Chapter 40.

Nursing Care of a Child with Respiratory Disorder

Terms:
1. Adventitious sounds - extra or abnormal breathing sounds
a. Stridor - is a continuous high-pitched, crowing sound heard predominantly on inspiration.
- the cause of this sound is generally the partial obstruction of the larynx or trachea.
- may be heard in conditions such as croup and foreign body obstruction.
- it’s typically loudest over the anterior neck, as air moves turbulently over a partially-obstructed upper airway.
b. Wheezing - a high-pitched continuous musical sound.
- this is caused by air passing through an obstructed, narrow airway.
- what we often refer to as rhonchi is the sonorous wheeze, which refers to a deep, low-ptched rumbling or coarse sound as air
moves through tracheal/bronchial passages in the presence of mucus or respiratory secretions.
-it is commonly heard in the lungs during expiration.
- it may be heard in asthma, emphysema, and chronic bronchitis

C. Crackles - are also known as alveolar rales

-the sound crackles create are fine, short, high-pitched, intermittent crackling sound
- the cause of crackles can be from air passing through fluid, pus or mucous.
- commonly heard in the bases of the lung lobes during inspiration.
- coarse crackles sound quality is low-pitched and moist, it may be heard in pulmonary edema and bronchitis.
-Fine crackles sound quality is like hair rubbing near the ear and may be heard in congestive heart failure and pulmonary
fibrosis
D. Pleural rub- results form the movement of inflamed pleural surfaces against one another during chest wall
movement
- harsh grating or creaking
- potential causes are tuberculosis and pneumonia.
-best heard in the lower anterior lungs and lateral chest during both inspiration and expiration.

2. Aspiration - inhalation of foreign object into the airway

3. Atelectasis - collapse of alveoli
4. Clubbing - a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips; a response to hypoxia
5. Cyanosis - a blue tinge to the skin indicating hypoxia
6. Expiration - carbon dioxide-filled air discharged to the outside
7. Hypoxemia - deficient oxygenation of the blood
8. Hypoxia - inadequate oxygenation of body tissue
9. Inspiration - delivery of warmed moistened air via the respiratory system tot he alveoli
10. Paroxysmal coughing - series of expiratory coughs after a deep inspiration
11. Pneumothorax - the presence of atmospheric air in the pleural space
12. Retraction - indentation of intercostal spaces reflecting difficulty breathing

Asthma
Asthma is a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells, eosinophils, T-lymphocytes
and neutrophils. In susceptible individuals, this inflammation causes symptoms which are usually associated with widespread but variable inflow
obstruction that is often reversible either spontaneously or with treatment.
Asthma tends to occur in children with a tendency to react with hypersensitivity to allergens. Mast cells release histamine and leukotrienes
that result in diffuse obstructive and restrictive airway disease.

Mechanism of disease
Asthma primarily affects the small airways and involves three separate processes: bronchospasm, inflammation of bronchial mucosa, and increased
bronchial secretions (mucus).

Signs and Symptoms:

Wheezing, exhausted, paroxysmal cough with thick mucus production

Treatment: Control of triggers

Avoidance of triggers which include irritant gases, weather changes, cold air, exercise, respiratory infections, certain foods, additives and drugs.

Therapeutic Management
Child with mild, persistent Asthma
 Usually is prescribed an inhaled anti-inflammatory corticosteroid as Fluticasone daily.
Child with moderate persistent symptoms
Usually is prescribed an inhaled anti-infammatory corticosteroid daily and a long-acting bronchodilator at bedtime.

Pneumonia
Cause. Possibly bacterial (pneumococcal, streptococcal, staphylococcal, so chlamydial)
or Viral (Respiratory syncytial virus RSV)

Pneumococcal Pneumonia: with this, children may have blood-tinged sputum as exudative serum and red blood cells invade the alveoli. After 24-
48 hours, the alveoli are no longer filled with red blood cells and serum, but fibrin, leukocytes and pneumococci. At this point, the child’s cough no
longer raises blood-tinged sputum but thick purulent material.
S/s: high fever, nasal flaring, chest pain, chills, dyspnea. Taychypnea and tachycardia develop. Crackles may be present. Breath sounds become
bronchial.
Therapeutic Management:
Either Ampicillin or a third-generation cephalosporin.
Humidified oxygen
Chlamydial Pneumonia: Symptoms usually begin gradually with nasal congestion and a sharp cough. It progress to tachypnea with wheezing and
crackles. It is treated with Erythromycin.
Viral Pneumonia: There may be diminished breath sounds and fine crackles.
Therapeutic management:
Antipyretic for the fever
Intravenous fluid if the child is dehydrated or exhausted from feeding

Respiratory System
Functions:
- Gas exchange (refers to O2 and CO2) between the atmospheric air, blood and tissue cells
-Air distribution
-Regulation of the pH of body fluid
Nose - Filters foreign materials
Pharynx - a passageway for air and food, provides a resonating chamber for speech sounds, and houses the tonsils, which participate in
immunological reactions against foreign invaders.
- closes when swallowing, opens when breathing
Larynx - a short passageway that connects the pharynx with the trachea
Trachea - also called the windpipe
Carina - divides left and right bronchus
Cilia - hair-like structure

Body Mechanism
Mucucillary clearance - Body’s defense mechanism
Goblet cells - produces mucus to trap any foreign materials
- produces 3 ounces of mucus daily
Cough reflex - body’s mechanism
Sneezing - body’s mechanism in getting rid of the dust

Bronchodilation - Smooth muscle relaxes (sypathetic)

Bronchoconstriction - Smooth muscles constrictc (parasympathetic)

Beta 1 - Heart
Beta 2 - Lungs

Agonist - Neurotransmitter for sympathetic

- e.g. Epinephrine and Salbutamol
-when activated, there is an increase in Cyclic Adenosine Monophosphate (CAMP) that causes smooth muscle relaxation or bronchodilation

Alveoli - Functional units of the lungs

Pneumocytes - cells in lungs
2 types of Pneumocytes
-type 1 - responsible in the gas exchange
-type 2 - produces surfactant

Lecithin Spingomyelin - Surfactant that prevents collapse of the alveoli

3 Phases of respiration
1. Pulmonary ventilation - inspiration and expiration
2. External Respiration - Gas exchange happens in the lungs
3. Internal Respiration - gas exchange is in the cells (cellular levels)

Muscles that aids in breathing

- Diaphragm - major muscle (75% role)
-during exhalation, the diaphragm relaxes
-External intercoastal muscle (25% )

Medulla - respiratory center in brain

Factors that can disturb breathing

1. Lung compliance - conotes stretchability of the lungs (e.g. Pneumonia, TB)
2. Airway resistance - if airway is clear, there is easy passage of oxygen (e.g. Bronchitis, Asthma, or increase mucus secretions
3. Surface tension - if surface tension is high, there is collapse of lungs

What prompts your body to breath?

- Because of the accumulation of CO2 in the body
Respiratory Disorders
Condition Signs & Symptoms Management
Laryngotrachealbronchitis/ - initial unproductive cough, - Croup Tent -with high humidity and cold mist to loosen
Coup becoming peculiarly brassy: secretions, reduce mucosal edema
Types: barking cough -keep clothing and linens always dry
1. Acute Spasmodic Laryngitis -hoarseness of voice -monitor oxygen concentration (initially 15 L and then
-less common -tachypnea readjust flow to 8 L)
2. Acute LTB - most common in -inspiratory stridor - sharp, high- -tack in tent to prvent oxygen from coming out
children pitched sound made as air attempts -Bed rest: NPO with IVF
3. Acute Infectious Laryngitis to pass through the narrowed, - No Sedatives - restlessness is one of the signs of respiratory
4. Acute Epiglotitis - commonly inflamed, edematous laryngeal distress in children
caused by H. influenzae: most openings -Semi-fowler’s position
severe -cyanosis, pallor, restlessness -ET tracheostomy set at the bedside
(early signs of distress) -Medications: Syrup of Ipecac to relieve laryngeal edema,
Major problem: Laryngospasm r/t -marked retractions Epinephrine, Corticosteroids.
mucosal edema and production of -fever -TSB every 15 minutes for fever
thick, tenaceous exudates -cherry-red epiglottis -If child suddenly develops respiratory distress, D/C TSB and
put him back inside the croup tent STAT
Bronchiolitis -severely ill for 48-72 hours, then -Bed rest: NPO with IVF - to prevent aspiration due to
- an acute respiratory infection gradually improves during the next respiratory distress
involving the bronchioles wherein 4-5 days (virus is self limiting). If - Humidified oxygen - to liquefy secretions
there is blockage of excess air severity lasts for more than 72 -Proper positioning - prone for the compression of overly
from the alveoli resulting in hours, there is probably a distended lungs, semi-fowler’s with slight neck extension for
overdistention of the lungs superimposed bacterial infection fuller chest expansion
-Cause: respiratory syneytial virus -Restlessness, nasal flaring, rales, -Medications:
(a para-influenza virus) retractions, dyspnea, cyanosis Beta-adrenergic bronchodilators
-Predisposing factors: -Tachycardia Epinephrine
A. Low socio-economic status -With or without fever Anti-viral agents: Ribarrin
B. Parental smoking - Respiratory Acidosis Antibiotics
Sodium bicarbonate for acidosis
Chapter 41. Nursing Care of the Child with a Cardiovascular Disorder
Term
1. Acyanotic heart disorder - heart or circulatory anomalies that involve either a stricture to the flow of blood or a shunt that moves blood from the
arterial to the venous system ( oxygenated to unoxygenated blood or left-to-right shunts)
2. Balloon angioplasty - procedure usually by way of cardiac catheterization in which a catheter with an uninflated balloon at its tip is inserted and
passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and may relieve the stenosis.
3. Cardiac catheterization - a procedure in which a small radiopaque catheter is passed through a major vein in the arm, leg, or neck into the heart to
secure blood samples or inject dye, to evaluate cardiac function
4. Cyanosis - is blue tinge to the skin indicating hypoxia
5. Cyanotic heart disease - cardiac anomaly when blood is shunted from the venous to the arterial system as a result of abnormal communication
between between the two (deoxygenated blood to oxygenated blood; right-to-left shunt)
6. Diastole - relaxation of the heart chambers
7. Echocardiogrpahy - ultrasound involving the use of high-frequency sound waves to locate and study the movement and dimensions of the cardiac
structures
8. Electrocardiogram (ECG) - written record of the electrical voltages generated by the contracting heart
9. Fluoroscopy - a radiologic serial-images technique
10. Innocent heart murmur - heart murmur of no significance; also called insignificant or functional heart murmur
11. Left-to-right shunts - heart or circulatory anomalies that involve blood movement from the arterial to the venous system (oxygenated to
unoxygenated blood)
12. Organic heart murmur - murmur occurring as the result of heart disease or a congenital defect
13. Polycythemia - an increase in the number of red blood cells that results as a compensatory response to insufficient oxygenation of the blood
14. Postperfusion syndrome - a complication after cardiac surgery manifested by fever, splenomegaly, general malaise, hepatomegaly, and
leukocytosis
15. Right-to-left shunt - cardiac anomaly when blood is shunted from the venous to the arterial system as a result of abnormal communication
between the two (deoxygenated blood to oxygenated blood)
16. Systole - contraction of the heart chambers
17. Vasculitis - inflammation of the blood vessels
Cardiovascular System
Blood Vessels:
-Vein - carries deoxygenated blood towards heart; can have valve, prevents backflow
- Arteries - Carries oxygenated blood away from the heart
- Capillaries - smallest blood vessels; most numerous numbers

Heart Layers
-Epicardium
-Myocardium
-Endocardium

Heart Sounds
S1 (Lub) - closing of Mitral/Bicuspid valve & tricuspid valve
- Atrioventricular valve
S2 (Dub) - closing of Pulmonary & Aortic Valve
- Semilunar valve
S3 (ta) - Heard after S1 and S2 (ventricular gallop)
- Common in children
- “Lubdub-ta”
S4 (ta) - Heard before S1 ( Atrial gallop)
- “ta-lubdub”

Systole - contraction of ventricles (closing of AV valves)

Diastole- relaxation
 Capillaries
(Blood loses O2 Arterioles Arteries Aorta Aortic
and gains CO2 Semilunar Valve

Venules Left Ventricle

(Small veins)

Blood Flow (Lungs-heart-body

tissues) Mitral/Bicuspid
Veins valve
Blue - Carries unoxygenated
blood

Red - carries oxygenated blood

Left Atrium
Superior vena
cava, Inferior Vena
Cava, Coronary
Sinus

Pulmonary
Right Atrium veins

Lungs (Blood
Tricuspid Right Pulmonary Pulmonary loses CO2 and
Valve Ventricle Valve Arteries gains O2)
Cardiac Disorder
Condition Signs and Symptoms Management
Rheumatic Fever Major: 1. Bed rest to decrease workload of the heart
-Collagen disease: 1. Polyarthritis 2. Provide a quiet environment
characterized by damage to 2. Carditis- inflammation of the heart 3. Maintain proper body alignment to prevent deformities
connective tissue and 3. Chorea - involuntary movement d/o 4. Increase intake of nutritional foods
usually blood vessels 4. Erythema marginatum - rashes 5. Limit joint movements
- cause unknown: frequently 5. Subcutaneous nodules 6. Pharmacotherapy
follows infection with - Acetylsalicylic Acid (ASA) - to ↓ inflammation and pain
Group A Beta Hemolytic Minor: - Steroid - to reduce inflammation
and Streptococci 1. Fever -Penicillin - to eradicate pathogen and prevent recurrence
2. Arthralgia- joint pain -Diuretics
3. Body weakness
4. Easy fatigability
5. Epistaxis

-↑ ASO titer, ESR

-C-reactive CHON test
-ECG, 2 DEcho
Kawasaki Disease / - fever for 5 or more days -Primarily supportive and directed toward controlling fever,
Mucocutaneous Lymph -Conjunctival congestion (Blood shot preventing dehydration, and minimizing possible cardiac
Node Syndrome eyes) complications
-acute febrile illness of -strawberry tongue 1. Aspirin to control fever and suppress inflammation
unknown etiology -Erythema on soles and palm, edema, 2. Intravenous gamma globulin
associated with vasculitis feet hard to touch, constant pain and 3. Administer digitalis, diuretics
primarily affecting the heart discomfort 4. Monitor cardiac status, not for signs of dysrhythmias
-skin changes: erythematous rash, 5. Provide optimal nutrition
pruritus 6. Administer analgesics for joint pain PRN
 -lymphadenopathy 7. Surgery (PRN) coronary bypass
Congenital Heart Diseases (CHD)
- It is the most common cardiac problem in children
-Any structural lesion in the heart or blood vessels that is directly proximal to the heart is described as a congenital heart defect.
- Anatomic defects of the heart prevent the proper flow of blood to the lungs and/or body.
- Children with symptomatic CHD have chronic problems related to decreased cardiac output, congestive heart failure and hypoxia and cardiac
rhythm disturbances
- Acyanotic defects characteristically have a left-to-right shunt (Oxygenated to unoxygenated blood flow)
-Cyanotic defects characteristically have a right-to-left shunt(unoxygenated to oxygenated blood flow)

Types of Congenital Heart Defects

Acyanotic Defects Cyanotic Defects
Increased Pulmonary Blood Flow -Ventricular Septal Defect (Most common Hypoplastic Left Heart Syndrome
CHD)
-Atrial Septal Defect
-Patent ductus arteriosus
-Atrioventricular Septal Defect
Decreased Pulmonary Blood Flow/ Pulmonary Stenosis Tetralogy of Fallot
Stenotic Lesions Aortic Stenosis Tricuspid atresia
Coarction of the Aorta Pulmonary atresia
Variable Pulmonary Blood flow Total anomalous pulmonary venous return Truncus Arteriosus
Transposition of Great blood vessels

Risk Factors
Maternal Genetic Factors
Rubella in early pregnancy and advanced maternal age History of CHD in other family members
Poorly nourished mother Trisomy 21 (Down’s syndrome)
Alcoholism
Exposure to coxsackievirus
Diabetes Mellitus
Ingestion of lithium
Specific Defect Signs and Symptoms Management
Ventricular Septal -Loud, harsh, holosystolic murmur -Digoxin and diuretics to relieve symptoms of CHF
Defect (VSD) that begins at about 4-8 weeks of age -High calorie formula to promote growth
Hole between the two - O2 saturation is higher than normal in -Nasal gastric feeding for infants who are excessively
ventricles: most common right ventricle tachypneic and tires easily with feeding
cardiac defect; small -Congestive heart failure (tachypnea, -Surgical correction is required in large VSD between 3-12
VSD closes naturally in diaphoresis, easy fatigability) months of age to prevent the development of pulmonary
the first 2 years of life -Failure to thrive vascular disease
-Dysrhythmias
-Small defects may be asymtomatic
Atrial Septal Defect -soft systolic murmur -Preoperative intervention is only indicated in the infant or
(ASD) -Widely split S2, unaffected by child with a large ASD that results in CHF
Hole between the two respiratory pattern -Diuretics to control the symptoms of CHF
atria: small ASD closes -Enlarged right side of the heart - Treatment can be therapeutic catheterization (closing using
naturally -Increased O2 saturation in the right an implantable umbrella) or surgery (median sternotomy with
atrium patch closure or stitch closure) in the pre-school age because
-Mild CHF there is possibility of spontaneous closure in the first 2 years of
-May be asymptomatic (small ASD) life
Patent Ductus -Continuous machinery-like murmur -In premature infants, closur eis attempted by the infusion of
Arteriosus (PDA) (best heard just below the left clavicle) Indomethacin, which inhibits the synthesis of prostaglandin.
Accessory fetal vessel -Tachycardia (Prostaglandins are a group of fatty acid substaces present in
between the pulmonary -Enlargement of left ventricle may tissues and are responsible for a number of cellular
artery and the aorta fails -wide pulse pressure interactions. They are responsible for maintaining patency of
to close: common in -Bounding pulse the ductus arteriosus
premature infants; -Tachypnea -closure is indicated in the full-term symptomatic CHF infant
closure occurs naturally -elective closure with a therapeutic catheterization or surgical
within 12 hours to 2-3 ligation before 5 years of age
weeks
Pulmonary Stenosis Right ventricular enlargement -Neonates with moderate to severs forms of PS require the
(PS) Systolic ejection murmur infusion of Prostaglandin to maintain patency to the ductus
Narrowing of the Exercise intolerance arteriosus. This provides adequate blood flow to the lungs until
pulmonary valve or CHF, cyanosis surgery can be performed
artery -can be opened with balloon procedure (balloon
valvuloplasty) through cardiac catheterization
-the treatment of choice is the surgical valvotomy
Coarctation of the -increased blood pressure and O2 -surgical repair and reconstruction is usually needed
Aorta (COA) - saturation in the upper extremities as -the most common surgical repair is dissection of the stenotic
Narrowing of the aorta compared with the lower extremities area and end-to-end anastomosis of the 2 segments of the
due to a constricting -headache aorta. The older child should have an elective repair after 3-5
band -vertigo, epistaxis years of age as there appears to be a decreased risk of
-Absence or diminished femoral or lower recoarction when the repair is performed at this age
extremity pulses -Balloon angioplasty can be used to dilate the stenotic area
-CHF, decreased cardiac output
Transposition of Great -severs cyanosis hours to days after birth -Prostaglandin (PGE) is initiated to promote oxygenated blood
Blood Vessels (TGV) (as PDA closes) flow from the pulmonary artery to the aorta via retrograde
The aorta rises from the -various murmurs blood flow through the PDA
right ventricle instead of -presence of AD & VSD - Emergency atrial septostomy is performed to create a
the left & the pulmonary -CHF connection between the right and left sides
artery rises from the left -The treatment of choice is the Arterial Switch Procedure
ventricle instead of the
right. This condition in
incompatible with life if
there is no PFO, ASD,
VSD.
Atrioventricular Septal Long systolic murmur Treatment of CHF
Defect (AVSD) CHF Surgery is performed in the first year of life, but should always
Or Atioventricular be completed by 2 years of age because of the potential for the
Canal, is associated with development of irreversible pulmonary vascular disease
a septal defect in the
atrium and ventricle as
well as involvement of
the AV valves; more
common among children
with Trisomy 21
Truncus Arteriosus -mild cyanosis despite supplemental -Treatment of CHF
(TA)- result from failure oxygen -Surgical repair is performed within the first 6 weeks of life
of the embryologic trunk -S/S of CHF -Surgical Repair includes:
to divide into the -Loud, contibuous murmur with a loud 1. Removal of the PA from the common trunk and the defect is
pulmonary arteries and click (associated with the closure of the sutured closed
the aorta; a single truncal valve) 2. Repair of VSD
arterial trunk arises from 3. Placement of a valved homograft conduit connecting the RV
the heart giving rise to to PAs
the pulmonary arteries,
the aorta, and the
coronary arteries. There
is also a single “truncal
valve’ in place of the
aortic and pulmonary
valves and large VSD.
TA is associated with
DiGeorge syndrome.
Tricuspid Atresia -No blood flow from the right atrium to -Prostaglandin E1 (PGE1) infusion is used until an emergency
The tricuspid valve is the right ventricle shunt procedure can be performed. Generally requires several
completely closed, is -severe cyanosis within hours after birth complex surgeries.
incompatible with life if (increased as the PDA closes) -Palliative surgical repair includes:
there is inadequate - CHF A. BT shunt
pulmonary blood flow. - Failure to thrive B. Glenn Shunt
-associated defects C. Fontan procedure - when the child is greater than 2 years of
include ASD, VSD, and age
varrying degrees of RV
hypoplasia
Aortic Stenosis (AS) Left ventricular enlargement -Pre-op management - PGE1 infusion to promote retrograde
Narrowing of the aortic Murmur blood flow from the ductus arteiosus to the distal past the
valve that causes Chest pain aortic valve
obstruction to the left Decreased cardiac output - opened with balloon procedure or surgery
ventricular outflow and A. Aortic Valvotomy - for infants
the amount of blood that B. Aortic Valvuloplasty - for older children
can be ejected from the - Valve replacement can be performed with an artificial valve
LV. or pulmonary autograft
-Children who are recipients of artificial valves must be on
lifetime anticoagulation therapy to prevent clot formation on
the valve
Tetralogy of Fallot Murmur -Pre-operative Management:
(TOF) Cyanosis A. Place the infant in the knee-chest position and allow the
Four anomalies are Polycythemia older children to squat. These position will decrease systemic
present: Thrombi formation venous return as well as increase systemic vascular resistance
A. Pulmonary stenosis Severe dyspnea, hyperpnea in the hope of decrease right to left shunt allowing more blood
B. VSD Squatting position to flow to the lungs
C. Dextroposition Hypercyanotic spells (tet spells) B. Morphine SO4 - to relieve symptoms of agitation and break
(overriding) of the aorta Acidosis the cycle of hyperpnea
D. Right ventricular Clubbing of the finger C. Volume resuscitation - to decrease blood viscosity
hypertrophy Growth retardation D. Supplemental oxygen
- most common cyanotic Failure to thrive -Palliative modified Blalock-Taussig (BT) shunt is often
heart defect CXR shows classic boot-shaped heart performed until child is able to have the surgical corrective
repair
-Complete repair is usually performed between 6-12 yrs old
Hypoplastic Left Heart -Right ventricular enlargement - PGE1 infusion to maintain patency of ductus arteriosus
Syndrome (HLHS) -severe general cyanosis within hours of -Cardiac transplantation for survival
 Lack of development of birth -Three-staged palliative surgical procedure
the left ventricle (small, -severe decreases in cardiac output A. Modified Norwood procedure - during the 1st week of life
hypoplastic, (hypotension, tachycardia, tachypnea. B. Hlenn shunt - at 4 to 6 months of age
nonfunctional) Cyanosis) C. Modified Fontan procedure - at approx 2 to 3 years of age
secondary to mitral
valve atresia or aortic
atresia

Diagnostic Tests and labs

1. Chest X-ray (demonstrates increased heart size)
2. Echocardiogram ( demonstrates the location and size of the defect)
3. Electrocardiogram
4. ABGs, CBC, Electrolyte panel
5. Therapeutic and diagnostic cardiac catheterization

Therapeutic Nursing Management

1. Avoid situations that increase cardiac demands (fever, pain, agitation)
2. Avoid unnecessarily disturbing the infant
3. Monitor child’s weights
4. Provide small frequent feedings. Feed with increased calorie formula PRN
5. Administer Oxygen PRN
6. Administer digoxin and observe for signs of digoxin toxicity - anorexia, nausea, vomiting and pulse irregularities
7. Administer diuretics PRN. Replace potassium if furosemide is used
8. Maintain accurate fluid intake and output record
9. Prepare for cardiac catheterization, surgical palliation and/or corrective procedures
10. Protect from infection

Pharmacology
1. Digoxin (Lanoxin) - Hold dose for bradycardia
2. Diuretics: Furosemide (Lasix), Chlorothiazide (Diuril), Spironolactone (Aldactone)
3. Prostaglandin (PGE1) infusion to keep PDA open utnil surgical palliation can occur
4. Indomethacin to prmote PDA closure
5. Vaccination (to prevent infection)

Palliative Surgical Procedures:

1. Blalock-Taussig Shunt - the Left Subclavian Artery is anastomosed to the Left Pulmonary Artery
2. Glenn Shunt - The Superior Vena Cava is disconnected from the right atria and sutured directly to the right Pulmonary Artery
3. Fontan Procedure - Performed to connect the Inferior Vena Cava blood to the Pulmonary Artery
Norwood Procedure - the main pulmonary arte
Chapter 42. Nursing Care of the Child with an immune Disorder
Terms:
1. Allergen - antigen that causes the release of mediating substances causing tissue injury and allergic symptoms
2. Anaphylaxis - acute hypersensitivity (type 1) reaction characterized by extreme vasodilation that leads to circulatory shock and extreme
bronchoconstriction that decreases the airway lumens
3. Angioedema- edema of the skin and subcutaneous tissue
4. Antigen - any foreign substance (molecule) capable of stimulating an immune response
5. Autoimmunity - an inability to distinguish self from non-self, causing the immune system to carry immune responses against normal cells and
tissues
6. B lymphocytes - lymphocytes formed in the bone marrow; responsible for antibody formation
7. Cell-mediated immunity - type of immune response due to T-lymphocyte activity
8. Chemotaxis - “calling leukocytes into the area
9. Complement - a special body protein that is capable of lysing cells, comprised of 12 different proteins that are normally nonfunctional molecules
but become active with the immune response
10. Contact dermatitis - example of a delayed or type IV hypersensitivity response; it is a reaction to skin contact with an allergen (a substance
irritating only to the person with prior sensitization)
11. Cytotoxic response - cells are detected as foreign and immunoglobulins directly attack and destroy the cells without harming surrounding tissue
12. Cytotoxic T-cells- T lymphocytes that have the specific feature of binding to the surface of antigens and directly destroying the cell membrane
and therefore the cell
13. Delayed hypersensitivity - T-lymphocytes activity occurring solely without an accompanying humoral response
14. Environmental control - as many common allergens as possible are removed from the environment
15. Hapten formation - process whereby a substance, not antigenic in itself, becomes antigenic when combined with a higher-weight molecule,
usually protein
16. Helper T cell - lymphocytes that stimulate B lymphocytes to divide and mature into plasma cells and begin secretion of immunoglobulins.
17. Humoral immunity - immunity created by antibody production or B-lymphocyte involvement
18. Hypersensitivity response - excessive antigen-antibody response when the invading organism is an allergen rather than a simple immunogen
19. Hyposensitization - immunotherapy; a process to diminish an allergic response
20. Immune response - body’s action plan devised to combat invading organisms or substances by leukocyte and antibody activity
21. Immunity - the ability to destroy invading invading antigens
22. Immunocompetent cells - cells capable of resisting foreign invaders
23. Immunogen - substane (antigen) that can be readily destroyed by an immune response
24. Lymphokine - a substance that contains or prevents migration of antigens
25. Lysis - Killing
26. Macrophage - mature white blood cells
27. Memory cells - B lymphocytes that are responsible for retaining the formula or ability to produce specific immunoglobulins
28. Phagocytosis - destruction of invading substances
29. Plasma cells - B lymphocytes that secrete large quantities of immunoglobulins
30. Suppressor T cells - T cells that reduce the production of immunoglobulins against a specific antigen and prevent their overproduction
31. T lymphocytes - lymphocytes that are produced by the bone marrow but mature under the influence of the thymus gland
32. Tolerance a state of not responding to an allergen
33. Urticaria - swelling and itching caused by capillary dilation
Chapter 43. Nursing Care of the Child with an Infectious Disorder
Terms
1. Catarrhal Stage - inflammation of the nose and throat during infectious diseases
2. Chain of infection - method by which organisms are spread and enter a new individual to cause disease
3. Complement - a special body protein that is capable of lysing cells; compromised of 20 different proteins that are normally nonfunctional
molecules but become active with the immune response
4. Convalescent period - interval between when infectious symptoms begin to fade and the child returns to full wellness
5. Enanthem - rash on the mucous membrane
6. Exanthem - a skin rash
7. Exotoxin - poison produced by some bacteria
8. Fomites - inanimate objects, such as soil, food, water, bedding, towels, combs, or drinking glasses that provide a means of infection transmission
9. Incubation period - time between the invasion of an organism and the onset of symptoms of infection
10. Interferon - a protein that protects against viruses
11. Koplik’s spots -small irregular bright red spots with a blue-white center point, appearing on the buccal membrane with measles
12. Means of transmission - method of spread of pathogens that cause infectious disease
13. Portal of entry - means by which a pathogen can enter a person’s body
14. Portal of exit - method by which organisms leave an infected person’s body to be spread to others
15. Prodromal period - a time between the beginning of non-specific symptoms and specific infectious symptoms
16. Reservoir - container or place in which organisms grow and reproduce
17. Septicemia - pathogenic organisms in the blood stream
18. Susceptible host - individuals more prone to infection than others
19. Toxoid - extract of a toxin with reduced virulence
CHAPTER 44 Nursing Care of the Child with a Hematologic Disorder
Terms
1. Agranulocytes - white blood cells without granules in the cell cytoplasm
2. Allogeneic Transplantation - transfer of body tissues from an immune compatible donor
3. Aplastic Anemia - depression of hematopoietic activity in bone marrow affecting all blood cells
4. Autologous transplantation - transplantation using the person’s own previously removed tissue
5. Blood dyscrasias - hematologic disorders
6. Blood plasma - liquid portion containing proteins, hormones, enzymes, and electrolytes
7. Direct bilirubin - water-soluble end breakdown product of heme that is combined and excreted in bile
8. Erythroblasts - large, nucleated early red blood cells
9. Erythrocytes - red blood cells
10. Erythropoietin -a hormone produced by the kidneys that stimulates red blood cells development
11. Granulocytes - white blood cells with granules in the cell cytoplasm
12. Heinz bodies - oddly shaped particles in red blood cells
13. Hemochromatosis - deposition of iron in body tissues from destruction of red blood cells
14. Hemoglobin - a complex protein that is the oxygen-carrying component of red blood cells
15. Hemolysis - destruction of red blood cells
16. Hemosiderosis - deposition of iron in body tissues
17. Hypodermoclysis - subcutaneous infusion
18. Leukocytes - white blood cells
19. Leukopenia - a decrease in the number of white blood cells
20. Megakaryocytes - immature thrombocytes
21. Normoblasts - a developmental stage of RBC after erythroblasts
22. Pancytopenia - reduction of all blood cell components
23. Petechiae - pinpoint, macular, purplish-red spots caused by intradermal or submucous hemorrhage
24. Plethora - marked reddened appearance of the skin
25. Poikilocytic - irregular in shape
26. Polycythemia - an increase in the number of red blood cells that results as a compensatory response to insufficient oxygenation of the blood
27. Priapism - persistent, painful erection
28. Purpura - hemorrhagic rash or small hemorrhages occurring in the superficial layer of skin
29. Reticulocytes - a developmental stage of red blood cells prior to the formation of mature RBCs
30. Sickle cell crisis - term used to denote a sudden, severe onset of sickling with sickle-cell anemia
31. Sickle cell trait - the existence of hemoglobin and abnormal hemoglobin, a disease carrier
32. Synergetneic transplantation - transplantation between a donor and recipient who are generally identical
33. Thrombocytes - platelets
34. Thrombocytopenia - decreased platelet count

Components of the Blood

- Plasma - 55%
- Formed elements - 45%
A. Erythrocytes
▪hemoglobin as the primary component
▪oxyhemoglobin
▪Carbaminohemoglobin
 B. Leukocytes
C. Thrombocytes

Plasma Proteins (fibrinogens, albumin, globulins)

Albumin - important protein in blood
-promotes “oncotic pressure” which is a pulling force of H2O
*if less albumin, there’s leaking of water that would cause edema
Fibrinogens - clotting process
Globulins - IgA, IgB, IgE, IgM, IgG

Formed Elements
A. Thrombocytes (platelets) - coagulation - causes blood clot (normal level of platelets 150,000-450,000 mm3)
Dengue fever - decrease platelet; caused by virus that attacks platelets

Clotting Process

Extrinsic Pathway (wound) Intrinsic Pathway

 Tissue Trauma Damaged in endothelial
cells/platelets

Release of tissue Factor

Activates Factors XII
Ca²⁺
Activates Clotting Factor X
Activates Factors X

Formation of Prothrombin II
Ca²⁺
Ca²⁺

Converts Prothrombin II to thrombin

Ca²⁺

Converts Fibrinogen I Activates Factor XII

Loose Fibrin threads Strengthens and stabilizes the fibrin thread

B. Leukocytes (WBC)
A. Granular Leukocytes -
Study clot
1. Basophils - anti-inflammatory
2. Eosinophils - activates when there is helminths (parasites) and allergic reactions
 3. Neutrophils- photocyte
B. Agranular Leukocytes -
1. Monocytes - big phagocytes
2. Lymphocytes - T-Lymphocytes & B Lymphocytes
*Increased WBC indicates infection

C.Erythocytes (RBC) - Produced in bone marrow

-120 days lifespan
-Transport oxygen
Hemoglobin - carries oxygen
Hematocrit - percentage of erythocytes in the blood

*If hematocrit is low (30%): Decreased RBC (hemorrhage or anemia);

What prompts the bone marrow to produce RBC?

=Kidney monitors the Oxygen and production of O2 and releases special enzyme called “Renal Hematopoietic Factor” that would travel and reach
the liver and convert Erythropoietinogen and convert again to Erythropoietin which is delivered to bone marrow and would induce erythropoiesis.

What makes up RBC?

1. Iron - component of hemoglobin that causes attraction of Oxygen
Hemoglobin - Heme - iron part
Globin - Protein
2. Vitamin B12
3. Amino Acids
4. Cobalt
5. Copper
6. Globin
7. Folic Acid
5 Reasons why RBC is a specialize cell for O2 transportation
1. Biconcave shape - allows greater surface for RBC to accommodate more O2
2. Flexible
3. Has no nucleus
4. Has no mitochondria
5. Most abundant cell in the blood and presence of hemoglobin

Hematologic Disorders
Condition Signs and Symptoms Management
Hemophilia -prolonged bleeding from any - Control bleeding
-defects in clotting mechanism of blood : two wound -Prevention of bleeding with use of factor
most common deficiencies are: -Bleeding into the joints replacement
1. Factor VIII, classic hemophilia (hemarthrosis) resulting to A. Drugs that replace deficient coagulation
2. Factor IX, Christmas disease pain, deformity and retarded Factors
growth 1. Antihemophilic Factor - obtained from
- hereditary influence: X-linked gene -anemia human sources: provides concentrated
classically occurring in males, and females as -epistaxis Factor VIII
carrier -Intracranial hemorrhage 2. Antihemphilic plasma
-Platelet count - normal 3. Factor IX complex contains factors II,
-Prolonged coagulation time VII, X (concentrated)
-Increased PTT B. Adjunctive Measures
1. Episilon-aminocaproic acid (Amicar):
inhibits the enzyme that destroys formed
fibrin and increase fibrinogen activity in
clot formation
2. Fibrinogen: maintains plasma fibrinogen
levels required for clotting materials
3. Thrombin : supplies physiologic levels of
natural material at superficial bleeding sites
 to control bleeding
Nursing care:
1. Immobilize of the affected joints
2. Compression of the bleeding site
3. Elevation of the body part
4. Application of cold compresses
5. Select safe toys: prevent trauma
6. Avoid use of aspirin or ibuprofen
7. Provide counseling since disease is genetic
8. Treat the child as normally as possible, avoid
overprotectiveness and overpermissiveness
Sickle Cell Anemia - Colic - 1st sign in infants *Prevent Crisis:
-Autosomal disorder affecting hemoglobin (Severe pain in joints, back, 1. Avoid infection, DHN, and othe rconditions
-defective hemoglobin causes RBC to become extremities) causing strain on body, which precipitates a
sickle shaped and clump together under -Difficulty concentrating urine crisis: prophylactic use of flu vaccines
reduced oxygen tension -Frequent infections 2. Avoid hypoxia, treat respiratory tract
-chronic, severe, hemolytic disease _Delayed Growth and infections STAT
development 3. Avoid DHN - causes a rapid thrombin
Sickle Cell Crisis: -Hb 6-9 g/dl formation
* Vaso-occlusive crisis: most common and - decreased ESR, increased 4. Daily fluid intake should be calculated
only painful type: results from sickled cells WBC according to body wt. (130-200 ml per kg).
obstructing blood vessels causing occlusion, -Vaso-occlusive crisis: During crisis, fluid needs to be increased
ischemia, and potential necrosis *fever, acute abd’l pain especially if the child is febrile
(visceral hypoxia)
*Splenic Sequestration crisis: results form the *hand-foot syndrome *During crisis:
spleen pooling large quantities of blood, which (dactylitis - symmetrical 1. Adequate hydration (may need IV therapy)
causes a precipitous drop in blood pressure and painful soft tissues swelling of 2. Proper positioning, careful handling
ultimately shock: acute episodes occurs most hands and feet in the absence of 3. Exercise is tolerated (immobility promotes
commonly in children between 8 months - 5 trauma) thrombus formation and respiratory problems)
years of age, can result in death from anemia *arthralgia without an 4. Adequate ventilation
and cardiovacular collapse: Chronic exacerbation of anemia 5. Control of pain: use of narcotic analgesics
manifestation is termed functional asplenia 6. Blood transfusions for severe anemia
-Splenic Sequestration Crisis
* Aplastic Crisis: diminished RBC production: * preicipitous decrease in BP *Genetic counseling:
may be triggered by a viral or other infection *Shock 1. Disorder mostly occur in blacks: can be found
in Mediterranean people
*Hyperhemolytic crisis: Increased rate of RBC Aplastic crisis: 2. Screen young children for the d/o since clinical
destruction *Profound anemia manifestations usually do not appear before 6
months of age
Hyperhemplotic crisis: 3. If both parents are carriers, each pregnancy has
-jaundice, anemia 25% chance of producing a child with the disease
-reticulocytosis
Leukemia Acute Leukemia * Acute Leukemia
* Acute Leukemia -sudden onset of high fever -Systemic chemotherapy
-is a malignant proliferation of white blood -thrombocytopenia and -Bone marrow transplant may be possible
cell precursors (blasts) in bone marrow or abnormal bleeding such as -Antibiotic, antifungal and antiviral drugs
lymph tissue and their accumulation in nosebleeds, petechiae, easy -Transfusion may also be given of platelets to
peripheral blood, bone marrow and body bruising after minor trauma and prevent bleeding and red blood cells to prevent
tissues. prolonged menstruation anemia

*Leukemia, Chronic Granulocytic Leukemia, Chronic Leukemia, Chronic Granulytic

Characterized by abnormal overgrowth of Granulycytic -Aspirin to prevent stroke
granulocytic precursors in bone marrow and -Anemia (fatigue, weakness, -Local splenic radiation or splenectomy to increase
peripheral blood and body tissues. decreased exercise tolerance, platelet count
pallor, dyspnea, tachycardia -Leukapheresis or selective leukocyte removal
-thrombocytopenia -Allopurinol to prevent secondary hyperuricemia
-hepatosplenomegaly with or colchicine to prevent gout
abdominal discomfort and pain
 in splenic infarction
*Leukemia, Chronic Lymphocytic Leukemia, Chronic Leukemia, Chronic Lymphocytic
Is marked by an uncontrollable spread of Lymphocytic -Systemic chemotherapy includes alkylating
abnormal, small lymphocytes in lymphoid Early Stage:fatigue, malaise, agents, usually chlorambucil or cyclophosphamide
tissue, blood, and bone marrow. fever and nodal enlargement and sometimes steroid when autoimmune
hemolytic anemia or thrombocytopenia occurs.
Advance stage:weight loss, -Local radiation treatment
liver or spleen enlargement,
bone tenderness, and edema
from lymph node obstruction
-bone marrow involvement
may lead to anemia, pallor,
weakness bleeding and
infection

Chapter 45. Nursing Care of the Child with Gastrointestinal Disorder

Terms:
1. Aganglionic megacolon (Hirchsprung’s disease) - absence of ganglionic innervation to the muscle of a section of the bowel.
2. Appendiciti - inflammation of the appendix
3. Beriberi - deficiency f vitamin B1 involving tingling and numbness of extremities, heart palpitations and exhaustion
4. Celiac Disease - sensitivity or immunologic response to protein, particularly the gluten factor of protein found in grains--wheat, rye, oats
and barley
5. Crohn’s disease - inflammation of segments of the intestine affecting any part of the gastrointestinal tract, but most commonly in the terminal
ileum
6. Dehydration - an excessive loss of body water
 7. Gastroesophageal reflux - (commonly called achalasia in infants); a neuromuscular disturbance in which the gastroesophageal (cardiac) sphincter
and the lower portion of the esophagus are lax, allowing easy regurgitation of gastric contents into the esophagus
8. Hepatitis - inflammation and infection of the liver
9. Hiatal hernia - intermittent protrusion of the stomach up through the esophageal opening in the diaphragm
10. Inguinal hernia - protrusion of a section of the bowel into the inguinal ring
11. Insensible fluid loss - fluid loss occurring as a result of evaporation from skin and lungs and from saliva
12. Intussusception - invagination of one portion of the intestine into another
13. Irritable bowel syndrome - presence of either intermittent episodes of loose and normal stools or recurrent of abdominal pain
14. Keratomalacia - necrosis of the cornea with perforation, loss of ocular fluid and blindness
15. Kwashiorkor - disease caused by protein deficiency
16. Liver transplantation - surgical replacement of a malfunctioning liver by a donor liver
17. McBurney’s point - one third of the way between the anterior superior iliac crest and the umbilicus; location of the appendix
18. Necrotizing enterocolitis - (NEC) development of necrotic patches in the bowel, interfering with digestion and possibly leading to a paralytic
ileus; seen in infants in intensive care nurseries
19. Nutritional marasmus - disease caused by disease caused by by deficiency of all food groups, basically a from of starvation
20. Overhydration - excess body fluid,usually extracellular fluid
21. Pellagra - deficiency of niacin involving dermatitis and resembling a sunburn
22. Peptic ulcer - shallow excavation formed in the mucosal wall of the stomach, the pylorus or the duodenum
23. Pyloric stenosis - hypertrophy or hyperplasia of the muscle surrounding the pyloric sphincter (opening between the lower potion of the
stomach and the beginning portion of the intestine, duodenum) making it difficult for the stomach to empty
24. Rickets - deficiency of vitamin D involving poor bone formation
25. Steatorrhea - large, bulky, greasy stools
26. Ulcerative colitis - inflammation of continuous intestinal segments, typically the colon and rectum, with the distal colon and rectum most
severely affected
27. Volvulus - a twisting of the bowel causing obstruction
28. Xerophthalmia - dry and lusterless conjunctivae caused by vitamin A deficiency

Condition Signs and Symptoms Management

Cleft Lip * difficulty in sucking - Cheiloplasty - surgical repair or closure of the cleft lip; usually done as early as
 - Incomplete fusion of child cannot form a possible (because of the child’s inability to meet sucking needs and to avoid speech
facial processes (fusion vacuum with the mouth to defects) using the Rule of 10
of maxillary & suck but may be able to -at least 10 weeks old
premaxillary processes breast-feed (sometimes the - weighing at least 10 lbs
between 5-8 weeks of breast fills the cleft making - having at least 10 g hemoglobin
fetal life) sucking easier) * Nursing Care
-Cause uknown: possibly * milk escapes through the 1. Preoperative nursing care
related to hereditary nose A. Feed in an upright position to prevent aspiration; provide small frequent
influence, prenatal *difficulty in swallowing feedings (the child gets tired easily)
infection, maternal drug * problem of swallowed air B. Feed with a soft large-holed nipple or rubber tipped syringe placed on the top
ingestion caused by mouth breathing and side of the tongue, toward back of the mouth
-Bilateral or unilateral results in: C. Burp frequently because of swallowed air
(more common on the A. Abdominal distention D. Teach parents to give water after each feeding to cleanse the infant’s mouth
left side) B. Mucous membranes of E. Prevent infection from irritation of the lip (1). restrain infant’s arm if needed.
-More common in males the oropharynx become (2) provide a pacifier to increase sucking pleasure
-Can be incomplete dried and cracked leading 2. Postoperative Nursing Care
(involves the upper lip & to infection - Common complication - respiratory distress during the first 48 hrs due to:
dental ridge) or complete A. Swelling of tongue, mouth & nostrils (put downward pressure o the chin to
(involves the upper lip, increase air passage)
nasal septum & dental B. Increased respiratory secretions
ridge; usually continuous C. Difficulty in adjusting to a smaller airway
with cleft palate) * maintain a patent airway
1. Problem because of edema of the nose, tongue and lips combined with the
child’s habit of breathing through the mouth
2. Proper equipment such as laryngoscope, endotracheal tube and suction at or
near the bedside
* Moisten the OS with sterile NSS
* Avoid pressure on the suture line (Steri strips/Logan’s bow is applied on the suture
line to decrease tension)
 1. Never let the child suck on the apparatus
2. Prevent crying; encourage the parent to stay with the infant; anticipate the side
or sitting up, to prevent hypostatic pneumonia
3. Place the child supine with arm or elbow restraint; change position to the side
or sitting up, to prevent hypostatic pneumonia
4. Remove restraints only when supervised
* Formula feeding - resume 3-4 weeks postop: upright position: use a rubber-tipped
medicine dropper and place at the side of the mouth away from the suture line
1. OS is removed before feeding
2. After feeding the suture line is cleansed with a cotton-tipped applicator w/c is
dipped in 1/2 strength H2O2 in order to prevent crusts which cause uneven
healing, infection, leaving ugly scars
3. Then a new Steri strip or Logan’s bow is applied
* Support the parents by accepting and treating the child as normal
Cleft Palate * Difficulty in feeding * Age of repair is usually after the child has grown but before speech is well
-failure of union of * Predispose to infection, developed
embryonic structure of especially aspiration *Cleft palate Repair - usually at 18 months; not earlier than 10-12 months because it
face (palatal structures pneumonia can harm the tooth buds not too late because the palate can become too rigid and the
fuse between 9 & 12 * Problems with speech child might develop undesirable speech patterns
weeks) (palate is needed to trap air *Velopharyngeal flap operation at 8-9 years of age - to revise previous repair,
- cause unknown : maybe in the mouth ) correct nose deformities and reconstruct the nasopharynx for speech improvement
related to hereditary, * excessive dental caries * Nursing Care
maternal drug ingestion, * Displacement of the 1. Preoperative Nursing Care : Same as for Cleft lip except
prenatal infection maxillary arch A. Feed upright to prevent aspiration
-more common in girls * hearing problems caused B. Feed by gavage if necessary
-may involve the soft or by recurrent otitis media C. Encourage early use of spoon and cup
hard palate and may (eustachian tube connects D. Teach parents the need for proper dental hygiene and regular dental
extend into the nose the nasopharynx and supervision
forming an oronasal middle ear and easily 2. Postoperative Nursing Care
passageway. transports foreign material Complication : hemorrhage
to the ear) A. Avoid use of suction that traumatizes the operative site
B. Place the child in a prone Trendelenberg position to prevent aspiration and
promote postural drainage. Elbow restraints are also applied.
C. Use of mist tent is recommended
D. Sucking, blowing, talking , laughing or putting objects into the mouth are
not allowed
E. Provide liquid diet : no milk, because of curd formation on the suture line
F. Feeding
= paper cups are used. NEVER spoon, fork, straw or glass
=rinse with sterile water after feeding
=small frequent feedings are resumed 3-4 weeks postop
G. Recognize the need for emotional support of the parents is greater, since
recovery is longer and prognosis is uncertain
Tracheoesophageal *Excessive amount of *Preoperative Nursing Care
Anomalies secretions - outstanding 1. Keep NPO
- Esophageal atresia - sign which occurs soon 2. Maintain in upright position to prevent reflux of gastric contents into the
failure of the esophagus after birth tracheobronchial tree
to form a continuous A. Constant drooling 3. Suction oropharynxto remove accumulated secretions
passage from the B. Excessive mucus in 4. Place in incubator with high humidity to aid in liquefying secretions and thick
pharynx to the stomach nasopharynx causing mucous
cyanosis, which is easily 5. Administer oxygen PRN
- Tracheoesophageal reversed by suctioning 6. Assist in bougie treatment (elongation of proximal pouch using a mercury
fistula- abnormal sinus * intermittent cyanosis - weighted dilator or film catheters inserted briefly each day
connection between the due to aspiration from the 7. Observe for signs of respiratory distress
esophagus and the blind upper pouch 8. Change position to prevent Pneumonia
trachea *Abdominal distention - 9. Monitor fluid intake and output
air from the trachea passes 10. Give antibiotics as ordered to prevent or treat associated pneumonitis
- Types: through the fistula into the
1. Type I/A - upper & stomach *Surgery
lower segments of the *choking, sneezing and 1. Primary repair - esophageal anastomosis and division of fistula
esophagus are blind, no coughing during feeding 2. Gastrostomy and Cervical Esophagostomy are performed temporarily until infant
connection to the trachea with regurgitation of gains weight
2. Type II/B - upper end formula through the mouth 3. Staging of surgical repairs (repeated operations separated by periods of time as the
of esophagus opens into and nose infant/child gains weight)
the trachea, blind lower * inability to pass a
segment catheter through the nose *Postoperative Nursing Care
3. Type III/C - proximal or mouth into the stomach 1. Observe for signs of stricture at the anastomosed site (refusal to feed, pronounced
esophageal atresia *Diagnostic evaluation: coughing, dysphagia, atelectasis)
combined with distal A. Maternal history of 2. Maintain a patent airway
tracheoesophageal fistula polyhydramnios A. Suction mouth and pharynx PRN - mark catheter to determine how far it can be
(most common type: B. Flat plate x-ray of inserted without disturbing the anastomosed site
85%) abdomen and chest reveals B. Frequent change of position and stimulate crying to prevent pneumonia but
4. Type IV/D - both presence of gas avoid hyperextension of the neck to prevent tension on the suture line
upper and lower ends of 3. Provide high humidity to liquefy thick secretions
the esophagus open into 4. Perform proper care of chest tubes if used
the trachea by a fistula 5. Maintain adequate nutrition by oral, parenteral or gastrostomy method
5. Type V/E - the “H” A. Oral feeding may be started at 6-14 days postop
type: no esophageal - low residue diet to keep the stools soft
atresia but with fistula: -Feed slowly in upright position to allow time for swallowing
rare type -oral hygiene to prevent bacterial growth
6. Type VI/F - stenosis 6. Provide a pacifier if oral feedings are contraindicated
occurs 2/3 of the way 7. Encourage parental participation & teach them to provide comfort and physical
down the esophagus: contact, because hospitalization is usually long, to promote strong parent-infant
obstruction may be bonding
partial or complete
Pyloric Stenosis * projectile vomiting after *Fredet-Rmstedt procedure - surgical treatment of choice; longitudinal splitting of
-congenital hypertrophy 1-2 feedings during the 2nd the hypertrophied muscle
of muscular tissue of the to 4th week of life * Preoperative Nursing Care
pyloric sphincter, usually *non-bile-stained vomitus 1. Keep NPO when vomiting occurs
asymptomatic until 2 to 4 *constipation 2. Monitor intake and output
weeks after birth *marked weight loss and 3. Feed by gavage
dehydration A. Thickened feeding at frequent intervals (delay the emptying time of the
-has a hereditary *Distention of the stomach, thus increasing satiety & making vomiting less likely to occur)
tendency and occurs in epigastrium B. Feed slowly on the semi-upright position
male infants * visible R-L peristalsis C. Burp PRN (peristalsis is poor)
*Palpable 1-2 cm olive- D. Observe precautions in NGT feeding
shaped mass in the RUQ * Postoperative Nursing Care
*string sign can be seen in = Paralytic Ileus - common complication (NGT is inserted for gastric
the barium enema decompression)
1. Position the child on his side with his back supported (immediate postop
period)
2. Teach parents the specific feeding method
A. Gradual increase amounts of clear liquids that contain glucose and electrolytes
during the 4-6 hours post-op
B. Dilute formula is given on the 2nd day, with increasing concentration at each
feeding until in full formula can be given on 48 hours post-op
C. Use a medicine dropper to ensure that the child obtains only a small amount to
decrease stress the pylorus
D. Feed in a high Fowler’s position for 45-60 minutes and place on the right side
after feeding with head of bed slightly elevated to increase gastric emptying time
Intussuception * acute paroxysmal * Treatment: immediate surgical correction
-invagination or abdominal pain *Preoperative nursing care
telescoping of a portion *bilous, fecaloid vomitus 1. Keep NPO
of the small intestine into *abdomen is rigid, tender, 2. Monitor intake and output
a distal segment of the distended 3. Observe for signs of dehydration
intestine *meconium ileus 4. Maintain nasograstric suction (gastric decompression)
 *sausaged-shaped mass *Postoperative Nursing Care
-congenital life- palpable in RUQ 1. Keep operative sites clean and dry
threatening obstruction *empty RLQ 2. Position infant on side rather than abdomen to prevent pulling legs up under the
of the intestine * Currant jelly - loose, chest
bloody, mucoid stools 3. Colostomy care
-more common in infants * “coiled spring” pattern - 4. Avoid use of tight diapers and clothes around the abdomen
3months - 5 years Ba enema
(children have * Gangrene of the bowel
hyperactive lower (complication)
intestinal tract); 50%
occur in ages <1 year
Hirschprung’s Disease/ * delay of passageway of *Treatment: Surgical removal of the aganglionic portion of the bowel
Congenital Aganglionic meconium for the neonates * Colostomy if necessary
Megacolon * for older infants - * Swenson’s pull-through
- congenital absince of persistent constipation, -an abdominoperineal removal of the abnormal section of the bowel with an
parasympathetic poor feeding, failure to anastomosis of the remaining normal colon to the anal canal
ganglion nerve cells thrive, irritable and fretful, *Duhamel Soave’s approach - endorectal pull-through
(which control fever, severe prostration, *Preoperative Nursing Care
defecation) usually in the passage of ribbon or 1. Small frequent feedings of a decreased residue diet. Semi-fowler’s position
rectosigmoid area that pellet-like stools 2. Daily enema - use only isotonic solutions (saline solution - 1 tsp NaCl + 500ml
causes enlargement of *Complication: diarrhea tap water)
the bowel proximal to the results from enterocolitis 3. Administration of antibiotics and stool softeners
defect
-a lower GIT obstruction * Postoperative Nursing Care
-etiology unknown 1. Parenteral feeding
-familial predisposition 2. Gastric suction & indwelling urinary catheter may be used for an indefinite period
3. The anal sphincter may be dilated daily
4. Note for the presence of bowel sounds and passage of normal stool (these
determine the success of the procedure)
Diaphragmatic Hernia * cyanosis & respiratory *Treatment: immediate surgical repair
- protrusion of abdominal distress present *Nursing Care:
organs (usually stomach immediately after birth 1. Support parents due to critical condition
and intestines) in to the *Scaphoid abdomen 2. Preoperatively keep on NPO
thoracic cavity, usually (empty, normally dome- 3. Correction or respiratory acidosis e.g. Sodium bicarboate
on the left side, shaped) 4. Gastric suction to remove secretions and swallowed air from the stomach and
displacing the heart to *diminished or absent intestine before and after surgery
the right side of the chest breath sounds 5. Preoperatively position the infant on affected side with the head elevated to allow
& the lung collapses * (+) bowel sounds on full expansion of the unaffected side
-failure of development chest auscultation 6. Postoperatively feed the infant by gavage to decrease chances of swallowing air
of the posterolateral *intercoastal and subcostal
portion of the diaphragm retractions are observed
resulting in a
pleuroperitoneal canal
(foramen of Bochladeck)
-etiology unknown
Volvulus - Nausea, vomiting, Teatment:
-a twisting of intestine at cramps, abdominal pain, -Surgery
least 180 degrees on its absence of bowel *Post-op nursing care:
mesentery, volvulus movements and failure to 1. Monitor vital signs, watch out for fever (a sign of sepsis), and tachycardia and
results in blood vessel pass flatus hypotension (signs of septic shock)
compressionand -Distended abdomen 2. Monitor fluid intake and output (including stools), electrolyte values, and
ischemia. -X-rays may show complete blood count
* may result from an markedly dilated sigmoid 3. Encourage frequent coughing and deep breathing
anomaly of rotation, an colon 4. Reposition the patient every 2 hours
ingested foreign body, or -Upper GI series shows, in
an adhesion midgut volvulus,
*occurs in bowel obstruction
segment with a -WBC - >15,000/μl in
mysentery long enough strangulation; >20,000/μl
to twist. in bowel infarction.

Chapter 46. Nursing Care of the Child with a Renal or Urinary Tract Disorder
Terms:
1. Acute Transplant rejection - reaction to a transplanted organ, usually occurring within the first 3 months after transplantation
2. Alport’s syndrome - a progressive chronic glomerulonephritis inherited as an autosomal dominant disorder
3. Azotemia - accumulation of nitrogen waste in the bloodstream
4. Bowman’s capsule - double-walled chamber enclosing the glomerulos of the kidney
5. Dialysis - separation and removal of solutes from body fluid by diffusion through a semipermeable membrane
6. Enuresis - involuntary passage of urine past the age when a child should be expected to have attained bladder control
7. Epispadias - opening of the urinary meatus on the dorsal or superior surface of the penis
8. Exstrophy of the bladder - midline closure defect occurring during the embryonic period of gestation (first 8 weeks) and resulting in the
bladder lying open and exposed on the abdomen
9. Glomerular filtration rate - rate at which substances are filtered from the blood to the urine
10. Glomerulonephritis - inflammation of the glomeruli of the kidneys
11. Hydronephrosis - enlargement of the pelvis of the kidney with urine as a result of back pressure in the ureter
12. Hypospadias - urethral defect in which the urethral opening is not at the end of the penis but on the ventral (lower) aspect of the penis
13. Nephrosis - altered glomeruli permeability due to fusion of the glomeruli membrane surfaces causing abnormal loss of protein in urine
14. Patent Urachus - failure of the urachus 9narrow tube that joins the bladder to the umbilicus in utero) to close properly during embryologic
development, leading to the development of a fistula between the bladder and umbilicus
15. Polycystic kidney - large fluid-filled cysts forming in place or normal kidney tissue
16. Postural proteinuria - also called postural albuminuria; condition in which albumin spills into the urine when children stand upright for an
extended period and decreases when resting in the supine position
17. Prune belly syndrome - sever urinary tract dilation that develops as early as intrauterine life from an unknown cause
18. Vesicoureteral reflux - retrograde flow of urine from the bladder into the ureters

Genitourinary Disorders
Condition Signs & Symptoms Management
Nephrotic Syndrome * periorbital edema * Diet: high CHON, moderate Na restriction
- idiopathic * marked hypoalbuminemia *Ambulation is advised if without edema: Bed rest when acutely ill
-increased glomerular membrane *olyguria *Semi-fowler’s position
activity to large molecules *progressive wasting of *Skin care
causing considerable quantities skeletal muscles due to A. NEVER apply heat, no use of adhesives or plasters
of plasma CHONs (albumin) to negative nitrogen balance: B. Frequent position changes
escape into the urine stick-like extremities C. Binders for scrotal edema
- congenital autosomal recessive *tires easily, poor appetite D. Liberal use of non-allergenic powder or cornstarch
trait *BP - normal or slightly E. Careful washing and drying of skin folds with mild soap and
increased water, putting cotton between skin surfaces
* Hyperlipidemia *Daily weighing
* Dx tests results *Monitor I&O
A. Serum albumin - <2.5 *Reverse isolation
g/dl *Medications:
B. Cholesterol - >200 - Prednisone - drug of choice: produces diuresis in 8-14 days after
mg/dl initial treatment
C. UA - albuminuria, -Diueretics -
increased specific -Antimicrobial agents
gravity, microscopic
 hematuria
Wilm’s Tumor *abdominal mass on the left -do not palpate abdomen to prevent rupture of the tumor capsule
(Nephroblastoma) side -monitor bowel sounds and BP
- malignant neoplasm of the *Abdominal distention, -Surgical removal of the tumor
kidneys abdominal pain - Chemotherapy
- most common intraabdominal *Hematuria -Radiation therapy
tumor *Anorexia, pallor, lethargy
-familial predisposition *Dyspnea, chest pain
(autosomal dominant trait) related to lung metastasis
-idiopathic *weight loss, fever
-Common in males *HPN
-peak incidence at 3 years of age *Dx test: IVP
Increased occurrence in siblings
and identical twins
Bartter’s Syndrome *poor feeding, vomiting, *Symptomatic
-Inability of the renal tubules to constipation *Fluid and electrolyte resuscitation
reabsorb electrolytes *DHN *Medications: Prostaglandin inhibitor (Aspirin and Indomethacin),
-A rare congenital disease *Polyuria KCL - 10 mEq/kg/day
-autosomal recessive in origin *Excessive thirst
-a hereditary disorder marked by *Physical features: large
juxtaglomerular cell hyperplasia, head, down-turned mouth,
hyperaldosteronism, protruding pinna of the ears
hypokalemic alkalosis, increased
coneof plasma renin in the
absence of HPN and by mental
retardation and short stature
-common in Africans and
Americans
Alport Syndrome -hematuria * Supportive; symptomatic
- most common type of -proteinuria *dialysis
 hereditary, nephritis -hearing loss Renal transplantation
-autosomal dominant trait -cataracts
-Common in males -complication: Chronic
-a hereditary disorder marked by Renal Failure
progressive prelonephritis or
thickened and sclerosed
glomeruli and occasionally
ocular defects
APSGN -Henaturia or tea-colored -CBR
-acute post-streptococcal urine -Low-sodium, low-CHON, Low-K diet
glomerulonephritis -Peri-orbital edema -Medications: Anti-HPN, MgSO4, Digitalis (if with heart failure),
-hypersensitivity reaction of the -Oliguria or Anuria Penicillin (drug of choice), Diuretics
kidneys to Group A Beta -weight gain -Daily weighing
Hemolytic Streptococci -Pallor, fatigue, SOB -Monitor I & O
-Mild to moderate HPN Dialysis
-Anorexia, vomiting
-increased BUN, Creatinine,
ESR

Chapter 47. Nursing Care of the Child with Reproductive Disorder

Terms
1. Amenorrhea - Absence of menstrual flow
2. Cryptorchidism - failure of one or both testes to descend from the abdominal cavity to the scrotum
3. Dysmenorrhea - painful menstruation
4. Endometriosis - abnormal growth of extrauterine endometrial cells, often in the cul-de-sac of the peritoneal cavity, the uterine ligaments,
and the ovaries
5. Fibrocystic breast disease - benign multiple cysts in the breasts
6. Gynecomastia - enlargement of the breasts; excess development of male breast tissue; transient occurrence in normal adolescence
7. Hermaphrodite - having both ovaries and testes
8. Hydrocele - collection of fluid in the scrotal sac
9. Menorrhagia - an abnormally heavy menstrual flow
10. Metrorrhagia - bleeding between menstrual periods
11. Mittelschmerz - abdominal pain during ovulation from the release of accompanying prostaglandins
12. Orchiectomy - removal of the testis
13. Orchiopexy - surgery to repair undescended testes
14. Orchitis - inflammation of the testes
15. Pelvic Inflammatory Disease (PID)- infection of the pelvic organs: the uterus, fallopian tubes, ovaries, and their supporting structures
16. Sexually Transmitted Disease (STD) - those spread through sexual contact with an infected partner
17. Toxic Shock Syndrome - an infection usually caused by toxin-producing strains of Staphylococcus aureus organisms
18. Varicocele - abnormal dilation of the veins spermatic cord
19. Vulvovaginitis - inflammation of the vulva or vagina

Reproductive Disorders
Condition Signs and Symptoms Management
Endometriosis * dysmenorrhea (pain begins 5-7 days Treatment:
-denotes the presence of before menstruation, reaches its peak -Progestins and oral contraceptives relieves symptoms
endometrial tissue outside on days of bleeding, and lasts for 2 to -Gonadotropin-release hormone agonists, by inducing a
the lining of the uterine 3 days. pseudomenopause and, thus a medical oophorectomy, have
cavity * Infertility shown a remission of disease and are commonly used.
-theories of causes: *suprapubic pain, dysuria, hematuria -Conservative surgery
A. Transtubal regurgitation * painful defecation, rectal bleeding
of endometrial cells and with menses, pain in the sacrum Special Consideration:
implantation at ectopic sites *nausea and vomiting 1. Minor gynecologic procedures are contraindicated before
B. Coelomic metaplasia and after menstruation
(repeated inflammation may 2. Because infertility is a possible complication, advise the
induce metaplasia of patient who wants children not to postpone childbearing.
mesothelial cells to the
endometrial eputhelium)
C. Lymphatic or
hematogenous spread to
account for extraperitoneal
disease
Pelvic Inflammatory -profuse, purulent vaginal discharge, Treatment:
Disease sometimes accompanied by low-grade -antibiotic therapy begins after culture specimens are
-any acute, subacute, fever and malaise obtained
recurrent or chronic -lower abdominal pain Nursing management:
infection of the oviducts and -check for fever, intake and output
ovaries, with adjacent tissue -Gram stain, culture and sensitivity -Watch for abdominal rigidity and distention, possible signs
involvement. testing aids selection of the of peritonitis
-inflammation of the cervix, appropriate antibiotic -stress the need for the patient’s sexual partner to be
uterus, fallopian tubes,and -ultrasonography to identify a uterine examined and if necessary, treated for infection
ovaries, which can extend to mass
the connective tissue lying -culdocentesis to obtain peritoneal
between the broad ligaments fluid or pus for culture and sensitivity
- the most common bacteria testing
 found in cervical mucus are
staphylococci, streptococci,
diphtheroids, chlamidiae,
and coliforms, including
Pseudomonas and
Escherichia coli
Premenstrual Syndrome - behavioral - mid to severe Treatment:
-appears 7-14 days before personality changes, nervousness, -Diuretics, antidepressants, vitamins such as B complex,
menses and usually subsides hostility, irritability, agitation. Sleep progestins, prostaglandin inhibitors, and nonsteroidal anti-
with its onset. disturbances, fatigue, lethargy and inflammationdrugs
-the biological theories depression -Diet low in simple sugars, caffeine and salt
offered to explain the cause - somatic - breasts tenderness,
of PMS include such swelling, abdominal tenderness or *Education and reassurance that PMS is a real physiologic
conditions as a progesterone bloating, joint pain, headache, edema, syndrome are important parts of treatment
deficiency in the luteal phase diarrhea or constipation and
of the menstrual cycle and exacerbations of skin problems (acne
vitamin deficiencies or rashes), respiratory problems
(asthma), neurologic problems
(seizures)

Chapter 48. Nursing Care of the Child With Endocrine or Metabolic Disorder
Terms:
1. Carpal spasm - hand spasm involving abduction of the hand and flexion of the wrist with the thumb positioned across the palm
2. Exophthalmos - protrusion of the eyeballs
3. Glycosuria - excess glucose in the urine
4. Hormones - chemicals produced by ductless glands of the endocrine system
5. Hyperfunction - overfunction of a gland or organ
6. Hyperglycemia - increased blood glucose level
7. Hypofunction - underfunction of a gland or organ leading to acute or chronic insufficiency
8. Hypoglycemia - decreased blood glucose level
9. Hypothalamus - an organ located in the center of the brain that is the regulator of the autonomic nervous system
10. Ketoacidosis - a lowered serum pH resulting from accumulation of ketones
11. Latent tetany - neuromuscular irritability associated with hypocalcemia
12. Manifest tetany - muscular twitching and carpopedal spasms from hypocalcemia
13. Pedal spasm - foot spasm manifested as the foot is extended, the toes are flexed, and the sole of the foot is cupped
14. Polydipsia - excessive thirst
15. Polyuria - excessive urination
16. Sella turcica - a depression of the phenoid bone
17. Somogyi phenomenon - rebound hyperglycemic response, typically manifested with nighttime hypoglycemia and early morning hyperglycemia

Endocrine Disorders
Condition Signs and Symptoms Management
Phenylketonuria (PKU) *Mental retardation from * Early detection: test for PKU at birth
*an inherited error in the damage to the Nervous system A. Guthric Blood Test: effective in newborns, testing should be
metabolism of phenylalanine by build up of phenylalanine done after 72 hours of life
*Strong musty odor in urine B. Ferric Chloride Urine Test: effective only hen infant is over 2
*lack of the enzyme from phenylacetic acid weeks of age, when brain damage may have occurred
phenylalanine hydroxylase * Absence of tyrosine *Diet: Low-phenylalanine: use Lofenalac PKU-I or Phenyl-free as
prevents conversion of decreases the production of a milk substitute and restrict foods to those low in this amino acid
phenylalanine (an essential melanin and results in blond (usually continued until the child is 6-8 years of age)
amino acid) into tyrosine hair and blue eyes
*Common in Caucasians *Fair skin is susceptible to
*autosomal recessive trait eczema
Celiac Disease or *Progressive malnutrition, * Diet:
Mucovisacidosis or Gluten- stunted growth, wasting of A. Gluten-free
induced Enteropathy extremities, distended B. High in calories and protein
*autosomal recessive trait abdomen C. Low-fat
*chronic intestinal *Steatorrhea: fatty, foul, D. Small frequent feedings. Adequate fluids
malabsorption and inability to frothy, bulky stools E. Supplemental Iron
digest gluten, a protein found *diarrhea F. Vitamin supplements, all in water-miscible form
mostly in oats, barley, wheats *anorexia and irritability * protect the child from infection
and rye *Rickets (decreased Vit. D),
bleeding (decreased Vit. K),
Xerophthalmia (decreased
vitamin A)
Cystic Fibrosis *Respiratory: *prevent respiratory tract infection
*hereditary disorder of -chronic cough, purulent, 1. Chest physiotherapy
exocrine glands foul-smelling sputum 2. Nebulization - aerosolized bronchodilators
*autosomal recessive trait - tachypnea, wheezing 3. Use of expectorants, mucolytics and antibiotics
Pathology: -barrel-chest 4. Avoid antitussives and antihistamines
- defect is in overproduction of -digital clubbing, cyanosis * Promote optimal nutrition
mucus or an absence of normal - spontaneous 1. Replacement of pancreatic enzymes (Cortazym, Pancreos),
mucus-removing mechanism pneumothorax given with cold food in the middle of a meal
-pancreas becomes fibrotic, 2. Replacement of fat-soluble vitamins in water-miscible form
with a decrease production of *GI involvement: 3. High-protein diet of easily-digested food, normal fat content,
pancreatic enzymes (late -meconium ileus high calories
complication -diabetes) -rectal prolapse *Promote mobility and activity
-increased viscous mucous in -steatorrheic stool 1. Encourage activity and regular exercise
the respiratory tract 2. Help the child regulate activity to own tolerance
*Sweat Glands *Promote a positive body image
-increased concentration of 1. Encourage good hygiene
NaCl 2. Select clothes that compensate for protuberant abdomen and
-salty taste emaciated extremities
*Provide for emotional support and counseling for the child and
 *Liver family
-possible cirrhosis from 1. Long-term problem causes financial and emotional stresses
biliary obstruction,
malnutrition or infection
-portal hypertension leads
to esophageal varices

Chapter 49. Nursing Care of the Child with Neurologic Disorder

Terms:
1. Astereognosis - difficulty identifying objects placed in the hand when the eyes are closed
2. Automatism - complex purposeless movements, such as lip smacking or fumbling hand movements
3. Autonomic dysreflexia - a powerful sympathetic reflex reaction that causes signs of hypertension, tachycardia, flushed face, and severe occipital
headache
4. Central Nervous System (CNS) - the brain, the spinal cord, and the surrounding membranes or meninges that protect the delicate tissues from
normal trauma
5. Cerebrospinal Fluid (CSF) - the fluid in the subarachnoid space, which serves as a cushion to the spinal cord
6. Choreoathetosis - rapid, purposeless movements
7. Choreoid - irregular and jerking movements
8. Decerebrate posturing - typical posture occurring when the midbrain is not functional; characterized by rigid extension and adduction of arms and
pronation of the wrists with the fingers flexed; legs extended and the feet plantar flexed
9. Decorticate posturing - a child’s arms adducted and flexed on the chest with wrists flexed, hands fisted; lower extremities extended and internally
rotated; feet plantar flexed; denotes brainstem involvement
10. Diplegia(paraplegia) - paralysis of the lower extremities
11. Dyskinetic - disordered muscle tone
12. Graphesthesia - ability to recognize a shape that has been traced on the skin
13. Hemiplegia - paralysis of both extremities on one side
14. Kinesthesia - ability to distinguish movement
15. Neurons - nerve cells
16. Peripheral nervous system (PNS) - the cranial nerves, the spinal nerves, and the somatic and visceral divisions
17. Pulse pressure - the gap between systolic and diastolic blood pressure
18. Quadriplegia - paralysis of all four extremities
19. Status epilepticus - a seizure that lasts continuously for more than 30 minutes or a series of seizures form which the child does not return to his
or her previous level of consciousness
20. Stereognosis - the ability to recognize an object by touch

1. Assessment
A. Health history (chief complaints, present illness, previous illness, family and social history)
B. Physical Assessment
C. Diagnostic tests
*X-ray (Roentgenogram) photography/radiography
- reveals tumors or injuries but does not show the details of soft tissue necessary to diagnose many brain problems

*Computed Tomogrpahy (Computed Axial Tomography) -

- 100% more effective than conventional x-ray
- CT - picturing a cut using computer
- involves scanning a person’s head with a revolving x-ray generator: x-rays that passes through tissue x-ray sensors, which sends
information to a computer that constructs image that appears as a “slice of brain” on a video screen
- scans are then stacked by the computer to give a 3-D view
-Detects hemorrhage, tumors, CVA lesions
- Prep: No special physical preparation
Explain procedure
Approximate 20-30 minutes without contrast medium, 60 minutes with contrasts medium
Procedure is painless
Check for allergy to iodine id contrast medium is used (injected intravenously)
 *Magnetic Resonance Imaging (MRI)
- also called nuclear magnetic resonance
- has advantage of avoiding use of harmful radiation
- magnetic field surrounding the head induces brain tissues to emit radio waves that can be used by a computer to construct a sectional
image. Sharper image than any other
- detects small brain abnormalities
- Prep: no physical preparation
Remove credit cards, watches, etc. Damaged by magnet
Check for presence of clips in brain, pacemaker’s metal prosthesis, or other implants that could be damaged by magnet
Explain procedure - 60 minutes duration; painless, lie still, procedure is noisy, patient may become frightened while enclosed inside.
No adverse reactions.
*Ultrasonogrpahy / Echoencephalopathy
- high frequency sound (ultrasound) waves are reflected off anatomical structures to form images
- no harmful radiation in diagnosis of hydrocephalus, tumors in infants

*Electroencephalography (EEG)
Indications: to detect electrical abnormalities indicating intracranial pathology
Detects an existence or type of epilepsy
Preparation: no special preparation
Patient be quiet and rested before procedure
Scalp and hair clean
Discontinue tranquilizer stimulants, anticonvulsants, coffee, tea 48 hours prior to the procedure

Invasive Procedures
A. Pneumoencephalography - X-ray
- study of ventricular and cisternal system by introducing air through lumbar or cisternal tap (contrast media)
- for visualization and localization of brain lesion by using x-ray
- not frequently used today because of its life-threatening effect. (contraindicated in increased cranial pressure)
B. Ventriculography
 - used when spinal or cisternal tap contraindicated by introducing air to ventricles through trepine openings (burr holes) into the skull
C. Cerebral Angiography
- Radiography (x-ray) visualization of cerebral arterial and vein, determines site, size and pathological process; localize tumors, abscess,
aneurysms and hematoma
- contraindicated: severe liver, kidney and thyroid disease, patient receiving anticoagulant therapy; those with recent thrombotic/ embolic episodes
- Prep: A clear liquids on morning or procedure
Assess for allergy to iodine
If carotid artery is used, assess neckline arc
Sedation may be given before the procedure
Check vital signs and baseline neuro exam immediately prior to procedure
Explain tests: 2-3 hours, hot feeling when dye is injected, metallic taste in mouth, uncomfortable lying down
- post: on bed rest overnight
Frequent vital signs and neuro checks
Assess site for hematoma and distal pulse for circulation
Check carotid site for difficulty in breathing & swallowing, check girth
Dye used may raise ICP and caused decreased extremity strength or person’s LOC
*Myelography - X-ray
-Contrast radiogrpahic technique used to outline the spinal cord and subarachnoid space
-Using LT, CSF is withdrawn after recoding opening pressures
-When 6-12 ml has been collected or drained, contrast medium is instilled
-specific gravity of contrast is greater than CSF to direction of flow after injections depends on tilt of X-ray table and patient position
-oil based contrast medium - spinal needle remains in place though out test to allow removal of contrast medium
-water-based absorbed from subarachnoid space. No need to aspirate
-Duration: 60-90 minutes
-Prep: discomfort during lumbar tap
NPO 4-8 hours
Cleansing enema
-Post: Nurse must know type of contrast medium
Oil-based: flat on bed 6-24 hours to reduce CSF leakage and decrease frequency of headache
 Increased fluid intake to decrease headache and replenish CSF
Water-based: head of bed elevated 30-60 degrees at all times for 8-24 hours to prevent contrast from travelling to middle fossa or
reaching hypothalamus which may lead to severe headache, nausea and vomiting and seizure activity
When oil-based contrast was not entirely removed, the head of bed may also be elevated 30-6- degrees
Monitor vital signs and neuro status including urinary output

*Lumbar Puncture/ Spinal Tap

-Insertion of a needle into subarachnoid space of spine
-Quite dangerous in presence of intracranial mass lesion. Decrease ICP by removal of CSF may cause brain to herniate downward through
tentoriom and foramen magnum
-Normal CSF pressure: 15-50 mmHg
-Indication: therapeutic and diagnostic purpose (L3-L5)
-Diagnostic : Measurement of CSF
Visualization and laboratory exam
Note signs of blockage due to a tumor or other pathological conditions of the spinal cord
-Therapeutic: removes blood or pus to the subarachnoid space
Inject drugs/serum
Decreases ICP
Spinal anesthesia
-Preparation: Consent
Empty bladder/bowel
Sedation 20-30 minutes
-Position: at the side with both knees and head flexed

*Electromyography (EMG)
-introduce needle to skeletal membrane
-measure changes in electrical potential of membrane and nerves
-determine presence of neuromuscular disorder and myopathies
 Physical Assessment in Neurologic Nursing
Categories of Neurologic function
1. Cerebral function (LOC, mental status, language)
2. Cranial Nerves
3. Motor system and cerebellar functions
4. Sensory system
5. Reflexes

Neuro check or brief neurologic assessment - rapid repeated evaluations of several key indicators of Nervous system status:
1. LOC - Glasgow Coma Scale (GCS) and Ranchos Los Amigos (RLA)
2. Pupil size and dilatation (response)
3. Verbal Responsiveness
4. Extremity strength and movement
5. Vital signs

Always begin with assessment of cerebral function including LOC; because neurons are extremely sensitive to changes, so cerebral dysfunction
usually serves as earliest sign of developing CNS disorder.

A. Cerebral Function
1. Level of consciousness person is aware of self and the environment and is able to respond appropriately to stimuli.
A. Level of arousal - wakefulness; always assess objectively, stating what is actually observed.
1. Alert 2. Confused 3. Drowsy 4. Stupor
Terms used to describe LOC
Term Characteristics of Client
Full consciousness Alert; oriented to time, place and person; comprehends spoken and written words
Confusion Unable to think rapidly and clearly, easily bewildered, with poor memory and short attention span;
misinterprets stimuli; judgment is impaired
Disorientation Not aware of or not oriented to time, place and person
 Obtundation Lethargic, somnolent; responsive to verbal or tactile stimuli but quickly drifts back to sleep
Stupor Generally unresponsive; may be briefly aroused by vigorous, repeated or painful stimuli; may shrink away
from or grab at the source of stimuli
Semicomatose Does not move spontaneously; unresponsive to stimuli, although vigorous or painful stimuli may result in
stirring, moaning or withdrawal from the stimuli, without actual arousal
Coma Unarousable; will not stir or moan in response to any stimulus, may exhibit non-purposeful response ( slight
movement) of area stimulated but makes no attempt to withdraw
Deep Coma Completely unarousable and unresponsive to any kind of stimulus, including pain, absence of brainstem
reflexes, corneal, pupillary and pharyngeal reflexes and tendon reflexes

Ways in stimulating the client:

-Use auditory stimulus first - speak patient’s name in normal tone of voice
-Tactile Stimulus next - touching gently, squeezing hand, shaking shoulder
-Painful stimuli (only for unconscious)
*peripheral - apply pressure over nailbed using a blunt object like pen or firmly pinch the Achilles tendon between thumb and index
finger.
*central - use elbow or knuckles to apply pressure on sternum. Be cautious, it can cause easy bruising.
B. Orientation - use open ended rather than question requiring yes or no.
1. person - ask name, self-identity usually remains intact until late in decrease LOC
2. Place - state location correctly, or conclude whether he’s in hospital or home or ask about a city
3. Time - ask month and year. Day and date may be too specific we even tend to ask the date sometimes

Glasgow Coma Scale - another way to assess LOC decreasing subjectively and increases reliability
Observation Response Score
Eye response Opens spontaneously 4
Opens to verbal command 3
Opens to pain 2
No response 1
Motor response Obeys command 6
Localizes pain 5
 Flexion-withdrawn 4
Assumes flexor posture 3
Assumes extensor posture 2
No response 1
Verbal response Oriented and converses 5
Confused but converses 4
Uses inappropriate words 3
Incomprehensible sounds 2
No response 1
*Record C if eyes are closed by swelling
* Record T if an endotracheal or tracheostomy tube is in place
**Perfect score: 15 - alert, follows simple commands, completely oriented to TPP
**Coma bracket: 7 or less
**Lowest possible score: 3 - deep coma, poor prognosis

Neurologic Disorders
Condition Signs and Symptoms Management
Cerebral Palsy *difficulty in feeding, esp. *For easier feeding, use a spoon and blunt fork, with plate
*neuromuscular disability in controlling in sucking and attached to the table
voluntary muscles (caused by damage to swallowing *Provide child with increased calories because of excessive
the motor cortex, basal ganglia, *Asymmetry in motion or energy expenditure, increased protein for muscle activity, and
cerebellum: with associated sensory, contour of the body increased vitamins (especially B6) for amino acid metabolism
intellectual, emotional or convulsive *delayed motor *Provide rest periods in an area with less stimuli
disorders) development and speech *Set limits and control activity level
*major causes include: 1. anoxia of the *Excessive or feeble cry *Protect from accidents resulting from poor balance and lack of
brain 2. congenital or neonatal infection *any of the muscular muscle control
of the CNS abnormalities listed under *provide helmet for protection against head injuries
*affects young children, usually the types *always restrain in chair, bed and car seats
becoming evident before 3years of age *Keep safety as main objective in play
*nonprogressive, but persists throughout *Do not overstimulate. Toys should have educational value and
life appropriate for the child’s developmental level and ability
*Recognize that difficulty in the toilet training is because of
Types: poor muscle control
1. Spastic (65%): hyperactivity of *Provide special bowel and bladder training
muscle stretch reflex which becomes *Refer fro speech therapy
worse with rapid passive motion *Protect the child from exposure to respiratory infections
2. Dyskinetic: major manifestation is *Be alert for signs and symptoms of aspiration Pneumonia
athetosis, slow, wormlike, involuntary *Explain that frequent dental caries occur and there is a great
puposeless movement need for dental supervision and care
3. Ataxic failure of muscle coordination *Teach the parents to brush the child’s teeth if muscular
4. Tremor: A rhythmic purposeless dysfunction is present
movement that becomes worse with *Recognize common ocular disorders
excitement or intentional movement *encourage parents to have child’s hearing checked
5. Flaccid: decrease muscle tension periodically
6. Rigid: persistent stiffness of the *Surgical management:
muscles on movement, which becomes A. Tenotomy of adductor and obturator- transection of tendon
less severe with rapid passive motion B. Neurectomies - excision of a part of a nerve, improve
mobility
C. Dorsal Rhizotomy - transection of a nerve root
D. Ventrolateral thalamotomy - surgical destruction of selected
areas of the thalamus
*Pharmacological Treatment:
A. Relexants - to reduce spasticity
B. Antibiotics - for infections
C. Valium - for sedation
Spina Bifida *Sac at the back, intact, * Protect against infection because breakdown of the sac leaves
-a malformation of a spine in w/c the open or leaking the spinal cord open to the environment
posterior of the laminae of the vertebrae *s/s of increased ICP 1. Area must be kept clean, especially from urine and feces
fails to close: most common site is the *sensory and motor loss 2. Diaper is not used, but sterile gauze with antibiotic
lumbosacral area *bladder and bowel solution or moist saline dressing may be placed over the sac
-associated defects include weakness or dysfunction 3. Avoid pressure on the sac, use a donut ring
paralysis below the defect, bowel and *clubfeet *Maintain function through proper position; place in prone
bladder dysfunction, clubfeet, dislocated position, hips slightly flexed and abducted, feet hanging free of
hip and hydrocephalus Complications: mattress, and a slight Trendelenberg slope to reduce spinal
-meningitis fluid pressure
Types: -hydrocephalus *because of restriction in position, feed child in prone position:
1. Spina bifida occula - defect only of -severe neural defects establish eye contact and encourage parents to visit and feed
the vertebrae: spinal cord and meninges the child
are intact *Foster elimination in the infant with a neurogenic bladder
2. Meningocele - meninges protrude A. Use the Crede method or slight pressure against the
through the vertebral defect abdomen for complete emptying of the bladder
3. Meningomyelocele - meninges and B. . While the infant is prone, apply pressure to the abdomen
spinal cord protrude through the defect: above the symphysis pubis with sides of the fingers are
most serious type counterpressure with thumbs against the buttocks
C. Cholinergic agents may be used to treat hypotonic bladder
Arnold-Chiari syndrome *Surgical management:
-defect of the occipito-cervical region A. Closure of sac within 48 hours of birth
with swelling and displacement of B. Shunt procedure if with hydrocephalus
medulla into the spinal cord *Postoperative Nursing Care
1. Measure the head size to determine whether hydrocephalus
is occurring
2. Monitor for signs of increased ICP
3. Prevention of infection
4. Adequate nutrition
5. Skin care
6. Prone position
7. Monitor I&O
8. Monitor movements of the LE
Hydrocephalus *Increasing head size in Treatment:
-abnormal accumulation of CSF within the infant because of open 1. Removal of the obstruction
the ventricular system sutures 2. Mechanical shunting of fluid to another area of the body
*Bulging fontanels, A. Ventriculoperitoneal shunt: catheter passed
Classification: Macewen’s sign (cracked subcutaneously to the peritoneal cavity
1. Noncommunicating obstruction pot sign) B. Ventriculoatrial shunt: catheter passed from a lateral
within the ventricles such as congenital *Prominent scalp veins ventricle to the internal jugular vein to the right atrium of the
malformation, neoplasm or hematoma and taut, shiny skin heart
2. Communicating: inadequate *sunset eyes (sclera *Nursing care:
absorption of CSF resulting from visible above the iris), 1. Prevent breakdown of scalp, infection and damage to the
infection, trauma or obstruction by thick bulging eyes, papilledema spinal cord
arachnoid membrane or meninges of the retina A. Place the infant in a Fowler’s position to facilitate
*head lag especially draining of fluid: postoperative positioning should be flat
important after 4-6 with no pressure on the shunted side
months B. When holding the child, support the neck and head
* Increased ICP: C. Observe the shunt site (abdominal site in peritoneal
projectile vomiting not procedure) for infection
associated with feeding, 2. Monitor for increasing ICP
irritability, anorexia, high A. Carefully observe neurologic signs
shrill cry, convulsions B. Measure head circumference
*Damage to the brain C. Use minimal sedatives or analgesics which can mask
because of increased symptoms
pressure of blood flow to D. Check the valve frequently for patency
the cells, causing necrosis 3. Promote adequate nutrition
A. Monitor for vomiting, irritability, lethargy and anorexia
because these will decrease the intake of nutrients
B. Perform all care before feeding to prevent vomiting,
hold infant if possible
C. Observe for signs of dehydration
 4. Keep eyes moist and free of irritation if eyelids
incompletely cover corneas
5. Postoperative nursing care:
A. Bed rest with minimal handling to prevent damage to the
shunt
B. Continued shunt revisions are usually necessary as
growth occurs
*Pharmacology:
1. Osmotic diuretic (Mannitol) - to decrease ICP
2. Acetozolamide - decrease CSF production
3. Antibiotics

Seizure disorders : Epilepsy - thought to result from disturbances in the cells of the brain that causes them to give off abnormal, recurrent,
uncontrolled electrical discharges. This is brought about by the change in the permeability of the cell population and ion concentration, which
produce neurons that are hyperexcitability and demonstrate hypersynchrony, producing an abnormal discharge.

Characteristics of Seizures:
Type of seizure Etiology Characteristics Clinical Signs Aura Postictal Period
Grand Mal Most common Generalized, Aura Present: Flashing Present: Need for
characterized by loss Cry light, smells, sleep for 1-2 hours,
of consciousness for Loss of consciousness spots before eyes. headache is
several minutes The Fall dizziness common
Tonic-clonic
incontinence
Petit Mal Usually occur Sudden impairment in Sudden vacant facial Not present Not present
during childhood or loss of expression with eye
& adolescence. consciousness with focused straight
Frequently little or no tonic-clonic ahead. All motor
decreases as movements. Occur activity ceases
child gets older without warning. Has perhaps for slight
 tendency to appear few symmetric twitching
hours after arising or above the eyelids.
when the person is Possible loss of
quiet. muscle tone.
Consciousness returns
Psychomotor Occurs at any Sudden change in Often appears Present: Complex Present: Confusion.
age awareness associated intoxicated. May do hallucination or Amnesia. Need for
with complex antisocial things such illusions sleep
distortion of feeling & as exposing self or
thinking & partially carrying out violent
coordinated motor acts. Automatic
activity. Longer than complaints may
petit mal. occur: chest pain, rep,
distress, tachycardia,
GI distress and urine
incontinence
Jacksonian-focal Occur almost Depend on site of Commonly begin in Present: Present
entirely in focus. May or may not hand, foot, or face. Numbness
patients with be progressive May end in grand mal Tingling
structural brain seizure. Crawling
disease Feeling
Myoclonic May antedate May be very mild or Sudden involuntary Not present Not present
grand mal may have rapid contraction of muscle
months or years forceful movements group, usually in
extremities or trunk.
Akinetic Not common Peculiar generalized Person falls in flaccid Rarely present Not present
tonelessness state. Unconscious for
a minute or two.

Nursing Assessment:
 1. Obtain seizure history, including prodromal S/S, seizure behavior, postictal state, history of status epilepticus.
2. Document the following about seizure activity:
A. Activity before attack, such as visual, auditory, olfactory, or tactile stimuli; emotional or psychological disturbances; sleep; stress, fatigue
B. Description of movement including where movement or stiffness started; type of movement including where movement or stiffness started;
type of movement and parts involved; progression of movement; whether beginning or seizure is witnessed
C. Position of the eyes and head; size of the pupils
D. Presence of automatism, such as lip smacking or repeated swallowing
E. Incontinence of urine or feces
F. Duration of each phase of the attack
G. Presence of unconsciousness and its duration
H. Behavior after attack, including inability to speak, any weakness or paralysis, sleep
3. Psychosocial effects of the seizures --stigma attached.
4. History of drug or alcohol abuse
5. Compliance and medication-taking strategies

Interventions:
Nursing Management:
1. Monitor for:
A. Serum levels for therapeutic range of medications
B. Toxic side effects of medications
C. Platelet and liver functions for toxicity
2. Patent airway until fully awake after seizure
3. Stress regular intake of medications
4. Safe environment by padding side rails and removing clutter
5. Lace bed in low position
6. Do not restrain during seizure
7. Do not put anything on the mouth during seizure
8. Place on the side during the attack to prevent airway obstruction
9. Protect the head during a seizure; place cloth as pads
 10. Stay with client when ambulating or who is in a confused state during seizure
11. Anticonvulsant medications:
A. Phenytoin sodium (Dilantin, Phenobarbital (Luminal) or grand mal, focal, psychomotor)
B. Trimnethadione (Tridione) for petit mal
C. Diazepam (Valium) for status epilepticus

Health Teaching:
1. Determination of the existence of trigger factors for seizures; skipped meals, lack of sleep, emotional stress
2. Importance of following medical regimen
3. Avoidance of alcohol - interferes with drug metabolism
4. Encourage patient and family to discuss feelings and attitudes about epilepsy
5. Wear a Medic Alert card or bracelet
6. Modify lifestyle that includes exercise, mental activity, and nutritional diet. Avoid driving, contact sports, gymnastics, swimming.

Emergency Management:
Status Epilepticus. A series of generalized seizures without return to consciousness between attacks. This also includes continuous clinical and/or
electrical seizures lasting at leats 5 minutes, even without impairment of consciousness.

Interventions:
1. Establish an airway and maintain blood pressure
2. Obtain blood studies for glucose, BUN, electrolytes and anticonvulsant drug levels
3. Establish IV lines and keep open for blood sampling
4. Administer IV anticonvulsant slowly to ensure effective brain tissue serum concentration.

Chapter 50. Nursing Care of the Child with a Disorder of the Eyes or Ears
Terms:
1. Accomodation - adjustment of the eye to focus on a close image (ophthalmology); the ability to adapt thought processes to fit what is perceived
2. Amblyopia - reduced vision in one eye; “lazy eye”
3. Astigmatism - congenital or acquired unevenness of the curvature of the cornea
4. Blepharitis marginalia -
5. Cerumen - waxlike secretion produced by ceruminous glands in the external auditory meatus (ear canal).
6. Diplopia - double vision
7. Enucleation - eye removal
8. Fovea Centralis - (the center of the macula); an area of closely packed cones on the retinas where color is best perceived
9. Goniotomy - surgical procedure used to treat congenital glaucoma
10. Hyperopia - farsightedness
11. Light refraction - manner that light is bent as it passes though the lens of the eye
12. Myopia -nearsightedness
13. Nystagmus - rapid, irregular eye movement
14. Orthoptics - eye exercises
15. Ptosis - drooping of the eyelid
16. Stereopsis - depth perception; the ability to locate an object in space relative to another object
17. Strabismus - crossed eye
18. Tympanocentesis - withdrawal of fluid from the middle ear through the tympanic membrane

Chapter 51. Nursing Care of the Child with a Musculoskeletal Disorder

Terms
1. Apposition - the amount of end-to-end contact of bone fragments
2. Arthroscopy - direct visualization of a joint with a fiber-optic instrument
3. Cartilage - connective tissue
4. Diaphysis - central shaft of a long bone
5. Distraction - a technique that allows the cells of the brain stem that register an impulse as pain to be pre-occupied with other stimuli so the pain
impulse cannot register;use of an external device to separate opposing bones, thus encouraging new bone growth
6. Epiphyseal plate - area where the increase in the length of long bones occurs
7. Epiphysis - rounded end portion of a long bone
8. Fracture - break in the continuity or structure of bone
9. Malleoli - rounded prominence on either side of the ankles
10. Metaphysis - thin area between the diaphysis and epiphysis in long bones
11. Myopathy - disease of the muscular system
12. Periosteum - outside sensitive layer covering of central shafts of long bones
13. Remodeling - new bone tissue replacing old bone tissue
14. Sequestrum - dead bone tissue detached from adjoining healthy bone
15. Smooth Muscle - a tissue specialized for contraction, composed of smooth muscle fibers (cells), located in the walls of hollow internal organs,
and innervated by autonomic motor neurons
16. Striated muscle -
17. Traction - pulling on a body part in one direction against counterpull exerted in the opposite direction to reduce dislocation and immobilize
fractures

Musculoskeletal Disorder
Condition Signs & Symptoms Management
Congenital Club foot (Talipes) * foot cannot be *Treatment is most successful when started early in infancy, since
-foot has been twisted out of manipulated by passive delay causes muscles and bones of legs to develop abnormally, with
position in utero exercises into correct shortening of tendons
position *Nonsurgical treatment: gentle repeated manipulation of the foot or
Types: forcible correction under anesthesia and application of a wedge cast
1. Varus - inward rotation and/or a Denis Brown splint.
2. Valgus - outward rotation *Casting is changed as often as every 3-7 days over period of
3. Calcaneous - upward rotation approximately 10 weeks. Follow -up must continue for several years
4. Equinas - downward rotation after completion of active treatment to prevent recurrence of the
5. Equinovarus - foot is fixed in arthrodesis (surgical fusion of joint), releasing of tight ligaments,
plantar flexion (downward) and lengthening or transplantation of tendons
deviated medially (inward); most *follow-up care:
common 1. Muscle reeducation (by manipulation) and proper walking
2. Heels and soles of braces or shoes prescribed following
correction must be kept in repair
3. Corrective shoes may have sole and heel lifts on lateral border
to maintain proper position
*Nursing Care:
1. Observe toes for signs of circulatory impairment; make sure toes
are visible at the end of the cast
2. Exercises as ordered
3. Cast care
4. Skin care
Congenital Hip Dysplasia *limited abduction of leg *Treatment is directed toward enlarging and deepening the
Head of the femur does not lie on the affected side acetabulum by placing the head of the femur within the acetabulum
deep enough wihtin the *asymmetry of gluteal, and applying constant pressure
acetabulum and slips out on popliteal and thigh folds *Proper positioning: legs slightly flexed and abducted
movement (may be caused by *audible click when 1. Pavlik harness
lack of embryonic development abducting and externally 2. Frejka Pillow: a pillow splint that maintains abduction of the
of the joint or position in utero) rotating hip on the affected legs
side: Ortolani’s sign 3. Bryant’s traction
*apparent shortening of the 4. Spica cast: from the waist to below the knees
femur: Galeazzi’s sign 5. Brace
* Waddling gait and *Surgical intervention such as open reduction with casting
lordosis when the child *Nursing Care:
begins to walk 1. Adequate nutrition: small frequent feedings
2. Regular ROM exercises
 3. Prevent circulatory impairment: elevation of casted leg, check
circulatory status,
4. Prevention of hypostatic pneumonia: frequent changing of
position: blowing bubbles to promote lung expansion
5. Cast care: skin care

Chapter 52. Nursing Care of the Child with a Traumatic Injury

Terms:
1. Allografting - transfer of body tissue between two genetically dissimilar individuals
2. Autografting - transplantation of tissue from one part of the body to another in the same individual
3. Contrecoup injury - an injury resulting from a blow to one side of the skull that causes the brain to rebound and then injure the opposite side
4. Debridement - the removal of foreign material from a burn or wound
5. Drowning - asphyxiation because of submersion in a liquid
6. Escharotomy - a surgical incision into the head crust that forms over a burn
7. Heterografts - tissue from another species (such as a pig) used as a temporary skin covering
8. Near-drowning - a state in which a person has survived drowning
9. Otorrhea - discharge from the external ear
10. Plumbism - lead poisoning
11. Rhinorrhea - discharge from the nose
12. Stupor - lethargy and unresponsiveness

Poisoning
Condition Signs & Symptoms Management
Salicylate Poisoning *Hyperpnea, hyperpyrexia *Treatment
-toxic condition caused by *DHN 1. Induce vomiting
ingestion of salicylates, most *Hyperventilation A. If unconscious, gastric lavage
often in the form of Aspirin *Loss of consciousness B. It conscious:
*Causes stimulation of the *Lethargy Give syrup of Ipecac 1/2 hour after ingestion
respiratory center; alteration of *Vomiting Administer activated charcoal after ipecac syrup
CHO and lipid metabolism; *Metabolic Acidosis Administer saline cathartics
respiratory acidosis; increased *Bleeding, if chronic ingestion 2. IV fluids: F/E electrolytes including NaHCO3
O2 consumption and CO2 3. Vitamin K if bleeding
production; inhibition of 4. Monitor I & O
platelet aggregation and 5. Place on a cooling blanket
prothrombin production, 6. Monitor ABG results
bleeding tendencies 7. Monitor neurologic status
*toxicity begins at 150-200 8. Anticonvulsants may be given
mg/kg 9. Peritoneal dialysis in severe cases
*peak effects: 2-4 hours;
duration: 8 hours
Lead Poisoning (Plumbism) -abdominal colic *Preventive measures through education, proper housing,
-Most common between 9 -constipation supervision of children
months and 3 years of age, -anorexia, vomiting *Goal of treatment: reduce concentration of lead in the blood and
usually from eating lead chips - weight loss soft tissues by promoting excretion and deposition in bones
from peeling paint or sucking -pallor, fatigue A. Dimercaprol
on objects with lead-based -clumsiness. Irritability B. Vitamin D, Calcium and Phosphorus
paint -loss of coordination
-Lead is absorbed through GIT -Ataxia, seizure
and pulmonary system; -lead line on teeth
deposited in the bones, soft -insomnia, joint pains
tissues; excreted via feces, -increased blood lead level
urine, sweat A. Normal: <40mcg/100ml of
-toxic effects due to enzyme blood
inhibition: enhanced by low B. Treatment needed 60 mcg
dietary iron and Ca intake or higher
C. Brain damage occur 80
mcg
 BURNS
Burns - cell death due to an exposure to extreme heat
Classifications
Layer Presentation Healing
1st degree - Epidermis Redness (Erythema) 3-7 days
Partial 2nd degree - Epidermis + Dermis Blister/most painful Average 21 days (Nursing management: cover
the area
3rd degree - Skin + Subcutaneous Charcoal-colored skin Skin grafting
(Edema + eschar) *common 1. Autograft - patient is the donor
is compartment syndrome 2. Xenograft (Heterograft) - animals;
Full thickness cow/pig
3. Allograft - cadaver
4th degree - skin + SubQ + Painless Amputation/skin grafting
muscles + bones

Assessment:
(Rapid) TBSA - Total Body Surface Area
Roles of Nines: used for 9 years old and above
Head (including neck) - 9%
Each arm - 9%
Anterior Thorax - 18%
Posterior Thorax - 18%
Each leg - 18%
Perineum - 1%
Total of 100%
Major Burns = ≥25% TBSA or sites (head, neck, thorax)

Systemic Complications: (major Burns)

1. Hemodynamic Instability - begins immediately when there is injury in blood vessel wall
2. Respiratory Dysfunctions - carbon monoxide poisoning (pathognomonic sign: cherry-pinked face/skin)
Nursing Priority: O2 supplement of 100% via tight fitting non-rebreather mask
3. Organ Failure - Due to hemodynamic instability
4. Hypermetabolic response - due to physical injury
Implications:
A. Increased metabolic acid - metabolic acidosis (↓pH, ↓HCO3)
Drug of Choice: Sodium Bicarbonate (NaHCO3)
B.↑ Calorie Requirements (Normal1,800 - 2,100/day)
-6,000 - 8,000/day (TPN)
Diet: ↑Calorie, ↑CHON, ↑CHO, ↑Fats, ↑Vitamins
5. Sepsis/immune dysfunctions
*↑Risk: infection
A. Priority: reverse isolation
B. Strict aseptic technique
C. Antibiotic (broad spectrum)
Silvadene - Silver Sulfadiazene - common
6. Pain
*Analgesics: Morphine SO4 dosage: 2mg/hour until pain goes away
7. Emotional Trauma

5 stages of Burns
1. Emergent Phase - actual exposure
2. Shock phase - first 24-48 hours
*Movement: Plasma to interstitial
 *F/E imbalances
A. Hemoconcentration
B. Hyponatremia
C. Hyperkalemia
D. Hypovolemia
E. Decrease urine output
F. Metabolic acidosis
3. Diuretic / fluid remobilization phase
Occurs 2-5 days after burn
Movement: interstitial to plasma
F/E imbalances:
A. Hemodilution
B. Hypernatremia
C. Hypokalemia
D. Hypervolemia
E. Increased urine output
F. Metabolic acidosis
4. Rehabilitation/covalescent phase - begins when diuresis is completed

Phases of Burn Care Priorities:

1. Emergent phase / shock phase
Priorities:
A. First Aid (RACEE)
Rescue patient
Alarm
Contain the fire
Extinguisher
Evacuate
B. Prevention of shock/respiratory distress
 C. Detection and treatment of injuries
D. Wound assessment and care

2. Diuretic phase or Fluid Remobilization phase

Priorities:
A. Wound care and closure
B. Prevention or treatment of complication
C. Nutritional support
3. Rehabilitation phase
Priorities:
A. Prevention scars and contractures
B. Physical, occupational and vocational rehabilitation
C. Functional and cosmetic reconstruction
D. Psychosocial counseling

Treatment: (drugs)
1. Antibiotics
2. Analgesics
3. NaHCO3
4. Vitamin supplements
5. Anti-PUD
6. Stool softeners
7. Anti-cholinergic
8. Anti-scar (Contractubex)

Other Treatments:
1. Fluid replacement
2. O2 supplement
3. Procedure :
 A. skin grafting: post-operative Nursing management: elevate affected part to decrease edema and promote venous return
(note: do not cover the grafted site)
B. Amputation: post-operative: best position: elevate affected part
Note: if AKA, elevate on the first 24 hours post op, then flat on bed to prevent hip contractures
Nursing Care:
1. O2 supplement
2. Reverse isolation
3. Watch for complications

Common complications:
A. Respiratory dysfunction - common cause of death
B. Infection - 2nd cause of death
Antibiotics
Strict Aseptic technique
Wound care - wound irrigation (PNSS) - common solution
Daikin’s Solution - mixture of Sodium Hypochloride (unstable solution)
-best time to prepare - the time you will use it
-irrigate the wound immediately after Daikin’s solution by PNSS
-Do not soak the wound with the solution
C. Metabolic Acidosis
D. Pain
E. PUD - stress ulcer
F. Shock
G. Organ Failure
H. Contractures - prevented by positioning properly
1. Best position: Anatomical position
I. Compartment Syndrome
1. Elevate
2. Inform Physician
 Treatment:
A. Hydrotherapy - common complication: Hypothermia (earliest); Infection (late)
B. Escharotomy
C. Fasciotomy
J. Scar - Prevention: anti-scar stocking
Best time to wear stockings: a week after wound is healed (completed)
23 hours per day
16-18 months, maximum of 2 years