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SELECTED PEDIATRIC DISEASES
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Respiratory Anatomy & Physiology
• The respiratory system consists of two main parts- the upper and the lower tracts
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Respiratory Anatomy & Physiology
The UPPER respiratory system consists of:
• 1. nose• 2. sinuses• 3. mouth• 4. pharynx• 5. larynx• 6. epiglottis
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UPPER RESPIRATORY TRACT INFECTION
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ACUTE NASOPHARYNGITIS (CORYZA)
• Most frequent infectious disease in children
• Average of 10-12 colds/ year
• Incubation period- 2-3 days
• The COMMON COLDS
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1. Rhinovirus-most common cause
2. Parainfluenza virus
3. Respiratory syncytial virus (RSV)
4. Adenovirus
5. Influenza virus
6. Coxsackie virus
ETIOLOGIC AGENT
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SIGNS AND SYMPTOMS
1. nasal congestion
2. watery rhinitis
3. low grade fever
4. mucus membrane is edematous
5. cervical lymph node may be swollen and palpable
6. body malaise
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TREATMENT
• Common colds is self-limiting
• supportive care
• relief of nasal obstruction - use of isotonic saline drops and aspiration
• antipyretic or analgesic agents
• antitussive is sometimes used for persistent cough
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StreptococcalPharyngitis
• Strep throat• Spread by infected nose or throat mucus
through coughing or sneezing
S/sx: pain on swallowing, fever, headache, swollen lymph nodes, swollen hyperemic tonsils w/ OR w/out pus
Dx: throat SWAB and culture & sensitivity
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Group A beta-Hemolytic Streptococcal Bacteria – Gram (+) bacteria
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1. antibiotics- 10 day-course of oral antibiotics (Pen G or Clindamycin)
2. high fluid intake
3. relief of pain
• COMPLICATION: Rheumatic Fever, Rheumatic Heart Disease, Acute Glomerulonephritis
TREATMENT & MANAGEMENTPHARYNGITIS
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TONSILLITIS
term commonly used to refer to infection and inflammation of palatine tonsils
palatine tonsils - located on both side of pharynx
Adenitis - refers to infection and inflammation of the adenoids ( pharyngeal) tonsils
adenoids - located in the nasopharynx
Tubal tonsils - located at entrance to the Eustachian tube
Lingual tonsils - located at base of tongue
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• <3 years old - often viral
• school age children – often bacterial
ETIOLOGY
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Signs and Symptoms
1. difficulty of swallowing (dysphagia)
2. painful swallowing (odynophagia)
3. fever
4. lethargy
5. mouth breathing
6. difficulty hearing (Eustachian tube)
7. halitosis
8. sleep apnea
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TREATMENT
1. antipyretic
2. analgesics
3. Antibiotics ( 10 day course – usually Penicillin but may be Erythromycin if allergic to penicillin) is prescribed for bacterial infections to prevent the complication of rheumatic fever.
4. Surgical – tonsillectomy with adenoidectomy
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INDICATIONS FOR TONSILLECTOMY
1. chronic tonsillitis (not done if inflamed
because may spread infection)
2. Recurrent tonsillitis (4-6x/year)
3. Peritonsillar Abscess
4. Sleep apnea
Nursing diagnosis: Pain related to Surgical Procedure
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TONSILLECTOMY
Post –op Care:• 1. Observe for, & report unusual bleeding
( frequent swallowing)• 2. Help prevent bleeding by discouraging the
child from coughing & clearing the throat.• 3. Position the child on the side or the
abdomen (prone) to facilitate drainage from the throat
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TONSILLECTOMY
• 4. Provide appropriate teaching . Instruct the child & parents to:
• a. Observe activity restrictions, especially upon the child’s return to school.
• b. Avoid persons with known infections.• c. Avoid acidic & other irritating foods.• d. Monitor the child for bleeding, especially
immediately postoperatively & 5 to 10 days post op when tissue sloughing
occurs.
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EPISTAXIS
1. keep pt in upright position with head tilted slightly forward to minimize the amount of blood pressure in nasal vessels, keep blood moving forward not back to nasopharynx
2. apply pressure to the side of the nose with your fingers, may have ice compress
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EPISTAXIS
3. Ask the child to stop crying because crying increases pressure in the blood vessels of the head and prolonged bleeding
4. control of bleeding, can give epinephrine
(1:1000) to constrict blood vessels
5. can put nasal packing for continuous pressure on the site of the ruptured blood vessel
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Epiglottitis
• Inflammation of epiglottis ("cherry-red“)
• Hemophilus influenza type B
• 2-7 yo
Pathophx: upper respiratory infection inflammation of epiglottis
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EPIGLOTTITIS
S/sx: high fever, sore throat, cough hoarseness, drooling, dysphagia
Dx: CBC, elevated c-reactive protein (CRP), culture of epiglottis, neck xray
> it is considered an emergency because the swollen epiglottis is not allowing the airway to open.
- this emergency situation occurs most commonly in children between 3 and 6 years of age.
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E P I G L O T T I T I S
NURSE ALERT!!! “ Never illicit gag reflex-may cause complete obstruction”
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Nsg Dx:
Ineffective breathing pattern r/t inflammationIneffective airway clearance r/t inflammationParental anxiety r/t respiratory distress in child
MANAGEMENT• Emergency treatment (intubation)• Moist air• hydration• O2• Antibiotics – chloramphenicol, co-amoxiclav• Assurance to avoid agitation
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LOWER RESPIRATORY TRACT INFECTION
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Respiratory Anatomy & Physiology
The LOWER respiratory system consists of:
• 1. Trachea
• 2. Bronchus
• 3. Bronchioles
• 4. Respiratory unit
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The BRONCHI• RIGHT BRONCHUS
• Wider• Shorter• More Vertical
• LEFT BRONCHUS
• Narrower• Longer• More horizontal
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Retraction
• Supraclavicular/ Suprasternal retraction - suggest upper airway obstruction
• intercostal retraction- suggest lower airway obstruction
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Bronchitis
• Inflammation of bronchi • Starts as URTI
S/sx:• initially low grade fever, colds • 3-4 days after, roughening breath sounds, rales, dry,
hacking unproductive cough • Cough w/ sputum production - clear to purulent,
dyspnea, chest pain
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BRONCHITIS
Dx: clinical
Elevated C-reactive protein (CRP) – bacterial
Mgmt:
rest
CPT
Fluids
antibiotics
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BronchitisViral Bacterial
Etio Rhinovirus,Influenza,
RSV, Parainfluenza
adenovirus, paramyxovirus
S. pneumoniae,
S. aureus,
H. Influenzae,
M. Catarrhalis
S/sx Rhinitis, cough, malaise, chills, mild fever, sore throat
higher fever and a more prod cough
Dx Clinical
Xray – normal
Elev c-reactive CHON
Course Mild & self-limiting Up to 2 weeks
Rx supportive empirical; amox-tetracycline, erythromycin
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Bronchiolitis
• inflammation & swelling of bronchioles w/ mucous in airways
• RSV,parainfluenza, Adenovirus, influenza
• 0-2 yo, peak 6 mos old
• transmitted via droplets
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Pathophx:
mild upper respiratory infection edema of airway and accumulation of mucus airway narrowing hypoxemia
S/sx: wheezing, tachypnea, wet hoarse cough, fever, poor appetite, difficulty sucking, restless sleep, retractions
Dx: cxr, pulse oximetry, throat culture
BRONCHIOLITIS
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BRONCHIAL ASTHMA
• chronic, reversible , obstructive airway disease, characterized by wheezing. It is caused by smooth muscle spasm w/ hypertrophy of the bronchial tubes, or swelling of the bronchial mucosa, after exposure to various stimuli.
Hypersecretion of mucus Most common chronic disease in childhood. Most
children experience their first sx by 5yo• exercise, nocturnal occurrence, seasonal, hx of allergy,
stress
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Types of Bronchial Asthma
A. Extrinsic or Atopic Asthma: r/t external allergens such as:
• -contactants: dust, chemicals, soaps, perfumes, lotions, make-up
• -inhalants: dust, hay, scents, smoke, sprays• -ingestants: food, milk, chicken, beef, pork, eggs, etc.• -Sudden changes in temperature
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Types of Bronchial Asthma
B. Intrinsic or Non-Atopic Asthma= not r/t external allergens
Stress
Fatigue
Lack of Sleep
Anxiety
C. MIXED type of Asthma= both types present
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Pathophysiology of Asthma
• Heredity + Allergens &/or Stress
• Release of IgE from B lymphocytes
• IgE + Mast cells of respiratory tract = damage to mast cells
• Release of: Histamine, Bradykinin, Serotonin, Leukotriennes, Prostaglandins, ECF-A, SRS-A from damaged mast cells to respiratory membranes
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Bronchial Asthma
• =S-ecretions: copious, viscous, sticky, stringy, whitish
• =S-pasms: laryngo-tracheo-bronchial spasm• =S-welling: edema of the airway
• Airway Obstruction
•
Dyspnea
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Signs & Symptoms of Bronchial Asthma
• Successive episodes of coughing: dry, hacking, non-productive cough
• Increased respiratory secretions: whitish, stringy• Wheezing on expiration• Prolonged expiration• Dry lips and mucous membranes (mouth)• Dyspnea, Tachypnea, Tachycardia• Apprehension and restlessness
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Nursing Interventions
Long-term Goal: Patient will achieve an open airway and adequate ventilation as manifested by normal VS and relief of symptoms
Short-term Goal:a. Liquify secretions
b. Easily expectorate and drain secretions
c. Relieve spasms
d. Decrease swelling of airways
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Nsg Dx:
Impaired Gas Exchange r/t bronchiolar obstruction, atelectasis and hyperinflation
Parental anxiety r/t respiratory distress in child
Management• nebulization• hydration• O2 • positioning• TSB• Monitor VS esp RR• support
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Pneumonia• Inflammation of lung parenchyma
Bacterial and atypical pathogens:NB – GBS, Gr (-) bacilli, chlamydiaChildren – S. pneumoniae, H. Influenzae, M. catarrhalisAdolescents – S and M Pneumoniae, M. catarrhalisHospital acquired – Pseudomonas, Klebsiella, E. Coli,
Enterobacter sp
Viral Pneumonia - RSV, Parainfluenza, Adenovirus, Influenza
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Pathophx: aspiration/hematogenous/inhalation
alveoli inflammation hypoxemia
S/sx: fever, chills, cough, irritability, poor feeding, restlessness, headache, GI sx, tachypnea, use of accessory muscles, decreased BS, crackles, dullness on percussion, chest retractions
Dx: cxr, blood and sputum c/s
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PNEUMONIA
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UncommonCommonCommonInc RR
Non-toxicVariableToxicToxicity
Low-gradeVariableHighFever
InsidiousVariableAbruptOnset
5-15 yoAnyAnyAge
AtypicalViralBacterialParameter
UncommonCommonCommonInc RR
Non-toxicVariableToxicToxicity
Low-gradeVariableHighFever
InsidiousVariableAbruptOnset
5-15 yoAnyAnyAge
AtypicalViralBacterialParameter
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AtypicalViralBacterialPerimeter
UncommonvariablecommonInc WBC
Fine crackles, wheezing
variable(+) consolidationfew crackles
PE
Bullous myringitis, pharyngitis
Mild coryzaMild coryzaAssoc sx
Non prodNon prodProductiveCough
AtypicalViralBacterialPerimeter
UncommonvariablecommonInc WBC
Fine crackles, wheezing
variable(+) consolidationfew crackles
PE
Bullous myringitis, pharyngitis
Mild coryzaMild coryzaAssoc sx
Non prodNon prodProductiveCough
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Nsg Dx:• Ineffective breathing pattern r/t physiologic effects
of Pneumonia
- O2, monitor VS, CPT, encourage coughing and deep breathing
• Risk for deficient fluid volume r/t diminished oral intake and increased insensible fluid losses sec to diaphoresis, dyspnea and fever
- weigh and monitor daily, sips of fluid, temp control, monitor I and O
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PNEUMONIA
• Activity Intolerance r/t effects of Pneumonia and Tachypnea
- rest periods, O2, small frequent feedings, gradual increase in activity, support and contact with family
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Tuberculosis• High incidence in infancy and adolescence
• Primary Complex – based on xray; first encounter of a child w/ TB; Ghon’s tubercle w/ lymphangitis and regional (hilar) lymphadenopathy
• Primary Pulmonary TB – clinical TB
• d/t Mycobacterium TuberculosisDx: exposure, s/sx (2 or more), PPD, Chest Xray,
sputum AFB test
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POSITIVE PPD TEST
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Classification of TB
Class I TB exposure – (+) exposureClass II TB infection – (+) exposure and PPDClass III TB disease – active TB or 3 or more of
criteria Exposure, s/sx, (+)
tuberculin test, xray, sputum exam, culture
Class IV TB inactive – (+/-) hx of prev TB, (+/-) hx of prev hx of chemotherapy,
(+)xray evidence of healed lesion and (+) PPD
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S/sx: fever, wt loss, cough, anorexia, night sweats, painless lymphadenopathy
Tx: Intensive INH, Rifampicin, PZA x 2 mos
Maintenance INH, Rifampicin x 4 mos
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Respiratory Distress Syndrome
• Preterm, infants of diabetic mothers, C/S, hx of asphyxia
S/sx: inc RR, chest retractions, nasal flaring,expiratory grunt, cyanosis, HPN, hypothermia
Dx: ABG, Xray
Mgmt: surfactant replacement, O2, ventilation, supportive care
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Decreased surfactant
lungs collapse
Inc pulmonary resistance
blood shunts through F.O. and D.A.
poor lung perfusion and gas exchange
further decrease in surfactant hypoxia
acidosis
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Cardiovascular Disorders
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Fetal Circulation
• placenta provides the exchange of gas and nutrient
• four shunts in fetal circulation:– Placenta– Ductus venosus– Foramen Ovale – Ductus arteriosus
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CONGENITAL HEART DEFECTS
• CHD are structural defects of the heart, great vessels, or both that are present at birth.
• Children with CHD are more likely to have associated defects such as tracheoesophageal fistula (TEF)
• CHD is second only to prematurity as a cause of death in the first year of life.
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1.Acyanotic Heart Disease L R shunt high pressure to low pressure oxygenated to unoxygenated blood
2. Cyanotic Heart Disease R L shunt
low pressure to high pressure
3. Obstructive Defects
CONGENITAL HEART DEFECTS
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ACYANOTIC HEART DISEASE1. Atrial Septal Defect
• Opening between atria• late childhood/early adulthood• S/sx: cyanosis(CHF), dyspnea,
fatigue, failure to thrive, split S2
• Mx: Abx, surgery 1-3 yo• Cx: endocarditis, heart
failure• Postop: monitor arrhythmia,
administer antibiotics
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ACYANOTIC HEART DISEASE2. Ventricular Septal Defect
• Opening in ventricular septum
• Most common• S/sx: respi infections, failure
to thrive, dyspnea, fatigue, pansystolic murmur
• Mx: close spontaneously otherwise surgery <2 yo
• Cx: pulmonary HPN, endocarditis, heart failure
• Postop: monitor arrhythmia, administer antibiotics
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ACYANOTIC HEART DISEASE3. Patent Ductus Arteriosus
• Aorta to pulmonary artery• Common in prematurity,
high altitude, maternal rubella
• females• S/sx:clubbing, dyspnea,
“machinery murmur” (2nd-3rd ICS)
• Cx: heart failure, endocarditis, pulmonary artery stasis/HPN
• Mx: Indomethacin, surgery
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CYANOTIC HEART DISEASE1. Tetralogy of Fallot (TOF)
• S/sx: cyanosis, clubbing, dyspnea, fatigue, squatting, “Tet spells”, failure to thrive, systolic murmur, polycythemia
• Cx: thromboembolism, CVA• Mx: O2, knee-chest position,
surgery 1-2 yo• Postop: monitor for arrhythmia Blalock Taussig: anastomose SC
and pulmo art. - avoid BP and venipuncture in right arm
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CLUBBING IN TETRALOGY OF FALLOT
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CLUBBING OF THE FINGERS
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CYANOTIC HEART DISEASE2. Transposition of the Great
Vessels
• Aorta from R ventricle• Pulmonary a. from L
ventricle• Males• S/sx:cyanosis,
murmurs• Mx: PGE for PDA,
Balloon catheter to create ASD, definitive surgery 1 wk-3 mos
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CYANOTIC HEART DISEASE3. Total Anomalous Pulmonary
Venous Return
• Pulmonary vein drain to SVC or R atrium
• PDA or foramen ovale essential
• S/sx: cyanosis, fatigue
• CX: R heart failure• Mx: PGE, surgery
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OBSTRUCTIVE DEFECT Coarctation of the Aorta
• Constriction of aorta• S/sx: asymptomatic HPN,
irritability, headache, epistaxis, dyspnea, claudication, higher BP in upper extremities, dec femoral and distal pulses,systolic murmur
• Cx:chronic HPN• Mx:surgery 2 yo• Postop: monitor
abdominal pain, antihypertensives
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Ndx: Ineffective cardiopulmonary and peripheral tissue
perfusion related to impaired cardiac function • Proper positioning to maintain respiration• Conserve energy to promote rest• Quiet activities and stimulation• Anticipate needs• Administer prescribed drugs
COARCTATION OF THE AORTA
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Activity intolerance r/t effects of congenital heart defect and dyspnea
• Rest periods• Adequate nutrition small frequent feedings iron supplementation
COARCTATION OF THE AORTA
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Obstructive Defect2. PULMONIC STENOSIS
Obstruction of blood flow from the right ventricle to the pulmonary artery
PULMONIC VALVE
Backflow of blood towards the right ventricle
Right Ventricle has to PUMP HARDER to push the blood to the pulmonary artery for Oxygenation
RIGHT VENTRICULAR ENLARGEMENT
RIGHT-SIDED CONGESTIVE HEART FAILURE
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Obstructive Defect3. AORTIC STENOSIS
• Involves an obstruction of the ventricular outflow of the blood
• S/SX: faint pulse, hypotension, tachycardia, poor feeding, exercise intolerance, chest pains
• DX; ECG, Echocardiography reveals left ventricular hypertrophy.
• MX:• Surgical aortic valvulotomy or prosthetic valve
replacement.• - Balloon Angioplasty to dilate the narrow valve.
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Obstructive Defect3. AORTIC STENOSIS
Obstruction of flow to the AORTA• AORTIC VALVE
Backflow of blood towards the LEFT VENTRICLE
Left Ventricle has to PUMP HARDER to push the blood to the AORTA for distribution of oxygenated blood
LEFT VENTRICULAR HYPERTROPHY with Regurgitation of oxygenated blood back to the LUNGS
LEFT-SIDED CONGESTIVE HEART FAILURE (Respiratory Signs)
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Kawasaki Disease/Mucocutaneous Lymph Node
Syndrome
• Before puberty, peaks 4 yo
• S/sx:spiking fever x 5 days, bilateral conjunctivitis, reddened pharynx, dry lips, strawberry tongue, cervical lymphadenopathy, peripheral edema, erythema and desquammation, truncal rash, arthritis
• Patho: Respi infection immune complex systemic vasculitis aneurysm and MI
• Dx: clinicalMx: Salicylates and Immunoglobulins
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KAWASAKI DISEASE
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• Risk for ineffective peripheral tissue perfusion related to inflammation of blood vessels
- Observe for chest pain, color changes, vomiting
• Pain r/t swelling of lymph nodes and inflammation of joints
- Comfort measures, administer pain medications
KAWASAKI
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KAWASAKI
Other Measures:
Protect edematous areas
Record intake and output
Offer soft food
Administer prescribed medication
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Rheumatic Fever
• Autoimmune• Grp A Beta hemolytic strep• 6-15 yo, peaks 8 yo• 1-3 wks after untreated infection• Dx: 5 major criteria –
polyarthritis, carditis, subcutaneous nodules, erytHema marginatum, sydenham’s chorea
minor – fever, polyarthralgia, hx of RF, inc ESR, antecedent strep infection
• To diagnose, either 2 major or 1 major and 2 minor
present• Cx:mitral valve insufficiency and
myocarditis
J. N. E. S.
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RHEUMATIC FEVER
Mgmt: salicylate, penicillin
Ndx:
Risk for noncompliance r/t knowledge deficit about importance of long term therapy
- prevent initial and recurrent attacks
Decreased cardiac output r/t disease process- bed rest, comfort and appropriate activities
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RHEUMATIC FEVER
Nursing Care
• Monitor vital signs
• Provide adequate nutrition
• Promote safety to prevent chorea related injuries
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Gastrointestinal Disorders
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Cleft Lip and Palate
• failure of fusion of maxillary and median nasal process
• hereditary• unilateral/bilateral• Males
Mx: surgery - Cheiloplasty• Rule of 10’s- AGE=10 wks,
WT=10 lbs, HgB=10 gm
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Cleft Palate
• midline opening of palate
• usually w/ Cleft lip• Female• surgery 6-18 mos -
allow anatomic changes <1 yo ie formation of palatine arch and tooth buds
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Ndx:• Risk for imbalanced nutrition, less than
body requirements r/t feeding problems• Risk for ineffective airway clearance r/t
oral surgery• Risk for infection during post op period
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Nursing CarePreop• Adequate nutrition; sips of fluid btw feeding in
upright position; use rubber tipped syringe; Burp • Prevent ear and upper respiratory tract infection• Address body image and speech concerns• Reassurance to parents
Postop• monitor respiratory distress d/t edema,
hemorrhage• Suction mucus and blood gently• dropper feeding 1st 3 weeks; regular feeding after• Anticipate needs and position to prevent tension
on sutures • Position side lying in cleft lip; prone in cleft palate
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Tracheoesophageal Fistula
• Communication of the esophagus and trachea• maternal hydramnios and prematurity• S/sx:coughing, choking, cyanosis, dyspnea,
excessive secretion, abdominal distention• Dx: Ba swallow
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TEF
Ndx:• Risk for imbalanced nutrition, less
than body requirements r/t inability for oral intake
• Risk for infection r/t aspiration or seepage of stomach contents into lungs
• Risk for impaired skin integrity r/t gastrostomy tube insertion site
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Nursing carePreop• Suction regularly• Elevate the head• Gastrostomy feeding• hydration• O2
Postop
1. Observe for respiratory distress
2. Proper positioning –avoid hyperextension of neck
3. Continue suction
4. Prevent wound infection
5. Provide pacifier
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Hirschprung’s Disease
• Aganglionic megacolon• Absence of innervation to a
bowel segment usually rectosigmoid colon
• No peristaltic activity in affected area
• Familial• males• S/sx:constipation,
ribbonlike stools or no meconium, abdominal distention, vomiting
• Dx: Ba enema, biopsy• Mx:colostomy, surgery
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HIRSHSPRUNG’S DISEASE
Ndx:
• Constipation r/t reduced bowel function
• Imbalanced nutrition, less than body requirements r/t reduced bowel function
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Nursing CarePreop1. Daily enemas w/ 0.9% NaCl *Tap/hypotonic water will cause cardiac
congestion or cerebral edema2. Minimal residue diet w/ vitamin supplementation3. Position semi fowlers to relieve dyspnea from
distended abdomen4. pacifier
Postop1. Observe for abdominal distention2. Small frequent feedings after NGT removal3. Colostomy care4. Assist parents to cope with children’s feeding
problems
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Intussusception• 2-6 mos• Invagination of intestine < 1 yo – idiopathic
> 1 yo – “Lead point”• S/sx:intense abdl pain,
vomiting, blood in stool “currant jelly”, abdominal distention (sausage shaped mass)
• NECROSIS: fever, tachycardia, rigid abdomen
• Dx:sonogram “coiled spring”• Mx:Ba enema (reduction by
hydrostatic pressure), surgery
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Ndx:• Pain r/t abnormal abdominal peristalsis• Risk for deficient fluid volume r/t bowel
obstruction • Nsg care:
1. NPO
2. Adequate hydration via IV therapy
3. Promote parent-infant bonding
4. Provide comfort measures - pacifier for infants
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• Hypertophy/hyperplasia of pyloric sphincter
• Males• S/sx:nonbillous vomiting,
s/sx of of dehydration and wt loss, abdominal distention, “olive” sized mass RUQ, visible peristalsis
• Dx:xray-”string sign”, USG, endoscopy
• Mx: surgery
Pyloric Stenosis
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PYLORIC STENOSIS
Ndx:• Risk for deficient fluid volume r/t
inability to retain food• Risk for infection at site of
surgical incision r/t danger of contamination from feces d/t proximity of incision to diaper area
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PYLORIC STENOSIS
Postop1. dropper feeding 4-6 hrs after surgery 45 min-
1 hr duration; oral rehydration soln then half strength breastmilk/formula at 24 hr interval
2. Side lying position
3. Monitor weight and return of peristalsis
4. Wound care
5. Pacifier for oral needs
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Celiac Disease/Gluten sensitive Enteropathy/Celiac Sprue
• Malabsorption syndrome that occurs when the mucosa of the proximal small intestine is sensitive to gluten. (wheat, rye, oats, barley)
• inability to absorb fat, thus steatorrhea, deficient fat soluble vitamins, malnutrition and distended abdomen
• S/Sx appears bet 1-5 yo after introduction of gluten in the diet.
• S/sx:diarrhea, wt loss, anorexia, irritability, anemia (Fe deficiency)
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Celiac Disease
Pathophysiology:• Intolerance for or inability to digest gluten
>>>accumulation of the amino acid glutamine>>>toxic to intestinal mucosal cell>>> intestinal villi atrophy >>>reduction of absorptive surface of the small intestine.
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Celiac Disease
• CELIAC CRISIS (due to ingestion of gluten, infections, prolonged fasting) = acute vomiting and diarrhea & may lead to F & E imbalance & rapid dehydration.
• Dx: Biopsy of the jejunum reveals the mucosal surface with hyperplastic villus atrophy. ( Definitive diagnosis of celiac disease). This characteristic lesion return to normal after dietary restriction of gluten which helps confirm the dx.
• Mx: hydration, gluten free diet, vitamin & Fe supplementation , avoid cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some chocolates, some ice cream, donuts, pies, hotdogs,
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Celiac Disease
Foods allowed:• 1. Meats: beef, pork, poultry & fish• 2. Eggs• 3. Milk & dairy products: milk, cheese,
cream• 4. Fruits & veg: all• 5. Grains: rice, corn, gluten free wheat flour,
corn flakes, corn meal & gluten free pre-cooked cereals
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Diaphragmatic Hernia
• Herniation of intestinal content into the thoracic cavity
• Left side• S/sx:respiratory difficulty,
cyanosis, retractions, (-) breath sounds affected side, scaphoid abdomen
• Cx: pulmonary HPN• Mx: ’E’ surgery
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DIAPHRAGMATIC HERNIA
Ndx:Risk for ineffective airway clearance r/t
displaced bowelRisk for imbalanced nutrition, less than
body requirements, r/t NPO status
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Nursing Care
Preop• Elevate head • Low intermittent suction
Postop1. Semi-fowlers
2. Maintain warm, humidified envt – lung fluid drainage
3. Suction prn
4. Chest pptx
5. NPO – prev pressure on diaphragm
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Necrotizing Enterocolitis
- Bowel develops necrotic patches, interfere w/ digestion, lead to paralytic ileus, peritonitis and perforation
- D/t ischemia sec shock or hypoxia, infection, immature GIT immune protection
S/sx: abdomen tense and distended, stool (+) for occult blood, > 2 ml gastric residual, bradycardia, apnea
Dx: abdominal xray
Mgmt: d/c feeding, IV or TPN, Antibiotic, colostomy, surgery for perforation
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Inguinal Hernia
• Protrusion of a bowel through the inguinal ring
• males• S/sx: painless lump in the
groin • Cx: bowel strangulation• Mx: surgery <1 yo • Post op Nursing care:
wound care
assess circulation in the
leg
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Cystic Fibrosis
• Autosomal recessive• Dysfunction of exocrine glands; inc viscosity
of mucous glands • Affects lungs, pancreas, intestines and sweat
glands• S/sx: GI - meconium ileus, rectal prolapse,
steatorrhea, malnutrition, failure to thrive
Respiratory – recurrent infection,cough, dyspnea, clubbing, cyanosis
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Sweat Gland – ”salty taste”
Other – males infertile, abnormal glucose tolerance
Dx: history, sweat test (NaCl 2-5x the normal), absence of pancreatic enzymes, immunoreactive trypsinogen in blood and pulmonary involvement
Mx: chest physiotherapy, antibiotics, pancreatic enzymes, vitamins, lung or pancreas transplant
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CYSTIC FIBROSIS
Ndx:
• Imbalanced nutrition, less than body requirements r/t inability to digest fats
• Ineffective airway clearance r/t inability to clear mucus from the respiratory tract
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Nursing Care
1. Hi calorie, Hi CHON, moderate fat diet
2. Nebulization and physiotherapy
3. Frequent Position changes when in bed
4. Oral care
5. Adequate rest and comfort
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Neurological Disorders
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Brain Tumor
• Second most common form of cancer in children• 1-10 yo, peak 5 yo• Usual location - brainstem or cerebellum• TYPES:
Astrocytoma- glial tissue; 5-8 yo
Medulloblastoma – cerebellum; 5-10 yo; cause compression of 4th ventricle; most common
Brain stem tumor – support tissue of neural cells; paralysis of 5th-7th, 9th-10th CN
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S/sx: headache, vision changes, vomiting, enlarging head circumference, papilledema, lethargy, ataxia, nystagmus, personality changes, seizures, lethargy, coma
Dx: skull films, bone scan, CT scan, Lumbar puncture, MRI, angiography
Mx: surgery, chemotx
BRAIN TUMOR
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Preop1. Stool softeners2. Dexamethasone3. Dilantin 4. Shave head5. Prepare patient and family
psychologically
BRAIN TUMOR
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Postop1. Proper position – low fowler’s2. Anticipate needs3. Saline eye drops as needed4. Monitor VS and NVS5. Regulate IV6. Observe head dressings7. Provide comfort and opportunity for self
expression
BRAIN TUMOR SURGERY(CRANIOTOMY)
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Benign Febrile Seizure
• 6 mos - 5 years • fever >/= 38.5C• generalized tonic-clonic • rarely persist > 10 minutes• Postictal stage• 30-40 % recurrence• (+) family history
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CONVULSION/SEIZURE
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NURSING CARE
• Turn child to side & allow to drool
• Do not restrain
• Do not put anything in the mouth
• Dec temp
• Refer if:
sx persist
another sx occurs
delirious/difficult to rouse after sx
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Erb Duchenne’s Paralysis
• Damage on C5-C6 due to birth trauma• Unilateral• S/sx: shoulder adducted, internally
rotated, elbow extended, forearm pronated and the wrist flexed “waiter’s tip”, (-) moro reflex
• Mx: PT, surgery• Nsg care: advise exercise and frequent
follow up
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ERB DUCHENE’S PALSYC5 & C6
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Cerebral Palsy• Damaged motor function d/t anoxic brain injury
secondary to infection, perinatal asphyxia, metabolic disorder
• Nonprogressive
• TYPES: Spastic– most common (65%); hypertonicity
Athetoid/dyskinetic – worm-like
Ataxic – wide based gait w/ repetitive movement
Mixed – spastic and athetoid
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• S/sx: spasticity/rigidity, difficulty feeding, delayed speech and motor devt, mood swings, impulsive, short attention span, irritable
• Dx: Clinical
• Mx: antispastics, antibiotics, surgery, nutrition, prevention of injury, PT
NDx: Risk for injury r/t neuromuscular impairmentSelf care deficit r/t neuromuscular impairment
- ensure safety, assist in ADL, ensure adequate nutrition, assist children achieve maximum potential
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Hydrocephalus• Impaired circulation and absorption of CSF
2 TYPES:
1. Obstructive/Noncommunicating – w/n ventricular system
2. Nonobstructive/Communicating – obliteration of SA cisterns or malfunction of arachnoid villi
S/sx: head enlargement, ant fontanel wide and bulging, scalp veins dilated, broad forehead, sclera bshows above iris, brisk tendon reflexes, spasticity, irritability, lethargy, poor appetite, cracked pot sound on percussion
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Ndx:
Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure
- monitor vs, head circumference, I and O
- O2
- position flat or head 30 deg
- do not lie on operative site
HYDROCEPHALUS
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Risk for imbalanced nutrition, less than body requirements, related to increased intracranial pressure
- NPO until bowel sounds return
- position head w/o flexion
- observe for constipation
- note how child sucks
- IV fluids
- obtain daily weight
HYDROCEPHALUS
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Spina Bifida• Collective term for all SC disorders
Spina Bifida Occulta – posterior laminae fail to fuse
- dimpling, abnormal tufts of hair
Meningocoele - meninges herniate through unformed vertebrae; protrusion covered by a layer of skin
- usually occurs in the lumbar region
- protrusion is covered by a skin layer or only the clear dura mater
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SPINA BIFIDA
Myelomeningocoele – SC and meninges protrude through the vertebrae defect
- absent motor and sensory function
- flaccidity, lack of sensation in LE
- loss of bowel and bladder control
- may be accompanied by hydrocephalus
Dx: sonography
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• Risk for infection r/t rupture or bacterial invasion of the neural tube sac
- position side lying or prone
- keep sac moist
- place under radiant warmer
- post op – prone until site is healed• Risk for ineffective cerebral tissue perfusion r/t
increased intracranial pressure
- measure head circumference
- assess for s/sx of inc ICP
SPINA BIFIDA
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• Risk for impaired skin integrity r/t required prone positioning
- reposition head every 2 hrs if w/ hydrocephalus
- change diapers frequently• Impaired physical mobility r/t neural tube d/o
- passive exercises
- may use leg braces, crutches
- inspect lower extremities and buttocks for irritation or possible infection
• Risk for impaired elimination r/t neural tube d/o
- intermittent catheterization
- surgery
SPINA BIFIDA
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Meningitis
• Inflammation of meninges
• Bacterial, Tuberculous, viral
S/sx: opisthotonus, neck rigidity, irritability, high pitched cry
Dx: Lumbar puncture, Bld C/S, Ct scan, MRI
NDx: Risk for infection r/t presence of infective organism
Tx: Abx
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Hematologic Disorders
HEMATOLOGIC DISORDERS
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Iron Deficiency Anemia
Infant’s iron supply 4-6 mos
Anemia – 9-24 mos
S/sx: pallor, tachycardia, irritability, Hg < 9 g/dl, susceptible to infection
Mgmt: iron fortified formula, iron rich diet and vitamins
Nsg care: give iron w/ vit c, use w/ dropper at the back of the mouth, expect black stools, provide iron rich food
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Hemophilia A• Inherited interference w/ blood coagulation
• Factor VIII
• Sex linked recessive
• S/sx: excessive bleeding
NB – apparent
Pre-school – accidents/falls
School age – bleeding between joints
Adolescent – ulcers, hematuria
• Mx: factor VIII transfusion
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NDx: Acute pain r/t bleeding into joints
Nursing Care
• Promote safety
• Watch out for bleeding – rest area, ice compress, elevate body part
• Monitor transfusion reaction
• Passive ROM
• Assist in gaining control of situation
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Hemophilia B
• Christmas Factor• Clotting Factor IX
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ACUTE LYMPHOCYTIC LEUKEMIA
• Uncontrolled proliferation of WBC
• Lymphoblast
• Most frequent CA in children
• 2-16 yo
• Males
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S/sx: pallor, low grade fever, lethargy, petechiae, bleeding, vomiting, anorexia, bone pain, painless lymphadenopathy
Dx:WBC variable w/ blasts, low platelet and hematocrit, anemia
BMA > 25% blast cells
LEUKEMIA
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BONE MARROW ASPIRATION
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Mx: chemotherapy
Cx: CNS s/sx, renal failure
NDx: Risk for infection r/t decreased immune function
Activity intolerance r/t reduced oxygen carrying capacity of blood
LEUKEMIA
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Nursing Care
• Prevent infection
• monitor bleeding and transfusion reactions
• Provide comfort and pain alleviation
• Health teaching
• Emotional and psychological support
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Genitourinary Disorders
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Urinary Tract Infection• Females• E coli• Ascending infection• S/Sx:infants – mimic GI d/o; dysuria, frequency,
hematuria, low grade fever, abdominal pain and bedwetting
• Dx: urine culture suprapubic any amount clean catch > 100,000/ml• Mx: antibiotic hydration
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Acute Glomerulonephritis
• Inflammation of glomeruli or kidney
• Follows infection with strep10-14 days
• 5-10 yo• Males
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S/sx:sudden onset of edema and hematuria, proteinuria, hypertension
Dx: urinalysis and 24 hour urine hypoalbuminemia inc ESR, BUN, Crea,
antistreptolysin O
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Mx: semi fowlers diuretics, antibiotics
O2 antihypertensives
Nsg Care: quiet play activities diet – normal CHON, mod salt
restriction, fluid restriction daily weight and output
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Nephrotic Syndrome
• Altered glomerular permeability(autoimmune); inc permeability to albumin
• 3 yo• Males• Minimal change syndrome • S/sx: proteinuria, edema-
periorbital area, hypoalbuminemia, hyperlipidemia
• Dx: urinalysis and 24 hr CHON, inc ESR
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Mx:steroids, immunosupressant
NDx: Risk for decreased fluid volume r/t CHON and fluid loss
Imbalanced nutrition: less than BR r/t CHON and fluid loss
Nsg care: Adequate nutrition, proper diet – decrease saltWeigh daily, monitor I and OProtect edematous areasAdminister prescribed drugsHealth teaching
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Wilm’s Tumor
• Malignant tumor of the kidney• Associated with other anomalies • 6 mos-5 yo, peaks 3-4 yo• Good prognosis• S/sx: abdominal mass, hematuria, low grade
fever, anemia, wt loss• Dx: CT scan• Mx: Nephrectomy, radiotherapy avoid abdominal palpation
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Hypospadia/Epispadia
A. Hypospadia B. Epispadia
C. Hypospadia w/ chordee
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Hypospadia - common - chordee - fibrous band
Mx: surgery
Nsg care: Post op – pain relief assist parents in coping
UROGENITAL DEFECTS
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Cryptorchidism(Undescended Testis)• Failure of one or both testes to descend• Descend up to 6 weeks at birth• May be d/t dec testosterone
S/sx: right testis more common
Mx: chorionic gonadotrophin hormone
Orchiopexy 1 yo
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Other Diseases
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Sudden Infant Death Syndrome
• 1 mo-1 year old, peaks 2-4 mos • Full term/preterm• sudden and silent• the victim seems healthy• sleeping on prone position• Theories of causation: abnormalities in the brain
and metabolic disorder
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Maternal risk factors - cigarette smoking during pregnancy, maternal age < 20 yo, poor prenatal care, low weight gain, anemia, use of illegal drugs and alcohol, low socioeconomic status
Newborn risk factors – cyanosis, tachycardia, respiratory distress, irritability, hypothermia, poor feeding
S I D S
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S I D SNsg Dx:
Dysfunctional grieving r/t loss of a child
Management• assist psychologically - intense grief and
guilt for parents
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Atopic Dermatitis
• 2 mos-3 yo• R/t food allergyS/sx: papular and vesicular skin
eruptions w/ erythema, pruritus, dry,flaky scales upon healing
Mx: reduce allergen, topical steroids
NDx: Impaired skin integrity r/t eczematous lesion
Nsg care: Reduce allergen Prevent skin dryness and
pruritus
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Normal Skin
Smooth micro-reliefLow roughnessRegular desquamation
Dry SkinTortuous micro-reliefHigh roughnessIrregular desquamation
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ATOPIC DERMATITIS
• NURSING MANAGEMENT
1. MEDS: ANTIHISTAMINES, ANTIPRURITICS, STEROIDAL CREAMS
2. Minimize the risk of infection
3. Promote skin integrity
4. Family Health teaching• Cotton fabrics, use mild detergents• Daily baths to hydrate the skin• Use topical moisturizers
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Otitis Media
• Inflammation of the middle ear• 6-36 mos, 4-6 yo• S. Pneumoniae, H. Influenzae, M. Catarrhalis• Follows URTI
S/sx: pain in affected ear, fever
Cx: hearing impairment
Mx: antibiotics, analgesics, antipyretics
NDx: Acute pain r/t inflammatory process
- provide comfort, reinforce completion of antibiotic, offer liquids and finger food (prev pain when chewing)
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Diarrhea
Viral – Rotavirus, AdenovirusBacterial – Shigella, Salmonella, CholeraProtozoan – Amoeba
TYPES:Mild: fever, irritable, 2-10 episodes/day, dry
mucous membranes, tachycardia - 2.5-5% wt lossMx: oral rehydration
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Severe: fever, tachycardia, tachypnea, pale and cool skin, apprehensive/lethargic, obvious s/sx of dehydration, UO scanty, several episodes of loose stools
- 5-15% wt lossCx: dehydrationMx: fluid and electrolyte replacementDx: Stool exam and culture, Electrolyte determinationNDx: deficient fluid volume r/t fluid losses in stools
- promote hydration and comfort, Record I and O
DIARRHEA
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Protein Energy Malnutrition
MarasmusLow calorie, low CHON
0-2 yo
(-) edema
“all skin and bone”
(+) growth retardation
Apathetic, quiet
Good appetite
Infrequent skin/hair changes
Anemia uncommon
KwashiorkorLow CHON
1-3 yo
(+) edema
Wasting variable
Growth retardation variable
Irritable, moaning
Poor appetite
(+) skin and hair changes
(+) anemia
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PoisoningUsually 2-3 yo
Soap, cosmetics, detergents, drugs
Males>females – children
Females>males – adolescent
Mx:
1. Det age wt, type of poison swallowed, ime of ingestion, route of poisoning, amt ingested, present condition of child
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2.Use syrup of ipecac to induce vomiting except:
caustic, corrosive, hydrocarbon, px is comatose
3. Activated charcoal then syrup of ipecac
4. Monitor VS
5. refer to hospital/poison control center
POISONING
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POISONING
Acetylsalicilic acid (Aspirin)
S/sx: nausea, vomiting, fever, profuse sweating, flushing, hyperthermia, hyperventilation, convulsions, coma
Mx: stabilize airway and breathing
Fluid and electrolyte replacement
Activated charcoal
Alkalinization of urine
hemodialysis
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Down’s Syndrome
Trisomy 21
Maternal age >35 yo, paternal age >55
Features: nose is broad and flat, eyelid have an extra fold of tissue at the inner canthus, palpebral fissure slants upwards, white specks in iris, tongue protrudes, back of the head is flat, neck is short, extra fat pad, low set ears, poor muscle tone, short thick fingers, simian crease, cognitively challenged
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Poor immune function
Congenital heart diseases – Ventricular Septal Defect
Cataract
ALL occurs 20x more
Mx: early education and play opportunities
prevention of infection
counseling and support
DOWN’S SYNDROME
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Child Abuse
• Non accidental injury inflicted by an adult
• Physical, emotional, sexual
• Children grow up to be abusers themselves and are violent
• Nsg Resp: treat injury, report to DSWD, NGO, Bantay Bata
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SIGNS OF CHILD ABUSE
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Substance Abuse
• Use of chemicals• Improve mental state• Induce euphoria• Peer pressure• Feel more confident• Adolescent rebellion
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TYPES OF ABUSED SUBSTANCES
Tobacco - sign of maturity
Alcohol - most frequent - no stigma
Amphetamines – sense of well being, alertness, self esteem and wt loss
Anabolic steroids – improves athletic ability
Marijuana – stress reliever bec gives a sense of well being, altered sensory perception
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TYPES OF ABUSED SUBSTANCES
Hallucinogens – distortions in vision, smell or hearing
Opiates – physiologic craving
Cocaine – inc VS, dec appetite, cardiovascular arrest, euphoria,
excitement, hallucinations
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ASSESSMENT OF SUBSTANCE ABUSE
• Failure to complete homework• Poor reasoning ability• Decreased school attendance• Frequent mood swings• Deteriorating physical appearance• Recent change in peer group• Negative perception of parents
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Nursing Intervention
• Caution against drug abuse• Provide counseling• refer to rehab facilities
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Thank you!