Exam 3 Review
Mayra Paredes, DNP, RN
NURS 3552 Holistic Nursing: Care of the Children and Families
University of St. Thomas
Carol and Odis Peavy School of Nursing
Fall 2022
The Child with Endocrine Dysfunction
Diabetes Insipidus….Disorder of what?
Diabetes Insipidus Clinical Manifestations
The principal disorder of the posterior pituitary
Results from hyposecretion of antidiuretic hormone (ADH [Vasopressin])
Uncontrolled diuresis
Primary causes: familial or idiopathic
Secondary causes: trauma, tumors, granulomatous disease, aneurysm
Sx: polyuria and polydypsia
Diabetes Insipidus Clinical Manifestations
Dx: restrict fluid – observe ∆ in urine volume and concentration
CT question: what nursing assessments would you make during the DX period?
Test dose of Vasopressin
Hormone replacement of vasopressin (IM or IN)
Unresponsiveness usually indicates nephrogenic DI
Nursing:
 Counsel parents to investigate enuresis and excessive thirst, or irritability relieved by bottle
feeding of water
 Careful hydration assessments, including labs
 Rx is life-long, medic-alert bracelet
Diabetes Insipidus
Hyper-secretion of the posterior pituitary (↑ ADH)
Water from kidneys is reabsorbed into circulation
Signs & symptoms: fluid retention, hypotonicity, (↓ serum osmolality, ↑ urine osmolality
When Na+ levels reach 120 mEq/L - anorexia, N/V, irritability, personality changes
Symptoms disappear when ADH is decreased
Immediate mgt – restrict fluids 1/4th – ½ maintenance
Diabetes Mellitus (DM)
A total or partial deficiency of insulin
The most common endocrine disorder of childhood
Peak incidence in early adolescence
3 major groups:
 Type 1
 Type 2
 Maturity onset diabetes of the young (MODY)
Type 1 Diabetes
Characterized by destruction of beta cells, usually leading to absolute insulin deficiency
Typically, onset in childhood and adolescence, but can occur at any age
Most DM of childhood is type 1
Symptomology is more easily recognized in children than adults.
Type 1 Diabetes
Arises because of insulin resistance
Onset usually after age 40
Native American, Hispanic, and African-American children are at increased risk of type 2 DM
Affected persons may or may not require insulin injections
Therapeutic Management of Type 1 DM
Insulin therapy
Glucose monitoring: goal range 80-120 mg/dl
Laboratory measurement of hemoglobin A1c
Urine testing for ketones:
 Not routinely used EXCEPT:
 Helpful to test every 3 hours during illness and whenever glucose is ≥240 mg/dl when illness
not present
Therapeutic Management of Type 1 DM
Nutrition
Exercise
Teach patient and family how to manage hypoglycemic episodes
Illness management
Management of DKA
Diabetes Self-Monitoring in Children Purpose
Self-monitor of blood glucose
By testing their own blood, children are able to change their insulin regimen to maintain their
glucose level
Ideal 80 to 120 mg/dl
Diabetes Mellitus Clinical Manifestations
Polyphagia
Polyuria
Polydipsia
Weight loss
Irritability
Fatigue
Poor wound healing
Which clinical manifestations are often noticed
first?
Diabetes and Exercise
Same nutrition needs as other children
Timed with insulin
Consistent calories, snacks
Fit to activity patterns
No concentrated sugar, limit fat, increase fiber
Exercise – encourage! Often unplanned in children
Exercise lowers BS and insulin needs
Hypoglycemia Manifestation and Treatment
Before meals and when insulin peaks
Sx – may be difficult to distinguish from hyperglycemia – if in doubt give CHO
Parent Ed: EWS, milk for simple reactions; 10-15G CHO followed with complex CHO
Child to carry glucose
Glucagon – IM or SQ – indirect action – 10-15” onset
Hypoglycemia Manifestation and Treatment
Integral part of insulin therapy
Signs and symptoms need to be recognized
early and promptly
When are hypoglycemic most commonly?
Manifestations
 Weakness
 Dizziness
 Headache
 Drowsiness
 Seizure
 Coma
 How do we treat?
The Child with Musculoskeletal or Articular Dysfunction
How to Understand infection under cast
Osteomyelitis
Begin abruptly: pain, warmth, tenderness, ↓ ROM, fever, irritability
Marked leukocytosis
Bone cultures obtained from biopsy or aspirate
Early x-rays may appear normal
MRIs and bone scans for diagnosis
Osteomyelitis
Infants and older adolescents are at risk for lack of containment of infection with spread into the
joint.
Prompt, vigorous IV antibiotics for extended period (3-4 weeks or up to several months)
Monitor hematologic, renal, hepatic responses to treatment
Probiotics if needed
Osteomyelitis Treatment
Complete bed rest and immobility of limb
Pain management concerns
Long-term IV access (for antibiotic administration)
Nutritional considerations
Long-term hospitalization, physical therapy
Psychosocial needs - diversions
Osteogenesis imperfect treatment
What is osteogenesis imperfect?
 Rare genetic disorder characterized by fragile/brittle bones
Signs/Symptoms?
 Multiple fractures
Treatment?
 Primarily Support
 Rehab
 Positional contractures
 Muscle weakness
Immobilization risks
Most difficult aspect- Immobilization
Physiologic Effects
 Osteopenia
 Joint contracture
 Deep vein thrombosis
Psychological Effects
 Diminished environmental stimuli
 Decreased communication
 Depressed
Table 29-1 page 944
Cast care and holding
Keep the casted extremity elevated
Avoid denting the plaster cast with fingers. So how do you hold the cast?
Observe extremities. What are we looking for?
Page 952
Cast care and holding
Cast care and holding
The Child with Neuro/Neuromuscular Dysfunction
Pediatric Neurological Assessment
Purpose:
To establish an accurate, objective baseline of
neurological information
Allows comparison of findings with baselines
and changes
Pediatric Neurological Assessment
Pediatric Assessment
 Children under 2 years require special evaluation
 Infants and young children: Observe spontaneous
and elicited reflex responses
 Family history
 Health history
 Physical examination
Pediatric Neurological Assessment
Vital Signs
Skin
Eyes
Motor Function
Posturing
Reflexes
Respiratory Management
Airway management is primary concern
Cerebral hypoxia may cause irreversible brain damage after 5 minutes
CO2 causes vasodilation, increased cerebral blood flow, and increased ICP
May have minimal gag and cough reflexes
Risk of aspiration of secretions
Increased Intracranial Pressure (ICP)
Early signs and symptoms may be subtle
As pressure increases, signs and symptoms become more pronounced and level of consciousness
(LOC) deteriorates
Increased ICP
Cranium – highly sensitive to pressure & to changes in volume
Infants with open sutures compensate by widening sutures
Causes of ↑ ICP: tumors, edema, bleeding
Early signs and symptoms may be subtle
As pressure increases, signs and symptoms become more pronounced and level of consciousness
(LOC) deteriorates
Clinical Manifestations of Increased ICP
Infants
• Irritability, poor feeding
• High-pitched cry, difficult to soothe
• Fontanels: tense, bulging
• Cranial sutures: separated
• Eyes: setting-sun sign
• Scalp veins: distended
• Increased occipitofrontal circumference
Children
• Headache
• Vomiting, with or without nausea
• Seizures
• Diplopia, blurred vision
Nursing Care of the Unconscious Child
Outcome and recovery of unconscious child may depend on level of nursing care and
observational skills
Emergency management:
 Airway
 Reduction of ICP
 Treatment of shock
Altered Pituitary Secretion
Syndrome of inappropriate antidiuretic hormone (SIADH) may accompany CNS diseases
◦ Decreased UO* with hyponatremia and hypo-osmolality
◦ Child appears over hydrated
Treatment of SIADH:
◦ Fluid restriction, observe for electrolyte balance
Diabetes Insipidus s/p intracranial trauma:
◦ Large amounts of diluted urine with danger of dehydration
◦ Fluid administration, observe for electrolyte imbalance
◦ Vasopressin administered
Nursing Care Needs
Elimination: Foley, stool softeners
Hygienic care:
 Skin integrity
 Mouth care 2x/d, protect lips
 Eye irritation d/t absent corneal (blink) reflexes – artificial tears, protective dressing as needed
Position and exercise: HOB 30º, side lying or semi-prone with face in dependent position
Stimulation:
 Use tactile stim only if it has a calming effect; hearing is intact
Family support:
 Dealing with prolonged grief…searching for hope…life support decisions
ICP medication treatment
Osmotic diuretics for cerebral edema
Anti-seizure medications, with or without sedatives
Controversy over barbiturates
Paralyzing agents – with sedatives for the combative child - ↓ ICP
Antibiotics
Corticosteroids – for inflammatory conditions
Bacteria Meningitis
Pathophysiology
 Bacteria induced infection
 Meninges barrier
• Bloodstream and brain barrier
• Protects immune system to attack brain
 Acute inflammation of the CNS
• Blood-brain barrier is disrupted
Bacteria Meningitis
Clinical Manifestations
• Fever
• Chills
• Headaches
• Vomiting
Diagnostic Evaluation
 Lumbar puncture
• Fluid pressure is measured
• Cultures are obtain
• Blood cell count obtain
• Increased WBC
• Decreased Glucose
Bacteria Meningitis
Therapeutic Management
 MEDICAL EMERGENCY
• Isolation precautions
• Initiation of antibiotic therapy
• Maintenance of hydration
• Maintenance of ventilation
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Reduction of ICP
Management of systemic shock
Control of seizures
Control of temperature
Treatment of complications
Bacteria Meningitis
Nursing Care Management
 Neurological Assessment
 Medication therapy
 Pain Management
 Very little stimulation
Spina Bifida
Pathophysiology
Normal formative stages of nervous
system.
 Spinal development starts at 20 days of
gestation ending the fourth week.
 Neural groove develops, deepens, and
elevates margins leading to spinal
closure.
Failure to neural tube closure.
Abnormal increase in cerebrospinal fluid
after tube closure.
Most common defect of the central nervous
system (CNS).
Malformation of the spinal canal and cord.
What are you seeing?
Myelomeningocele: The Sac
May be fine membrane: prone to leakage of CSF; easily ruptured
May be covered with dura, meninges, or skin
Location and magnitude of defect determine nature and extent of impairment
If defect below 2nd lumbar vertebra:
 Flaccid paralysis of lower extremities
 Sensory deficit
Not necessarily uniform on both sides of defect
Myelomeningocele: The Sac
Prevent infection
Assess neurologic and associated anomalies
Early closure in 12-72 hours after birth (within 24 hrs if sac is leaking)
 Prevent stretching of other nerve roots and further damage
Myelomeningocele positioning and treatment
Nurse Role
 Neurological assessment
 Monitor neurological involvement
 Monitor urine output
 Prevent infection
 Skin breakdown
 Contractures
 Encourage bonding
 Provide family support
Pre-Operation Care
 Place in warmer with no clothes.
 Positioning the patient prone.
 Maintain sac moist.
 Apply dressing and change frequently.
 Prevent infection.
Post-Operation Care
 Monitor for infection.
 Antibiotic Administration.
 Pain Management.
 Positioning.
Interventions for spinal cord injury
When do they start?
How do you stabilized a patient?
How will you keep the patient’s airway?
Positive glucose test from nasal discharge meaning
“Brain fluid leaking"
Clinically to confirm the presence of cerebrospinal fluid (CSF) rhinorrhea
Use of glucose oxidase reagent strips to distinguish cerebrospinal fluid rhinorrhoea from clear
nasal discharge following head injury.
The cerebrospinal fluid (CSF) glucose test measures the amount of glucose, or sugar, present in
the fluid.
Seizures
Most common pediatric neurological disorder
Seizures are an underlying disease process
 Infections
 Neurological
 Metabolic
 Trauma
Seizures
Pathophysiology
 Abnormal electrical discharges
 Group of neurons with excessive excitement
 Loss of inhibition
Etiology
 Acute symptomatic seizures from acute
insult (e.g., head trauma, meningitis)
 Remote symptomatic seizures: no
immediate cause, but identifiable with prior
brain injury
 Cryptogenic seizures: no clear cause
 Idiopathic seizures: no known cause
• Box 28-6, pg. 957
Seizures Classifications
Seizure Classifications
• Partial Seizures
• With a local onset and involve a relatively small location of the brain
• Generalized Seizures
• Without a local onset and involves both hemispheres of the brain
• Unclassified Epileptic Seizures
• Different types of seizures- No classifications given
• Box 28-7
• Table 28-3
Seizures Diagnostic Evaluation
Physical Examination
Neurological Assessment
Neuroimaging test
• EEG
• Video EEG
• LP
• CT
• MRI
Seizure Therapeutic Management
Goal of treatment
 Discover and correct the cause
 Seizure disorders is to control the seizure
 Reduce their frequency and severity
Nursing Management/ Seizure Precautions
Observe the seizure
 Note the start and duration of the seizure
 Vital signs
Nursing interventions needed
• Provide oxygen
• Nasal Cannula
• Simple mask
• By flow
• Prevent injury
• Suction if needed
• NEVER LEAVE THE PATIENT!!!!!
Accurately document the events/interventions
• Eye movements
• Muscular contractions
• Alterations in consciousness
• Postictal state
Questions? Concerns? Comments?