Surgery= z plasty done during 1-3 months (scatter incision.
Cleft palate is for speech, 6 months bottom teeth comes, 78 months top teeth comes in Need to repair palate 9-12
months before the top teeth start coming in they don’t want
teeth to come in the middle of the palate then child need to
go to dental. increase risk for respiratory infection and ear
infection its more serious than clef lips. Surgery is
Between 7&15 months because of top teeth erosion
Goal of cleft palate: Fix, improve speech and feeding,
great dental development, nurture their self-image.
After surgery still monitor up to 3 or 4 years if we still
notice deficits still treat them
Family follow up care USE cup or osto syringe nothing in
the mouth. Give mash food 4-6 weeks, it takes 6 weeks to
heal
For cleft palate they are at risk for Otitis media and dental
problems.
Teach signs of otitis media
Future need for cleft palate: Speech dental ear aids and
social adjustment
❖
surgery (Z plasty done 1st 3 months of life
(staggering incision line that minimize scarring).
Specializer feeders: Haberman feeder, pigeon bottle,
mead-Johnson cleft palate feeder. May need lactation
specialist, take 18-30 minutes to feed give frequent
burping head upright make sure they not aspirating .
Implementation: assist with feeding, emotional support,
perform post op care, help maintain healthy home
environment, making referrals
Preoperatively – at risk for aspiration, ineffective family
coping, grieving, and alteration in nutrition pump milk).
~ Post-Op Care – main goal is directed at protecting the
operative site.
Soft elbow immobilizers (restraints) – prevent the
infant’s hand from rubbing and touching the surgical
site. Do not leave the infant unattended when immobilizers
are used. We don’t want crust on the suture line either
Cleft lip supine but clefty palate prone. **Avoid metal
utensils or straws after cleft palate repair – may disrupt
suture line best way to feed is by cup, no pacifier
** Nutrition – Begin with clear liquids, then give halfstrength formula or breast milk. Use cup or syringe or
dropper inside of mouth. Give high-calorie soft foods after
cleft palate repair because rough foods can disrupt surgical
site. Pay attention to oral hygiene, restrain as need and
follow up with speech therapist. After surgery teach parent
how to feed and recognize signs of complication (fever,
vomiting, respiration distress)
Child may need further evaluation of speech, for presence
of ear infection, or recommendation for plastic surgery
NOTHING BY MOUTH
Pyloric senosis:
**malnutrition, dehydration, infection and metabolic
alkalosis. Projectile vomiting after feeding peristalsis wave
that go left right. After vomiting the need more
food(hungry), blood inside vomit,give an IV(until surgery)
ultra sound and put on NPO, can give pacifier with glucose
to soothe them
Fix hydration and metabolic alkalosis. Olive shape means
surgery no olive shape then they wait a little
Medical management- NPO, IV correct fluid, ng tube to
decompress to stop projectile vomiting. suction is set on
low intermittent.
Preop- assess hydration status, weight, abdominal girt,
remain NPO, IV fluid.
Post op- feed (clear liquid, then ½ strength, then full
strength formula,), elevate head of bed, turn on right-side
this facilitate gastric emptying, assess incision site for signs
of infection, its together no drainage nor inflammation,
document I&O
Pre op- urine specific gravity
GER/GERD:
Plastic cerebral palsy because of decrease muscle tone,
risk factor-premature, long term ng tube, hernias, agents to
lower LES
Pulmonary symptoms-(wheezing, bronchitis ,
cough,asthma, failure to thrive, aspiration pneumonia)
Assessment finding- vomiting weight loss recurrent
pneumonia apneas in little children
treatment of choice medication with severe they can have
fundal citation as a last resort since Gerd can fix by 12-18
months
small frequent feeding to prevent regurgitation.
Treatment=diet, position (elevate head of bed) medication
and lastly surgical. Don’t put child in car seat after feeding
parents should hold child upright for 15-20 minutes to
prevent regurgitation which can lead to aspiration. SIT
THE CHILD UPPPPP!!!!
Medical management= positional, older children feed and
walk not lie down
Nursing considerations= nutrition I&O with hydration
status, u want them to have urinary output
Educate- causes of refluxhow to avoid and symptoms to
watch for. We don’t want the to regurgitate and aspirate the
same thing choke on own vomit. emmotion emotional
support rest and comfort hand washing sit up 15 to 20
minutes after feeding at night orally hydrate them
Intussusception:
the intestine prolapses and then invaginates or telescopes
into another.
Bilious emesis
Palpable abdominal mass (RUQ). Empty RLQ
(dance sign)
Red, currant jelly-like stools (stool mix of
blood and mucus)
Inflammation and swelling at the infected site edema
babay will end up with temporary ostomy.
Jelly stool, abdominal pain (tall tell sign crying with
knees up trying to push bowel out) bearing down
Medical management= Ng tube decompress and reduce
vomiting, use air to push bowel out if that don’t work
then the child going to surgery.
Questions we need to ask whats the duration, intensity,
frequency and description.(WE WANT PARENTS TO
SAY MY BABY WAS FINE UNTILL START
VOMITING AND HAVE STOMACH MUCUS IN
STOOL)
Treatment= hydrostatic (saline) reduction if don’t work
surgery, HOPE CHILD DON’T GET GANGRENE OR
ELSE THEY WILL GET OSTOMY
Preop= if in shock- () gastric suctioning, ng tube
restrain them, medicate with “VERSAID” enema)
If we give enema we should get brown stool if not we
will prepare for surgery passage of brown stool may
indicate that the intussusception has been reduced
Post op= antibiotic, keep NG tube in monitor site suture
together, bowel sounds in all 4 quadrants, emotional
support especially to parents. PAIN MANAGEMENT
IS OUR TOP PRIORITY
Hirschsprung Disease
congenital ganglionic megacolon
Clinical Manifestations
Nb – abdominal distension, feeding intolerance,
bilious vomiting, and failure to pass meconium
within the first 24-48 hours after birth.
Older child – failure to gain weight, malnutrition,
and chronic severe constipation, fecal masses
easily palpable (LLQ)
Remember, if you’re not absorbing nutrients
because stool is sitting where it’s not supposed to
be, then the body is being deprived. Walk around
with a big hard belly!
Older children have a history of chronic
constipation with foul-smelling, pellet-like stools,
ribbon-like stools, or liquid stools
Lack of peristatsis. Unable to pass meconium 24-48 hrs,
newborn: they don’t suck don’t want any fluid, they vomit
bile and abdominal distension
infant period: inadequate weight gain, constipation, hx of
abdominal distension, diarrhea and vomiting, they can have
bacterial infection called enteral colitis if not diagnoses
inflamed,
childhood: chronic constant constipation, pass ribbon like
fowl smelling stool, fecal masses in stomach (LLQ),
malnourished and fail to gain weight
do enema lower gi series and xray to look for solid mass
treatment: surgery in two stages. 1st stage infancy 6-15
month or 15-20 pounds temporary colostomy on
transverse colon (semi stool
2nd stage is pull-through procedure remove bad part and
attach good to rectum and close temporary ostomy) new
technology connect in one stage it depends on how bad
colon is.
Benefit of one step is to avoid multiple operation but they
don’t get to rest the bowel. Maintain hydration isotonic
enema (don’t want to pull out fluid we want to maintain
electrolyte)
Monitor vital sigh don’t want sepsis(temperature and BP)
Teach parents how to care for ostomy, check bowel sounds,
no rectal temp no rectal!!! Give NG tube
Inflammatory:
Appendectomy: can’t jump up and they having pain on the
right it’s a sigh of appendicitis. They have a lot of guarding
rebound pain
Treatment: surgery if pain stop it means it burst they no
longer treat of it burst. Now they watch if it don’t resolve
the do surgery to clen them out. Ng tube to decompress,
uncomplicated they go in take it out they should be fine.
They can go bk to school. If rapture they can get peritonitis
so they treat with antibiotics and then they watch them if
they start to become septic then they do surgery. GI
intubation is ng tube at low intermittent suction. They will
get antibiotic and pain management
NEC:
Usually in preterm but now in infants. acute Inflammation
of intestine. They have to bacteria in the stomach cereal
high in sugar which bacteria loves wrong bacteria, breast
milk is good because mom breast have everything plus its
low in sugar. poor o2 in bowel (intestinal ischemia)
We see: distended abdomen (do abdominal girt), gastric
distension(gas), blood in stool, diac comes back positive
Do xray- sassage, air, CBC- decrease hgb increase WBC,
look for signs of sepsis we can see it in our cbc with diff
and . CBC look for sausage shape free air and delitation of
intestine
Treatment: •
NPO (replacing po fluids with IVs
decreases the need for O2 and circulation to the bowel)
•
N/G tube to low suction (to prevent gastric
distention)
•
IVs (to maintain F&E balance)
•
IV antibiotics
Nursing care- •
Check vs with BP~monitor for changes
that indicate bowel perforation, septicemia, or shock
•
Check abdomen frequently q2h for distention
•
Position infant on side or supine to avoid
pressure on the distended abdomen
•
Listen for BS
•
Test gastric secretions and stools for occult blood
•
Strict I&O
•
IV antibiotics
•
Strict hand washing
Prognosis is good once found early
Acute gastroenteritis:
Diarrhea, medication. Hyperactive bowel sounds.
Treatno food or fluid to rest bowel give something bland no
pepto no Gatorade clear liquid diet popsicle frozen
Pedialyte ice chip no more than 30ML I've ooz ns every 15
minutes for infant children. give Zofran look smell and
consistency of vomit sin turgor and mucos men sunken
frontonel is dehydration (for dehydration put child on bolus
the iv fluid to rest stomach. (give sugar salt and potassium
with potassium make sure patient voided)
How to cure rotavirus= roto vaccine
Celiac disease:
The absorption of protein, carbohydrates, calcium, iron,
folate, and vitamins A, D, E, and K, and B12 become
impaired.
Infancy – chronic diarrhea, growth impairment,
and abdominal distension
Poor appetite, lack of energy, and muscle wasting
with hypotonia
Atypical signs – nausea, vomiting, abdominal
pain, bloating, tooth enamel defects, and
aphthous ulcers
-
Delayed growth, iron deficiency, and abnormal
liver function tests
Gluten intolerance problem with IgA, 6-18 months. Main
complication is lymphoma in small intestine,
We see steatorrhea (fatty stool Stools are greasy, foulsmelling, frothy and excessive) chronic diarrhea, anorexia
(decrease appetite), failure to thrive, abd distention and
pain. Do chemistry we gonna see low calcium, albumin low
hgb, IgG, stool sample to check for fat.
Management: gluten free diet include corn and rice
product, soy, potato flour, rest milk soy base formula,
fresh fruits EXAM!! Nurses responsibility is always
diet, exercise and health promotion. Supplementation
with fat-soluble vitamins, vitamin B12, folic acid,
calcium, and iron may be needed.
Easily identified gluten-based foods are bread, cake,
doughnuts, cookies, and crackers. Parents may need to
purchase prepared rice or corn-flour products or make their
own bread and bakery products
Giardiasis:
Infants – diarrhea, vomiting, anorexia,
avoidant/restrictive food intake disorder (failure
to thrive).
Older children – abdominal cramps, intermittent
loose foul-smelling, watery, pale, and greasy
stools
Obesity: Acanthosis nigricans –
hyperpigmentation and thickening of the skin
with velvety irregularities in the skin folds of the
back of the neck, axillae, and flexor skin
surfaces. Sign that pt going to have type 2
diabetes.
Npo, and fastin blood glucose level
Hypothyroidism:
T3 and T4 and need calcitonin and thyroid hormone for
these to develop
If untreated child will have congenital hypothyroidism start
in utero but can also start in infancy, infant will have
creationism if left untreated.
Complication: skeleton malformation learning disability,
delayed sexual maturation.
Hormones secreted by thyroid: thyroxin, T3, T4 (for
growth and development), TSH control thyroid hormone,
TSH secreted by anterior pituitary gland, TSH is regulated
by thyrotropin-releasing factor.
Infants: Lethargy, hyperthermia, puffy face swollen tongue,
short leg in relation to trunk, cognitive impairment, short
sature, big neck,
Infant: hoarse cry,jaundice,respiratory difficulty
Older children: bone and muscle dystrophy, and cognitive
impairment (dwarfism), Look for elevated TSH, LOW
T3&4 decrease iodine uptake means absence of thyroid
tissue, gonadotropin levels increase they mature too fast)
ECG show bradycardia
Medical management: give thyroid hormone and
supplemental vitamin d (calcitonin need vitamin d), routine
monitoring of TSH and T4 also monitor anterior pituitary
gland (check for tumor).
Nursing intervention: administer meds as order frequent
rest, encourage cough and deep breathing exercise, ristrict
sodium, fluid restriction skin care check tongue, put on side
to sleep to prevent airway obstruction, rectal temperature is
best in thyroid patient, talk to parents about coping,
monitor vital signs HR should be 120 beats per. Adolescent
girls need thyroid replacement if they get pregnant. They
need to do growth chart since they can suffer from
dwarfism. Teach the fam this is for life , how to give meds
and persistent with it, don’t out in formula because the
infant not going to finish it sinv=ce it don’t taste good,
monitor pulseits a sign of drug overdose.
Diabetes:
Type 1 need insulin, type 2 is obesity and they make little
insulin and they can take oral glycoside,
Result in malfunction in carbs,protein and fat metabolism.
Type 1 pass down , dx is blood glucose of 126 after no
caloric intake for 8 hrs, type 2 the look at hemoglobin A1C
lose 30 pounds. if hgA1c is 60.5 they will give oral
glucoside.
Type 1 do accucheck to say over 400 know 4 P’s, ONSET
IS SCHOOL AGE. Type 2 insulin resistance they usually
heavy we see this in adolescent. Tall tell sign acetone
breath and Kussmaul respirations. They need to know
injection site, use the bathroom a lot is a sign, check the
neck, play station is one of the reason y adolescent is now
having type 2 diabetes. Type 2 body build up resistance, no
longer stores it and no longer breaks down glucose.
See in type 2: 3P’s (polyphagia, polydipsia and polyuria),
fatigue, blurred vision, slow healing infection, itchy dry
skin, numbness or tingling in the hands or feet use oral
glucoside to facilitate them (metformin), Biguanides
(metformin): The “insulin sensitizer” reduces hepatic
glucose production. Tell parents to get type two in an
exercise program to lower cholesterol, increase vascular
resistance,
See in type 1: 3P’s (polyphagia, polydipsia, and polyuria),
fatigue, blurred vision, unexplained weight loss despite
food, diminished reflexes, irritability, N/V, fruity odor of
breath, Kussmaul respiration.
New: Insulin injection sites. Give all morning insulin in one
site (e.g., arms) and all evening insulin in another (e.g.,
legs) because of different rates of absorption from these
sites. Space injections about 1.25 cm (0.5 in.) apart. Teach
s/s of hyper or hypo glycemic, how to monitor and correct,
insulin shock is (hypoglycemic effect) if the glucose is
below 6o. teach them if they exercising too much how to
balance give them glucose. You need 15 kal to raise
glucose level. Rebound hyperglycemic effect this is when
u have too much glucose they will need sliding scale.
“Honeymoon” phase is a period during new-onset diabetes
when the child has some residual beta-cell function, which
reduces exogenous insulin requirements. However, insulin
requirements does eventually return. Blood glucose levels
of 200 mg/dL or greater without fasting
Fasting glucose of 126 mg/dL or greater
Fasting lipid profile since dyslipidemia is usually
present (↑ triglycerides & LDL cholesterol)
Insulin therapy for type 1 – often need several daily
injections on insulin before meals and at bedtime to
maintain an optimal glucose level. A basal-bolus insulin
regimen has resulted in improved glycemic control.
Basal insulin is administered once a day using a very longacting insulin (Glargine [Lantus] or Detemir [Levemir]).
A bolus of rapid-acting insulin (lispro [HumaLog], aspart
[NovoLog], or glulisine [Apeira]) administered with each
meal and snack based on the carbs consumed and glucose
level.
KEDOACIDOSIS:
Give them regular insulin, iv insulin cannot mix with
anything else, we have to be adamant about monitoring
their blood sugar, when they in DKA, watch because they
going to be in metabolic acidosis.teach
Management: right dieat and make sure the exercise, give
emotional support to the child and fam especially newly
diagnosed, they heal poorly, teach how to recognize signs
of hypo and hyper glycemia, they should seek medical
attention if they get cuts because they not going to heal
well, they need to have a endocrinologist and see a
nutritionist, they need to be able to monitor caloric intake
with insulin, do I&O.
Put on sliding scale, dangerous especially when child is
sick. Give isotonic solution with IV insulin
NEUROLOGIC:
Neurological function: Neurological disabilities in children
result from congenital malformation, body injury and
infection. Things that make LOC CHANGE: CO2 in the 60’s
cause decrease LOC OR RISE AT 45 change in LOC. Fever
cause 1% rise in o2 requirement and some medication
sedate the patient eg sedative and antiepileptic affect
neurological function. Seizure and intercranial pressure
cause child to have loss LOC. In children suture of the head
are not connected because brain not fully developed, and
they come through birth canal so we have to pay attention
to head (do head circumference up to 3 years old) also
look at neck, kids have excessive spinal mobility because
they still growing and muscle not fully developed.
GLASGOW coma scale to assess client LOC. It tests eye
mobile, & verbal. We look at client behavior if they are
responding appropriately, look at pupil evaluation which
tell if cranial nerve working as well as amount of fluid in
the brain, look at motor function for coordination, monitor
vitals to look for Cushing response. V/S allow pt to
maintain temp control. Two sign of brain stem damage is
Decorticate posture decerebrate
KNOW FOR EXAM: Decorticate or flexion posturing (Fig.
27-4, A) occurs with severe dysfunction of the cerebral
cortex or with lesions to corticospinal tracts above the
brainstem. Typical posturing includes rigid flexion with the
arms held tightly to the body; flexed elbows, wrists, and
fingers; plantar flexed feet; legs extended and internally
rotated; and possibly the presence of fine tremors or
intense stiffness. Decerebrate posture or extension
posturing (see Fig. 27-4, B) is a sign of dysfunction at the
level of the midbrain or lesions to the brainstem. It is
characterized by rigid extension and pronation of the arms
and legs, flexed wrists and fingers, a clenched jaw, an
extended neck, and possibly an arched back. Unilateral
extension posture is often caused by tentorial herniation.
A, Flexor or decorticate posturing, characterized by rigid
flexion, is associated with lesions above the brainstem in
the corticospinal tracts. B, Extensor or decerebrate
posturing, distinguished by rigid extension, is associated
with lesions of the brainstem.
Delirious= they not oriented at all, disoriented means they
cant recognize place nor person, Obtunded: sleeps and,
once aroused, has limited interaction with environment •
Stupor: requires stimulation to arouse • Coma: vigorous
stimulation produces no response • Lethargic: awakens
easily but exhibits limited responsiveness
FOR NEURO Pay attention to: LOC, check cranial nerves,
fontanel I don’t want a lot of fluid in the braid because it is
high is sodium and glucose which can lead to infection,
look at cognitive according to age, 3 year old should know
how many color, vocabulary. Look at pupil it should be 35mm higher than 5mm means brain blown out if less than
3 means u high or sedated, you want to look at vital signs
(V/S) is a late sign of intercranial pressure), temperature
and respiration are the only two vital sign connected to
the nervous system, posture go with motility and
coordination, neck stiffness is another sign to tell
something is wrong with brain, monitor with familiar hx
with headache and seizure activity because they run in the
fam. You want baby cry to be stimuli base. 14 or 15 on
Glasgow scale is good for infants and the lower is 3 but
that’s not good infants love to cry, children good score
should be 15.
seizure. Surgery is last resort. Nurses responsibility- wear
braces.
INCREASE CRANIAL PRESSURE: The brain compensates for
increase cranial pressure by limiting blood flow to the
head, replace CSF (cerebrospinal fluid) into spinal cord or it
will increase absorption and decrease production of CSF by
withdrawing water from brain tissue into the blood then
try to excrete through the kidneys. Case of increase cranial
pressure: from tumor, accumulation of fluid in ventricular
system, hemorrhage, edema to blood or trauma to the
head.
Meningitis: COMPLICATION: COMA AND DEATH. In older
kids they do the opisthotonic position (head and neck
hyperextended to relieve discomfort, the child may have a
positive kernig or Brudzinski sign or both, A, To test for
Kernig sign, raise the child’s leg with the knee flexed. Then
extend the child’s leg at the knee. If any resistance is noted
or pain is felt, the result is a positive Kernig sign. This is a
common finding in meningitis. B, To test Brudzinski sign,
flex the child’s head while in a supine position. If this
action makes the knees or hips flex involuntarily, a
positive Brudzinski sign is present. This is a common sign
in meningitis.
Manifestation: resistance to be held, increase cry when
legs raise for diaper change; in child u will see headache
neck rigidity and Brudzinski sign and Kernig. They always
complain about the neck. Test CSF fluid via lumbar
puncture it should be clear and have glucose. Lumbar to dx
neurological problems. Calaps of the circulatory system
then the child die. Look for signs of shock, poor perfusion,
delayed cap refill, V/S changes, increase pulse and
decrease BP, decrease LOC. Bacterial meningitis the child
will hyperflex the neck to get comfort, with viral the child
is just crying. Onset is URIs, the child will get headaches,
restlessness, V, patiki is bad, rash bad.
the main complication we want to prevent is brain death,
cardiac arrest, or respiratory arrest. Respiration is affected
because medulla Balangao is in the head and is responsible
for breathing also temperature is monitored by
hypothalamus.
In infants look for bulging fontanel, WITH normal
pulsation and irritability, high pitch cry, increase head
circumference, decrease LOC, altered feeding and
distended vein in the scalp, separated suture line,
sunsetting sign in the eyes,
In a child: V/N, headache, double vision, or seizures
Main clinical manifestation in both sets: steering, decrease
motor activity, sleeping more, weight loss, LATE SIGN:
PUPIL CHANGES, POSTURING, CHANGES IN V/S INCREASE
BP, DECREASE HR, DECREASE RESPIRATION,
Medical management: docs might do lumbar puncture if
child having fever bt we don’t want that, we treat
according to cause if its infection they treat like
meningitis(antibiotics); if its trauma related, we use
corticosteroids and diuretics (mannitol). we monitor the
ICP level. MAKE SURE PT KEEP BREATHING BECAUSE OF
THE MEDULLA ABLANGATA. DON’T DO Valsalva
Maneuver we want pt to have quiet environment and
treat pain. Monitor for Sodium and glucose loss they going
to be on seizure precautions.
Seizures: this should not last for six minutes, after 15
minutes it’s an emergency, we don’t them to hurt their
head. Don’t see febrile seizure pass 6 mths -5 years we see
in toddler (we don’t see past 3 years), TREAT FEVER WITH
ANTIPYRETICS. If having longer than 5 then you need to
work up the child for seizure activity, you want to make
sure febrile seizure only occur when child have fever
(101.5 F) low grade temp for infant (100) toddler (100.5),
preschooler (100.5), school age (100.5), 3 month old (100101), newborn under 3 months (100.4). babies get spinal
tap if can’t find the source of fever. Epilepsy recurring
seizure. Watch how long seizure last. MEDS: Keppra,
gabapentin, lamitol. Maintain a therapeutic level in blood
therapeutic blood level to test, parent should come in
every 3 months that way child should not be having any
What you should do: isolate child 24 hr, give antibiotic,
may give dilantin if seizure activity. With bacterial
meningitis- V/S, fever control with antipyretics, observe
for inappropriate syndrome of antidiuretic hormone,
monitor electrolyte(sodium glucose). Bacterial Meningitis:
elevated WBC, decrease glucose, increase protein. For
viral: spinal fluid is clear or slightly cloudy, WBC slightly
elevated, but glucose should be normal culture neg.
Complication: encephalitis (seen in bacterial meningitis. Its
inflammation of the brain.
s/s: headache, drowsiness may lead to coma, seizure in
infants, Fever, cramps abdominal pain, vomiting.
Treatment: –
Corticosteroids/immune globulin (to
bring down the swelling of the brain), if caused by herpes
virus give ACYCLOVIR, antibiotic to treat bacteria, sedate
to prevent seizure activities, give O2 and maintain airway.
Hydrocephalus: increase CSF in the ventricles of the
brain.(obstruction in ventricular system or malfunction
then we have extra fluid circulating. Put in a tube that
allow fluid to drain. Detected with bulging fontanel. s/s
depend on the type of obstruction and child age. Early sign
is rapid increase of baby’s head, scalp vain bulging
fontanel, irritability and poor feeding, shiny scalp, dilated
vein, separated fontanel. Late signs sunset in the eyes,
bossy vomiting and high pitch cry. measure head cir, CT
scan (structure), MRI (see whats happening at
subarachnoid level), AND ENGIOGRAM, xray (separation of
suture and to make sure fontanel are not widen.
Treatment: –Ventriculoperitoneal (VP) shunt or
ventriculoarterial (VA) shunt (less common drain from
ventricle to heart), with the VP shunt if child not mobile
they going to have many reconstructive surgery because
they keep pressing down the pump/valve. Shange their
position q2h. meds of choice if they start to develop
seizure), tetrytol Dilantin or Dallam.
Nursing care: change position q2h to prevent hypostatic
pneumonia, observe for signs of intracranial pressure(ICP),
and for infection at surgical site of along shunt line, I&O
CSF should be no more that 25-50 more than urine. Pre
op-Assess for signs of ^ ICP, check LOC, Monitor VS for
changes from baseline, Measure HC everyday; plot and
graph (for accuracy), Position head to prevent skin
breakdown (sheep skin, lamb’s wool), Do not stretch or
strain neck muscles, Post op- look for signs of infection
↑T, HR, RR, poor feeding, ↓ LOC, local inflammation at
the operative site • Check incision site for leakage and test
any drainage for glucose.
Spina bifida: spinal sac congeninal, imperfect closure,
develop a cyst. Take folic acid to prevent. Use saline to
keep most and prevent bacteria from going in.
myelomeningocele is the worse one nerves coming out.
They will have curvature. cause drug use, genetic,
maternal malnutrition, lac of folic acid. 16 and 18 weeks of
gestation is when u can see it via ultrasound. Geriatric
pregnancy (35 yeas old)can cause it
Nursing care: prevent sac from drying out, we need to
protect the sac, prevent rapture or leakage of the CSF,
prevent trauma or pressure on the sac, keep lesion free
from feces and urine. Post op- teach familily/parents its
going to be a long term effect ,they need love and care.
After surgery place infance prone or sidelying, observe for
signs and symptoms of infection, these patients can have
meningitis or increase intracranial pressure. Promote
urinary elimination if they can parents have to cath them,
Meds: Ditropan to improve the bladder capacity, cat q4h,
promote bowel training or put on suppository of enema,
monitor their diet(fiber, an fluids), have latex allergies
(spina bifida and cerebral palsy), 5 things you need to do
with these babies.
Cerebral palsy: chronic non progressive disorder,a group
of disorder from a malfunction motor center and neuro
pathway in the brain. Cognitive impairment (hearing and
speech impairment, visual impairment and seizure.
Manifestation: vary with age and type, sometimes we see
mental retardation, suspected during infancy when child
have FEEDING PROBLEM, we going to look for
coordination in conjunction if child cant put hand to face,
self care deficit, communication problem, coordination
and mental problems, GROSS MOTOR DELAY (from all
type)
Treatment: •Botulinum toxin has been used to manage
spasticity problems (spasm. Levodopa help with athetoid
problems (involuntary writhing movement). They have
hypotonia.
Parents should do selfcare, look what mental retardation
they have, parents need to learn how to communicate
assist with locomotion, aids to feed them and help them
become independent, we want them to increase intellect
with socialization,
Medication: muscle relaxants (decrease contractures) antianxiety (decrease excessive motions assoc. with athetosis
Treatment: PT, ST, OT
INJURY of the brain:
Car accident, shaking the baby; use GLASCO coma scale;
LOC, Arousal awareness, Cranial nerve responses, Motor
response, loc mental state confuse rest irritability pale skin
vomiting head circumference headaches memory loss
(older kids), Medical emergency if pupil is asymmetric,
Near-Drowning:
If its cold water we can save them the cut off time is 6
minutes, warm water is a proble they lose more O2
hypoxic in the brain, give immediate treatment, in the ER
we want to know how long they were submerge,
problem after near drowning- hypoxemia, aspiration in
lungs, hypothermia, hycapnia, acidosis and lead to
cardiac arrest, just fake CPR just try to helpthen call
911 do ABGs, make sure they not in acidosis,
give antibiotic epinephrin to decrease spasm observe for
neurologic impairment. Do the brain dead test(
hyperventilate then turn off the machine if CO2 build up
we should take a deep breath in if they don’t they are
brain dead.
Signs and symptoms
Prognosis affected by length of submersion, physiologic
response, exposure to hypothermia
–
Hypoxia is the primary problem
–
Pulmonary edema, pneumonia
• Treatment and nursing care
–
On-site CPR
–
Immediate transportation to a trauma facility
–
Intensive pulmonary care
–
Risk of cerebral edema and anoxia
Intellectual disability: Intellectual disability: NOTE: when
they lay constantly on the side due to immobility, they
damage the shunt. Intellectual function (IQ less than 70 to
75) • Onset before age 18 years • Functional strengths and
weaknesses • — American Association on Intellectual and
Developmental Disabilities (formerly AAMR)
Classification of IQ  Educable, mild: IQ 50 to 75 
Trainable, moderate: IQ 35 to 55  Severe: IQ 20 to 40 
Profound: IQ less than 20 to 25.
Help parents know the developmental milestone. For
cerebral palsy help parent to establish ways to
communicate, we want to make sure they can hear and
whatever routine at home we want to keep them on the
same at hospital, keep them discipline by having parents
set limit, they will have temper tantrum with nurses
because they can’t express themselves and we cant pick
up cues, we want these kids to socialize its going to be
hard because they are honest. Our job to make sure these
kids can function with other kids and develop their
psychosocial. Do not forget this parent they will want to
isolate their child, watch for sexual action because they
are driven by Id. Do age appropriate
Down syndrome: Down syndrome: trisomy 21. Risk factor
is maternal age older than 35,
Key signs: brush field sign in the forehead, flat nose and
forehead, hypotonia (undeveloped muscles) sensitivity,
retardation can go from mil-moderate-severe- protruding
tongue, small head with slow brain growth, simian crease,
upper slanted eyes, genital and perineal abnormalities,
heart defects VSD (mostly) and ASD, teach family how to
feed and position them, they have frequent UTI and ear
infections, ways to prevent down syndrome they do
chromosome testing and amniocentesis,
Nursing interventions: vaccination for URIs, cardio care
since they at risk for heart defect, speech therapy monitor
for every milestone. Stay consistent with the
Fetal alcohol syndrome:
dx: deformity of the head and face + 2 of below:
(Microcephaly vertical ridge in upper lip, thinned
upper lip short, upturned nose Small eyes, upward,
outward slant to the eyes)
Always stay below 10% percentile
Deformities of the head and face~ at least two of these
four signs  Microcephaly  vertical ridge in upper lip,
thinned upper lip  short, upturned nose  Small eyes,
upward, outward slant to the eye
Denver tool test
Same as down syndrome; measure interlect with Denver
tool
Notes: chronically consume 3 or more drinks per day. They
function well. They have prenatal growth retardation, and
a postnatal growth retardation they don’t meet height
growth and weight and head circumference, they always
below 10% percentile. Decrease CNS function, small head,
slow response in CNS their motor skill is toxic (shaky,
tremors).
Attention deficit disorder: ADD: Inattentive, impulses
might or might not include hyperactivity or combined, it
has to continue for 6 months dx at school age. It appears
b4 age 7. They can’t follow adult instruction they may
want to, but they can’t finish a task. Keep redirect them
the first thing that comes to mind they act on it.
S/S: inattentive to details, careless with school-work and
other activities, can’t organize self, can’t finish a game
can’t concentrate, easily frustrated,
Treatment: renin, Strattera, limit sweets and food coloring
this will increase attentiveness
Autism:
Autism is social behavior while ADD is impulsive. They do
parallel play. They love to be alone, they have some
degree of mental retardation, no cure,
Asperger syndrome: highly functional, able to learn and
able to function with other people, they still have
symptoms of social and emotional and they very rigid with
schedule, if they on a schedule they will be able to
function. It’s a full-time job, for parents they should go to
counseling, keep them on a routine, prevent them from
self-abuse or violent behavior (this comes when you
abruptly try to change their schedule). With ADHD KIDS
THAT ARE BAD AND HAVE BEHAVIORAL ISSUES IF YOU
CHANGE THEIR ROUTINE ABRUPTLY IT WILL NOT GO WELL
FOR YOU, let them know and ease them into it.
When you lay the children supine, they have abduction of
the hips. If the infant is faced on the back the hip flexed
the hip will abduct when the doctor presses on the femur.
We hear a click, or a jerk produced by the femoral head.
The sign signify hip dislocation in older patients. Braslow
sign: when the hips are flexed 90 degree. Pelvic ultrasound
can also be used. Harness vest: If the patient is dx before 6
month they keep the vest on. After 6 months they get it
taken off and get cast because it will interrupt their growth
pattern. Nursing management to assess sign of hip
dysplasia , neuro checks of cns, teach how to apply the
harness and maintain abduction, maintain skin integrity.
Don’t put any lotions or oils under the strap. You want the
kid to not be able to walk or crawl. Only allowed vest off
for 1 hr a day. If the kid is not treated by 2 one leg will be
longer than the other. As a result they have to get pins.
Compartmental syndrome affects the muscles; They
complain of PAIN, numbness, burning sensation, foot and
hand asleep or paralysis, poor oxygenation. Assess for
pain, feel the muscle if it is tight and measure the muscle
and compare it to the other side. Check pulses below level
of injury.DO NOT ELEVATE AFFECTED LIMB! KEEP IT
BELOW LEVEL OF THE HEART. This will require surgical
intervention. They will need to relieve the pressure ( the
cast is too tight).
Legg-Calve-Perthes Disease:

Necrosis vascular compromise leading to flatting
of the femur. Cause unknown. more common in
boys 4-8. Venus obstruction. Thrombosis.
Trauma because vessels are occluded.
It has four stages:

Stage 1- vascular. Blood supply to the femur
head is interrupted.

Stage 2- blood is return to the femur head.
Fragmentation. Dead bone reabsorbed.

Stage 3- reocculation process.

Residual oval shape.
Treatment: surgery they place the femur in the socket.
Complication: immobility
Management: contain femoral head in socket. Bed
rest. Wear braces from 6-18 months. Osteotomy. Spike
pad on for 2 months.. CAST CARE CHECK FOR CMS, I&O,
REPOSTION Q 2, PROVIDE EMOTIONAL SUPPORT. Don’t
play in contact sport.
FRACTURES:
SPINAL FRACTURES ARE BAD! Should be rare unless they
have ostero disorder. Other than that they will do a
workup for child abuse.
Most common bone broke is clavicle. When you look at
the fracture always make sure no trauma to growth plate.
Typical bone healing is fast in children. Look for swelling,
pain, numbness, peripheral pulse is good past the
fracture. CMS!!
Once they have the cast check for the 5 P’S. Open and
closed procedure. Pin care. We have to assess for the 5 Ps.
TEACH not to get cast wet, no scratching, no lotions.
Pulmonary edema possible. Don’t move patient with
traction with weight (usually scheduled).
RICE therapy for 30 mins at a time. Compression with ace
bandage.
CLUB FOOT:
Happens in the uterus. The foot turns. They try to cast to
the foot without surgery. They can do simple exercises and
casting. Casting every 1 or 2 weeks. Make sure to do CMS
checks. Parents should make appointments. Don’t get cast
wet and clean. Inspect toe pink and remind to elevate
feet. If you notice smells then tell dr. cast come off every 2
weeks.
HIP DYSPLASIA:
Present at birth. How they position in utero. Left hip more
commonly abnormal. The hip is unstable. Psychological
factors or compression in utero. Teach safety measures,
how to bathe and feed children, dress in cool pj.
Scoliosis: try to correct by teenage years because that’s
when full growth occur. Curvature can be in the, spinal,
lumbar thorospino segment. TALL TELL SIGN THE BATHING
SUIT IS CROOKED; this can be structural or progressive of
the vertebrate. Pain is not associated to idiopathic
scoliosis.
Congenital ◦result of vertebral abnormalities ◦associated
with other congenital anomalies (spina bifida)
Paralytic ◦common in individuals with certain
neuromuscular diseases ◦CP, MD, paraplegia, quadriplegia.
you will see Visible curvature of the spine Rib hump when
child is bending forward Asymmetric rib cage Uneven
shoulder or pelvic heights Apparent leg length
discrepancy. They do test in 6,7, & 8th grade to check for
scoliosis. This affect breathing because lungs cant expand
enough. Dx is done by taking child to locker room and
check for curvature if positive they will go to bone doc.
auto spinal fusion is the surgery done for these pt (put a
rod in to make it straight). Nonsurgical child will get
bracing (◦bracing (worn 16-23 hrs/day) ◦Boston~
decreases lumbar lordosis ◦Milwaukee~includes a neck
ring; used for high thoracic curves). WEAR COOL SHIRT
UNDER BRACE TO PREVENT rashes.
Nursing management: School nurse screens for scoliosis
beginning 5th grade If bracing monitor closely Negatives of
bracing include: ◦discomfort in warm weather, skin
irritation ◦teen girls find bracing cosmetically offensive
Promote self-esteem and normalcy.
Preop= make sure you know what their lung capacity is
like
Post op= check neuro status and neuro checks in the
extremities, check pulse sensation, maintain pain, do fluid
and electrolyte, watch for bleeding and make sure they
are urinating, check for bowel sounds because these things
happen under general anestetics. Pulmonary Hygiene
◦incentive spirometer ◦log roll patient side to side (to
prevent damage to the fusion and instrumentation)
Orthoplast jackets used for some patient
Osteomyelitis: infection of the bone it takes 30 days to
heal so kids go home with picc line and get antibiotic u see
with arthritis and leukemia, bone scan is used for dx, give
vigorous IV antibiotic for a month, monitor child
hemologically, renal, hepatic responses to treatment.
Osteogenesis imperfecta: brittle bone (fractures, pain
they can die and the get scoliosis as well. Type I ◦ Type IA—mild bone fragility, blue sclera, normal teeth, presenile
deafness ◦ Type I-B—same as A except with abnormal
dentition ◦ Type I-C—same as B but no bone fragility ◦ Two
thirds of all cases are type I Type II ◦ Lethal; stillborn or die
in early infancy ◦ Severe bone fragility with multiple
fractures at birth ◦ Autosomal recessive inheritance. They
can take meds to increase bone density, they can do
counselling. GENTLE GENTLE GENTLE
Muscular dystrophies:
Duchenne muscular dystrophy is progressive deterioration
of muscle. They can be healthy then suddenly become ill.
It affects all large muscle groups. Onset 3 & 5 mostly in
boys.
Complication: they can live to early teens. Their mind
function, dx Prenatal testing if positive family history
Suspected based on clinical appearance, in Blood:
Polymerase chain reaction (PCR) for the dystrophin gene
mutation Confirmation by EMG, muscle biopsy, and serum
enzyme measurement Serum CPK and AST levels are high
in the first 2 years of life, before onset of weakness. These
kids will meet all milestones until age 2 when they start
having muscle weekness.
Clinical manifestation: illness become apparent at age 3
and 6 years, failure to achieve motor milestones, child
going to have problem getting up, GOWER SIGN IS TALL
TELL SIGN FOR DYSTROPHY.
Muscular dystrophies Physical Exam ◦ Toe walking ◦ Large
firm calf muscles ◦ Fibrotic or “doughy” feel to the muscles
◦ Widely based lordotic stance ◦ Waddling Trendelenburg
gait ◦ Lower extremities show early weakness of gluteal
muscle strength ◦ Positive Gower sign.
Management: orthopedic, metabolic, and physical
therapy, social service, and nursing care, genetic
counselling and family support. THIS IS A TRMINAL ILLNESS
NO EFFECTIVE TREATMENT. These patients only get meds
to stop muscle spasm (baclofen) (muscle relaxant) goal is
for mobility and independence promote growth and dev
and prevent complications help them cope,