NCM 104

Pediatric Nursing
Prepared by: Adahlia T. Basco RN, MAN

NERVOUS SYSTEM DEVELOPMENTAL DISORDERS

Hydrocephalus
-An imbalance of CSF absorption or production - Result in head enlargement and increased ICP Types: - Communicating
Adhesion from inflammation, such as meningitis Cerebral atrophy Result of impaired absorption from subarachnoid space Head injury

- Non communicating
- Obstruction of CSF within the ventricular system

Signs and Symptoms

Infant
Increased head circumference Bones of the head are thin and widely separated and produce cracked pot sound on percussion( Macewen sign) Anterior fontanel tense, bulging and non pulsating Dilated scalp vein Frontal bossing Sun setting eyes Underdeveloped neck muscle

Child
Irritability and lethargy Headache upon awakening Nausea and vomiting Ataxia Nystagmus

Late signs
High shrill cry Seizure activities

hydrocephalus

Surgical Management
-Bypassing the blockage and draining the fluid from the ventricles to a location where it can be reabsorbed Ventriculoperitoneal shunt (VP Shunt)- CSF drains into the peritoneal cavity from the lateral ventricle Atrioventricular shunt (AV Shunt)- CSF drains into the right atrium of the heart from the lateral ventricles, bypassing the obstruction.
Used in children with abdominal pathology

 Ventriculoperitoneal shunt

Management Postoperatively
Monitor vital signs and neurological signs Position on unoperated side to prevent pressure on the shunt valve Flat on bed(to avoid rapid reduction of ICF) Observe for increased ICP( if increased elevate the head of the bed to enhance
gravity flow through the shunt)

Monitor for signs of infection and assess dressing for drainage Measure head circumference Monitor I&O Provide comfort measures Administer antibiotic or anticonvulsant as prescribed Instruct the parent to recognize shunt infection or malfunction

****Headache and lack of appetite are the earliest common signs of shunt malfunction

Prevention
Regular prenatal care Protect the baby`s or child from head injuries Keep the child immunization up to date

NEURAL TUBE DEFECT

1. Anencephaly
Absence of the cerebral hemispheres. It occurs when the upper end of the neural tube fails to close in early uterine life. It is revealed by elevated level of AFP in maternal serum or on amniocentesis and confirmed by sonogram. Children cannot survive because of no cerebral function.

2. Microcephaly
Is a disorder in which brain growth is so slow that it fails more than 3 standard deviations below normal on growth charts. The defect maybe caused by intrauterine infection such as rubella, CMV or toxoplasmosis. May also be caused by severe malnutrition or anoxia in early infancy.

Spina Bifida
CNS defect as a result of neural tube failure to close during embryonic development. Associated deficits include
Sensory motor disturbance Dislocated hips Clubfoot hydrocephalus

Defect closure is usually done during infancy

Types of Spina Bifida

Spina Bifida occulta

Posterior vertebral arches fail to close in the lumbosacral area. Spinal cord remains intact and usually is not visible. Meninges are not exposed on the skin surface Neurological deficit are not usually present
Spina Bifida Cystica

Protrusion of the spinal cord and its meninges Result in incomplete closure of the vertebral and neural tubes, resulting in sac like protrusion in the lumbar or sacral area

 Meningocele
Protrusion involves meninges and a sac like cyst that contains CSF in the midline of the back, usually in lumbosacral area No involvement of spinal cord Neurological deficits are not usually present

Myelomeningocele
Protrusion of meninges,CSF,nerve roots and a portion of spinal cord. The sac is covered by a thin membrane that is prone to leakage or rupture Neurological deficits are evident.

Assessment
Depend on the spinal cord involvement Visible spinal defect Flaccid paralysis of the leg Altered bowel and bladder function Hip and joints deformities

 Spina bifida

 Spina bifida cystica occulta

spina bifida

 Meningocele

myelomeningocele

Management
Evaluate the sac and measure the lesion Perform neurological assessment Monitor for increase ICP (indicates developing
hydrocephalus)

Measure head circumference Assess anterior fontanel for fullness Protect the sac, cover with a sterile moist (normal saline) non adherent dressing to maintain the moisture of the sac and contents. Change the dressing 2-4 hours as

 Place in prone position to minimize tension on the sac and the risk of infection. Diapers may be contraindicated until the defect has been repaired Use aseptic technique to prevent infection Assess the sac for redness, clear or purulent discharge, abrasion, irritation, and signs of infection.
Elevated temperature Irritability Lethargy Nuchal rigidity

 Assess for physical impairment such as hip and joint deformities. Prepare the child and family for surgery Administer antibiotic as prescribed to prevent infection. Administer anticholinergics to improve urinary continence and laxatives to achieve bowel continence in the child, and antispasmodics to control bladder spasm.

MENINGITIS
Inflammation of the brain and spinal cord meninges. Usually follows onset of respiratory symptoms Condition common in infant and toddlers. (Haemophilus Influenzae Type B) Viral meningitis associated with viruses like mumps, herpes virus and enterovirus. Bacterial meningitis causes acute infection in subarachnoid space

Good prognosis if rare complication recognized early and organism responsive to antibiotic therapy

 It can be transmitted by droplets; organism enter the blood from the nasopharynx or middle ear. Inflammation may involve all three meningeal membranes. ( dura mater, arachnoid and piamater) Test result Lumbar puncture shows increases CSF pressure, cloudy, increased WBC count

Signs and Symptoms

Signs and symptoms vary depending on the type, age of the child and the duration of illness.
Fever, chills Vomiting, diarrhea Poor feeding or anorexia Nuchal rigidity Poor or high pitched cry Altered level of consciousness Bulging anterior fontanel in infant Muscle or joint pain Kernig`s sign and Brudzinski`s sign Petechial or purpuric rashes( bacterial meningitis)

 Brudzinski`s sign * the child flexes the

knees and hips in response to passive neck flexion.

Kernig`s sign
* the child is unable to extend the leg when the hip and knee are flexed

Management
Follow standard precaution Provide isolation for first 24 hours Oxygen therapy Maintain adequate nutrition Perform neurological assessment Monitor I&O Administer antibiotic as prescribed Determine close contact of the child with meningitis, the contact will need prophylactic treatment

Diagnostic Test
Lumbar puncture

Reye`s Syndrome
Acute encephalopathy that follows a viral illness and is characterized by cerebral edema and changes in the liver. The exact cause is unknown It is recommended that aspirin ( salicylate)not be administered to children with varicella or influenza. Acetaminophen ( tylenol ) is considered the medication of choice for pediatric patient The goal of treatment is to maintain effective cerebral perfusion and control increasing ICP

Assessment
History of systemic viral illness 4-7 days before the onset of symptoms Malaise Nausea and vomiting Irritability Progressive neurological deterioration

Nursing Intervention
Assess neurological status Monitored for altered level of consciousness and signs of increase ICP Monitor I&O Provide rest and decrease stimulation in the environment Monitor for sign of bleeding and sign of impaired coagulation.

Seizure Disorders
Sudden transient alteration in brain function resulting from excessive levels of electrical activity in the brain. Classifications
Partial
Localized in one area of the brain

Generalized
Occurs in both hemisphere

Assessment
Obtain information from the parent about the time of onset, precipitating events and behavior before and after the seizure Determine the child history related to seizure

Seizure Precaution
Raise the side of the bed when the child is sleeping or resting Pad the side rails and other hard objects Place a waterproof mattress or pad on the bed or crib Instruct to wear or carry medical identification Instruct the child precautions to take during potentially hazardous activities

 Instruct the child to swim with companion Instruct the use of a protective helmet and padding during bicycle riding, skateboarding and inline skating. Alert caregivers to the need for any special precautions.

Emergency Treatment
Ensure patent airway Time the seizure episode If the child is standing or sitting, ease the child down to the floor Place a pillow or folded blanket under the child`s head; if no bedding is available, place own hands under the child`s head or lap. Loosen restrictive clothing

 Remove eyeglasses if any Clear area of any hard objects Allow seizure to proceed and end without interference, if vomiting occurs turn to side as a unit. Do not restrain the child, or place anything in the child`s mouth, or give any food or liquid. Administer medication as prescribed Remain with the child until fully recovers Observe for incontinence, which may occurred during seizure

Cerebral Palsy
Disorder characterized by impaired movement and posture resulting from abnormality in the extrapyramidal or pyramidal motor system. Spastic CP- most common clinical type which represent an upper motor neuron type of muscle weakness

Signs and Symptoms

Extreme irritability and crying Feeding difficulties Stiff and rigid arms or legs Delayed gross development Abnormal motor performance Alterations of muscle tone Abnormal posturing (opisthotonic) Persistence of primitive infantile reflexes

 Cerebral palsy

 Cerebral palsy

Management
Goal of management
Early recognition and intervention to maximize the child abilities

Multidisciplinary team approach to meet the needs of the child Therapeutic management includes;
Physical therapy Occupational therapy Speech therapy Education and recreation

Assess the child`s developmental level and intelligence

 Encourage early intervention and participation in school programs. Prepare for using mobilizing devices to help prevent or reduce deformities. Encourage communication and interaction on a functional level, not on the child chronological age. Provide a safe environment Provide safe appropriate toys for age and developmental level

 Implement seizure precaution if necessary Position upright after meals Administer medication as prescribed to decrease spasticity Surgical intervention are reserved for the child who does not respond to more conservative measures or for the child whose spasticity causes progressive deformity.

Mental Retardation
Sub-average general intellectual functioning along with deficit in adaptation in behavior with onset before the age of 18. Down syndrome is a congenital condition that results in a moderate to severe retardation and it has been linked to an extra group G chromosomes, chromosome 21 ( trisomy 21).

Assessment
Deficit in cognitive skills and level of adaptive functioning. Delays in fine and gross motor skills Speech delays Decrease spontaneous activity Nonresponsive Irritability Poor eye contact during feeding

 Mental retardation

 Mental retardation

Management
Medical strategies are focused at correcting structural deformities and treating associated behaviors. Implement community and educational services using a multidisciplinary approach. Promote care skills as much as possible Assist with communication and socialization skills Facilitate appropriate playtime

 Initiate safety precautions as necessary. Assist the family with decisions regarding care. Provide information regarding support services and community agencies.

Autism
A severe mental disorder beginning in infancy or toddlerhood Apparent to the parents before the age of 3 Characterized by impairment in reciprocal social interaction and in verbal and non- verbal communication. The cause is unknown and the prognosis maybe poor. Diagnosis is established on the basis of symptoms and thru the used of specialized autism assessment tools Also known as infantile autism

Assessment
Disturbance in the rate and appearance of physical, social and language skills. Abnormal responses of body sensations Abnormal ways of relating to people, objects and events. The child is self absorbed and unable to relate with others No delusions or hallucinations or incoherence the affected is the intelligent and response.

 The child may play happily alone for hours, but have temper tantrums if interrupted. Language disturbance often includes repetition of previously heard speech and reversal of the pronoun I and You If the child can talk, she uses speech, not for communication but to repeat words or phrases meaninglessly The child may develop an unusual attachment to a significant object and display frequent rocking and spinning, twirling and other bizarre behaviors.

autism

Management
Determine the child`s routine, habits and preferences and maintain consistency as much as possible Determine the specific ways in which the child communicates. Facilitate communication through the use of picture boards. Evaluate the child for safety. Implement safety precaution as necessary for self injurious behaviors such as head banging.

 Monitor for stress and anxiety. Avoid placing demands on the child. Initiate referrals to special programs as required. Provide support to the parents.

Attention Deficit Hyperactivity Disorder (ADHD) A developmental disorder characterized by a developmentally inappropriate degrees of in attention, overactivity, and impulsivity. One of the most common reasons for referral of children to mental health services Diagnosis is established on the basis of self reports, parent and teacher report, and psychological assessment

 Childhood problems include :

lowered intellectual development Some minor physical abnormalities Sleeping disturbance Behavioral or emotional disorders Difficulty in social relationships

Assessment
Fidgets with hands or feet or squirms in the seat Easily distracted with external or external stimuli Difficulty with following through on instructions Poor attention span Shift from one uncompleted activity to another Talks excessively Interrupts or intrudes on other Engages in physically dangerous activities

Management
Provide environmental and physical safety measures Enhance capabilities and self esteem Encourage support groups for parents Administer prescribed medication
Methylphenidate hydrochloride (Ritalin) Pemoline ( Cylert) Dextroamphetamine Sulfate (Dexadrine)

Instruct the child and parent regarding medication administration that the positive effects may be seen 1-2 weeks

Tourette`s Disorder
Characterized by recurrent involuntary and rapid movements affecting various parts of the body Accompanied by vocal noises such as barks and grunts. One of the less common possible symptoms of Tourettes yet the most highly publicized would be Coprolalia (outburst of obscenities and curse words).

Management
Establish a one to one relationship Protect the child from harm by providing a helmet and protective padding Allow the child to have a favorite toy or other object Provide positive reinforcement for appropriate behaviors Maintain eye contact Assess suicide potential Provide safe environment

 Set limits on socially inappropriate or manipulative behaviors Encourage the child to confront tension and frustration before they emerge as inappropriate behaviors Provide noncompetitive group activities

Child Abuse
Involves emotional or physical abuse or neglect. Sexual exploitation or molestation by caretakers or other individual. Types
Physical abuse Physical neglect Emotional abuse Sexual abuse

Physical Abuse
Unexplained bruises burns or fractures Bald spots on the scalp Apprehensive child Extreme aggressiveness or withdrawal Fear of parents Lack of crying when approached by stranger

Physical Neglect
Inadequate weight gain Poor hygiene Consistent hunger Inconsistent school attendance Constant fatigue Reports of lack of child supervision delinquency

Emotional Abuse
Speech disorders Habit disorder ( sucking, biting, and rocking) Psychoneurotic reactions Learning disorder Suicide attempt

Sexual Abuse
Difficulty walking or sitting Torn, stained, or bloody underclothing Pain, swelling, or itching of the genitals Bruises, bleeding, or lacerations in the genital or anal area Unwillingness to change clothes or to participate in gym activities Poor peer relations Delinquency Changes in sleep performance Self destructive behavior

Head Injury
Pathological result of any mechanical force to the skull, scalp, meninges, or brain Manifestation defend on the type of injury and the subsequent amount of increased ICP. Head injuries are one of the most common causes of disability and death in children.
Concussion Contusion Skull fracture

Concussion
A concussion is an injury to the head area that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event.

Contusion
A contusion is a bruise to the brain. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck.

Skull Fracture skull fracture is a break in the skull bone

Causes
Falls Motor vehicles accident Direct blow to head Shaking of the child

Signs and Symptoms Head Injury

mild head injury
raised, swollen area from a bump or a bruise at the site of the blow small, superficial (shallow) cut in the scalp

Sensitivity to noise and light Irritability Confusion Lightheadedness Problems in balance Problems in memory and concentration Change in sleeping pattern

Blurred vision Tired eyes Ringing in the ears Alteration in taste Fatigue and lethargy

 Moderate to severe head injury

loss of consciousness severe headache that does not go away repeated nausea and vomiting loss of short term memory, such as difficulty remembering the events that led right up to and through the traumatic event slurred speech difficulty with walking weakness in one side or area of the body sweating

 coma (a state of unconsciousness from which a person cannot be awakened; responds only minimally, if at all, to stimuli; and exhibits no voluntary activities) vegetative state (a condition of brain damage in which a person has lost his thinking abilities and awareness of his surroundings, but retains some basic functions such as breathing and blood circulation) locked-in syndrome (a neurological

pale in color seizures or convulsions behavior changes including irritable blood or clear fluid draining from the ears or nose one pupil (dark area in the center of the eye) looks larger than the other eye deep cut or laceration in the scalp open wound in the head (The scalp contains many blood vessels and a cut or laceration due to trauma can be associated with substantial bleeding and blood loss.)

 Diagnostic tests may include:

blood tests x-ray - a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. electroencephalogram (EEG) - a procedure that records the brain's continuous, electrical

Dx test
computerized tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce crosssectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Assessment (ICP)

Early Signs
Headache Visual disturbance, diplopia Nausea and vomiting Dizziness or vertigo Slight change in vital signs Change in pupillary response and equality Sunsetting eyes Slight change in level of consciousness Infant- bulging fontanel, wide suture,
Increased head circumference Dilated scalp veins, high pitched cry

 Late Signs
Significant decreased in LOC Cushing`s Triad: increased systolic blood pressure and widened pulse pressure, bradycardia and irregular respirations Decorticate posturing: Adduction of the arms at the shoulders, the arms being flexed on the chest with the wrist flexed and the hands fisted
The lower extremities being extended and adducted (severe dysfunction of cerebral cortex)

 Decerebrate posturing: rigid extension and pronation of the arms and the legs (dysfunction at the level of the midbrain) Fixed and dilated pupils

Decorticate

 Decorticate and Decerebrate posturing

Implementation
Monitor airway Assess injury; immobilize the neck if cervical injury is suspected Monitor vital signs and neurological function Monitor for decreased responsiveness to pain Initiate seizure precaution

 Maintain on NPO status or clear liqiud if prescribed administer oxygen and IVF as ordered Monitor IVF carefully to avoid aggravating any cerebral edema and to minimize overhydration Elevate the head of the bed 15 to 30 degrees if not contraindicated Position so that the head is maintained midline to facilitate venous drainage and avoid jugular veins compression

 Assess wound dressing for the presence of drainage and monitor for nose or ear drainage (indicates leakages of CSF) Administer tepid sponge bath or place in hypothermia blanket if hyperthermia occurs suctioning thru the nose is contraindicated
high risk of secondary infection Probability of catheter entering the brain through a fracture

 Administer acetaminophen for headache Anticonvulsant for seizure Antibiotic if laceration is present and tetanus toxoid as appropriate Sedation are withheld during the acute phase of injury Monitor for signs of brain stem involvement Monitor for asymmetric pupils (epidural hematoma)

Ingestion of Poison
A. LEAD POISONING
Excessive accumulation of lead in the blood

causes
Pathway for exposure may be food, air or water Dust and soil contaminated with lead may be a source Lead enters through ingestion or inhalation or through placental transmission to an unborn child when the mother is exposed

 Most common route is ingestion either from hand to mouth behavior from contaminated objects or from eating loose paint chips When lead enters the body, it affects the erythrocytes, bones and teeth, and organs and tissues brain and nervous system (CNS effect is the most serious)

Universal Screening
Children in high risk areas must be screened earlier at the age of 1 to 2 years Child ages of 3-6 who has not been screened should be tested

Targeted screening
Acceptable in low risk areas At the age of 1-2 (or a child between the ages of 3-6 who has not been screened) may be targeted for screening if determined to be at risk

Blood Lead Level Test (BLL)

Used for screening and diagnosis BLL less than 10 ug/dL: reassess or rescreen in 1 year. BLL 10-14 ug/dL:provide family lead education, follow up testing if necessary BLL 15-19 ug/dL:provide family lead education, follow up testing, initiate action for BLL of 20-44 ug/dL

 BLL 20-44ug/dL:Bll greater than 20 is considered acute BLL 70 ug/dL: medical treatment is immediately provided
Including coordination of care Clinical management Environmental investigation Lead hazard control

Erythrocyte protoporphyrin test

An indicator of anemia Normal value for a child is 35ug/100 ml of whole blood

Chelation therapy
Removing lead from the circulating blood and from some organs and tissue Does not counteract any effects of the lead Medication : dimercaprol, calcium disodium edetate (CaNa2EDTA), succimer (Chemet)

 Dimercaprol is contraindicated in children with allergy to peanuts because medication is prepared in a peanut oil solution Ensure adequate urinary output before administering medications Provide adequate hydration and monitor kidney function for nephrotoxicity when medication is given because it was excreted in kidney

 Follow up lead level to monitor progress are essential Provide instruction to parents about safety from lead hazards, medication administration and need for follow up Confirm that the child will be discharged to home without lead hazard

 B. Acetaminophen (TYLENOL)
Seriousness of ingestion is determined by the amount ingested and the length of time before intervention Toxic dose is 150mg/kg or greater in children

assessment
First 2-4 hours;
Malaise nausea vomiting Sweating pallor weakness

Late period;
24-36 hours: child improves

Hepatic involvement
May last up to 7 days and be permanent
Right upper quadrant pain Confusion Elevated liver enzymes and bilirubin jaundice stupor prolonged PT

management
Administer antidote (N-Acetylcystein)
Dilute antidote in juice or soda because of its offensive odor Loading dose is followed by maintenance doses

 C. Acetylsalicylic Acid (aspirin, ASA)

May be caused by acute ingestion or chronic ingestion Acute to severe toxicity occurs with 300-500 mg/kg Chronic: more than 100mg/kg/day or more

assessment
GI effects
Nause and vomiting thirst from dehydration

CNS effects
Hyperpnea confusion Convulsion coma Circulatory collapse tinnitus respiratory failure

Renal effects: oliguria Hematopoietic effect: bleeding tendency Metabolic effects

Diaphoresis Hyponatremia dehydration hypocalcemia fever hypoglycemia

assessment
Child is pale, irritable and weak Gross hamaturia, or dark smoky cola colored or red brown urine Proteinuria (produce excessive foam in the
urine)

Oliguria or anuria Urinary debris, moderate to high specific gravity, low ph

management
Induce vomiting with syrup of ipecac or perform gastric lavage Administer activated charcoal to: decrease
absorption of salicylate

Administer IV`s, sodium bicarbonate, electrolytes and volume expanders Administer Vit. K Administer glucose Prepare the child for dialysis as prescribed if unresponsive to therapy

Hematologic Disorders of Pediatric Patients

Parts of the Blood

Erythrocytes (RBC) transport oxygen and carry CO2 from the body cells Leukocytes (WBC) defense against antigen invasions Thrombocytes (Platelets) for capillary hemostasis and primary coagulation

Test for Coagulation

Prothrombin Time (PT) 11-13 sec, factors V, VII, X Partial Thromboplastin Time (PTT) 3045 sec, factors VIII, IX Bleeding Time 3-10 min Tourniquet Test 0-2/ 2-cm area

Leukemia
most common childhood cancer. is a group of multifactorial, malignant diseases of the bone marrow and lymph nodes. Proliferation of abnormal white blood cells that arise from precursor cells in the blood forming elements.

 These immature WBCs do not function properly and they compete for metabolic elements that are required by RBCs and platelets.

The most common form of leukemia is Acute Lymphocytic Leukemia (ALL). Other forms include Acute Mylogenous Leukemia (AML) and chronic forms of leukemia.

Sickle Cell Disease

Description
Congenital hemolytic disease that result from defective hemoglobin (Hb), it is partly or completely replaced by abnormal sickle hemoglobin(HbS). Insufficient oxygen causes the cell to assume a sickle shape, it becomes rigid and clumped together obstructing capillary blood flow resulted to impaired circulation. Pain Tissue infarction swelling

 Autosomal recessive disorder Sickling may produce hemolysis (cell destruction) Causes: - Heterozygous inheritance of the HbS producing gene(defective Hb gene from each parent or being African American Signs and Symptoms: - s/s usuallydevelop until after age 6 months -chronic fatigability, unexplained dyspnea - joint swelling - aching bones - chest pain - ischemic leg ulcer

Increased susceptibility to infection Pulmonary infarction and cardiomegaly Jaundice or pallor Delayed growth and development Spiderlike body build( narrow shoulder and hip, long extremities, curve spine, and barrel chest) in adult Tachycardia Hepatomegaly and, in children splenomegaly Systolic and diastolic murmurs Sleepiness with difficulty awakening Hematuria Pale lips, tongue,palms and nail beds Fever persisting for 2 or more days.

Assessment of Crisis
Sickle cell crisis is the acute exacerbation of the disease. Vaso- occlusive crisis

Most common type Caused by stasis of blood with clumping of the cell in the microcirculation, ischemia and infarction
Splenic sequestration crisis

Life threatening crisis caused by pooling of blood in the spleen Signs include profound anemia, hypovolemic shock and death
Aplastic crisis
Pallor, lethargy, sleepiness, dyspnea, possible coma Markedly decreased bone marrow activity RBC hemolysis-triggered by viral infection or depletion of folic acid Profound anemia and pallor

Nursing Intervention Avoidance of extreme temperature, high altitudes, and non pressurized air travel Avoidance of stress Well balanced diet-high caloric, high protein Folic acid rich food Maintain adequate hydration Bed rest with crises- assist the child to assume
comfortable position so that the child keeps the extremities extended to promote venous return, elevate the head of the bed Apply warm compress to painful areas of the patients body, unless he has neuropathy

 Administer analgesic as prescribed and antipyretic as necessary Administer antibiotics as prescribed Use strict aseptic technique when performing tx. Administer oxygen and blood transfusion as prescribed to increase tissue perfusion Monitor patient`s vital signs, intake and output and CBC and other laboratory investigation Instruct the child and the parent about early signs and symptoms of crisis and the measures to prevent it

Iron Deficiency Anemia

Iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBC`s Commonly result from blood loss, increased metabolic demands, syndromes of gastrointestinal malabsorption,malignant tumors and dietary inadequacy Most common form of enemia

Signs and Symptoms

Pallor Weakness and fatigue Irritability Spoon shaped brittle nails Tachycardia Decreased appetite Red, swollen, smooth, shiny, and tender tongue (glossitis) Corners of the mouth may be eroded, tender, and swollen

Nursing Intervention
Increase oral intake of iron Provide oxygen therapy as necessary Give prescribed analgesic for headache and other discomfort Administer iron supplement as prescribed Teach the child and parents that liquid iron preparation stains the teeth and should be taken through straw. Instruct the child and the parent about the side effect of iron supplement (black stool,constipation,
and foul aftertaste)

Aplastic Anemia A deficiency of circulating erythrocytes resulting from the arrested development of RBC`s within the bone marrow Causes
Chronic exposure to myelotoxic agent Viruses Infection Autoimmune disorder Allergic states

Diagnostic Procedure

Bone marrow aspiration Signs and Symptoms: - pancytopenia tachycardia - petechiae fatigue - bleeding purpura - pallor - weakness

Nursing Management
Administer blood transfusion (D/C when bone marrow
begins to produce RBC`s)

Corticosteroid and immunosuppressive therapy as prescribed

Prepare for splenectomy- it is done with enlarged spleen that
is destroying normal RBC`s or suppressing their development.

Prepare the child for bone marrow transplant Administer ALG or ATG as prescribed and monitor for allergic reaction Advice the parent to obtain a medic alert bracelet for the child.

Iron Rich Food

Liver Meats Egg yolks Dark green leafy vegetables Bread and cereals Kidney beans raisins

Idiophatic Thrombocytopenic Purpura (ITP)

is a result of decrease in the number of circulating platelets in the presence of adequate megakaryocytes (precursors to platelets). Cause is unknown, autoimmune disorder. Occurs 2 weeks after a viral infection or in a newborn of a mother with ITP.

DENGUE HEMORRHAGIC FEVER

(H-FEVER)

Acute febrile disease, rarely fatal unless it progresses to hemorrhagic shock syndrome CA: Chikungunya virus or Dengue virus 1,2,3,4 MOT: Aedes Aegypti- tiger/striped mosquito IP: 1 week Susceptible age: 5-9 y/o

SIGNS AND SYMPTOMS

1st 4 days- febrile or invasive stage, abdominal pain, headache, flushing, vomiting, conjunctival infection, epistaxis 2nd stage- 4th -7th day- toxic or hemorrhagic stage- low temp, severe abdominal pain, vomiting, hematemesis, melena, signs of shock 3rd stage- 7th to 10th day-convalescent pd, generalized flushing

Classification of DHF
GRADE I Flu-like symptoms Rash Hermans sign (+) tourniquet test Abdominal pain GRADE II Grade I Spontaneous bleeding GRADE III Grade II Beginning symptoms of circulatory failure GRADE IV Grade III shock

Management of DHF
Dx: Tourniquet test (Rumplel Leads Test), Platelet count Curative: Non-aspirin analgesic I.V. fluid replacement Diet: low fat, low fiber, non-irritating, non-carbonated, no dark colored food

Disseminated Intravascular Coagulation (DIC)

is an acquired disorder of blood clotting that results from excessive trauma or some similar underlying stimulus an imbalance occurs between clotting activity and fibrinolysis. A common complication seen during pregnancy. Can occur in children with acute infection.

Hemophilia

X- linked recessive trait Hereditary bleeding disorder Characterized by greatly prolonged coagulation time Result from deficiency of specific coagulation factor. Hemophilia A (classic hemophilia) resulting from
deficiency of factor VIII

Hemophilia B ( christmas disease) resulting

from deficiency of factor IX

Incurable

 Male inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Signs and Symptoms
Abnormal bleeding in response to trauma and surgery. Joint bleeding causing pain, tenderness, swelling, and limited range of motion Tendency to bruise easily Prolonged PTT, bleeding time and PT normal Pain and swelling in weight bearing joints

Rh INCOMPATIBILITY
Condition which develop when a pregnant woman has an Rh negative blood type and the fetus has Rh positive blood type. The mother`s immune system treat the Rh positive fetals cells as a foreign substance and then produce antibodies against the fetal blood cells crossing the placenta into the fetus resulting to destruction of the fetus circulating blood cells( hemolysis)

Complications
Hydrops fetalis
s/s Severe anemia Heart failure Hepatomegaly Respiratory distress Purpura

 Kernicterus Early s/s High bilirubin level Extreme jaundice Absent Moro reflex Poor sucking Lethargy High pitched cry Mid s/s Opisthotonus Bulging fontanel seizures

 Kernicterus Late s/s (full neurological syndrome)

High frequency hearing loss Mental retardation Muscle rigidity Speech difficulties Seizures Movement disorder

Exams and Tests

Positive Direct Coombs test Hemolysis in the infant blood Elevated cord blood bilirubin

Treatment

RhoGam- a special immune globulin ( used as

preventive measures) Treatment of affected infant
-Mild Rh Incompatibility
Aggressive hydration Phototherapy -Hydrops fetalis Amniocentesis Intrauterine fetal transfusion Early induction of labor

- Kernicterus
Exchange transfusion phototherapy

 Thalassemia Major
An autosomal recessive disorder Characterized by the reduce production of one of the globin chains in the synthesis of hemoglobin. Also known as Cooley`s Anemia
Signs and Symptoms Severe anemia Pallor, failure to thrive Hepatosplenomegaly Frequent infection Microcytic and hypochromic RBC`s Small body and large head (characteristic features)

Management
Instruct the administration of folic acid that will stimulate the production of blood cells Blood transfusion Treatment is supportive- to maintain Hgb levels Give iron as prescribed, monitor for iron overload, administer chelation therapy with desperal- to treat overload and prevent organ
damage

Provide genetic counseling

HYPERBILIRUBINEMIA
Yellowish discoloration of skin and eyes due to excessive bilirubin. It is a result of hemolytic process in the neonate. It can be physiologic (appears on 2nd day or 3rd day of life) or pathologic ( resulting from underlying disease. Also called as infant jaundice.

Signs and Symptoms

Yellowing of the skin Yellowing of the eyes

An easy way to test for infant jaundice in a baby of any race is to gently press your finger on the baby`s forehead or nose.

CAUSES
If present at birth or appears in 24 hours Severe bruising An infection in the baby`s blood (sepsis) Rh Incompatibility If develops in or last past the second week of life Liver malfunction Severe infection Enzyme deficiency Abnormality in baby`s RBC

Screening and Diagnosis

Risk assessment Follow up visit with the baby`s doctor 3-5 days after your baby is born Measure the bilirubin level

Signs and Symptoms (severe jaundice)

Deep yellow or orange skin tone Extreme sleepiness High pitched cry Poor sucking Weakness or limpness

COMPLICATIONS

Kernicterus ( hyperbilirubinemia)
Damage to newborn`s brain Deafness Severe developmental disabilities Unusual form of cerebral palsy

TREATMENT
Phototherapy IV Immunoglobulin (IVIg) Exchange blood transfusion

NURSING CARE OF CHILD WITH RENAL SYSTEM DYSFUNCTION

Nephrotic Sydrome
A viral condition that affects glomerular filtration and causes loss of protein.

The cause maybe hypersensitivity to antigen antibody reaction or an autoimmune process

Clinical Manifestations:
Generalized edema, massive, Proteinuria, frothy urine Hypoproteinemia Elevated BUN and Creatinine Decreased oncotic pressure edema Hypovolemia renal system response Oliguria increased specific gravity Altered skin integrity Altered body image NO HYPERTENSION

Acute Glumerulonephritis
Inflammatory response to streptococcus infection that causes inflammation of the glomeruli. More common in children age 3 7 years old.

Causes
Immunological disease Autoimmune disease Streptococcal infection, group A beta hemolytic History of pharyngitis or tonsilitis 2-3 weeks prior to symptoms

Clinical Manifestations:
Decreased urine output Gross Hematuria (cola colored urine) Increased specific gravity Increased BP Increased cardiac workload Facial or dependent edema, periorbital edema

Increased BUN and creatinine Azotemia Abdominal or flank pain Edema in the face and periorbital area or generalized Hypertension Increased antistreptolysin titer Headache, chills and fever Anorexia, nausea and vomiting

complications
Renal failure Hypertensive encephalopathy Pulmonary edema Heart failure

management
Monitor vital signs, weight, I&O and characteristic of urine Limit activity: provide safety measures Nutrition
Restrictions depend on the stage and severity of the disease In uncomplicated cases, regular diet but sodium is restricted to no added salt to food Moderate sodium restriction is prescribed for the child with hypertension or edema

 Fluid and sodium intake is restricted as prescribed as if edema is present and urine output significantly reduced Foods high in potassium are restricted during periods of oliguria Protein is restricted if the child has severe azotemia resulting from prolonged oliguria

Administer diuretics as prescribed if significant edema and fluid overload are present

Administer antihypertensive Administer anticonvulsant Initiate seizure precautions as indicated Administer antibiotics as prescribed for the child with evidence of persistent strep. Infections Monitor for edema and fluid overload, ascitis, pulmonary edema and CHF Monitor for signs of renal failure, cardiac failure and hypertensive encephalopathy

Urinary Tract Infection

Occurs more often in females than in males. Pathogens appear to enter the urinary tract most often as an ascending infection from the perineum. UTIs need vigorous treatment so they do not spread to involve the kidneys (pyelonephritis).

Clinical Manifestations
Low grade fever Mild abdominal pain Bedwetting enuresis s/s in adult may not be present in children (pain in urination, frequency, burning and Hematuria) Urine for culture in clean catch technique

Wilms Tumor
An encapsulated tumor that arises in renal tissue during embryonic development. Assessment: Abdominal mass in a child less than 3 years of age is the most common presentation

Nursing Care of Children with Musculoskeletal Problems

Congenital Hip Dislocation

The head of the femur is displaced from the acetabulum causing instability of the joint It is believed to be caused by positioning in the utero. More common in females and more often affects the left hip

CONGENITAL HIP DYSPLASIA

Assessment :
Limited abduction Ortolani Click (in infants only) Asymmetrical gluteal folds Shortened femur on the affected side Waddling gait

Talipes Equinovarus
Also known as clubfoot Caused by positioning in the utero Involves deformity of the ankle and foot If not corrected may interfere with ambulation

Assessment:
Abnormal positioning of foot Impaired gait

Management:
Serial casting Teach cast care use palms not fingers for lifting Neurovascular checks

Scoliosis
A lateral curvature of the spinal column Usually effects the thoracic area May cause body image disturbance, respiratory compromise or cardiac impairment

Assessment:
Occurs during adolescent growth spurt (ages 10-13 years old) Asymmetrical hemline Asymmetrical shoulder height Unequal leg lengths > 5 degree deviation on scoliometer Body image disturbance

SCOLIOSIS

Juvenile Rheumatoid Arthritis (JRA)

JRA is an autoimmune disease Occurs most commonly in girls ages 2-5 years and 9-12 years It may become a chronic disease or resolve during adolescence Interferes with growth and development when not treated

Assessment:
Joint pain and swelling, usually big joints (may affect few or many joints) and last for more than 6 weeks Limited ROM Fever Rash Lymphadenopathy Hepato and splenomegaly