketamine
 Hypnotics

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Routes for Pain Medication Administration
 Preferred routes:
o Oral, rectal, intravenous, topical, or local nerve block routes
o Epidural administration and conscious sedation also can be used.
o PCA pumps are for sickle cell patients

Common Adverse Events Associated with Use of Opioid Medications

 Constipation
 Pruritus
 Nausea and vomiting

Required Interventions When a Child is Receiving Moderate (Conscious) Sedation

They are not intubated, but they need to have
Ketamine needs a boost.
Look at levels of sedation!!!
 Moderate sedation is a medically controlled state of depressed consciousness.
 Ensuring that emergency equipment is readily available.
 Maintaining a patent airway.
 Monitoring the child’s level of consciousness and responsiveness.
 Assessing the child’s vital signs (especially pulse rate, heart rate, blood pressure, and respiratory rate).
 Monitoring oxygen saturation levels.

Nurse’s Role in Managing Procedure-Related Pain

 Use topical anesthetic at site of a skin or vessel puncture.use emela and LMX (takes 30 min to work)
TET: lidocaine mix for stiches
 Use nonpharmacologic strategies for pain relief.
 Prepare child/family ahead of time about the procedure.
 Use therapeutic hugging to secure the child.
 Use the smallest-gauge needle possible.
 Use intermittent infusion device or PICC for multiple samples.
 Opt for venipuncture in newborns instead of heel sticks if large amount needed.
 Use kangaroo care for newborns before and after heel stick. (warm pad)
 Provide nonnutritive sucking before the procedure.(sucrose water to suck on)

Chapter 6: Growth and Development of the School-Age Child (6-12)

Physiologic Growth of the School-Age Child

 Grows an average of 2.5 inches per year.
 Increases weight by average of 7 pounds per year.
 Early on, boys and girls are similar in height and weight.
 Later, girls may develop faster than boys in height and weight; boys will “catch-up” later.
 Secondary sexual characteristics begin to appear.
 Expectations of behavior should be consistent with age, not appearances.

Organ System Maturation (School-Age Child)

 Neurologic system:
o brain and skull grow very slowly; cognitive processes mature
o brain size is grown by age 10.

 Respiratory system:
o respiratory rates DECREASE; respirations are diaphragmatic in nature
o age 7 lungs mature

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  Cardiovascular system:
o Blood pressure INCREASE and pulse rate DECREASES.
o Heart decreases in size
 Immune system:
o matures to adult level around 10 years old; fewer infections experienced
 Gastrointestinal system:
o Deciduous teeth replaced by permanent teeth; fewer gastrointestinal upsets; stomach capacity
increases; caloric needs are lower but appetite may increase.
 Genitourinary system:
o Bladder capacity increases (age in years + 2 ounces) ex: age 9. 9+2=11 ; prepubescence occurs 2
years before puberty. Breast buds and growing of the testicles .
 Musculoskeletal system:
o Greater coordination and strength; muscle still immature and can easily be injured.
 Caloric needs are lessened.

Development of Fine Motor Skills:

 Hand usage improves. (handwriting)
 Eye–hand coordination and balance improve increases activity with improvement as well
 Can write, print words, sew, or build models.
 Takes pride in activities requiring dexterity and fine motor skills, such as playing musical instruments.

Signs of Vision Problems:

 Eye rubbing, squinting
 Avoiding reading
 Frequent headaches
 Holding reading materials close
 Problems with depth perception or hand-eye coordination
Sports-related eye injuries and eye protection are important in this age group.
Up until 3rd grade they are learning to read. IN 3rd grade, they struggle to have comprehension.

Vision Problems Frequently Identified:

 Amblyopia (also called “lazy eye”) is the term to describe the condition when one eye can focus better than
the other.
 Causes of Amblyopia:
o Uncorrected refractive errors or other eye defects in one eye (near-sighted, far-sighted or
astigmatism)
o Malalignment of the eye muscles (strabismus)
o Deprivation due to cataract formation in one eye (rare)

Language and Communication Skills:

 Vocabulary expands to 8,000 to 14,000 words.
 Culturally specific words are used.
 Reading efficiency improves language skills.
 More complex grammatical forms are used.
 Development of metalinguistic awareness occurs.
 Metaphors are beginning to be understood.

Emotional and Social Developmental Issues:

 Temperament- still have school aged fears.
 Self-esteem development
 Body image: look to parents or celebrities
 School-age fears: they can do self talk and
deep breathing

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  Peer relationships-most important relationships to them
 Teacher and school influences
 Family influences
 Make sure they know the plan and stick to the plan.

Developmental Theories—School-aged Years

Erickson: figuring out what they can achieve or what they can do. They are developing self worth, and. Build
on things. Give them easy things and then build up on it. start collecting things-Barbie’s, Pokémon cards.

Paiget: concrete operational learns by manipulating objects, no abstract thinking, understands time. They
can finally see perceptions that are not their won. Start collecting things. Start to understand conservation
such as water turning into ice, steam, etc.
Kohlberg: follow the golden rules, follow religion. They want to be. Good person
Freud: same sex friends. All girls or all boys. Relate to the opposite gender parent. Mom and son, dad and
daughter

Benefits of Physical Activity:

 Cardiovascular fitness: letting them go outside when they get home from school and then coming to do HW
will allow me to be more focused on HW
 Weight control
 Emotional tension release-avoid being upset
 Development of leadership and social skills

Safety Issues:
 Car safety-do not sit in front, out of booster=over 12years or over 80lbs.
 Pedestrian safety
 Bicycle and sport safety
 Fire safety
 Water safety-swim lessons: at age 5
 Abuse in children

Assessing Nutrition:
 Check height and weight compared to previous measurements; assess BMI for age.
o 95% is obese, 85-95%: overweight
 Nutrition history including a 24-hour recall of what was consumed.
 Inquire about family meals and the social aspects of eating including who prepares the meals.
 Solicit from both parent and child.
 Identify any knowledge gaps relating to nutrition.

Nutritional Needs of the Average-Weight (20 to 35 kg)

 1,800 to 2,100 mL of water per day (limit sugary beverages and juices)
 28 g protein
 800–1,000 mg calcium for 4 to 8 year olds, increases to 1,300 mg for 9 to 13 year olds

Nutritional Needs of the Average Sized School-Age Child (Age Groups)

Nutritional Needs of the Average Sized School-Age Child

Children also need:
 Fiber: 25 g for 4 to 8 year olds; 26–31 g for 9 to 13 year olds
 Moderate to vigorous exercise for 60 minutes per day
 Daily fruits and vegetables

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  Whole grain breads and cereals
 Non-fat (skim) or low-fat milk

Developmental Concerns:
 Television and video games (setting limits on both the
content and amount of time)
 School refusal (school phobia)
 Latchkey children and safety-kid gets left home alone
 Stealing, lying, cheating, bullying (whether as the perpetrator or the victim) teach prevention
 Fitting in with peer groups
 Tobacco and alcohol education

Promoting Appropriate Discipline:

 Children learn the natural and logical consequences of discipline.
 Parents should teach children rules established by the family, values, and social rules of conduct.
 Discipline should be consistent, applied fairly and focus on the development of the child.
o Reality discipline: to help them learn that they cannot get away from things. It should be
consistent and acknowledge positive behaviors
 Positive acknowledgement of positive behaviors are more likely to encourage those positive behaviors and
promote development.

Factors Determining Type and Amount of Discipline

 Developmental level of both the child and the parents
 Severity of the misbehavior
 Established rules of the family
 Temperament of the child
 Response of the child to rewards

Promoting Sleep and Rest

 12 hours of sleep required.
 Should have predictable bedtime expectations and wake-up times.
 Children may need help in winding down to promote sleep.
 Night terrors and sleepwalking may occur but should resolve by age 8 to 10 years.
Cultural Influences on Growth and Development:
 Habits
 Beliefs
 Language
 Religious customs
 Values (Family vs. Peers)

Chapter 12: Caring for the Special Needs Child

End of chapter and taking care of the patient that is dying**

Definition of Children With Special Needs

 “Those who have, or are at risk for, a chronic physical, developmental, behavioral, or emotional condition
beyond needs generally required by children”
 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal
and Child Health Bureau, 2008
 Children who have a terminal illness, or are otherwise dying

Children With Special Needs: Resources/Services Needed

 Prescription medication or durable medical equipment

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  Medical care (including transportation to care)
 Mental health and education services
 Physical, occupational, or speech therapy
 Treatment for emotional, developmental, or behavioral problems
 Financial assistance
 Family support

Impact of Having Special Needs on the Child

In general, development may be delayed compared to healthy, same-aged peers
 Infant: may fail to develop a sense of trust and bonding
 Toddler: may have difficulty developing autonomy
 Preschooler: may have difficulty achieving sense of initiative
 School-age child: may have difficulty achieving industry
 Adolescent: may have difficulty forming a sense of self-identity relative to peers

Impact of Having a Special Needs Child on the Family

 May experience a multitude of emotions and changes in their lives.
 May be overwhelmed with burdens of continual care.
 May experience fear, anger, sadness, guilt, frustration, or resentment.
 Siblings may feel cheated of parental time and affection.
 Financial burdens may increase due to cost of care and loss of income related to caregivers leaving work.
 Typical family activities may need to modified.

Stressors of Daily Life for Families of Children With Special Needs

 Housing situation changes.
 Sleep is affected.
 Carrying out basic activities of living is affected.
 Medical and technical care must be incorporated into daily life.
 Family identity and employment may be altered radically.
 Extended burden of care may affect health of caregivers.
 Siblings may feel neglected and act out.

Transition Times in Care of Special Needs Child

 Initial diagnosis or change in prognosis
 Increased symptoms
 When the child moves to a new setting (hospital, school)
 During a parent’s absence
 During periods of developmental change
 Arrival of new family members
Risk Factors for Vulnerable Child Syndrome
 Preterm birth
 Congenital anomaly
 Newborn jaundice
 Handicapping condition
 An accident or illness that the child was not expected to recover from
 Crying or feeding problems in the first 5 years of life

Principles Related to Family Involvement Families…..

 are a constant in the child’s life
 define who they are and their culture
 need access to relevant information and training
 deserve to receive culturally competent care
 know their strengths, limitations and fears
 merit mutual respect in caregiving relationships
 need to be responsible for outcomes

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Focus of Nursing Management of Children With Special Needs
 Case management and advocacy
 Screening and ongoing assessment of the child
 Provision of appropriate home care
 Care of the technology-dependent child
 Education and support of the child and family
 Referral for resources

Promoting Home Care for the Technology-Dependent Child

 Provide early discharge planning.
 Provide care and care coordination for the child at home.
 Identify potential problems in home environment to providing adequate care.
 Provide ongoing follow-up and routine well-child care of the former premature infant.
 Assess growth and development of the former premature infant based upon calculated age.

Long-Term Risks for the Premature Infant

Most are due to being premature
 Cognitive delays
 Visual impairment, chronic lung disease
 Cerebral palsy
 Attention deficit disorder
 Learning disabilities
 Difficulties with socialization
 Vulnerable child syndrome
 Alterations in muscle tone

**Causes of Failure to Thrive

 Inability to suck and/or swallow correctly
 Malabsorption- short gut
 G tube placed
 Inadequate preparation of food- adding more water in the formula-education and resources
 Diarrhea
 Vomiting
 Alterations in metabolism and caloric/nutrient needs associated with a variety of chronic illnesses
 Disrupted relationship with maternal figure

Resources for the Child With Special Needs

 Educational opportunities
 Financial resources
 Respite care
 Complementary therapies

Complementary Therapies Used by Families With Special Needs Children

 Homeopathic and herbal medicine
 Pet therapy
 Hippotherapy
 Music
 Massage
 Culture-specific therapies

Educational Resources for the Child With Special Needs

- Educational opportunities for children with special needs up to age 21 years are mandated by law
through:
 Education for All Handicapped Children Act (1975, amended as PL 99-457): early intervention from birth
to age 2 and preschool for 3–5 year olds.

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  Individual with Disabilities Education Act (2004) requires local school systems to provide for the education
of children with special needs through the public school system, from age 3 to 21 years.
 Education is usually provided in the local school system.

Components of Transition Planning

 Multidisciplinary care coordination including community resources
 Acknowledgement of the changing roles among the youth, family, and health care professionals
 Fostering of the youth’s self-determination skills
 Importance of a medical home

Adolescent Health Transition Project Schedule

 By age 14: ensure a transition plan is initiated; IEP must reflect post–high school plans.
 By age 17: explore health care financing for young adults (parents may be able to cover to age 26).
 By age 18: all rights transfer to teen at 18. Check the teen’s eligibility for SSI and SSI work incentive the
month the teen turns 18.
 College-bound?: encourage teen to contact the college’s campus student disability service program.
 By age 21: ensure that the young adult has registered with the Division of Developmental Disabilities for
adult services if applicable.

Teaching Points During Transition of Adolescent to Adult Care

 Diagnosis and medical hx to date
 Treatment rationale
 Symptoms of worsening condition
 Danger signs
 When to seek help from a professional (and from whom)
 Medical insurance process
 Detailed written plan of care
 Consultation with transition services coordinator

**Orders Related to End-of-Life Care

 Limitations of Care: Parents and patients (when able) may specify their wishes for care at the end-of-life.
The document is shared among all providers.
 “Do not resuscitate (DNR)”
o Withhold cardiopulmonary resuscitation if child’s heart stops beating
o May have special limitations as part of order (oxygen and comfort care but no compressions)
 “Allow Natural Death (AND): MOST IN KIDSIn some institutions DNR is being replaced by AND
“allow natural death”.
 Make the decision together as a family and involve the child in the decision.

Guidelines for Organ Donation

 Discussion should be separate from impending death or brain death notification.  as nurses, we do not
talk about organ donations-there are people who come to talk.
 Written consent is necessary.
 All expenses are borne by recipient’s family.
 State that the child’s appearance will not be marred.
 Family culture and spiritual beliefs must be considered.

Last Act’s Palliative Care Task Force Established Principles

 Respecting children’s goals, preferences, and choices
 Comprehensive caring
 Using the strengths of interdisciplinary resources
 Acknowledging and addressing caregivers’ concerns
 Building systems and mechanisms of support
 Hospice: child will be dying w/in two years
 Palliative child: making the child comfortable

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Focus of Palliative Care
 Managing pain and discomfort
 Providing nutrition
 Providing emotional support to the dying child and family
 Assisting the family through the grief process

Chapter 20: Nursing Care of the Child with an Alteration in Bowel Elimination/Gastrointestinal Disorder

Anatomy and Physiology of the Gastrointestinal System of Children

 Mouth: highly vascular; entry point of infection.
 Esophagus: LES not fully developed until age 1, causing regurgitation/reflux.
 Newborn stomach capacity only 10 to 20 mL. (1-2oz)
o Ask parent how often are you feeding the baby
 Intestines: small intestine not mature at birth.
 Biliary system: liver relatively large at birth; pancreatic enzymes develop postnatally, not reaching adult
levels until 2 years old. (wait until 6 months for motrin b/c of the maturity of the liver and the enzymes are
slowly being created.)
 Fluid balance and losses: proportionately greater amount of body water compared to adults.
o Focus on dehydration.
o Digestion and absorption- is important for growth
 BSA is 5 times more than adult
 They don’t excrete well as a newborn which causes problems with elimination
Assessment
 What is the problem? How long has the child had the problem? Has there been weight loss? Any hx or
traveled?
 Symptoms
o Abdominal pain? Stool? Diarrhea? Vomiting? Nutrition?
 Inspection
o Abdomen changes throughout life
o Children may need distraction during exam
• Can sit on Mom’s lap, breastfeed or use paci, explain what you are doing to preschoolers,
school age want to know what will happen next
o NBNB: No blood no bile in vomit
 Auscultation
o Auscultation before Palpation, Sucking makes easier in baby

 Percussion
o Tympanic sound? Dull?
 Palpation
o Supine if possible, warm hands, avoid tickling, place hand on top

Common Medical Treatments (chart 20.1)

 Hydration (oral, enteral and IV)
o Better to give enteral or oral first
 Providing adequate nutrition (oral, enteral and IV)
o Give the child smoothies
 Enemas and bowel preparations
 Ostomies—surgical opening into a digestive organ
 Probiotics—support/replace intestinal microbial flora
o Give yogurt to
 Medications
o Augmentin needs probiotics due to severe diarrhea

Stool Collection Techniques

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  If the child is in diapers, use a tongue blade to scrape a specimen into the collection container.
 If the child has runny stool, a piece of plastic wrap in the diaper may catch the stool specimen. Very liquid
stool may require application of a urine bag to the anal area to collect the stool.
 The older ambulatory child may first urinate in the toilet, and then the stool specimen may be retrieved
from the new or clean collection container that fits under the seat at the back of the toilet.
 For the bedridden child, collect the stool specimen from a clean bedpan (do not allow urine to contaminate
the stool specimen).

Data Collected in the Physical Assessment (least invasive to most)

 Auscultation
o Hyperactive or hypoactive bowel sounds
 Percussion
o Dullness, flatness, tympany
• Dull bladder indicates full bladder
 Palpation
o Reserve for last in sequence; palpable kidneys may indicate tumor or hydronephrosis; right lower
quadrant pain may warn of appendicitis.
 Least invasive to most invasive.
 Right lower pain appendicitis
 DO KUB- kidneys, urine, bladder. It is very quick.
 Dehydrated: fontanelles sunken, dry mucous membranes, dry eyes
 Yellow eyes: jaundice
 Bruise on the belly: signs of abuse
 Have pot belly as younger children
 Irritability and restlessness are the first signs of dehydration
 Lethargy is a late sign of dehydration

Common Laboratory and Diagnostic Tests

 Abdominal ultrasonography- once the KUB is done
 Barium swallow, small bowel series
 Blood work: amylase, electrolytes, lipase, LFTs
 Esophageal manometry/ esophageal pH probe
 Endoscopy (gastroscopy, colonoscopy): see if there is bleeding
 Hemoccult, stool sample/culture, stool O&P
 Hepatobiliary (HIDA) scan
 Liver biopsy
 Lactose tolerance test, urea breath test

Classes of Medications to Manage Gastrointestinal Disorders

 Histamine-2 blockers, proton pump inhibitors
o They do not prevent baby from spitting them, if just makes them less fussy or irritable
o Will use Prilosec, protonix
 Prokinetics (prevents stress ulcers)
 Antibacterial/antibiotics: use only if its bacterial related
 Corticosteroids, immunosuppressants
o Belly gets swollen, sugar increases
 Stimulants, laxatives (MiraLAX/stool softeners)
o Use fiber such as MiraLAX
 Antidiarrheals (NEVER with kids) and antiemetics
 Anticholinergics
 Anti-inflammatories

Tracheoesophageal fistula (TEF)

 Abnormal connection (fistula) between the esophagus and the trachea. Failure of the esophagus to
develop as a continuous passage separate from the trachea

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 o May occur separately or in combination
o Leakage of the esophagus
 Clinical Presentation
o Polyhydramnios while in utero
Inability to handle secretions, cyanosis while feeding
o Resistance when passing a feeding tube
o drooling
o 5 types-don’t need to know
 Diagnostics
o Xrays show coiling, Ultrasound of Renal System, Echo, of contrast evaluation
 Nursing Interventions
o Surgery NPO, fluids, TPN, elevate the head to prevent aspiration, help them not cry. **
o Prevention of aspiration
o Tube in proximal pouch
o Iv antibiotics and fluids prior to surgery in supine postion
o Chest Tube Care, elevated HOB 30 to 45 degrees, frequent suctioning with premeasured catheter,
tube feedings 2 to 3 days after surgery, if no leak, start oral feedings 5 to 7 days after *remove
Chest tube then*
o Make sure to keep in chest tube unless the child is actually able to eat
o

o FIGURE 20.7 Esophageal atresia and tracheoesophageal fistula. A. The most common type of
esophageal atresia, in which the esophagus ends in a blind pouch and a fistula connects the trachea
with the distal portion of the esophagus. B. The upper and distal portions of the esophagus end in a
blind pouch. C. The esophagus is one segment, but a portion of it is narrowed. D. The upper
portion of the esophagus connects to the trachea via a fistula.

Risk Factors for Gastrointestinal Disorders

 Prematurity Risk Factors for Dehydration
 Family history  Diarrhea
 Genetic syndromes  Vomiting
 Chronic illness  Decreased oral intake-no appetite
 Prenatal factors  Sustained high fever
 Exposure to infectious agents  Diabetic ketoacidosis
 Foreign travel  Extensive burns
 Immune deficiency, chronic steroid use

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Anomalies and Complications Associated With Cleft Lip and Palate
 Seen in 1 in 700 children
 Seen in utero about 2-3 months
 Fix lip around 2-3 months
 Fix palate when they hit a certain weight
 Want to get these surgeries done before 12 months b/c they need to learn how eat again

 Anomalies
o Heart defects
o Ear malformations
o Skeletal deformities
o Genitourinary abnormality
 Complications
o Feeding difficulties encourage breastfeeding
o Altered dentition
o Delayed or altered speech development
o Otitis media- not eating correctly-not draining properly
• Affects ears.
o Protect the suture line!!!!
o Post op- mittens on hands to avoid baby touching the stiches
• No suction/sucking no pacifier and straws, sippy cups
• Avoid crying & provide emotional support
• May supine or sidelying
• NPO immediately after surgery
• Keep the child calm
• Breastfeeding can still be done
• Haverman feeder- still allows them to suck b/c they are at risk for aspiration
• Check respiratory and nutrition.

Risk Factors for Intussusception (intestine telescopes into itself)

 Male gender (higher incidence)
 Meckel diverticulum
 Duplication cysts
 Polyps, hemangiomas, tumors
 Appendix
 Cystic fibrosis
 Celiac disease
 If stool is passed call the doctor since it has resolved itself
 Air enema: NG tube gets inserted, then they go to X-ray, and air is inserted to unravel the intestine
 Jelly like stool at assessment. If they poop they don’t have to have surgery anymore and make sure to call
MD

Celiac disease
 Also known as gluten-induced enteropathy or celiac sprue
 Permanent GI intolerance to dietary wheat and related proteins
o Four characteristics
• Steatorrhea
• General malnutrition
• Abdominal distention
• Secondary vitamin deficiencies
 See 15-3

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 o Endoscopy and tissue biopsy for definitive diagnosis
 Nursing Interventions and Education
o Teach patients and family about gluten free diet
o Encourage Support Groups
o Treat dehydration if necessary
o Avoid Wheat, barley, and Rye

Acute GI Disorders
 Dehydration, vomiting, and diarrhea
 Oral candidiasis and oral lesions
 Hypertrophic pyloric stenosis
 Necrotizing enterocolitis
 Intussusception, malrotation, and volvulus
 Appendicitis

Problems Related to Vomiting

 Gastroesophageal reflux (G E R D)
o Very common in babies, arching back, fussy, frequent pneumonia
• Prilosec OTC
• Hold upright for 20 mins after eating, Burp frequently, if severe, Nissen Fundoplication
(wrap the esophagus)
 Pyloric stenosis
o Projectile vomiting
• Failure To Thrive, weight loss, constantly hungry, olive sign- see on the belly button,
pyloromyotomy (bottom part of the intestines and wrap around to prevent the reflex)
 Volvulus
o Twisting that leads to impaired blood flow and death of segments
• First 6 months, intense crying, bilious vomiting, surgery, NPO and NG
• Most commonly seen in Preemies
 Intussusception
o Telescoping of intestine
• Moments of intense crying and vomiting, jelly stool, barium enema
 Necrotizing enterocolitis
o Seen in Premature children, chronic patients, leads short bowel/gut syndrome
• Will have a Gtube and will be NPO

GI Problems Related to Diarrhea

 Gastroenteritis- stomach bug
o Monitor for s/s of dehydration and know those
o IV fluids if necessary
o ORT (oral rehydration therapy)
• Give pt Gatorade, 5 ml every 5 minutes. If they vomited, they would have to let the nurse
know
• Zopago- ZO= order Zofran, PO= after 15 minutes, get a popsicle, GO= and then go home
o Often caused by
• Rotovirus infection
• Bacterial pathogens
• Antibiotic-associated etiology
 Child should be observed and brought in if they have prolonged vomiting, no
urination for 8 to 12 hours, depressed fontanel, lethargy, dry mucus membranes,
no antidiarrheals should be used (b/c they don’t need the bacteria to sit in their
stomach)
o Enteritis, Colitisinfection spread to other parts of stomach
 Teach personal hygiene

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 o Most diarrhea is spread by the fecal-oral route, make sure the water supply is clean and
protected from contamination, prepare food carefully, wash hands

Gastrointestinal Problems Manifested by Constipation

 Constipation
o An alteration in frequency, consistency, or ease of passage of stool
o May be secondary to other disorders
o Idiopathic (functional) constipation has no known cause
o Chronic constipation may be due to environmental or psychosocial factors
 First meconium should be passed within 24 to 36 hours of life ; if not, assess for
o Hirschsprung disease
o Hypothyroidism
o Meconium plug or meconium ileus (cystic fibrosis)
 Constipation in infants is often related to DIET
o Constipation in exclusively breastfed infants is almost unknown
• Infrequent stool may occur because of minimal residue from digested breast milk
 Formula-fed infants may develop constipation (high in iron)
 Nursing management: assess diet, active lifestyle, hydration
Crohns Disease vs ulcerative colitis
 Ulcerative colitis: bloody diarrhea and lots of steroids
 Crohns; fissures and abscess

 Peptic ulcer disease

o Causes by H. pylori
 Irritable bowel syndrome
o Causes either diarrhea or constipation
o Treated by fish oil
o Chart 20-2

Nursing Management of the Newborn with Omphalocele (born without a sac outside of the body) or
Gastroschisis (born with a sac outside of the body)
 Goals
o Preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by
minimizing fluid loss, and protecting the exposed abdominal contents from trauma and infection.
 Intervention
o Cover the abdominal contents with a non-adherent sterile dressing avoiding trauma to the
intestine, cover with plastic wrap to minimize heat and fluid loss; prevent abdominal distention
with low suction to orogastric tube, monitor fluid status.

Structural Anomalies of the GI Tract

 Cleft lip and palate
 Omphalocele and gastroschisis
 Hernias (inguinal and umbilical)
o Worry aafter 1 year old
o Teach parent to push it back in
 Anorectal malformations.(no anus when born)

Chronic GI Disorders
 Gastroesophageal reflux, peptic ulcer disease
 Constipation/encopresis
 Hirschsprung disease
 Short bowel syndrome- on bolus feedings (avoid TPN because you cannot live on TPN and may cause
liver issues/transplant)
 Inflammatory bowel disease
 Celiac disease

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  Recurrent abdominal pain
 Failure to thrive and chronic feeding problems

Hirschsprung’s Disease (MEGAcolon)

 Also called congenital aganglionic megacolon
o Mechanical obstruction from inadequate motility of the intestine
o Incidence is 1 in 5000 live births; more common in males and in children with Down syndrome
o Absence of ganglion cells in colon
 Assessment
o Failure to pass meconium in the first 24 hours of life with abdominal distention
o Constipation from birth, entercolitis
o Ribbon like, watery stools, FTT, poor weight gain
 Diagnosis
o X-ray, barium enema
o Anorectal manometric examination
o Definitive is a rectal biopsy: to see whats going on in the bowel
 Treatment
o Surgery (pg.738)
 Preoperative care
 Postoperative care:
 Two stages
 Temporary ostomy allow for growth and weight gain
 Parents are required to do rectal stretching of the rectum
 Second stage is the pull-through procedure reverse ostomy and create a anus

Gastrointestinal Problems Manifested by Abdominal Pain

 Appendicitis
o Assessment
 Starts periumbilical then moves to right lower quadrant
 Low grade fever, may have vomiting
 Rebound pain in RLQ, various signs like McBurney’s sign, cannot jump up and down,
complains of pain from the car ride
 Sign of rupture all of a sudden the pain disappears
 Tx w/ 6 weeks of antibiotics then remove the appendix
o Diagnostics
 CBC, show on CT? if not ultrasound ordered
 Ultrasound make sure bladder is full
o Nursing Interventions
 NPO, Vitals, prepare for surgery, pain scale and meds, incision check
 Inguinal hernia- defined by location
o Dx- Lump in groin, pain or swelling, can become strangulated or incarcerated
o Nursing Interventions
 Prepare for surgery
 Umbilical hernias are normal in babies

Signs and Symptoms of Crohn Disease and Ulcerative Colitis

 Abdominal cramping
 Infection in the stomach
 Increased risk for infection due to medications
 Nighttime symptoms, including waking due to abdominal pain or urge to defecate
 Fever
 Weight loss
 Poor growth
 Delayed sexual development
 Ulcerative colitis has bloody diarrhea

26
  Monitor H&H and get a CBC

Rome Committee 12-Week Criteria for Irritable Bowel Syndrome

 Abdominal pain relieved by defecation.
 Onset of pain or discomfort associated with a change in frequency of stool.
 Onset of pain or discomfort associated with a change in form of stool.
 No structural or metabolic explanation for this abdominal pain.
 Types can be designated as constipation, diarrheal, or mixed.
 Last pick after everything else is ruled out.

Colostomy and Ileostomy

Remember “STOMA” for Performing Ostomy Care #2
1. Set up the equipment:
 Warm, wet washcloths, or paper towels
 Clean pouch and clamp
 Skin barrier powder, paste, and/or sealant
 Pencil or pen
 Scissors
 Pattern to measure stoma size

Remember “STOMA” for Performing Ostomy Care #3

2. Take off the pouch (may need to use adhesive remover or wet washcloth to ease pouch removal).
3. Observe the stoma and surrounding skin. Clean the stoma and skin as needed, allowing it to dry thoroughly.
4. Measure the stoma, mark the new pouch backing, and cut the new backing to size.
5. Apply the new pouch.

Nursing Management of a Newborn with Meckel Diverticulum (RARE)

 Signs and symptoms
o Bleeding, anemia, severe colicky abdominal pain.
o Abdominal distention, hypoactive bowel sounds, guarding, abdominal mass, rebound tenderness.
 Management
o Administer ordered blood products and IV fluids. (slow bleed showed in hemoglobin lab)
o Maintain NPO status.
o Perform postoperative care and family education.

Oral Rehydration Therapy

 Oral rehydration solution (ORS) should contain 75 mmol/L sodium chloride and 13.5 g/L glucose
o (standard ORS solutions include Pedialyte, Infalyte, and Ricelyte).
 Tap water, milk, undiluted fruit juice, soup, and broth are NOT appropriate for oral rehydration.
 Children with mild to moderate dehydration require 50 to 100 mL/kg of ORS over 4 hours.
 After reevaluation, oral rehydration may need to be continued if the child is still dehydrated.
 When rehydrated, the child can resume a regular diet.
 Commonly uses Zofran
 Remember bolus. 10 for a pt 28 days or less. 20 for pt older than 28 days
 1.5-2

Psychosocial Concerns and Interventions for Children with GI disorders

 Children are considered medically fragile for lengthy period.
 There is much anxiety related to bowel resection.
 Long-term hospitalization is usually required; parents may miss work and time with other children.
 Encourage families to become the experts on their child’s needs and condition via education and
participation in care.
 Provide teaching so that the family is better able to care for the child in an outpatient setting.

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 Chapter 21: Nursing Care of the Child with an Alteration in Elimination/Genitourinary Disorder

Differences in Physiology and Anatomy of Children Affecting Genitourinary System

 Kidney: large in relation to the stomach; prone to injury.
 Urethra: shorter; risk for bacteria into bladder (UTI).
 Glomerular filtration rate: slower in infant; risk for dehydration.
 Bladder capacity: 30 mL in newborn; increases to adult size by 1 year.
 Reproductive organs: immature at birth until adolescence.

Normal Characteristics of Urine

 Color range
 Clear or colorless
 In newborns, production is 1 to 2 ml/kg/hr
 In children, production is about 1 ml/kg/hr

Common Laboratory and Diagnostic Tests

 CBC, BUN, electrolytes, creatinine, total protein, albumin
 Urinalysis (clean catch, suprapubic, or catheterized), culture and sensitivity
 Creatinine clearance
 Timed urine collections (24 hours) for creatinine, total protein
 Cystoscopy, urodynamic studies
 Voiding cystourethrogram (VCUG)
 Renal ultrasound, intravenous pyelogram (IVP)
 Renal biopsy

Disorders of the Renal System

 Urinary tract infection
o Common in children between 2 and 6 and in infants
 E. coli is the most common bacterial cause of UTI’s
 Symptoms may be subtle, sometimes only a fever
 Neurogenic Bladder in SB
 Will be seen during potty training
 Also seen in the beginning of life
o One of the most common conditions of childhood; 10% of children have a febrile UTI in the first
2 years of life
 Most important host factor is urinary stasis
 Uncircumcised males are at higher risk
 Check ears and take their urine when they have a fever to check for ear infection or UTI
o Type of UTI’s
 Recurrent (repeated episodes)
 Persistent (bacteriuria despite antibiotics)
 Febrile (typically indicates pyelonephritis)
 Urosepsis (febrile UTI coexisting with systemic signs of bacterial illness; urinary
pathogens in blood)
 Seen in babies under 8 weeks

UTI’s continued
 Contributing factor is urologic instrumentation
o Allows bacteria present in the opening of the urethra to enter the urethra or bladder
 Sexual intercourse promotes “milking” of bacteria from the perineum and vagina
o May cause minor urethral trauma
o Diagnostics
 Urinalysis is affordable, will show leukocyte, possible RBC’s, casts, but nitrites are the
gold standard

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  Upper tract infection involves the renal parenchyma, pelvis, and ureters
 Typically causes fever, chills, and flank pain
 Lower tract infection involves the lower urinary tract
 Usually no systemic manifestations
 A urine culture must be obtained after urinalysis in order to confirm the right antibiotics
o Parents should be encouraged to follow up for a repeat urine test
o Avoid bubble bath, rubber panties, wipe from front to back,
 Antibiotics for treatment (follow up to make sure the antibiotic is relevant to the cultures)

Urinalysis
 Normal Urinalysis
o pH: 5.0 to 8.5
o Specific gravity: 1.001 to 1.035
o Protein: Less than 20 mg/dl
o Urobilinogen: Up to 1 mg/dl
o None of the following:
 Glucose
 Ketones
 Hemoglobin (Hgb)
 White blood cells (WBCs)
o NITRATES ARE THE GOLD STANDARD FOR UTI!!!!!!!!

Urinary and Renal Disorders #1

 Structural disorders
o Bladder exstrophy
o Hypospadias/epispadias
o Obstructive uropathy
o Hydronephrosis
o Vesicoureteral reflux

Disorders of the Renal System

Vesicoureteral reflux
o Most common congenital anomaly
o Most common pathological finding in children with U T I's
o Can lead to chronic UTI’s
 Might remain on an antibiotic prophylactically
 Might need surgery if doesn’t resolve on it’s own
 Urine is sitting there which causes the UTI

Nephrolithiasis (renal calculi)

o Steady rise in incidence
 Obesity, increased sodium
o Various causes of disorder
o Clinical Presentation
 Colic type abdominal, flank, or back pain, possible n/v
 Hematuria (per urinalysis), UTI, Poor feeding
 Might require 24 hour urine collection, CT, or ultrasound to dx
 Watch them pee for 24 hr straight. And give them a strainer to keep the stone
 If the stone is not found they get a lithotripsy
 Give them pain meds
 Give adequate pain medication
 Strain urine
 Might require surgery
Acquired/functional disorders

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 o UTI
o Enuresis
o Nephrotic syndrome
o Acute glomerulonephritis
o Hemolytic-uremic syndrome
o Renal failure (acute and chronic)

Nephrotic syndrome:
o Most common presentation of glomerular injury in children
o Characteristics:
 Massive proteinuria
 Hypoalbuminemia
 Hyperlipidemia
 Edema
o Minimal change disease (most common) constitutes 80% of cases
 Also known as Idiopathic nephrosis
 Childhood nephrosis
 Minimal lesion nephrosis
o Assessment
 Often occurs after an URI (upper resp. infection), peaks in children between 2 and 5
 Edema is gravity dependent and occurs gradually and occurs around the eyes,
scrotal/sacral, asicities (wake up swollen-throughout the day the swells spreads) first in
the face-by the end of the day-ankles
 Weight gain, decreased UOP, anorexia (not hungry but still gaining weight), easily
fatigued, and HTN increase in blood pressure
 PROTEINURIA & EDEMA
o Treatment
o Supportive Care-teach parents how to do a dip stick and perform daily weights
o Diet
 Low to moderate protein
 Sodium restrictions when large amounts of edema are present
o Steroids (first line of therapy)
 Dose is 2 mg/kg divided into twice-a-day doses
 Prednisone is the drug of choice (least expensive and safest)
 At risk for infection (lowers the immune respsonse)
 At a very high risk of infection. (this is a priority)
 Runny nose, sore not healing
o Diuretics
 LASIX
o IV albumin infusion (pull of the extra fluid)
o Strict monitoring of daily weight
o Immunosuppressant's in non-responsive to steroids

Acute post-infectious glomerulonephritis

 Most common/studied form is post-streptococcal glomerulonephritis
 Caused by strep which travelled to the kidneys
 95% recover completely
 Types
o Most are post-infectious (pneumococcal, streptococcal, or viral)
o May be a primary event
o May also be from systemic disorder
 Clinical Presentation
o Generalized edema due to decreased glomerular filtration
o Especially in periorbital area

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 o Facial edema is more prominent in the morning
o Spreads during the day to involve the lower extremities and abdomen
o Coca-cola urine due to kidney spilling out protein and RBCs
 Hypertension due to increased extracellular fluid
 Oliguria (severely reduced volume)
 Hematuria
o Bleeding in the upper urinary tract, results in “tea or Coca-Cola urine”
 Proteinuria
o Increased amount of protein signifies increased severity of renal disease

Acute Poststreptococcal Glomerulonephritis (APSGN)

 An immune complex disease
o Occurs AFTER antecedent streptococcal infection and strains of group A beta-hemolytic
streptococcus (GABHS)
 Latent period of 10 to 21 days between the infection and onset of manifestations
o Monitor for acute hypertension
o Monitor the blood pressure every 4 to 6 hours
 Manage edema
o Daily weights
o Accurate I&O
o Daily abdominal girth
 Nutrition
o Low sodium, low to moderate protein
 Susceptibility to infections
 Bed rest is not necessary

Common Sites of Obstructive Uropathy

 Any obstruction along the ureter between the kidney pelvis and bladder
o Ureteropelvic junction (pelvis to ureter)
o Ureterovesical junction (lower ureter to bladder)
o Ureterocele (ureter swells into bladder)
o Posterior urethral valves (flaps of tissue in proximal urethra, males only)

Vesicoureteral Reflux Urine flow backward up the ureter

Renal Failure
 Condition in which the kidneys cannot concentrate urine, conserve electrolytes, or excrete waste products.
 May be acute or chronic
o When acute renal failure continues to progress, it becomes chronic (also known as end-stage renal
disease [ESRD]).
 Dialysis and kidney transplantation are treatment modalities used for ESRD.
o Peritoneal dialysis is preferred

Female Reproductive Organ Disorders

 Labial adhesions
 Vulvovaginitis
o Causes:
 Bacterial or yeast overgrowth.
 Chemical factors such as bubble bath, soaps, or perfumes found in personal care
products.
 Poor hygiene.
 Tight clothing may cause a heat rash in the perineal area.

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  Persistent scratching of the irritated area may result in the complication of superficial
skin infection.
 Pelvic inflammatory disease
o Manifestations of Pelvic Inflammatory Disease (PID)
 Fever
 Abdominal pain
 Pain with intercourse
 Dysmenorrhea (painful menstrual cycles)
 Abnormal uterine bleeding
 Long-term complications
 Chronic pelvic pain, ectopic pregnancy, and infertility related to scarring.
 Sexually transmitted infections
 Menstrual disorders
o Primary and secondary amenorrhea (over exercising, anorexia)
o Mittelschmerz and dysmenorrhea
o Menorrhagia and metrorrhaghia

Male Reproductive Disorders

 Phimosis and paraphimosis
o the foreskin of the penis cannot be retracted
o irritation or bleeding from the opening of the prepuce or dysuria (with phimosis), or pain and
swollen penis (with paraphimosis)
o Apply topical steroid medication as prescribed for phimosis, following gentle retraction to stretch
the foreskin back. Topical vitamin E cream
 Cryptorchidism
 Hydrocele and varicocele
 Testicular torsion

 Epididymitis
o Epididymitis (inflammation of the epididymis) is caused by infection with bacteria.
o most common cause of pain in the scrotum
o Encourage the boy to rest in bed with the scrotum elevated. Ice packs to the scrotum may help
with pain relief.
o Administer pain medications such as NSAIDs or other analgesics as needed.
 Sexually transmitted infections

Genitourinary Anomalies
 Cryptorchidism
o Undescended testis
 Correction between 6 and 18 months
 Hypospadias
o Congenital anomaly of the male urethra
 Incidence 1/250-300 live births
 Genetic and environmental factors
 Abnormal ventral placement of the urethral opening of the underside of the penis,
ranging from the glans to the perineum
o Severity- based on position of the urethral opening and the chordee (ventral curvature of the penis)
 Surgery between 6 and 12 months
 Goals of Surgery
o Enhance the child’s ability to void in the standing position with a straight stream
o Improve the physical appearance of the genitalia for psychological reasons
o Make sure sperm is coming out of the proper area that they wont be infertile
o Preserve a sexually adequate organ

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Benefits and Complications of Circumcision
 Benefits
o Decreased incidence of UTI, sexually transmitted infections, AIDS, and penile cancer, and in
female partners a decreased occurrence of cervical cancer.
o Gauze stays on for 24hrs
o Keep area moist with Vaseline
 Complications
o Alterations in the urinary meatus, unintentional removal of excessive amounts of foreskin, or
damage to the glans penis. BLEEDING

Epididymitis (Inflammation of the Epididymis)

 Swollen scrotum
 Caused by infection with bacteria.
 Most common cause of pain in the scrotum.
 Rarely occurs before puberty.
o If it does, it may occur as a result of a urethral or bladder infection related to a urogenital anomaly.
 Therapeutic management is directed toward eradicating the bacteria.
o If left untreated, a scrotal abscess, testicular infarction, or infertility may occur.

Testicular Torsion (EMERGENCY)

 A testicle is abnormally attached to the scrotum and twisted.
 Requires immediate surgery because ischemia can result if the torsion is left untreated, leading to
infertility.
 May occur at any age but most commonly occurs in boys aged 12 to 18 years.

Significant Data When Assessing Past Medical History for GU Disorders

 Past medical history
o Maternal polyhydramnios, oligohydramnios, diabetes, hypertension, or alcohol or cocaine
ingestion.
 Neonatal history
o Presence of a single umbilical artery, abdominal mass, chromosome abnormality, or congenital
malformation.
 Family history
o Renal disease or uropathology, chronic UTIs, renal calculi, or a history of parental enuresis.

Assessment Parameters for GU Disorders

 Burning on urination  Flank or abdominal pain; cramps
 Changes in voiding patterns  Distention in lower abdomen
 Foul-smelling or dark-colored urine  Nausea and/or vomiting
 Vaginal or urethral discharge  Poor growth; weight gain
 Genital pain, irritation, or discomfort  Fever
 Blood in the urine  Infectious exposure
 Edema  Trauma
 Masses in the groin, scrotum, or abdomen

Common Medication Classes for GU Disorders

 Antibiotics  ACE inhibitors and other antihypertensives
 Anticholinergics  Imipramine (tricyclic antidepressants for
 Desmopressin (DDAVP) enuresis)
 Diuretics  Immunosuppressants (for renal transplants)
 Corticosteroids  Albumin (IV)

Common Medical Treatments for GU Disorders

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  Urinary diversion  Vesicostomy
 Foley catheter  Appendicovesicostomy
 Ureteral stent  Bladder augmentation
 Nephrostomy tube  Dialysis (hemodialysis and peritoneal)
 Suprapubic tube

Disorders of the Renal System-“Purple rash” - provide hydration to pt

 Henoch-Schönlein purpura (H S P)
o Self-limiting
o Most fully recover
o Antecedent upper respiratory tract infection
 If intussusception occurs it is a surgical emergency
 If renal failure is present, emergent hemodialysis might be necessary
o Petechiae all over the body.
o Nursing Interventions:
 Measure blood pressure. Inspect the skin for a purpuric palpable rash and document the
size and location of lesions. Palpate the rash to determine its extent
 Gently palpate the joints for tenderness. Palpate the abdomen for tenderness. Note visible
or occult blood in the stool.
 Note cherry- or tea-colored urine, indicating the presence of blood in the urine
 . Monitor intake and output. Note the color of urine. Administer corticosteroids and
anticoagulants, alone or together, if ordered to reduce renal impairment

Hemolytic-Uremic Syndrome (HUS)

 Often typically preceded by diarrheal illness that includes hemorrhagic colitis.
 Damage is due to microthrombotic events in kidneys.
 Characterized by hemolytic anemia, thrombocytopenia, ARF.
 Other possible causes:
o Idiopathic
o Inherited
o Drug related
o Association with malignancies
o Transplantation
o Malignant hypertension
 Nursing Interven
o Institute and maintain contact precautions to prevent spread of E. coli O157:H7 to other children
(bacteria are shed for up to 17 days after resolution of the diarrhea)
o Maintain strict intake and output monitoring and recording to evaluate the progression toward
renal failudminister antihypertensives as ordered and monitor their effectiveness. Encourage
adequate nutritional intake within the constraints of prescribed dietary restrictions
o Monitor for bleeding as well as for fatigue and pallor

Nursing Goals for the Child With End Stage Renal Disease (ESRD)
 Promoting growth and development.
 Removing waste products and maintaining fluid balance via dialysis.- peritoneal dialysis is preferred as a
child.
o Assess the child receiving peritoneal dialysis for toleration of the fluid volume instilled within the
peritoneum.
 Minimize complications by maintaining adequate fluid and nutrition. (RISK OF UTI’S)
 Can be born with non-functioning kidneys.
 Encouraging psychosocial well-being.
 Supporting and educating the family.

Definitions Related to Enuresis

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  Primary enuresis: enuresis in the child who has never achieved voluntary bladder control.
 Secondary enuresis: urinary incontinence in the child who previously demonstrated bladder control over a
period of at least 3 to 6 consecutive months.
 Diurnal enuresis: daytime loss of urinary control.
 Nocturnal enuresis: night time bedwetting.
 Rule out medical- do urinalysis first
 Boys longer to potty train- up to 5-6 y/o, due to being in a deep sleep and won’t wake up to pee.

Restoring Fluid and Electrolyte Balance

 Monitor vital signs frequently and assess urine specific gravity.
 Ensure diet meets required guidelines to support growth.
 Maintain strict records of intake and output.
 Administer diuretics as ordered.
 When urine output is restored, diuresis may be significant.
 Monitor for signs of hyperkalemia and hypocalcemia.
 Administer packed red blood cell transfusions as ordered.
 Dialysis may become necessary.

Chapter 7: Growth and Development of the Adolescent

Growth and Development (Adolescent)

 Rapid physical growth in body size and proportions second only to growth in infancy
 Sexual characteristics and reproductive maturity occur
 Puberty begins in girls around 9 to 10 years old and in boys around 10 to 11 years old
 Cognitive and emotional development are dramatic
 Adolescents represent varying levels of identity formation
 Erickson believed that they are growing again and becoming who they are

Physiologic Changes in Adolescence

 Secretion of estrogen in girls and testosterone in boys stimulates physical sexual changes
 Physical development, hormonal changes, and sexual maturation occur during puberty
 Peak height velocity occurs at about 12 years of age in girls and 14 years of age in boys
 Muscle mass increase in boys and fat deposits increase in girls
 Estrogen and girls and testosterone in boys
 In boys during puberty the only things that really improving is their endurance. Their hand eye coordination
doesn’t grow until after puberty
 Late adolescence: hand and eye coordination improves most

Other Physical Changes in Adolescence

 Voice deepens (most dramatic in males)
 Limbs elongate disproportionately (may look “leggy”)
 Growth plates (epiphyseal) at the end of long bones begin to close
 Apocrine glands (sweat glands) activate in axilla and genital areas
 Skin changes related to increased sebaceous gland secretions may lead to skin eruptions (acne)
 Increase in body hair
 Hips widen in females, shoulders widen in males

Organ System Maturation (Adolescent) #1

 Neurologic system: growth of myelin sheath enables faster neural processing; cognitive growth increases
 Endurance then speed in males.
 Respiratory system: increase in diameter and length of the lungs; respiratory volume and vital capacity
increase
 Cardiovascular system: size and strength of heart increases; systolic blood pressure increases and heart rate
decreases
 Gastrointestinal system: full set of permanent teeth; liver, spleen, kidneys, and digestive tract enlarge

35
Organ System Maturation (Adolescent) #2
 Musculoskeletal system: linear growth is not complete until late adolescence in boys and occurs earlier in
girls; growth plates (which promote linear growth) begin to close at puberty. Adult height is attained when
growth plates have closed in late adolescence
 Integumentary system: skin is thick and tough; sebaceous glands are more active; sweat glands function at
adult level

Physical Changes Related to Puberty

Developmental Theories–Adolescence

Piaget: indent movement, they believe what they believe: black lives matter,
Kohlberg: they look at the world. Internal to themselves. They believe what they believe. They tend to think outside
of the present
Ways to Improve Communication with Teens
 Allow sufficient time for conversation
 Speak respectfully as you would to a colleague
 Talk face to face; be aware of body language (yours and the teen’s)
 Ask open-ended questions to clarify and promote understanding
 Reflect back what you think you heard so that he or she feels heard
 Choose words carefully so that message and intent are clear
 Be honest; don’t be afraid to say you don’t know
 Be liberal with praise; acknowledge effort
 Solicit the teen’s input in decision making as often as possible
 Clearly state expectations and set limits fairly

Influence of Peers During Adolescence

 Play essential role in identity of the adolescent
 Provide opportunities to learn negotiation of differences
 Provide recreation, companionship, and someone to share problems with
 Create stability in times of stress or transition

36
  Serve as credible sources of information and social reinforcement (behaviors, roles)
 Can have positive or negative influences

Safety Concerns for Adolescents

 Unintentional injuries
 Internet safety
 Motor vehicle safety (as a driver and as a passenger)
 Avoiding substance abuse
 Firearm safety
 Water safety

Factors Influencing the Adolescent’s Diet

 Peer pressure; growing wish for independence from family in food choices
 Low cost/convenience/easy access of fast foods
 Family culture relating to food and meal time rituals
 Lack of time/opportunities for family meals (busy schedules)
 Growing wish for independence in food choices
 Others?

Nutritional Assessment for an Adolescent #1

 Assess what the adolescent eats each day with open-ended questions as well as the access to food at home
and outside
 Inquire about the preferences from the different food groups
 Ask the number of times that fast foods, snacks, and other lower nutrition value foods are eaten per week
 Assess teen’s knowledge about nutritional content of his or her favorite foods
 Engage the teen in identifying healthy fast food options

 Provide education to the teen regarding nutritional value of favorite foods and suggest better alternatives
for those with lower nutritional value
 Provide resources for online and community resources about nutrition (MyPyramid.gov)
 Emphasize the role of physical activity in maintaining healthy weight; provide healthy physical activity
options not related to sports (60 minutes per day is recommended)

Sexual Health in Adolescents

 Sexual interest in opposite/same-sex partners is part of human development occurring in adolescence
 Teens need to learn about these new feelings and how to manage them in an appropriate way
 Conversations about sexual activity and health should be ongoing and built upon candor and trust
 Parents may need support in these conversations
 Navigating romantic relationships is an important developmental task for adolescents
 Sexually active teens must have access to contraceptives

Risks of Being Involved in an Unhealthy Romantic Relationship

 Imbalance of power in the relationship to the detriment of one of the partners
 Unsafe sexual activity (STIs)
 Unwanted pregnancy
 Dating violence

Areas of Focus to Encourage Growth and Development in the Adolescent

Endurance first speed later
 Sports and physical fitness
 Learning and participation in school activities
 Safety issues
 Proper nutrition and healthy eating habits
 Healthy sleep hygiene and adequate rest
 Personal care
 Healthy sexual life

37
  Appropriate discipline
 Mental health resources

Promoting Proper Hygiene for Adolescents

 Encourage frequent bathing and deodorant use
 Encourage washing face two to three times a day
 Discourage squeezing acne lesions and vigorous scrubbing of face
 Encourage frequent shampooing of hair
 Teach hygienic care for body piercings and tattoos
 Encourage sunscreen use; discourage artificial sun-tanning (tanning salons, chemical tans)

Caring for the Hospitalized Adolescent

 Provide opportunities for adolescent to maintain independence
 Encourage adolescent to participate in decisions
 Encourage socialization with friends through phone, e-mail, and visits when possible
 Identify any knowledge self-care deficits and provide resources

Developmental Concerns for the Adolescent

 Changes in body image  Suicide- most impt. Is the plan
 Peer groups  Homicide
 Violence  Substance use

Factors Contributing to Adolescent Violence

 Low self-esteem  Access to guns and cars
 History of victimization  Drug or alcohol use
 Peer or gang pressure  Less than optimal housing situation
 Poor family functioning  Lower socioeconomic class
 Limited parental supervision/parents  Racism
working extended hours outside of the home  Incarceration

Risk Factors for Suicide in Adolescents

 Depression or other mental health illness  Substance abuse
 Personal or family history of previous  Difficulties with sexual identity
suicide attempt  Socially isolated (loner, victim of bullying)
 Poor school performance  Marked changes in behavior (giving away
 Dysfunctional or disorganized family valued possessions)

Common Substances Abused by Children and Adolescents (page 202-KNOW slang terms)
 Marijuana (including synthetic marijuana)  Dextromethorphan (cough syrup)
 Alcohol  Bath salts
 Prescription opiates, sedatives, and  Hallucinogens
analgesics  Inhalants (inhaling fumes from aerosol
 Prescription stimulants (Adderall, Concerta, household products)
Ritalin)  Cocaine, crack
 Prescription CNS depressants (barbituates,  Heroin
benzothiazides, sleeping aids)

Topics for Discussion to Discourage Substance Abuse

 Short- and long-term effects of alcohol, tobacco, and drugs on health
 Risk factors and implications for unintentional injuries and unsafe/unwanted sexual activity
 The how and why of chemical dependency
 Impact of substance abuse on society
 Importance of maintaining a healthy lifestyle
 Importance of resisting peer pressure to use drugs and alcohol
 Importance of having confidence in teen’s own judgment

38
 QUESTIONS:
Is the following statement true or false? The most common reason for admission to the hospital for children with
congenital heart disease is heart failure.
 True. The most common reason for admission to the hospital for children with congenital heart disease is
heart failure.
 Rationale: Heart failure occurs most often in children with CHD and is the most common reason for
admission to the hospital for children with CHD. Heart failure also occurs secondary to other conditions
such as myocardial dysfunction prior to or following surgical intervention for CHD, cardiomyopathy,
myocarditis, fluid volume overload, hypertension, anemia, or sepsis, or as a toxic effect of certain
chemotherapeutic agents used in the treatment of cancer.

The nurse is assessing a child for cardiac disorders and documents the presence of clubbing of the fingers and toes.
Which of the following conditions might this indicate?
a. Infection b. Cyanosis
c. Edema d. Hypoxia
Rationale: The sign of an infection is fever. Cyanosis is a bluish tint to the skin due to decreased oxygenation.
Edema is swelling or bloating due to fluid imbalance.

1. The nurse accurately explains to a child’s parents that the point at which a person feels the highest intensity of a
painful stimulus is termed the pain threshold. False. The point at which a person feels the lowest intensity of a
painful stimulus is termed the pain threshold.
 Rationale: In addition to sending a message to the cerebral cortex, the thalamus also sends a message to the
limbic system, where the sensation is interpreted emotionally, and to the brain stem centers, where autonomic
nervous system responses begin.

2.The nurse assessing pain in children is correct in stating that the school-age child is usually able to communicate
the type, location, and severity of pain.  True. The school-age child is usually able to communicate the type,
location, and severity of pain.

3.The nurse is assessing the pain of a 3-year-old child. Which of the following pain assessment scales would be most
appropriate?
a. Visual analog scale b. Visual numeric scale
c. Word-graphic rating scale d. FACES pain rating scale

Rationale: The FACES pain rating scale is a self-report tool that can be used by children as young as 3 or 4 years of
age. The word-graphic rating scale is useful for children between 4 and 17 years old. The visual analog scale can be
used with children 7 years or older. The numeric scale can be used with children 8 years or older.

5.The school nurse conducting a vision screening program identifies a child with amblyopia. Both eyes were noted
to have visual acuity less than expected for the child’s age.
False. Amblyopia, or lazy eye, occurs when one eye is more nearsighted, farsighted, or astigmatic than the other eye
causing an imbalance in vision.--> Rationale: Malalignment of both eyes is referred to as strabismus.

6.The nurse obtains a nutrition history for a school-age child. The parent indicates the child’s favorite beverage is
apple juice and consumes three large glasses per day. The mother asks if this is a good thing. Which of the following
would be the best response for the nurse to reply to the mother?
A. Apple juice is very healthy. Keep up the good work!
b. Apple juice has quite a bit of sugar and no fiber. Could you substitute an apple for one of those servings?
c. As long as your child drinks plenty of fluids, she will be fine.
b. An 8-ounce serving of apple juice has about 24 g of sugar—the equivalent of 3 teaspoons of sugar, with
none of the fruit fiber that would be available in a whole apple. Rationale: Children need both fruit and fiber daily
as part of a healthy diet. Apple juice, while made from apples, concentrates the sugar and takes out the fiber. Water
and milk are good alternatives for beverages.

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7.The nurse is caring for a school-age child with cerebral palsy. Which of the following developmental tasks,
appropriate for this age, may be delayed?
a. Attachment to family
b. Sense of independence
c. Achieving industry
d. Forming a sense of identity

8.The Individuals with Disabilities Education Improvement Act (IDEA) of 2004 mandates federal government-
funded care coordination and special education for children up to 12 years of age.
False. The Individuals with Disabilities Education Improvement Act (IDEA) of 2004 (formerly called Public Law
99-457) mandates local government-funded care coordination and special education for children up to 21 years of
age.

9.The nurse initiates transition planning for adulthood when the patient reaches 21.
False. Transition planning is complex and requires education for the parent and child and coordination of services
long before the age of majority (18 years of age in most states).

10.The nurse is caring for a child with diarrhea related to infectious enteritis. The nurse accurately informs the
parents that most cases of diarrhea are bacterial in nature and therapeutic management is usually supportive in
nature.
False. Most cases of diarrhea are viral in nature and therapeutic management is usually supportive in nature
11.The nurse is auscultating the bowel sounds of a 4-year-old child and documents hypoactive bowel sounds. What
might this finding indicate?
a. Obstruction. Hypoactive bowel sounds indicate obstruction. b. Gastroenteritis
c. Diarrhea d. Infection

12.The nurse is assessing the cognitive development of an adolescent. Which of the following statements accurately
represents a normal finding at this stage?
a. the adolescent progresses from an abstract to a concrete framework of thinking
b. the adolescent develops the ability to think outside the present
c. all adolescents achieve formal operational reasoning at the same time
d. adolescent thinking starts out very introspective and then becomes egocentric

13.The nurse caring for an adolescent should educate the parents about the importance of monitoring their
adolescent’s interaction with peer groups.
True. The nurse caring for an adolescent should educate the parents about the importance of monitoring their
adolescent’s interaction with peer groups.

14.Suicide is the third leading cause of death in adolescents 15 to 19 years of age. True. Suicide is the third leading
cause of death in adolescents 15 to 19 years of age.

Chapters 19, 20, 21, 24, 26

Chapter 19: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

Circulatory Changes From Gestation to Birth #1

 The fetal heart rate is present on about postconceptual day 17.
 The four chambers of the heart and arteries are formed during gestational weeks 2 through 8.
 During fetal development, oxygenation of the fetus occurs via the placenta; the lungs, though perfused, do
not perform oxygenation and ventilation.
 The foramen ovale, an opening between the atria, allows blood flow from the right to the left atrium.
 The ductus arteriosus allows blood flow between the pulmonary artery and the aorta, shunting blood away
from the pulmonary circulation.

40
41
Cardiovascular Changes in Childhood
 Heart Rate.
o Faster in infancy (~120–130 bpm), decreases as the child ages.
o Nothing above 160.
 Blood Pressure.
o Lower in infancy (~80–55 mmHg), increases as the child ages.
 Respiratory Rate.
o Faster in infancy, decreases as the child ages.
 By adolescence, values approach adult levels.

Congenital Heart Defects

 Classifications of congenital heart defects
o Increased Pulmonary Blood Flow
 PDA, ASD, VSD
o Decreased Pulmonary Blood Flow (desats and cyanotic)
 Tetralogy of Fallot (TOF)
 Tricuspid Atresia
 Eisenmenger Syndrome
o Obstructive Disorders
 Coarctation of the aorta (COA)
 Aortic Stenosis (AS)
 Pulmonary Stenosis (PS) and Pulmonary Atresia (PA)
 TOF with PA
o Mixed Disorders
 Transposition of the great vessels, Truncus arteriousus, TAPVR, Hypoplastic Left Heart,
Ebstein’s anomaly
Congenital Heart Disease versus Acquired Cardiovascular Disease
 Congenital heart disease
o Structural anomalies that are present at birth.
o CHD accounts for the largest percentage of all birth defects.
 Acquired heart disease
o Disorders that occur AFTER birth (heart failure, most common reason for admission).
o Develops from a wide range of causes, or can occur as a complication or long-term effect of CHD.

Hemodynamic Characteristics of Congenital Heart Defects

 Types of CHD are classified as cyanotic or acyanotic based upon the relative degree of compromised
pulmonary circulation
 Disorders with decreased pulmonary blood flow: tetralogy of Fallot, tricuspid atresia.
 Disorders with increased pulmonary blood flow: patent ductus arteriosus (PDA), atrial septal defect (ASD),
and ventricular septal defect (VSD).
 Obstructive disorders: coarctation of the aorta, aortic stenosis, and pulmonary stenosis.
 Mixed disorders: transposition of the great vessels (TGV), total anomalous pulmonary venous return
(TAPVR), truncus arteriosus, and hypoplastic left heart syndrome.

Risk Factors for Cardiovascular Disorders in Childhood

 Congenital
o Congenital malformations, genetic syndromes, family history, maternal drug or alcohol exposure,
prematurity
 Acquired
o Infections (rheumatic fever, Kawasaki disease, endocarditis), obesity, diabetes, drug or alcohol
exposure, hypertension, chemotherapy, other diseases (connective tissue disorders, autoimmune or
endocrine diseases), organ transplant, hyperlipidemia

Diagnostic Tests for Cardiovascular Disorders

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  Pulse oximetry: most commonly used
 Electrocardiogram (ECG) and Holter monitoring.
 Cardiopulmonary monitoring: cardiac monitoring and Pulse Oximetry
 Echocardiogram
 Chest radiograph
 Exercise stress testing
 Laboratory tests including: CBC, BMP, C-reactive protein (CRP) (inflammation) , Erythrocyte
sedimentation rate (ESR)
 Arteriogram and cardiac catheterization

Congenital Heart Disease with Increased Pulmonary Blood Flow- PDA (NCLEX)
 Patent ductus arteriosus- Should close within 72 hours of birth normally.
o May be indicated by
 Heart Murmur-systolic murmur, mid to lower-left sternal border, Washing machine
sound (LEFT TO RIGHT SHUNTING)
 Wet sounding breath sounds, crackles
 Tachypnea, Increased WOB, or Apnea
 Poor Feeding, poor weight gain and growth pattern, fatigue, sweating with feeding,
excessive fluid weight gain b/c heart is pumping harder
o Diagnosis
 Wide pulse pressure- low diastolic pressures and high systolic
 Poor oxygen sats
 Bounding Pulses, Prolonged cap refill
 Enlarged Heart, Echo shows enlarged left heart chamber
o Nursing Interventions
 Decrease WOB (work of breathing) by providing rest periods, no clustered care, strict
I&O, DIGOXIN, give indomethacin or ibuprofen(keep it open until it can be surgically
repaired), monitor labs for thrombocytopenia, daily weights, provide prep for surgical
closure, and teach parents to watch fluid intake


Atrial Septal Defect

 Septal Walls fail to form

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 o Should close normally at 4-8 weeks in fetal development up to 1 year, but this will cause more
blood flow into the right side of the heart, increasing pulmonary blood flow
 Assessment
o Heart murmur, know as ejection systolic murmur due to blood forced from pulmonary valve, can
have atrial dysrhythmias and increased risk for emboli/ clot
o Recurrent URI’s, but few symptoms in children
o Can have SOB, tires easily while playing, poor feeding & poor growth if CHF develops (extra
fluid)
o Liver enlargement
 DX
o Echo show enlargement of right atrium and right ventricle
o EKG show thickening of the heart muscle
o Chest X-ray shows enlarged heart and increased blood flow to lungs
 Medical Management and Nursing Interventions
o Give digoxin and diuretics to decrease the load on the right side of the heart
o Provide pain medications to decrease O2 consumption
o Cardiac Cath to patch the hole
o Offer small frequent meals and feedings
o Monitor for s/s of CHF
o Monitor for increased WOB, grunting, retractions and flaring
o Caregiver Education- Look for bleeding (apply pressure if there is bleeding at the cardiac cath
site), antibiotics for dental work, follow up
 Risk for endocarditis

Ventral Septal Defect

 Most common congenital heart defect (30% of all defects), occurs at 4-8 weeks of fetal development,
75% close on their own, results in right ventricular hypertrophy with left to right shunting
 Assessment
o Asymptomatic or heart murmur
o SOB, Feeding difficulties, Systolic thrill in lower left sternal border, FTT
o Recurrent URI’s
 DX
o Echo-large left atrium

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 o Chest X-ray-Left heart cardiomegaly
 Nursing Interventions
o Same as ASD
 Surgical Interventions
o Will suture or patch the hole
o Occurs during first 6 to 12 months of life when the infant is over 2000 g so that when they patch
the site they don’t have to go back in.
 Not as bad due to the location


Tetralogy of Fallot (NCLEX)

 Associated with 22 deletion chromosome disorders like DiGeorge and Downs, occurs more frequently in
males, right to left shunting, comprised of 4 defects
o VSD between right and left ventricles, Obstructive right ventricular outflow, Overriding aorta lies
directly over VSD, Secondary thickening of the right ventricle (Right ventricular hypertrophy- due
to the muscles overworking casing the muscles structure to ), pulmonary stenosis
 Assessment
o Right to left shunting
o “Tet” spells- sudden, marked increase in cyanosis, syncope, can lead to hypoxic brain injury
o Increased cyanosis with irritability and crying due to lack of O2, clubbing of fingers, poor growth,
and often squat to improve blood flow from legs back to the brain, increasing systemic vascular
resistance
o PDA
o Heart murmur may be soft to loud
o Failure to gain weight, fainting, dyspnea on exertion, may remain pink with low mixing, sweating
when feeding
o Keep PDA open
o Will have lower O2 sat
 Nursing Interventions
o Cluster care and rest periods, give morphine to decrease agitation and inconsolable crying, give
O2 but know it won’t change sat or cyanosis, try to keep VSD open
o Prepare for multiple surgeries

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 o Teach parents the “Tet” hold (make smallpush legs up to chest to increase blood flow to the
heart/oxygen to the brain so that hypoxia is decreased)
o Requires multiple surgeries.
o Child may squat (tet Squad) to get more oxygen.

Tricuspid Atresia
 Defective or missing Tricuspid Valve, decreased blood flow to lungs
 Assessment
o Cyanosis, SOB
o Delayed Growth and poor weight gain
o Murmur due to ASD that is normally present
o Clubbing of fingers in older kids
 DX
o Echo, EKG, Chest X-ray, Cardiac Cath
 Nursing
o Prepare child for surgery, and multiple surgeries, requires immediate surgery for survival
o Nurse must maintain prostaglandin E1 administration
o Requires immediate surgery, but will require ECMO
o Use digoxin
 Education
o Life-long cardiology care with multiple surgeries
o Monitor for fluid retention, fast heart rate, and chronic diarrhea
o Monitor for SOB, bluish color, or slow growth

Eisenmenger Syndrome
 “Hole in the heart”, damage to the heart
 Must be fixed right away.
 ECHMO
 No baths after surgery
 No vigorous play, don’t get then upset, cluster care

Congenital Heart Disease with Obstructive Disorders

 Coarctation of the aorta
o Preductal, Ductal, Postductal *Turner’s Syndrome- females at risk*
o Assessment
 Few Symptoms, systolic ejection murmur, decreased femoral pulses, cardiomegaly, BP
are higher in upper extremities than in lower by more than 20mm hg less, HTN, SOB,
Failure To Thrive, signs and symptoms of CHF, 3 sign or reverse 3, “E sign”
 Give Digoxin, monitor perfusion, obtain BP in 4 extremities, restrict strenuous activity
 Aortic stenosis

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 o Can be caused from group A Strep
 Causes CP, fatigue, exercise intolerance causing death, monitor for s/s of CHF, decrease
in cardiac output
 Pulmonary stenosis-extra work on the heart-lead to pulm edema and heart failure
 Pulmonary atresia
 Tetralogy of fallot with pulmonary atresia


Congenital Heart Disease with Mixed Disorders

 Transposition of the great vessels
o Cardiac Emergency
 Upper extremities have decreased O2 vs lower, especially in right arm
 Profound cyanosis, especially while crying, quiet tachypnea (HR can be in the 200’s but
the pt is calm), murmur, CHF s/s
o Nursing Interventions
 O2 sats in right arm should be greater than 75%, surgery immediately, prepare family for
multiple surgeries
 Truncus arteriosus
 Total anomalous pulmonary venous return (T A P V R)
 Hypoplastic left heart
o 2nd most common defect
 Skin looks grey, difficulty feeding, usually fatal if not treated, difficulty breathing
 Will have three stage Norwood procedure
 Each stage pt has to gain a certain weight
 Ebstein’s anomaly

Acquired Heart Disease

 Cardiomyopathy
o Dilated, Hypertrophic, Restrictive
 CHF, sweating while feeding, murmur-gallop, frequent colds and PNU (due to stasis and
blood pooling )
o Nursing Interventions
 Acute vs Chronic(treat)

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  Congestive heart failure (C H F)
o Impaired myocardial function
 Tachycardia, fatigue, weakness, restlessness, pale, cool extremities, decreased blood
pressure, decreased urinary output
o Pulmonary congestion
 Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis
o Systemic venous congestion
 Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein
distention
o Nursing Interventions
 Monitor VS frequently; report s/s increasing distress, Assess respiratory function
frequently
 Elevate HOB or use infant seat, Oxygen as prescribed
 Administer digoxin and diuretics as prescribed
 Daily weights, Strict I/O, Report unusual weight gains
 Low-sodium diets or formula, breast feeding is recommended. Gavage (NGT) feedings if
NPO due to distress, Cluster care
 Often associated with acyanotic defects
 Condition in which the heart is unable to pump effectively the volume of blood that is
presented to it.
 Common complication of CHD.
 Reflects the increased workload of the heart caused by shunts or obstructions.
 Goals for treatment: 1) reduce the workload of the heart 2) increase cardiac output


Managing Digoxin: Administration- go to for children

 Before administering digoxin, nurse must take child’s apical pulse x 1 minute to assess for bradycardia.
 Hold dose if pulse is below normal heart rate (below 90-100) for child’s age.
 Therapeutic blood levels of digoxin are 0.8- 2.0 ng/mL.
 Keep in a safe place (i.e. locked cabinet)
 Families should be taught safe home administration of digoxin:
• Administer on a regular basis; do not skip or make up for missed doses
• Give 1 hour before or 2 hours after meals Do not mix with formula or food
• Take the child’s pulse before admin, and know when to call the caregiver
 Nurse must be acutely aware of the signs of digoxin toxicity. A small child or infant cannot describe
feeling bad or nauseated.
o Vomiting is a common EARLY sign of toxicity. This symptom is often overlooked because
infants commonly “spit up.”
o Teach parents about compliance. They must know the difference btwn the chil
o LATE SIGN: bradycardia
o Other GI symptoms include anorexia, diarrhea, and abdominal pain.
o Neurological signs include fatigue, muscle weakness, and drowsiness
o Hypokalemia can increase digoxin toxicity

 Improves contractility
 Increased cardiac output
 Decreased heart size
 Decreased venous pressure
 Relief of edema
 In children, digoxin (Lanoxin) is used almost exclusively because of its more rapid onset.
 Note the dose is calculated in micrograms (1000 mcg = 1 mg).
 During initiation, the child is monitored by means of an ECG to observe for the desired effects (prolonged
PR interval and reduced ventricular rate) and detect side effects, especially dysrhythmias.

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Infective Endocarditis
 Bacterial infection of endothelial surfaces of the heart including valves (most common), chamber walls, or
septum.
 Children with prosthetic valves are at higher risk than general population.
 Diagnosed based upon modified Jones Criteria
o Modified Jones Criteria (American Heart Association) (Table below)
 Acute rheumatic fever diagnosis requires presence of 2 major criteria or 1 major +
2 minor criteria

49
Watched the rest of their life. Ask “have you had a sore throat” (strep throat)
ESR and CRP are elevated due to inflammation

50
Aching bones
Pain in joint: arthralgia
Cardiomyopathy
 Definition: inflammation of the myocardium so that it cannot contract properly.
 Types: restrictive, dilated and hypertrophic.
 Risk factors include:
o Congenital heart defect, genetic disorders, inflammatory or infectious processes, post-transplant or
postoperatively after cardiac surgery, hypertension, Duchenne and Becker muscular dystrophy.
 Most commonly, no known reason (idiopathic).
 May present as heart failure or cardiac arrest (in adolescents with hypertrophic version).
 Treatment: targets improving heart function.

Kawasaki Disease- think RED

 Acute systemic vasculitis (autoimmune disease) (NCLEX name)primarily affects children <5 years of
age. (everything else is ruled out before diagnosed)
 More in males than females
 Causes inflammation and thrombi in coronary arteries.
 Symptoms include:
o High fever for 5 days that is unresponsive to antibiotics; chills, headache, malaise, extreme
irritability, vomiting, diarrhea, abdominal and joint pain, distinctive rashes (strawberry tongue,
palmar erythema), desquamation of perineum, fingers and toes, red eyes, red palms
o Inflammatory markers will be up in labs.
o Unrelieved by Tylenol or Motrin
o Temp never is below 100 F
 Treatment: IV immunoglobulin- passive immunity (can cause a rash and fever give Tylenol and
Benadryl child should be OK-monitor 24 hr. ) initially then and long-term aspirin (given for 6 weeks).
(10 days to treat or there will be heart problems)
o Can give aspirin b/c the benefit outweighs the risk.
 Requires long-term monitoring of coronary arteries.

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 

Comprehensive Assessment for Heart Transplant

 Done mostly in teenagers
 Chest radiograph, electrocardiogram, echocardiogram, exercise stress test, cardiac catheterization,
pulmonary function test.
 CBC with differential, prothrombin and partial thromboplastin time, serum chemistries and electrolytes,
blood urea nitrogen, and creatinine.
 Urinalysis and urine creatinine clearance.
 Blood, throat, urine, stool, and sputum cultures for bacteria, viruses, fungi, and parasites.
 Epstein–Barr virus, cytomegalovirus, varicella, herpes, hepatitis, and HIV titers.
 HLA typing and panel reactive antibody typing and titer.
 Computed tomography or MRI scan, electroencephalogram (recipient only).
 Consults with neurology, psychology, genetics, social work, nutritionist, physical and occupational therapy,
and financial coordinator, or case manager (recipient only).

Health History of the Present Illness

 When the symptoms started and how they progressed.
 Any treatments and medications used at home.
 History of orthopnea, dyspnea, easy fatigability, growth delays, squatting, edema, dizziness, frequent
pneumonia.
 Poor feeding, fatigue, lethargy, vomiting, failure to thrive.
 Diaphoresis, delays in motor development, cyanosis, tachypnea.
 Activity level compared to peers.
 EKG, labs to check the pt

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Past Health History
 Problems occurring after birth (associated congenital malformation).
 Birth history (any NICU stays?)
 Frequent infections.
 Chromosomal abnormalities.
 Prematurity.
 Autoimmune disorders.
 Use of medications, such as corticosteroids.

Family History of Risk Factors for Cardiovascular Disorders

 Family history of heart disease or CHD (investigate the history further if heart disease occurred in a first-
degree relative)
o Sudden death in a young family member
o Hyperlipidemia
o Diabetes mellitus

Signs and Symptoms of a Cardiac Disorder

 Cyanosis
 Irregular heart rate
 Edema
 Clubbing of fingertips ( late sign)
 Fever
 Retractions or increased work of breathing
 Prominence of precordial chest wall
 Visible, engorged, or abnormal pulsations
 Abdominal distention

Characteristics of Heart Murmurs

 Location on chest where best heard; radiate anywhere else?
 Relation to the heart cycle and duration.
 Intensity:
o Grade I—soft and hard to hear
o Grade II—soft and easily heard; grade III—loud without thrill
o Grade IV—loud with a precordial thrill
o Grade V—loud, audible with a stethoscope
o Grade VI—very loud, audible with a stethoscope or with the naked ear.
 Quality: harsh, musical, or rough; high, medium, or low pitch.
 Variation in sound with position (sitting, lying, standing).

Additional Disorders
 Hyperlipidemia, Hypertension
 Rheumatic heart disease (scarlet fever)
o Inflammatory disease occurring after group A beta-hemolytic streptococcal pharyngitis (GABHS)
 Infrequently seen in the United States; big problem in developing countries
o Self-limiting
 Affects joints, skin, brain, serous surfaces, and heart
o Most common complication of RF
 Damage to valves as a result of RF (rheumatic Fever)
 Jones criteria (presence of two major manifestations or one major manifestation and two minor
manifestations)
o Carditis, Polyarthritis, Erythema marginatum, Subcutaneous nodules, Chorea
o Erythema marginatum: similar to the Lyme disease rash

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 o Subcutaneous Nodules: are deep-seated lesions in the skin, located in the deep dermis and
subcutis,
 Subacute bacterial endocarditis
o Bacterial endocarditis (BE) and subacute bacterial endocarditis (SBE) are now referred to as
infective endocarditis (IE)
o Often a sequela of bacteremia in children with CHD or AHD
o Most common causative agents
 Streptococcus viridans or Staphylococcus aureus
 Fungal agents such as Candida albicans

Focus of Nursing Care for Child With a Cardiac Disorder

 Improving oxygenation.  Providing postoperative nursing care.
 Promoting adequate nutrition.  Preventing infection.
 Assisting the child and family with coping.  Providing child and family education.

Preoperative Assessments During Cardiac Surgery

 Temperature and weight measurements.
 Examination of extremities for peripheral edema, clubbing, and evaluation of peripheral pulses.
 Auscultation of the heart (rate, rhythm, heart sounds, murmurs, clicks, and rubs).
 Respiratory assessment, including respiratory rate, work of breathing, and auscultation of the lungs for
breath sounds.

Psychosocial Interventions
 Explain all that is happening with the child, using language the parents and child can understand.
 Allow the parents and child to voice their feelings, concerns, or questions.
 Provide ample time to address questions and concerns.
 Encourage the parents and the child, as developmentally appropriate, to participate in the child’s care.
 Encourage the child to be as active as is appropriate.

Parent Teaching for Cardiac Surgery

 Heart anatomy and its function.  Location of the incision and coverage with
 Events before surgery. dressings.
 Location of the child after surgery.  Postoperative activity level.
 Appearance of the child after surgery.  Nutritional restrictions.
 Medications
 .
Cardiac Catheter Procedure Care
 Preprocedural Care
o Prepare the child and family for the procedure
o Use developmentally appropriate materials to explain the procedure to the child
o Assess and mark pulses
o Baseline O2 saturation
o Nothing by mouth (NPO) prior to the procedure

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  Postprocedural Care
o Check the pulse distal to the site
o Monitor the temperature and color of extremities
o Take the vital signs every 15 minutes
o Monitor the blood pressure
o Monitor the dressing for bleeding or hematoma
o Monitor intake and output
o Monitor blood glucose levels

Chapter 24: Nursing Care of the Child With an Alteration in Cellular Regulation/ Hematologic or Neoplastic
Disorder

Functions of the Hematologic System

 Erythrocytes or red blood cells (RBCs)
o Responsible for transporting nutrients and oxygen to the body tissues, and waste products from the
tissues.
 Thrombocytes or platelets
o Responsible for clotting.
 Leukocytes or white blood cells (WBCs)
o Responsible for fighting infection.
o Granulocytes (neutrophils, eosinophils, and basophils) and agranulocytes (lymphocytes and
monocytes).
S&S
 Bruises, bumps, swelling, lumps
 Brain tumor: vomiting in the morning

Types of Anemia
 Nutritional deficiency
o Iron deficiency(switch from cow’s milk to formula, and during puberty), folic acid deficiency,
pernicious anemia(lack of b12)
 Toxin exposure
o Lead poisoning
 Aplastic anemia
o Acquired as an adverse reaction to medication
o Rare congenital bone marrow failure (Fanconi anemia)
 Hemolytic anemia
o Sickle cell anemia, thalassemias, hemophilia

Hematologic Disorders
 Iron-deficiency anemia
o Caused by an inadequate supply of dietary iron
o Generally preventable
o Predictable at developmental periods
 In premature infants, due to low fetal supply
 At 12 to 36 months, due to ingestion of large amounts of cow’s milk and diet
 In adolescents, due to rapid growth and poor eating habits
o Most common type of anemia
 Not enough healthy R B C's
 Diminished oxygen-carrying capacity of blood
 Screen at 12 months
 To treat

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  Transfusion if needed, below 7 and symptomatic
 Nutritional supplement (Vit. D)

Types of Hemoglobinopathies
 Sickle cell anemia
 Hemoglobin SC disease
o α-Thalassemia
o β-Thalassemia

Hematologic Disorders
 Sickle cell disease
o Ethnicity
 AUTOSOMAL RECESSIVE both parents have to have the gene makeup
 Occurs primarily in African Americans
 Occurs in 1 in 375 infants born in the United States
 One in 12 has sickle cell trait
o Occasionally also in persons of Mediterranean descent
o Also seen in persons of South American, Arabian, and East Indian descent
o If both parents have the trait, each child of theirs will have a 1 in 4 likelihood of having the disease
o Partial or complete replacement of normal hemoglobin with abnormal hemoglobin S (Hgb S)
 Hemoglobin in the RBCs takes on an elongated “sickle” shape
 Sickled cells are rigid and obstruct capillary blood flow
 Microscopic obstructions lead to engorgement and tissue ischemia
 Hypoxia occurs and causes sickling, leading to pain
 Usually pain happens in the same part of the body
o Large tissue infarctions occur
 Damaged tissues in organs; impaired function
o Splenic sequestration
 Ask if they still have their spleen
 May require splenectomy at an early age
 Results in immunity
o Don’t want sickle in the brain b/c it can cause stroke
o Meds keep the cells from being sticky and the other stops the blood from clotting
o Only cure is a bone marrow transplant
o Acute chest syndrome if sickle cell affects the lungs
o Heart attack if sickle cell affects the heart
o Dactylitis: swelling of fingers and toes. Affected by sickle cell
o Sickle cell in the spleen: the spleen will be removed
o Priapism: sickle In the penis and they have elongated erection

Sickle Cell Crisis

 Precipitating factors:
o Anything that increases the body’s need for oxygen or alters the transport of oxygen
 Trauma
 Fever, infection
 Physical and emotional stress
 Increased blood viscosity due to dehydration
 Ask where they usually sickle atmost likely to occur again
o Hypoxia
 Results from high altitude, poorly pressurized airplanes, hypoventilation,
vasoconstriction due to hypothermia
 Vasoocclusive-
 Most common type of crisis and is very painful

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  Stasis of blood with clumping of cells in the microcirculation leads to ischemia
and then infarction
 Signs are fever, pain, and tissue engorgement
 Aplastic Crisis
 Diminished production and increased destruction of RBCs
 Triggered by viral infection or depletion of folic acid
 Signs include profound anemia and pallor

• Nursing Management
 Monitor the child’s growth and watch for failure to thrive
o Carefully do a multisystem assessment
 Assess and treat pain
 Observe for the presence of inflammation or possible infection
 Carefully monitor for signs of shock
 Promote growth and development
 Goals
o Prevent sickling phenomena
o Treat medical emergencies
 Childhood vaccines
 Aggressive treatment of infection
 Possible prophylactic antibiotics in children from 2 months to 5 years of age
 ONLY bone marrow treatment to cure SS anemia
 Make sure to give lots of fluids
 Babies w/ sickle cell will be on penicillin until age 5
 Hydroxyurea: helps restore fetal blood supply.

Hemophilia
 A group of hereditary bleeding disorders that result from deficiencies of specific clotting factors
 Typically, an X-linked recessive pattern

 Hemophilia A
o Classic hemophilia (deficiency of factor VIII (8))
o Accounts for 80% of cases of hemophilia
o Kids will bring in their own factor medication (expensive for the hospital)
o At risk for nose bleeds, bleeding after procedures
o If they bleed a lot use Rest, ice, Compression and also give them Factor 8
o Give them desmopressin for mild hemophilia.
 Hemophilia B
o Christmas disease (deficiency of factor IX (9))
 Von Willebrand disease (vWD)
o Deficiency, abnormality, or absence of vWF and factor VIII
o Affects both males and females
 Hemarthrosis
o Bleeding into joint spaces of the knee, ankle, or elbow leads to impaired mobility and,
eventually, bony changes and disability
o Symptoms include warmth, pain, bruising, and decreased movement
 At risk for epistaxis, bleeding after procedures, and GI Bleeding
 Avoid sports
Medical Management of Hemophilia
o Replacement of missing clotting factors
o Desmopressin (DDAVP)
 IV
 Increases factor VIII activity by two to four times

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  Used for mild hemophilia
o Transfusions
 Prompt intervention to reduce complications
o Medications
o Exercise and physical therapy joints
 Make sure bones are moving
Nursing Care Management
• Prevent bleeding episodes
• Recognize and control bleeding
• Support the patient
o Pain
o Mobility
o Promote growth and development
• Support the family
o Education
o Prepare for home care
• Interventions
o Close supervision and safe environment
o Dental procedures in a controlled situation
o Shave only with an electric razor
o For superficial bleeding, apply pressure for at least 15 minutes and ice to promote vasoconstriction
• If significant bleeding occurs, transfusion for factor replacement

Managing Hemarthrosis:
During bleeding episodes, elevate and immobilize the joint
Ice
Analgesics
Range-of-motion exercises after the bleeding stops will help to prevent contractures
Physical therapy
Avoid obesity to minimize joint stress

The nurse is caring for a child with anemia caused by a deficiency in vitamin B12. What type of anemia is this child
experiencing?
a. Pernicious anemia
Rationale: Thalassemia and sickle cell anemia are a result of hemolytic disorders and folic acid deficiency is caused
by low dietary intake of green leafy vegetables, liver, citrus, or malabsorption of medication.

Complications of Lead Poisoning

• Lower levels
o Behavioral problems
o Learning difficulties
• Higher levels (requires chelation treatment): take bad blood out , separate it, and then return It back to the
body
o Encephalopathy
o Seizures
o Brain damage
Thalassemia (genetic)
They will need monthly blood transfusion.
They can take hydroxyurea.
• a-thalassemia
o Synthesis of the a-chain of the hemoglobin protein is affected.
• β-Thalassemia (more common)
o Thalassemia minor (also called β-thalassemia trait): leads to mild microcytic anemia; often no
treatment is required.

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 o Thalassemia intermedia: child requires blood transfusions to maintain adequate quality of life.
o Thalassemia major: to survive, the child requires ongoing medical attention, blood transfusions,
and iron removal.
o Treatment: blood transfusion-will reach a phase where the body won’t accept/fix with the blood
support family
o Ask their baseline hemoglobin
Clotting Disorders
• Idiopathic thrombocytopenia purpura (ITP)
o Body attacking itself and
• Henoch–Schönlein purpura
• Disseminated intravascular coagulation (DIC) (can’t clot)
o Happens usually during sepsis
o factors 2,5,8,10
o Septic shock,
• Factor deficiencies
o Hemophilia A (factor VIII deficiency)
o von Willebrand disease
o Hemophilia B (Christmas disease, factor IX deficiency)
o Hemophilia C (factor XI deficiency)

Signs and Symptoms of Idiopathic Thrombocytopenia Purpura

• Petechiae
o Pinpoint hemorrhages occurring on the body that do not blanch to pressure.
• Purpura
o Larger purplish areas of hemorrhage in which blood collects under the tissues.

Childhood Cancers Compared to Adult Cancers

Common Types of Childhood Cancers

• Blood: Leukemias (ALL (attacks B &T cells) [most common, 92% SUCCESS RATE] AML (more on the
bone marrow),
o  Positive DX: bone marrow aspiration
 They hit them hard at first
o Hodgkin disease (Reed-Steinberg’s cells. Swollen lymph node, one spot), non-Hodgkin
lymphoma(multiple locations, various different lymph nodes) (difference between)
 Can use radiation and chemo
• Brain: Medulloblastoma (most common), brainstem glioma, ependymoma, astrocytoma
o Headaches and vomiting in the morning, walking funny. swelling and vomiting, changes in ICP,
headache
• Other types:
o Neuroblastoma (low success rate-hard to treat), osteosarcoma,
o Wilms tumor(most common renal tumor-must be removed)
 DO NOT press on the mass-can cause the cancer to spread)

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 o rhabdomyosarcoma (multiple sites)
o retinoblastoma

Signs & Symptoms OF cancer IN CHILDREN

• Pain • Abnormal pupillary reflex
• Fever • Neurological changes (may indicate brain
• Ecchymosis and Petechiae tumor)
• Bone marrow (malignant invasion)
• Swollen lymph glands Bruising, lumps, and swelling S/S of cancer

Health History Related to Hematologic Functioning

• Birth and maternal history
o Low birthweight, gestational diabetes, if vitamin K given after birth.
• Recent illnesses related to blood cell distribution.
• Sleep/wake patterns.
• Bowel elimination patterns.
• Family history for inherited disorders.
• Typical diet for nutritional deficits.
• Risk for lead exposure.

Nursing Assessment for Aplastic Anemia

• Determine history of exposure to myelosuppressive medications or radiation therapy.
• Obtain a detailed family, environmental, and infectious disease history.
• Note history of epistaxis, gingival oozing, or increased bleeding with menstruation.
• Anemia may lead to headache and fatigue.
• On physical examination, note ecchymoses, petechiae or purpura, oral ulcerations, tachycardia, or
tachypnea.

Common Laboratory and Diagnostic Tests for Hematologic Disorder

• Complete blood count with differential • Hemoglobin electrophoresis
(ANC) • Blood type and cross-match
• Reticulocyte count- how quickly the RBC • Clotting studies
breaks down. Show the correlation btwn • Coagulating factor concentration
healthy and unhealthy RBCs • Iron and lead levels
o Do CRP labs which are going to • Serum ferritin
increase RBC

Main Components of the Complete Blood Count (CBC)

• RBC count: the actual number of counted RBCs.
• Hemoglobin (Hgb): measure of the protein made up of heme and globin.
• Hematocrit (Hct) (protein): an indirect measure of red blood cells.
• RBC indices: cell diameter, Hgb/RBC.
• WBC count: actual count of the number of WBCs in a volume of blood.
• Platelet count: number of platelets per blood volume. (ability to clot) low=bruises, thirst and winny
o Mean platelet volume (MPV): a measurement of the size of the platelets.

Laboratory and Diagnostic Studies to Assess Sickle Cell Disease

• Hemoglobin: baseline is usually 7 to 10 mg/dL; will be significantly lower with splenic sequestration,
acute chest syndrome, or aplastic crisis.
• Hgb electrophoresis: measures the type of Hgb (Hgb S, Hgb SS or Hbg F).
• Reticulocyte count: greatly elevated.
• Peripheral blood smear: presence of sickle-shaped cells and target cells.
• Platelet count: increased.
• Erythrocyte sedimentation rate: elevated. (ESR)

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 • Abnormal liver function tests with elevated bilirubin.

Nursing Diagnoses for a Child With a Hematologic Disorder

• Fatigue • Ineffective health maintenance
• Pain • Anxiety
• Impaired physical mobility • Ineffective family coping

Common Medical Treatments for a Child With a Hematologic or Neoplastic Disorder

• Blood product transfusion
• Supplemental oxygen • IV hydration
• Splenectomy • Lumbar puncture
• Hematopoietic stem cell transplantation • Radiation treatment

• Pain management, fluid, and oxygen

Common Medications for a Child With a Hematologic or Neoplastic Disorder

• Iron supplements, folic acid
• Deferasirox/deferoxamine
• Factor replacement (VIII or IX)
• Antibiotics (oral and parenteral)
• Hydroxyurea
• Intravenous immunoglobulin (IVIG)
• Chemotherapeutic agents (multiple classes)
• Biotherapy (Monoclonal Antibodies, interferons [, β])

Recommended Dosages of Elemental Iron for Iron-Deficiency Anemia

• For prophylaxis: 1 to 2 mg/kg/day, up to a maximum of 15 mg elemental iron per day.
• Mild to moderate iron deficiency: 3 mg/kg/day of elemental iron in one or two divided doses.
• Severe iron-deficiency anemia: 4 to 6 mg/kg/day of elemental iron in three divided doses.

Sources of Lead
• Paint in homes built before 1978 and dust from windowsills, walls, and plaster in older homes.
• Soil from sites where cars that used leaded gas had been parked.
• Glazed pottery and stained glass products.
• Lead pipes supplying water to the home.
• On the clothing of parents who work in certain manufacturing jobs.
• Certain folk remedies, such as greta or arzacon.
• Old painted toys or furniture .

Foods Rich in Iron (eat with OJ)

• Red meats (easiest for the body to absorb) • Enriched grains
• Tuna and salmon • Dried beans, peas, and fruits
• Eggs • Leafy green vegetables
• Tofu • Iron-fortified breakfast cereals

Chapter 26: Nursing Care of the Child With an Alteration in Metabolism/ Endocrine Disorder
Endocrine System
 Hormones are turned out during puberty
 Composed of glands, tissues, or clusters of cells that produce and release hormones in a negative feedback
system involving the hypothalamus and nervous system.
 Influences all physiologic processes
o Growth and development.
o Metabolic processes related to fluid and electrolyte balance and energy production.
o Sexual maturation and reproduction.
o The body’s response to stress.

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 o Maintenance of internal homeostasis.
 Cortisol levels are high during stress

Organs or Tissues of the Endocrine System

 Pituitary gland and hypothalamus (“control  Gonads (ovaries and testes).
centers”).  Islets of Langerhans located in the pancreas.
 Thyroid gland.
 Parathyroid glands.

 Adrenal glands.

Laboratory and Diagnostic Testing for Endocrine Disorders

 Newborn metabolic screening
o PKU: phenalynine problem. Lots of foods they cant eat
o Blot test
o Sickle cell screening
 Serum chemistry
 Random and timed serum hormone testing
 Growth hormone stimulation testing
 Blood glucose (fasting, random and OGTT), HgA1C
 Urine testing (ketone, glucose, 24 hour collections)
 Genetic testing
 Water deprivation study
 Bone age radiographs
 Imaging studies—CT, MRI, nuclear medicine, ultrasonography

Question #1
The nurse is caring for a child diagnosed with juvenile diabetes. Which of the following medical treatments
would be appropriate for this child?
d. Glucose monitoring

Common Medications for Endocrine Disorders

 Hypoglycemics (oral, injectable)  Hormone therapy (supplemental)
o Can cause changes in seizures or  Hormone suppression therapy
demeanor  Corticosteroids and mineralocorticosteroids
o D5 is super caustic to the vein and o Sugars to go up. Moon face etc
can blow the vein  Desmopressin acetate (DDAVP)

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Complications of Growth Hormone Deficiency and Therapy
 Altered carbohydrate, protein, and fat  Slipped capital femoral epiphysis (SCFE)
metabolism  Pseudotumor cerebri
 Hypoglycemia  Leukemia
 Glucose intolerance/diabetes  Recurrence of CNS tumors
o They stay in the hospital for 3 days  Infection at the injection site
to educate family members  Edema and sodium retention

Common Medical Treatments for Endocrine Disorders

 Dietary interventions.
 Glucose monitoring and insulin delivery via programmable pumps.
 Irradiation/administration of radioactive iodine.
 Surgery.

Pituitary Disorders
 Anterior hormones
o Growth hormone deficiency
o Hyperpituitarism
o Precocious puberty
 Posterior hormones
o Diabetes insipidus
o Syndrome of inappropriate antidiuretic hormone secretion

Pituitary and Hypothalamic Disorders

Hypopituitarism/Panhypopituitarism
o Growth hormone deficiency (G H D)
 Delayed growth less than 2 inches per year b/c pituitary gland is not produced the
hormone or not enough hormone
 They will take GH are night b/c that’s when you grow the most
 When they catch up they can stop taking the med
 LH & FSH are typically the ones that are not growing
o Diabetes insipidus (D I)
 The principal disorder of the posterior pituitary gland
 Results from undersecretion of antidiuretic hormone (ADH)
 Produces uncontrolled diuresis
 Primary causes are familial or idiopathic
 Secondary causes are trauma, tumors, granulomatous disease, infections, or
aneurysm
 Cardinal signs are polyuria and polydipsia, enuresis
 First sign is often enuresis accompanied by insatiable thirst
o Infants
 Irritability is relieved with feedings of water but not milk
 Dehydration often occurs
o Instruct parents on the difference between DI and diabetes mellitus (DM)
 Daily hormone replacement of vasopressin
 Unresponsiveness usually indicates nephrogenic DI

Hyperpituitarism
 Growth hormone excess
 Acromegaly
 Marfan’s syndrome
 Syndrome of inappropriate antidiuretic hormone (S I A D H)
o Produced by hypersecretion of the posterior pituitary (increased ADH)
 Signs and symptoms include fluid retention and hypotonicity

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  Kidneys are unable to reabsorb water
 Anorexia, nausea and vomiting, irritability, and personality changes
 Symptoms disappear when ADH is decreased
o Nursing Management
 Accurate I&O, diet high in protein and sodium, medications with meals
 Observe for signs of fluid overload
 Seizure precautions, Neuro checks
 Administer ADH-antagonizing medicines
 Fluid Restriction is key
Precocious Puberty
 Defined as sexual development before age 9 years in boys; before age 7 years in Caucasian girls; or before
6 years in African-American girls
o Occurs more frequently in girls
 Three types
o Central precocious puberty (CPP) (80%)
o Peripheral precocious puberty (PPP)
o Incomplete precocious puberty (IPP)
 Treatment of specific cause if known
 Central variety is treated with leuprolide acetate (Lupron Depot)
o Slows prepubertal growth to normal rates
o Treatment is discontinued at the age at which normal pubertal changes would resume
 Psychological support for the child and family

Goals of Nursing Management of Precocious or Delayed Puberty

 Educating the child and family about the physical changes the child is experiencing.
 Teaching how to correctly use the prescribed medications.
 Helping the child to deal with self-esteem issues related to the differences in the rate of growth and
development of secondary sexual characteristics compared to peers.
 Promoting age-appropriate physical development and pubertal progression.
 Be there for child

Comparison of Diabetes Insipidus versus Syndrome of Inappropriate ADH (SIADH)

Question #2: The nurse is caring for a child with diabetes insipidus. Which of the following clinical manifestations
would be expected for this child?
b. Serum osmolality greater than 300 mOsm/kg
Rationale: Other clinical manifestations of diabetes insipidus include urine specific gravity less than 1.005,
decreased urine osmolality, hypernatremia, increased urination, and dehydration/thirst.

Thyroid Disorders in Children

 Hyperthyroidism: rare in children

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 o Mostly seen as Graves Disease.
o Exophalmos: big eyes
o Very hyperactive
o Excessive T3, T4, T3 resin uptake.
o TSH usually low.
o Eyes bulged, nervousness, heat intolerance
o Treated by destruction of thyroid gland.
o Will be on Synthroid
o Must have compliant parents.
 Hypothyroidism: can be congenital or acquired diagnosed much later.
o Certain populations at risk (Downs, maternal hypothyroidism).
o Decreased thyroid hormones.
o Tiredness, constipation, cold intolerance
o Thin hair, gained weight
o Decreased T3, T4, T3 resin uptake.
o TSH usually elevated.
o Lifelong thyroid supplementation.

Hypothyroidism Versus Hyperthyroidism

Signs of Thyroid Storm (when hyperthyroidism is left untreated)

 Sudden onset of severe restlessness and irritability
 Fever
 Diaphoresis
 Severe tachycardia

Classification of Diabetes
 Type 1: caused by a deficiency of insulin secretion due to pancreatic β-cell damage.
 Type 2: consequence of insulin resistance that occurs at the level of skeletal muscle, liver, and adipose
tissue with different degrees of β-cell impairment.
 Diabetes secondary to certain conditions such as cystic fibrosis, glucocorticoid use (as in Cushing
syndrome), and certain genetic syndromes such as Down syndrome, Klinefelter syndrome, and Turner
syndrome .

Type 1 Versus Type 2 Diabetes Mellitus

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Signs and Symptoms of Diabetic Ketoacidosis
 Anorexia, nausea and vomiting. they need insulin. They will use Short acting
 Lethargy, stupor, altered level of insulin which is Regular (Humulin or
consciousness, confusion. Novolin)
 Decreased skin turgor.
 Abdominal pain.
 Kussmaul respirations and air hunger.  In the mean time , while waiting for insulin
 Fruity (sweet-smelling) or acetone breath drip given them bolus IV NS. Push fluids
odor. until the insulin is obtained
 Presence of ketones in urine and blood.
o Check urine and see for ketones
 Tachycardia, and if left untreated, coma and
death.  Kids need to be put on a pump. When they
have diabetes . cant be on a pump if pt is
 When kids are admitted with DKA they noncompliant. Teach and educate parents.
need an insulin drip. When they are sick
Give pt a snack before and after exercising.

Examples of Nursing Diagnoses for Endocrine Disorders

 Delayed growth and development.  Imbalanced nutrition: less than or more than
 Disturbed body image. body requirements.
 Deficient knowledge (specify).  Deficient or excess fluid volume.
 Interrupted family processes.  Noncompliance.

Promoting Growth for a Child With Congenital Hypothyroidism

 Measure and record growth at regular intervals.
 Measure thyroid levels every 2 to 4 weeks until the target range is reached on a stabilized dose of
medication.
 Obtain tests every 3 to 4 months for the first several years of life, changing to every 6 to 12 months during
adolescence.
 Monitor for signs of hypo- or hyperfunction, including changes in vital signs, thermoregulation, and
activity level.
 Provide adequate rest periods and meet thermoregulation needs.

Goals of Therapeutic Management of Diabetes Mellitus

 Achieving normal growth and development.
 Promoting optimal serum glucose control, including fluid and electrolyte levels and near-normal
hemoglobin A1C or glycosylated hemoglobin levels.
 Preventing complications. (decrease in wound healing-hand washing)

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  Promoting positive adjustment to the disease, with ability to self-manage in the home.

Insulin Type, Action, and Duration

Question #3: Is the following statement true or false?

The nurse teaching parents of a child with diabetes about insulin administration correctly informs them that short-
acting insulin has an onset within 15 minutes and lasts for 3 to 5 hours.
False. Rapid-acting insulin has an onset within 15 minutes and lasts for 3 to 5 hours.
Rationale: Short-acting insulin has an onset within 30 to 60 minutes and lasts for 5 to 8 hours.

CHART ON PAGE 1043

Complications of Diabetes Mellitus

 Retinopathy  Hypertension
 Nephropathy  Celiac disease
 Dyslipidemia  Hypothyroidism

Teaching Points for Diabetes Management

 Self-measurement of blood glucose.
 Urine ketone testing.
 Medication use.
 Signs and symptoms and treatment of hypoglycemia and hyperglycemia.
 Monitoring for and managing complications.
 Sick-day instructions.
 Laboratory testing and follow-up care.
 Diet and exercise as part of DM management.

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