Pediatric Nursing Review 2
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Transcript of Pediatric Nursing Review 2
PEDIATRIC NURSING
Review
ERICKSON’S PSYCHOSOCIAL STAGES OF
DEVELOPMENT
Infancy (0 – 1 year)
Toddler (1 – 3 year)
Preschool (3 – 6 years)
School (6 – 12 years)
Adolescent (12 – 18
years)
Trust vs. Mistrust
Autonomy vs. Shame
and Doubt
Initiative vs. Guilt
Industry vs. Inferiority
Identity vs. Role
Diffusion
PIAGET’S THEORY OF COGNITIVE
DEVELOPMENT
Sensorimotor Reflexes
(0 – 2 years)
Pre-operational/Pre-
conceptual (3 – 5
years)
Reliance on reflexes to
interact with
environment
Increase use of
language; unable to put
self in another’s place;
does not understand
relationship of size,
weight, volume
PIAGET’S THEORY OF COGNITIVE
DEVELOPMENT
Intuitive (5 – 7 years)
Concrete Operations (8
– 13 years)
Magical thinking;
egocentric; tendency to
center attention on one
feature
Inductive reasoning
(specific to general);
conservation-ability to
understand things are
essentially the same
even though its shape
and arrangement are
altered
PIAGET’S THEORY OF COGNITIVE
DEVELOPMENT
Formal Operations (13 –
16 years)
Capable of
introspection,
deductive reasoning;
able to formulate
hypothesis
PHYSICAL ASSESSMENT
By what age should the anterior fontanel be
closed?
a. 2 weeks
b. 6 months
c. 12 months
d. 18 months
d. 18 months diamond shaped
Posterior triangle in 2 months
Tells hydration
Should be sitting up
PHYSICAL ASSESSMENT
Posterior fontanel closed when?
A. 2 weeks
B. 2 months
C. 8 months
D. 12 months
PHYSICAL ASSESSMENT
Respiratory
Are young children thoracic or abdominal breathers?
Chest shape
Respiratory 1st vital signs on kids is what we do!!
Boys are thoracic
Girls stay abdominal
Are young children thoracic or abdominal breathers?
A-p diameter is less than transverse
Chest shape
Infants – shape is round
Children & adolescents – transverse diameter to anteroposteriordiameter changes to 2:1
WEIGHT
Birth weight doubles by 6 months
Birth weight triples by 12 months
IQ
IQ = Mental age/Chronological age x 100
GROSS MOTOR SKILLS
2-3 months
3 months
4 months
5 - 6 months
6 months
6 – 8 months
9 months
12 months
Holds head up
Holds head and chest up when prone
Rolls front to back
Rolls back to front
Holds head steady when sitting
Sits unsupported
Sits pull self 2 standing
Stands (alone & holding on)
FINE MOTOR
Circle by 3 years
Cross by 4
Square by 5
Triangle by 6
Social development
2 month smile
3 month breast milk,
6 month stranger anxiety
9 months waves bye bye
12 months comes when called speaks one word
15 months jargon babbles
18 month copies parents
2 yr. two words
FINE MOTOR
Bring hand together
Look for items dropped
from view
Rake finger food 6
months
Bang toys together – 9
months
Grasp
Transfer object by hand
– 6 months
Use thumb to grasp – 9
months
Nesting 1 object inside
another – 12 months
PEDIATRICS FEEDING AND PLAY
0-1 yo breast milk
4-6 mo iron fortified
6-8 mon yellow veggie
Play
Infants solitary play
Toddler parallel play
Preschool associative
or cooperative play
School-age competitive
play
HEALTH ASSESSMENT
Birth – 3 year old pull
the pinna down and
back
After 3 pull the pinna
up and back
PAIN MANAGEMENT
A 10 year old child has just had an appendectomy which of following tools is appropriate a VAS visual analogue Scale
Faces for at least 3-6 year old!!!
Kindergarten count to 100, know shapes, skip jump walk backward walk a straight line
Waiting for pain management “if you let the pain get too bad, the medication will not work as well” is what a nurse says
Give pain meds around the clock
Reevaluate or evaluate the effectiveness of pain med
EXPLORE
a primary care
provider prescribes 240
mg of Cefuroxme bid
PO for a 3 year with
OM. The medication is
available in a 200mg/5
suspension
How much mLs should
the child receive with
each dose?
Feeding tube
Check placement first
Flush tubing before
and after medication
Dissolve tab in
premeasured amt. of
fluid mea
Push slowly
IMMUNIZATION
Vastus lateralis site for
infants and children less
than 2 years
After 2 year, the ventral
gluteal both of these sites
can accommodate fluid
up to 2 ml
The deltoid site has a
smaller muscle mass and
can only accommodate
up to 1 ml of fluid
because size
PLAY ACTIVITIES & SEPARATION ANXIETY
Birth -3 mo visual &
auditory
3-6 months noisemaking
objects and soft toys
6-9 months teething toys
and social interaction,
stack, build cause they
sitting up
9-12 months push pull,
popcorn popping, large
blocks pull apart
Separation Anxiety
Parents at hospital are
toddler
Begins 9 months and
peaks at 18 months
Isolation washable toys
NUTRITION
Solids introduced to infant doubles his birth weight (5
to 6 months)
Are able to sit up at this age!!!
• First, give iron-fortified cereals.
• Next, give pureed or strained foods one at a time to
assess for food allergies.
• Finally, breast milk/formula should be decreased as
intake of solid foods increase.
NUTRITION
Preterm infants < 37 weeks & < 2,500 g
50-60 kcal/kg/daily parenteral
75 kcal/kg/daily orally
Breast milk
Dentition 6-8 teeth w/in 1st year
NUTRITION
0 – 1 year
4 – 6 months
6 – 8 months
8 to 10 months
After 12 months
Breast milk or formula
Iron-fortified cereal,
such as rice cereal
Yellow vegetables,
fruits
Meat
While milk, eggs,
strawberries, wheat,
corn, fish, and nuts
NUTRITION
Toddlers—1-3 year
Finger food “picky”
3 meals & 2 snacks daily
Small portions—healthy
Limit fruit juice—4-6 oz/day d/t sugar
Preschooler—3-5 years
Certain food for a period of time
3 meals & 2-3 snacks/daily all areas food pyramid
Schooler—5-12 years
Depends on activity
Balanced diet
Likes to be included in meal planning & preparation
Adolescent—12-20 years
Growth spurts
Fast food healthy difficult
2,000—3,000 kcal/daily
PLAY
Infants
Toddler
Preschool
School-age
Solitary Play
Parallel Play
Associative or
Cooperative Play
Competitive Play
INFANT PLAY ACTIVITIES
Birth – 3 months
3 – 6 months
6 – 9 months
9 – 12 months
Visual and auditory
stimuli
Noise-making objects
and soft toys
Teething toys and
social interaction
Large blocks, toys that
pop apart, and push
and pull toys
SEPARATION ANXIETY
Begins at 9 months and peaks at 18 months.
IM MEDICATION ADMINISTRATION
The vastus lateralis site for infants and children < 2
years.
After age 2, the ventral gluteal site can be used.
Both of these sites can accommodate fluid up to 2
ml.
The deltoid site has a smaller muscle mass and can
only accommodate up to 1 ml of fluid.
MEDS ADMINISTRATION
MEDICATION ADMINISTRATION
A primary care provider prescribes 240 mg of
Cefuroxime BID PO for a 3 year old with Otitis
Media. The medication is available in a 200 mg/5
ml suspension. How many mLs should the child
receive with each dose?
5ml x 240 mg = 1200 = 6 mL
200 mg x 1 200
Or
D/A x Q
240/200 x 5 = 6
MEDS ADMINISTRATION
List 3 intervention, with rationales, that a nurse can use to decrease the risk of medication errors when administering medications
Interventions
Have 2nd nurse verify dose calculation
Obtain accurate weight of child
Mix medication with small amounts or liquid or soft foods
Rationale
Adult meds forms may be used requiring calculation of very small doses
Dosages are usually based on weight or BSA
If med is mixed in large amounts of liquid or foods, the child may refuse to finish the dose
PAIN MANAGEMENT
Effectiveness of treatment evaluation
15 min after IV
30 min after IM
30-60 min after Orally & nonpharm. Therapy
Older children can give report
Physiologic changes BP, HR, RR are temporary
changes produced by anxiety associated with pain.
Initially, elevated VS will return to normal despite
persistence of pain
Self report using pain scales is useful in children over 7
year
Children 3-7 can comprehend how to use pain rating
scale—assess their ability & validate w/parents
PAIN MANAGEMENT
FLACC Behaviors 0-2 2-7 months
0/10 10 worst
CHEOPS 4/13 13 worst 1-5 years
FACES Use Drawing 3-older
VAS Scale numbered 7-older or as y/4.5
0-10 point to #
MEDICATION ADMINISTRATION
When administering oral medications to a child with a feeding tube, the nurse knows to:
a. Flush the tubing with NS before and after administration of the medication.
b. Dissolve tablets in a premeasured amount of fluid, measure into a syringe, and give slowly into the side of the mouth to prevent clogging the feeding tube.
c. Push slowly on the plunger of the administration syringe to gently administer the medication through the feeding tube.
d. Check tube placement, administer medication by gravity flow, flush adequately, and clamp tubing.
OTIC ADMNISTRATION
Birth to 3 years – Pull the pinna (auricle) down and
back.
After 3 years – Pull the pinna (auricle) up and back.
PAIN MANAGEMENT
A 10-year-old child has just had an appendectomy
following a ruptured appendix. A nurse is
monitoring the child’s response to antibiotics,
postoperative healing, and pain control Which of
the following tools is most appropriate for assessing
the child’s pain?
a. FLACC (Faces, Legs, Activity, Cry, Consolability
Scale)
b. FACES pain rating scale
c. Children’s Hospital Eastern Ontario Pain Scales
(CHEOPS)
d. Visual Analogue Scale (VAS)
PAIN MANAGEMENT
A nurse suspects that a 15-year-old adolescent is
experiencing pain. The nurse asks if the
adolescent would like her pain medication. The
adolescent tells the nurse that she will wait until the
pain worsens. Which of the following statements by
the nurse is most appropriate in response to the
adolescent’s pain?
a. “If you let the pain get too bad, the medication
will not work as well.”
b. “Just let me know when you are ready.”
c. “You need to take your pain medication now.”
d. “Are you sure you don’t want anything now?”
PAIN MANAGEMENT
Thirty to 60 minutes following the administration of an
oral pain medication to a child, it is important that a
nurse
a. Document the child’s pain on a rating scale.
b. Evaluate the effectiveness of the pain
medication.
c. Assess the child for bowel sounds.
d. Massage the child’s painful area.
HOSPITALIZATION
Infant
Toddler
Preschooler—separation anxiety too
School-age--seeks information for a way of control, sense when not being told the truth, stress related to separation from peers and regular routine
-
Adolescent--aintain composure, embarrassed about losing control, worries about outcome, may not be compliant if it makes them appear different from peer group
Experiences stranger anxiety
Experiences separation anxiety
Harbors fear of bodily harm; fears hospitalization is a punishment will ask for a Band-Aid!!!! They think they did something wrong
Fear loss of control
Body-image disturbance; feelings of isolation from peers
7YEAR OLD IN HOSPITAL APPROPRIATE NEEDS
Answer: provide play
activities that foster a
sense of normal routine
Girl like arts and craft
Boys like things to build
Toddler no small lago’s
because choking
Friction toys not near
oxygen
AGE-RELATED INTERVENTIONS
Infant
Toddler
Preschooler
School Age
Adolescent
Near nursing station, consistent caregivers
Parent to provide regular routine, appropriate choices—autonomy, consistent caregivers
Explain procedures, encourage independence—self care, validate feelings, express feelings, toys to allow for expression, “Do you want your med in a cup or spoon, younger children to handle equipment
Provide factual information, express feelings, maintain normal routine—time for school work, encourage to contact peer group
Factual information, include in planning of care for powerlessness, encourage contact peer group
HOSPITALIZATION
Which of the following nursing interventions is most
appropriate for the needs of a 7-year-old child being
hospitalized for an extended time?
a. Bring security items such as a toy and blanket
b. Provide play activities that foster a sense of
normal routine
c. Limit choices whenever possible
d. Restrict family visiting hours
DEATH AND DYING
Which of the following nursing interventions is the
most appropriate when working with a school-age
child who has a terminal disease?
a. Give factual explanations of the disease,
medications, and procedures
b. Perform all care for the patient
c. Tell the child that everything will be okay
d. Reinforce that being in the hospital is not a
punishment for any thoughts or actions
HYPOXEMIA
Tachypnea
Tachycardia
Restlessness
Pallor of the skin and
mucous membranes
Elevated blood
pressure
Work of breathing
Confusion and stupor
Cyanosis of skin and
mucous membranes
Bradypnea
Bradycardia
Hypotension
Cardiac dysrhythmias
Early Late
BRONCHIAL (POSTURAL) DRAINAGE
Schedule treatments 1 hour before meals or 2
hours after meals to decrease the likelihood of the
child vomiting or aspirating.
Bronchial drainage is more effective if other
respiratory treatments (e.g., bronchodilator
medication and/or nebulizer treatment) are
performed 30 minutes to one hour prior to postural
drainage.]
Give a treatment first if they are getting a treatment
and CPT
SUCTIONING
Suction should take no longer than 5 seconds.
Suction catheters should be one-half the size in
diameter of the child tracheostomy tube.
It is no longer the standard of practice to instill
sterile saline into the tracheostomy tube prior to
suctioning.
HYPOXEMIA
When assessing a child removed from an oxygen tent, a nurse recognizes which of the following signs and symptoms as an early indication of hypoxemia?
a. Nonproductive cough
b. Hypoventilation
c. Nasal flaring
d. Nasal stuffiness
Rationale: signs of hypoxemia early! Nonproductive cough, hypoventilation and nasal stuffiness are signs and symptoms of oxygen toxicity plus sub-sternal pain, N/V/Fat/H/sore throat
OXYGEN TOXICITY
Which of the following is the most appropriate nursing
interventions for a child experiencing oxygen
toxicity?
a. Immediately discontinue oxygen administration
b. Increase humidification of oxygen
c. Use lowest possible flow rate of oxygen
d. Monitor oxygenation with a pulse oximeter
Rationale: interventions include using lowest level
necessary to maintain adequate SaO2 levels. O2
should be discontinued gradually, should be
humidified.
OXYGEN SATURATION
Normal values
Acceptable values
Emergency value
Life-threatening value
95 to 100%
91 to 100%
Less than 86%
Less than 80%
OXYGEN ADMINISTRATION
A child with cystic fibrosis is hospitalized with an
acute episode of pulmonary manifestations. Which
of the following nursing interventions is
contraindicated for this child?
a. Perform chest physiotherapy three times daily
b. Administer oxygen at an increased flow rate
c. Deliver aerosolized medication to open bronchi
d. Teach the child to use a flutter mucus clearance
device
ASTHMA
Manifestations of asthma
Mucosal edema
Bronchoconstriction (from bronchospasm)
Excessive secretion production
Expiratory wheeze
Prolonged expiratory phase
Nonproductive, hacking cough know if having asthma attack you hear
Wheezes can be audible
Appearance may show enlarge chest wall anteroposterior diameter
ASTHMA
Treatment Beta 2 adrenergic agonists are bronchodilators
Albuterol
Salmeterol
Terbutaline
Glucocorticoids Prevent inflammation
Suppress airway mucus production
Promote use of beta2 receptor
Beclomethasone QVAR use low dose, difficulty speaking, hoarseness candidiasis
Prednisone
Pulmicort
Flovent
Leukotriene Antagonist Singulair
Mast cell stabilizer Cromolyn Sodium
Monoclonal Antibodies Xolair
B before C Beta agonist then Corticoid
No CPT during an asthma attack.
ASTHMA
A child is exhibiting suspected clinical manifestations
of asthma. The mother asks the nurse what tests
will be necessary to diagnose her child. Which of
the following diagnostic procedures should the
nurse tell the mother is most accurate for
diagnosing asthma?
a. Arterial blood gases
b. Chest x-ray
c. Pulmonary function tests
d. Allergy tests
ASTHMA
A child experiencing an acute asthma attack presents
to the ED. Which of the following medications
should a nurse prepare to administer to the child as
an intervention for an acute asthma attack?
a. Terbutaline (Brethine)
b. Beclomethasone dipropionate
c. Prednisone
d. Albuterol (Proventil) is expensive Proventil
albuterol is cheaper
INHALED STEROIDS
Side Effects
Difficulty speaking
Hoarseness
Candidiasis
TONSILLITIS
Tonsils filter viruses and bacteria.
Lymph tissue.
Highly vascular.
Tonsillitis caused by group A beta-hemolytic streptococci (GABHS)
Chronically infected tonsils may pose a potential threat to other parts of the body. Some children who have frequent bouts with severe tonsillitis may develop other diseases, such as rheumatic fever and kidney infection.
In younger children d/t immature immune systems
Tonsillectomy pre-op – CBC (anemia & infection)
RN intervention Tonsillitis (symptomatic—viral: rest, fluids, warm salt water gargles, Tylenol or ibuprofen for pain, NPO if surgery!
Tonsillectomy – post-op Side lying position initially with HOB up when fully awake
Nothing sharp in mouth, no straws, no sharp food
Look for frequent swallowing, clearing throat, restlessness, bright red emesis, tachycardia and/or pallor
Provide ice collar and throat moist
Clear liquid, soft, bland foods—no fruit punch
Avoid red colored foods and milk initially
Discourage coughing, throat clearing, and nose blowing
Limit strenuous activity for 2 weeks
Notify MD if bright red bleeding occurs, increase pain, lack of oral intake
TONSILLECTOMY
Discharge—must be able to tolerate oral fluids and soft foods, & void prior
Instructions
Call doctor if difficulty breathing, bright red bleeding, lack of oral intake, increase in pain and/or signs of infection
Not to put anything sharp in mouth
No spicy food or hard, sharp foods like corn chips
Limit strenuous activity and physical play w/no swimming for 2 weeks
Full recovery occurs usually within 10 days – 2 weeks!
RESPIRATORY INFECTIONS
Respiratory infections are less common in infants
from birth to 3 months of age because maternal
antibodies offer protection.
CROUP SYNDROMES
Bacterial Epiglottitis
Medical emergency
Caused by Haemophilus influenzae
Dysphonia, Dysphagia, Drooling
Inspiratory stridor
Sore throat, high fever
Tripod positioning
Racemic epinephrine
Prepare for intubation
Corticosteroids
Antibiotics
DO NOT EXAMINE THE CHILD’S THROAT WITH A
TONGUE BLADE OR TAKE THROAT CULTURES.
CROUP SYNDROMES
Croup or Acute Laryngotracheobronchitis (LTB)
Causative agents: RSV, influenza A and B, and
Mycoplasma pneumoniae
Barky cough
Inspiratory stridor
Low-grade fever
URI
Racemic epinephrine
Corticosteroids
Use of warm or cold mist
Possible need for emergency airway
DO NOT EXAMINE THE THROAT
RSV
Diagnosis of Respiratory Syncytial Virus (RSV) is
accomplished through
a. Collection of a sputum specimen
b. A throat culture
c. Nasal aspiration
d. Obtaining blood for a CBC
RSV
What are nursing interventions that would be
expected for a child hospitalized for pneumonia
caused by RSV?
Antipyretics for fever
O2 w/cool mist for comfort
IV &/or oral fluid therapy
Postural drainage and CPT
RESPIRATORY ILLNESS
Viral infections more common in toddler and
preschooler. Incidence decreases by age 5.
GABHS and Mycoplasma pneumoniae rates
increase after age 5.
RSV more common during winter and spring.
Mycoplasma pneumoniae more common in autumn
and early winter.
CYSTIC FIBROSIS
Hereditary; autosomal recessive trait; both
parents must carry the trait
Dysfunction of exocrine glands, causing glands to
produce thick, tenacious mucus
Thick mucus obstructs respiratory passages; also,
obstructs secretory ducts of the pancreas, liver, and
reproductive organs
Sweat and salivary glands excrete excessive
amounts of sodium and chloride
Bronchiectasis and emphysema may develop with
pulmonary fibrosis (these are two most common the
are sterile too reproductive wise)
CYSTIC FIBROSIS
Diagnostic Tests
Sweat chloride test
Absent pancreatic enzymes
Stool analysis indicating steatorrhea (undigested fat)
and azotorrhea (foul-smelling from protein)
Pulmonary function
Sputum C & S—infection
Abdominal X-ray—detects meconium ileus
CYSTIC FIBROSIS
Interventions
Bronchodilators then CPT (do 1 hour before meals or 2
hours after meals)
Flutter mucus clearance device
Pulmozyme nebulizer to decrease viscosity of mucus
Pancreatic enzymes with meals and snacks
High-caloric, high protein diet
Multiple vitamins, including water-soluble forms, of
vitamins A, D, E, and K
CYSTIC FIBROSIS
All of the following are assessment findings seen in a
child with cystic fibrosis except for:
a. Wheezy respirations
b. Clubbing of fingers and toes
c. Barrel-shaped chest
d. Rapid growth spurts
CHD
Key points
Present @ birth because anatomic abnormalities
Result primarily in HF and hypoxemia
Prevent normal blood flow
Any structural lesion in heart or blood vessel that is
directly proximal to the heart = CHD
Many defects spontaneously close
Diagnosed in 1st yr. of life
CHANGES AT BIRTH
FIG. 25-1 Changes in circulation at birth. A, Prenatal circulation. B, Postnatal
circulation. Arrows indicate direction of blood flow. Although four pulmonary veins
enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left
atrium; RV, right ventricle; LV, left ventricle.
RA
3 mm Hg
72-80%
RV
25/0-5 mm Hg
72-80%
Ao
115/80 mm Hg
95%PA
25/15 mm Hg
72-80%PV
9 mm Hg
95%LA
5-10 mm Hg
95%
LV
120/0-10 mm Hg
95%
ATRIAL SEPTAL DEFECT
Figure 25-1 ASD
VENTRICULAR SEPTAL DEFECT
Figure 25-2 VSD
ATRIOVENTRICULAR CANAL DEFECT
Unn Figure 25-3 Atrioventricular canal defect
PATENT DUCTUS ARTERIOSUS
Figure 25-4 PDA
COARCTATION OF THE AORTA
Figure 25-5 Coarctation of the aorta
COARCTATION
Increased blood pressure in the UE.
Increased saturation in the UE.
Weak or absent pulses in the LE
Nosebleeds
Headaches
Leg pain
Weak or absent LE pulse (indicate decreased CO)
AORTIC STENOSIS
Unn Figure 25-6 Aortic stenosis
PULMONIC STENOSIS
Unn Figure 25-7 Pulmonic stenosis
TETRALOGY OF FALLOT
Unn Figure 25-8 TOF
TOF
Pulmonary Stenosis
VSD
Overriding Aorta
Right ventricular hypertrophy
Polycythemia
Squatting position
Clubbing of fingers
Murmur
Severe dyspnea
Hypercyanotic spells
Acidosis
FTT
Growth retardation
TRICUSPID ATRESIA
Figure 25-9 Tricuspid atresia
TRANSPOSITION OF THE GREAT ARTERIES, OR
TRANSPOSITION OF THE GREAT VESSELS
Figure 25-11 Transposition of great vessels
TOTAL ANOMALOUS PULMONARY VENOUS
CONNECTION
Figure 25-12 Total anomalous
pulmonary venous connection
TRUNCUS ARTERIOSIS
HYPOPLASTIC LEFT-SIDED HEART
SYNDROME
Unn Figure 25-14 Hypoplastic left-sided heart syndrome
IMPLEMENTATION/ASSESSMENT
Palpate peripheral pulses, noting rhythm
irregularities and decreased strength or inequality
Palpate extremities for slow cap refill
Auscultate HR & rhythm,
Assess for bradycardia, tachycardia, or
dysrhythmias, heart sounds, murmurs or extra
sounds
Palpate and percuss abdomen for enlarged liver
and/or spleen
IMPLEMENTATION/ASSESSMENT
Sign & symptoms of HF
Impaired myocardial function
Tachycardia
Diaphoresis
decreased UOP
Fatigue
Pale & cool extremities
Weak peripheral pulses
Cardiomegaly
FTT
Anorexia
IMPLEMENTATION/ASSESSMENT
Sign & Symptoms of Pulmonary Congestion
Tachypnea
Dyspnea
Retractions
Nasal flaring
Exercise intolerance
Stridor
Grunting
Recurrent respiratory infections
IMPLEMENTATION/ASSESSMENT
Sign & symptoms of Systemic Venous Congestion
hepatomegaly
Peripheral edema
Ascites
Neck vein distention (not seen in infants)
Signs & Symptoms of Hypoxemia
Cyanosis
Clubbing
Polycythemia
Squatting
Chest deformities
Hypercyanotic spells (blue or “Tet”) = acute cyanosis and hyperpnea!
IMPLEMENTATION
Improve cardiac function
Administer Digoxin (check K, double check dose with another
RN, apical for one minute)
Afterload reduction
Monitor BP (before & after ACE inhibitors, assess for ↓BP,
monitor electrolytes)
Decrease cardiac demands
Rest, cluster care, minimize crying, etc.
Reduce respiratory distress
↑HOB, O2
Maintain nutritional status
Need ↑calories d/t ↑metabolic demands
Promote fluid loss
Diuretics, I & O, weight, electrolytes, hydration, fluid restriction
Support child/family
MANAGEMENT OF HYPOXEMIA
Children with heart defects can have hypercyanotic
“Tet” spells which can result in severe hypoxemia.
Immediately place the child in the knee-chest
position, attempt to calm the child, and call for help.
CARDIAC CATHETERIZATION
If bleeding occurs at the insertion site after the
cardiac catheterization, the first action the nurse
should implement is to
a. Apply pressure
b. Administer vitamin K
c. Call the surgeon
d. Apply a tighter pressure dressing
DIGOXIN
Administer one hour before or two hours after
feedings.
If the child vomits, do not re-administer the
dose.
If a dose is missed by more than 4 hours, withhold
the dose and do not double the next dose.
Observe for signs of digoxin toxicity:
slow pulse,
decreased appetite,
N/V
EPISTAXIS
Active bleeding from nose
Restlessness & agitation
Have child sit up with head tilted slightly forward to
promote drainage out of nose instead of down the
back of the throat.
Apply pressure to the lower nose.
Cotton or tissue can be packed into the nares that
is bleeding.
Ice across bridge of nose.
If bleeding last longer than 30 min., see medical
care.
LEUKEMIA
Most common cancer of childhood
Bone marrow dysfunction
Causes an increase of immature WBCs (blasts) to
be produced
Deficient RBCs cause anemia
Deficient mature WBCs (neutropenia) increase risk
for infection
Deficient platelets (thrombocytopenia) cause
bruising
Invasion of CNS causes increased ICP
Invasion of bone marrow causes bone bain
LEUKEMIA NURSING INTERVENTIONS
Good oral care. Soft brushes.
Avoid rectal temperatures.
Soft, bland diet.
High fiber diet.
Stool softeners/laxatives as needed.
Weigh daily.
Encourage fluids.
Prepare for hair loss.
LEUKEMIA
Low grade fever
Pallor
Increased bruising and petechiae
Listlessness
Enlarged liver, lymph nodes and joints
Constipation
Headache
N/Anx
Low platelet & RBC
Increased immature WBC
Late manifestations Hematuria
Ulceration in mouth
Enlarged kidneys and testicles
Increased intracranial pressure
IRON DEFICIENCY ANEMIA
Most prevalent nutritional and mineral deficiency in
the US.
Common in ages 6 months to 2 years and in
adolescents 12 to 20 years.
Hgb requires iron. Iron deficiency will result in
decreased Hgb levels
Can decrease oxygen to tissues
Cause growth retardation and developmental
delays.
Whole milk is not a good source of iron.
IRON DEFICIENCY ANEMIA
SOB
Pallor
Fatigue
Brittle fingernails
Systolic murmur
Labs:
CBC
RBC
RETICULOCYTE COUNT
FERRITIN
NURSING INTERVENTIONS
Preterm or LBWI require iron supplements
Breastfeed younger than 4—6 months
Iron-fortified formula
Modify diet—high iron, Vit. C & protein
Allow frequent rest periods
Restrict milk intake in toddlers.
Give only 1 qt. per day
Avoid until after a meal
Don’t carry bottle or cups of milk
NURSING INTERVENTIONS
Restrict milk intake in toddlers.
Give iron 1 hour before or 2 hours after milk or antacid. Give on empty stomach.
Give iron with vitamin C to help increase absorption.
Give with straw to avoid staining teeth. Rinse mouth out with water.
Stools may be tarry.
Increase fluids to prevent constipation.
Dietary sources: dried legumes, nuts, green leafy vegetables, red meat, foods iron fortified
Use Z track for parenteral injection—Don’t massage
BLOOD STUDIES
2 months
6 to 12 years
12 to 18 years
Hbg: 9 to 14 g/dL
Hct: 28 to 42%
Hbg: 11.5 to 15.5 g/dL
Hct: 35 to 45%
Hbg: 13 to 16 g/dL
(male)
Hbg: 12 to 16 g/dL
(female)
Hct: 37 to 49% (male)
Hct: 36 to 46 (female)
Age Hgb/HCT
IRON
A nurse is administering parenteral iron dextran to a
child by the Z-track method. Which of the following
strategies is correct when using the Z-track method
to administer iron?
a. Watch the child carefully for an allergic
reaction after administration.
b. Use the deltoid muscle for administration in
school-age children.
c. Massage the injection site for comfort after
administration.
d. Administer no more than 3 ml of iron into one site
at a time.
SICKLE CELL DISEASE
Autosomal recessive genetic disorder.
Promote REST
OXYGEN
Pain management: Tylenol or ibuprofen, opioids for severe pain.
Warm packs to painful joints.
Maintain fluids.
Blood products/exchange transfusion.
PROM to prevent venous stasis.
Prevent infection—hand washing, prophylactic penicillin
Complications: CVA and Acute Chest Syndrome Seizures, abnormal behavior, slurred speech, change in
vision, vomiting, severe headache
CVA: blood transfusions Q3-4weeks prevention
Chest syn.—chest pain, fever 101.3 F or higher, congested chest, tachycardia, dyspnea, retractions, decreased O2 sat
SICKLE CELL DISEASE
LABS:
Screening
CBC
Sickledex (detects HbS)
HGB electrophoresis (definitive dx)
Diagnostics:
Transcranial Doppler (TCD)
Assess intracranial vascular flow/detects CVA
Annually 2-16 yrs
HEMOPHILIA
X-linked recessive disorder.
Hemophilia A
Deficiency of factor VIII
Classic hemophilia
Accounts for 80% of cases
Hemophilia B
Deficiency of factor IX
Christmas disease
HEMOPHILIA
Labs:
aPTT
Factor specific assays
Platelets
Prothrombin
Whole blood clotting time
Diagnostic:
DNA
NURSING INTERVENTIONS
Avoid rectal temperatures.
Avoid unnecessary skin punctures.
Apply pressure for 5 minutes to injection sites.
Monitor urine, stool, and nasogastric fluid for occult
blood.
Rest and immobilize affected joints (hemarthrosis).
Arthrocentesis!
Elevate and apply ice to affected joints.
Soft toothbrush.
Medic Alert bracelet.
HEMOPHILIA
DDAVP—vasopressin increase factor VIII, not
effective for Hem. B
Factor VII
Corticosteroids
NSAID’s
Complications
Uncontrolled bleeding
Joint deformity—rest, immobilize, elevate, ice, ROM
after bleeding, ideal wt., exercise encourage
HEMOPHILIA
True or False:
Aspirin and ibuprofen are the best choices for pain
relief in a child with hemophilia.
RHEUMATIC FEVER
Inflammatory disease of connective tissue which
can include the connective tissue of the heart,
joints, CNS, and subq tissue.
Rheumatic fever can cause RHD which can result
in cardiac valve damage.
Usually occurs within 2 to 6 weeks following an
untreated upper respiratory infection (GABHS).
RHEUMATIC FEVER
Major Criteria
Carditis
Polyarthritis
Chorea – involuntary muscle movements, muscle
weakness, etc. (this is transitory & will resolve)
Subq nodules
Rash (erythema marginatum) – pink macular rash on
trunk and abdomen (not on face)
Minor Criteria
Fever
Arthralgia
NURSING INTERVENTIONS
Penicillin (erythromycin if child allergic to PCN) Assess for allergic response (hives, rash, anaphylaxis)
Assess for N/V/D
Aspirin for anti-inflammatory effect (rheumatic fever is bacterial and not viral in origin) Bed rest
Assist w/ADL’s if chorea prevent the child from bathing, feeding School work arranged
Chorea is self-limiting
Follow prescribed prophylactic treatment 2 daily doses of 200,000 penicillin
Monthly IM of 1.2 mill units of penicillin
Or Daily PO dose of 1 g of Sulfadiazine
Obtain prophylaxis therapy FOR ALL DENTAL WORK & INVASIVE PROCEDURES
ARRANGE medical follow-up Q5years
Elevated or rising serum antistreptolysin-O (ASO) titre – most reliable
IMMUNIZATIONS
Contraindications
Moderate to severe illness
Allergies (e.g., specific medications, eggs, gelatin, or
any vaccine)
Serious reaction following vaccine administration in the
past
History of seizures or other neurological condition
Immunosuppression (e.g., cancer, HIV, chronic steroid
use)
Blood transfusion, immunoglobulin, or recent TB test
Pregnancy
Vaccination Drug Contraindications Ages
DTap Adacel &
Boostrix.
Encephalopathy, seizures 2, 4, 6 months 15-18 months
Td
Hib allergic reaction latex, gelatin,
thimerosal (mercury)2, 4, 6, 12-15 months
RV rotavirus RotaTeq,
Rotarix
Diarrhea, vomiting, HIV 3 doses: 6 weeks
4-10 wks. apart
2 doses: 6 weeks
then 4 wks.
later
IPV (Poliovirus) Ipol allergic formaldehyde, neomycin,
streptomycin, or polymyxin B2, 4, 6-18 months 4-6 years
MMR Pregnancy, neomycin, gelatin 12-15 months, 4-6 yrs.
Varicella Pregnancy gelatin neomycin 12-15 months, 4-6 yrs.
PCV pregnancy 2, 4, 6, 12-15 months
Hep A pregnancy 12 months
Hep B Baker’s yeast 12 hrs after birth, 1-2 months,
6-8 months
Flu eggs TIV: Annually 6 months LAIV: @ 2 yrs.
nasally
MCV4 Guillain-Barre 11-12 yrs.
HPV2 HPV4 Yeast, pregnancy HPV2: 11-12 yrs (9 minimum)
HPV4: males (9 yrs.)
COMMUNICABLE DISEASES
Varicella (Chickenpox) Varicella-zoster virus VZV
No longer contagious once lesions have crusted over
Contagious 1 day before lesions to 6 days after first lesions appear
Very itchy
Direct contact, droplet, Incubation 2-3 weeks
Rubella (German Measles) Low-grade fever mild rash lasting 2 to 3 days
Rash begins on face, spreading down trunk
Prevent exposure to pregnant women
14-21 day incubation Contagious 7 days b4 to 5 days after rash appears
Measles (Rubeola) High fever
Koplik spots
Rash begins at hairline and spreads down body
Respiratory tract, urine, blood, 1-20 day incubation,
Contagious 4 days b4 to 5 days after rash appears
Pertusis (Whooping Cough) Nighttime cough; may have mucous plug
Droplet Isolation
Direct contact, indirect contact w/contaminated articles
6-20 days incubation, contagious during catarrhal stage b4 onset of paroxysms
Mumps Swollen parotid glands; earache with chewing
Paramyxovirus, contagious immediately b4 & after swelling begins
Saliva of infected person, direct contact, droplet, 14-21 day incubation
Infectious Mononucleosis Restrict activities for 2 to 3 months
OTITIS MEDIA
Lower incidence in breastfed infants.
Hearing difficulties and speech delays if OM becomes a chronic condition.
Myringotomy and placement of tympanoplasty tubes may be indicated for the child with multiple episodes
Tubes usually come out by themselves in 6 to 12 months.
IgA in breast milk—protect against infection
Acetaminophen 10—15 mg/kg Q4
Ibuprofen 10 mg/kg Q6
Amoxicillin is 1st Choice 4 OM Give high dose amoxicillin
80-90 mg/kg/day
Augmentin & azithromycin are 2nd line 10-14 days course
Observe for allergic reaction (rash, difficulty breathing etc.)
Discourage use of Decongestants or Antihistamines
Sit upright
Avoid smoke, people w/viral or bacterial respiratory infections
Up to date immunizations
WILM’S TUMOR (NEPHROBLASTOMA)
Malignancy that occurs in the kidneys or abdomen.
Metastasis is rare.
Avoid preoperative palpation of Wilm’s tumor.
Treatment involves:
Preop chemotherapy or radiation to decrease size of
tumor
Surgical removal of the tumor and affected organs
Chemo from 6 to 15 months.
NEUROBLASTOMA
Malignancy that occurs in the adrenal gland, the
sympathetic chain of the retroperitoneal area, head,
neck, pelvis, or chest.
Presents as asymmetrical, firm, nontender mass
in the abdomen. This mass crosses the midline.
Treatment involves:
Surgical removal of tumor.
Radiation in an emergency to decrease the size of a
tumor that is compressing the spinal cord.
Radiation to decrease the size of the tumors and
palliation for metastasis.
BONE MARROW DEPRESSION RESULTING IN ANEMIA,
NEUTROPENIA, AND/OR THROMBOCYTOPENIA
Monitor blood counts for anemia, neutropenia, & thrombocytopenia.
Monitor VS, low-grade temp. may be sign of infection.
Protect from sources of infection.
Avoid invasive procedures.
Avoid ASA/NSAIDs.
Administer filgrastim (Neupogen) to stimulate WBCproduction.
Administer epoetin alfa (Procrit) to stimulate RBCformation.
Administer interleukin-11 to stimulate PLATELETformation.
Soft toothbrush.
Rest periods.
A CHILD WHO IS 2 DAYS POSTOPERATIVE SURGICAL
REMOVAL OF A WILM’S TUMOR IS SOBBING AND
REPORTING ABDOMINAL PAIN. THE CHILD WAS
MEDICATED 30 MIN. AGO, AND THE NURSE OBSERVES
THAT THE CHILD’S ABDOMINAL GIRTH HAS INCREASED BY
6 CM FROM 2 HR PREVIOUSLY. THE CHILD’S SKIN IS COOL
AND MOIST. WHICH OF THE FOLLOWING ACTIONS SHOULD
THE NURSE TAKE FIRST?
A. ASSESS VITAL SIGNS AND DRESSING
B. PROVIDE DIVERSION FOR 30 MORE MINUTES
TO ALLOW MEDICATION TO TAKE EFFECT
C. REPOSITION THE CHILD INTO THE SEMI-
FOWLER’S POSITION
D. PROVIDE THE CHILD WITH A QUIET
ENVIRONMENT
HIV/AIDS
Viral infection—infects the T-lymphocytes, causing immune dysfunction.
CD4+ T-lymphocyte count determines the level of immuno-suppression.
Pregnant women with HIV are usually given antiviral medications during pregnancy.
Retrovir (Zidovudine)
14 wks. Gestation, thru out, & before onset of labor or C-section
Don’t breastfeed
Give 4 6 wks. After delivery
at least 30 minutes before or 1 hour after a meal
LAB: Enzyme immunoassay (antibody screen)
Confirmed by + Western Blot Testing
HIV/AIDS
Which of the following infections indicates that a child
with AIDS is severely ill?
a. Oral-pharyngeal candidiasis
b. Otitis media
c. Pneumocystis carinii pneumonia (PCP)
d. Herpes simplex virus
BURNS
First Degree
Superficial
Sunburn
Pain
Second Degree
Partial thickness
Extremely painful
Scalds
Third Degree/Fourth Degree
Full-thickness
Nerve endings destroyed = no pain
Lava burn
BURNS
Signs of inhalation injury may include mouth and
nose. Maintain airway.
Stop the burning process.
Flush with water.
Remove clothing.
Cover burn with clean cloth.
Provide warmth.
Obtain tetanus prophylaxis.
Moderate to severe burns: fluid replacement.
Pain management prior to wound care.
Wet dressing prior to removal.
SKIN INFECTIONS
Match the following skin disorders with their cause.
____Impetigo contagiosa A. Fungal infection
____Scabies B. Bacterial infection
____Lyme disease C. Viral infection
____Cold sore, fever blister D. Spirochete
____Ringworm E. Burrowing mite
ECZEMA
Which of the following medications can be used for
children with eczema?
Corticosteroids
Accutane
Peroxide
Antihistamines
Calamine lotion
HOW IS CRADLE CAP TREATED?
GASTROINTESTINAL
Rotavirus is a common cause of diarrhea in young
children.
Metronidazole (Flagyl) is used for the child who is
symptomatic of C. difficile.
Mild dehydration is 5% weight loss in infants.
Moderate dehydration is 10% weight loss in infants.
Severe dehydration is 15% weight loss in infants.
PINWORM (ENTEROBIUS VERNICULARIS)
Parasitic worm whose eggs when inhaled or
swallowed can cause perianal itching.
To assist in diagnosis: transparent tape is placed
over anus of child at night. Remove tape prior to
child awakening, toileting or bathing. Tape sent to
lab.
Wash bed linens and underwear in hot water and
dry in hot clothes dryer daily for several days.
Cleanse toys and child care areas thoroughly to
prevent further spread of disease.
Treat with PinX
ORAL REHYDRATION THERAPY (ORT)
Foods and fluids to avoid:
Fruit juices, carbonated sodas, and gelatin, which are
all high in carbohydrates, low in electrolyte content,
and have a high osmolality.
Caffeine, due to its mild diuretic effect.
Chicken broth or beef broth, which has too much
sodium and not enough carbohydrates.
Bananas, rice, applesauce, and toast (BRAT diet).
This diet carries low nutritional value, high carbohydrate
content, and low electrolytes.
PICA
Pica should be considered in which of the following
children presenting to the health clinic?
a. 7-year-old with nausea and vomiting for the
past 3 days.
b. 4-year-old with history of celiac disease
presenting with anemia and abdominal pain.
c. 2-year-old who is still drinking from a bottle and
presents with anemia.
d. 4-month-old who presents with crying, irritability,
and reddish-colored stools.
GI
Which of the following is the term used to describe
impaired motility of the GI tract?
a. Malrotation
b. Obstruction
c. Abdominal distention
d. Paralytic ileus
HIRSCHSPRUNG
Congenital aganglionic megacolon
Males > Females
Impaired colonization of ganglion distal portion of
GI tract
Internal sphincter fails to relax d/t missing inhibitory
neurotransmitter (NO)
Obstruction d/t preventing evacuation of stool, gas,
liquids
Enterocolitis
Stool accumulates
Absence of peristalsis
HIRSCHSPRUNG
HIRSCHSPRUNG
Diagnostic: rectal biopsy, barium enema
Failure 2 pass meconium w/in 24-48 hours
Refusal 2 feed
Bilious vomiting
Abdominal distention
FTT
Constipation
Ribbon-like foul stools
HIRSCHSPRUNG
Surgical removal aganglionic portion of bowel
1st 2 temporary ostomy proximally
2nd corrective surgery (wt. approx. 9kg)
Soave endorectal pull-through procedure
Ostomy closed 2 time of pull-through
RN INTERVENTIONS
Bonding
Coping
Consent
saline enemas, low fiber, high calorie high protein diets, TPN, oral antibiotics, fluid & electrolytes
Restriction of food & fluid prior 2 anesthesia
Atraumatic drugs administration (PO or existing IV) Versed
Wear loose-fitting gown w/underpants or PJ’s
Depends on Preop goals: hygiene, prep removing jewelry, x-ray, ht. wt., check teeth, NPO, voiding recording last void, allergies, check labs, fall & identification precautions, VS
Postop teachings
Crib ready
IV equipment ready
ABC, O2, IV, malignant hyperthermia immediate postop
Stay @ bedside until gag reflex return
O2 sat.
Suction available
Temp 4 hypothermia apply warm blankets
Baseline VS, LOC & activity
Pain
Check dressing: Bleeding
Foley cath care
Skin color & characteristic
Check bowel sounds, turning requirements
Observe 4 shock, abd. Distention
Assess bladder distention
Observe 4 dehydration
Detect infection
Preop care: Postop care:
FASTING REDUCING PULMONARY ASPIRATION
Ingestion Fasting hours
Clear liquids 2
Breast milk 4
Infant Formula 6
Non-human milk 6
Light meal 6
HIRSCHSPRUNG DISEASE
To confirm the diagnosis of Hirschsprung disease, the
nurse prepares the child for which one of the
following tests?
a. Barium enema
b. Upper GI series
c. Rectal biopsy
d. Esophagoscopy
GI
The passive transfer of gastric contents into the
esophagus is termed:
a. Esophageal Atresia
b. Meckel diverticulum
c. Gastritis
d. Gastroesophageal Reflux
PYLORIC STENOSIS
What are features & assessments of a patient with
this diagnosis?
PYLORIC STENOSIS
Olive-shaped mass in RUQ of abdomen and
possible observation of peristalsis when lying
supine.
Vomiting that occurs 30 to 60 minutes after a
meal and becomes projectile as obstruction
worsens.
Constant hungry.
Weight loss, signs of dehydration.
Diagnosed by ultrasound.
INTUSSUSCEPTION
Al, age 5 months, is suspected of having
intussusception. What clinical manifestations would
he most likely have?
a. Crying during abdominal exam, vomiting,
currant jelly-appearing stools
b. Fever, diarrhea, vomiting, and lowered WBC
c. Weight gain, constipation, and refusal to eat
d. Abdominal distention, periodic pain, hypotension
MECKEL’S DIVERTICULUM
Remnant of a fetal duct, which in most newborns
has resolved completely.
More common in boys.
Most symptoms occur in children less than 2 years,
but may occur in children up to 10 years.
May have abdominal pain, bloody stools without
pain, bright red mucus in infant stools.
Diagnosed using a radionucleotide scan.
CHILD IN A CAST
4 categories of immobilization
Upper—wrist, elbow
Lower—ankle, knee
Spinal & Cervical—spine
Spica cast—hip, knee
CAST
Gauze strips & bandages impregnated
Plaster cast mold closely to body part 10-72 hrs
drying
Synthetic casting dries 5-30 minutes
CAST APPLICATION
Dx: fear of bodily harm, loss of extremity
Use plastic doll or stuffed animal 2 explain procedure
During application—distraction
Bubbles, pets, activities at school
“this will help your arm get better”—futile
Extremities checked for
abrasions, cuts, skin alterations, rings causing
constriction from swelling
Gore-Tex liner under hip spica cast prevents
exposure 2 moisture
CAST APPLICATION
Dry rolls of casting material
Immersed in pail of H20
Wet rolls
Put on in bandage fashion & molded 2 extremity
Plaster cast
Underlying stockinet pulled over rough edges
Secured w/layer of wet plaster below rim (padding)
Petaled protected edges (wn/no stockinet form)
Synthetic casts
Usually don’t require padding on edges
NURSING CONSIDERATIONS
H20 evaporation can take 24-48 hrs
Fiberglass dries w/in minutes
Cast uncovered 2 dry inside out
Turn every 2 hours—help drying of body cast
Regular fan or cool air hair dryer
Heated fans or dryers contraindicated (remain wet beneath or burns)
Wet plaster cast—supported by pillow covered with plastic handled w/palm of hands
Dry plaster of paris cast—hollow sound when tapped
Hot spot felt—infection, report, window made to observe site
Chief concern—extremities may continue 2 swell, circulation compromised, neurovascular complication Body part elevated 2 reduce compromise—increase VR
Edema—casts a bivalve (cut A to P halves held 2gather w/elastic bandage)
Always check NEUROVASCULAR INTEGRITY (6 P’S INCLUDE PRESSURE, SENSATION, MOVEMENT, CIRCULATION, TEMP, EDEMA)
Absorbent diaper under perineal
NURSING CONSIDERATIONS
No alterations 2 car seats
Hip Spica cast—fed infants supine head elevated
w/hips & legs supported on pillow @ the side;
children prone easier from small table
AMPUTATION
Congenital absence
Traumatic loss
Osteosarcoma
Part Reattachment
Rinse limb gently w/NS
Loosely wrap in sterile gauze
Place wrapped limb in watertight bag
Cool bag in ice H20 (no freezing, no packing)
Label name, date, time then transport w/child
AMPUTATION
Goal: surgical amputation or repair focuses on
constructing adequately nourished stump
Smooth, healthy, padded, free of nerve endings
Prosthesis fitting
Subsequent ambulation
With no vascular or neurologic deficit—cast applied
2 stump immediately after procedure & pylon metal
extension & artificial foot attached
NURSING CONSIDERATIONS
Stump shaping postop elastic bandaging figure 8
Figure 8 decreases edema, controls hemorrhage & aids
developing contours 2 bear wt.
Stump elevation during 1st 24 hours
Monitor proper body alignment
Older children/adolescent
Arm exercises, bed pushups, parallel bars 4 prosthesis
training, full ROM above amputation daily several times
Teach stump hygiene—soap & H20 every day, check
skin irritation, breakdown or infection, DRY!
Phantom limb—teach preop, increasing limb pain with
ambulation should be evaluated (4 neuroma)
CONGENITAL CLUBFOOT
Deformity of ankle & foot
Forefoot adduction
Midfoot supination
Hindfoot varus
Ankle equinus
Described by position
CONGENITAL CLUBFOOT
Talipes
Varus—inversion or bending inward
Valgus—eversion or bending outward
Calcaneus—dorsiflexion (toes > heel)
Equinus—plantar flexion (toes < heel)
Most common talipes equinovarus! TEV
Plantar flexion w/bending inward
Unilateral > bilateral
May occur isolated defect
May occur association w/chromosomal aberrations,
orthrogryposis, CP, Spina Bifida
CONGENITAL CLUBFOOT
CONGENITAL CLUBFOOT
Classification
Positional Transitional, mild, postural
Intrauterine crowding
May correct spontaneously
Responds 2 simple stretching & casting
Passive
Serial
Syndromic Teratologic
Associated w/congenital anomalies
Usually require surgical correction high incidence of recurrence
Often resistant 2 treatment
Congenital Idiopathic
“True clubfoot”
Almost always require surgical intervention (d/t bony abnormality)
In otherwise normal child
CONGENITAL CLUBFOOT
CONGENITAL CLUBFOOT
DX: Apparent
Prenatal ultrasound or @ birth
Radiograph 4 bone placement
Therapeutic Management Painless plantigrade & stable foot
3 stages Correction of deformity
Maintenance of correction until normal muscle balance
Follow up observations
Serial casting
Manipulation & casting repeated 4 rapid growth (Denis Brown splint)
Maximum correction w/in 8-12 weeks
Radiograph or ultrasound evaluates bone relationship
Failure of alignment by 3 mons. (surgery) between 6-12 months of age
Foot/feet immobilized 6-12 postop walks after cast removed
Passive exercise
NURSING CONSIDERATION
Same as with cast
Passive exercise
Neurovascular checks
Watch for compartment syndrome
VS
Allow for drying
Skin integrity
Circulation!
Teach importance of regular cast changes
Reinforce & clarify orthopedist’s explanations & instructions
Teach cast care, potential problems, encourage parents 2 facilitate normal development
OB COMPREHENSIVE FOCUSED REVIEW
Day One Review
COMPLICATIONS OF NEWBORN
Complication of newborn: Hypoglyclemia
Risk factors
Assessment Under 40
Get them on breast
poor feeding
Hypothermia
Diaphoresis
Weak shrill cry
Lethargy
Flaccid
Seizures
Irregular respiration
Cyanosis
Labs: plasma glucose less 40 mg/dL
HYPOGLYCEMIA
Obtain blood per heel stick for glucose
Provide frequent oral and gavage feeding
HYPOGLYCEMIA CONTINUES
LGA Greater than 4000 gram
Above 90% tile
Risk factor Post term
Maternal DM
Fetal cardiovascular disorder of transposition
Genetics
Assessment Weight first indication
SQ fat
Signs of hypoxia
Birth trauma
Sluggishness
Hypotonia of muscles
Hypoactivity
Tremors from hypocalcemia
CONT’D
Monitor glucose
Initiate early feeding
Monitor thermoregulation
Identify and treat birth injuries
Surfactant for lung maturity
CIRCUMCISION PAIN MANAGEMENT
NPASS
Give oral Tylenol
BREASTFEEDING
Education
Feed 2-3 hrs 8-12 times in 24 hours
Colostrum day 1-3 provides passive immunity
Educate on the benefits
Reduces the risk of infection
Promotes rapid brain growth d/t large amounts of
lactose
Has water
Protein and nitrogen
ATTACHMENT OF MOTHER-INFANT
Assessment:
Looking at baby
Comparing the baby
Face to face
Smiles
Talks to
Response
Identifies characteristics