MCHN 2 - LECTURE Week 1 High Risk Pregnancy
CARE OF VULNERABLE GROUPS OF PREGNANT WOMEN
OUTLINE:
I.
II.
III.
High-Risk Pregnancy
Pregestational Conditions
A. Cardiovascular Disease
B. Endocrine Disorders
C. Hematologic Disease
D. Renal and Urinary Diseases
E. Respiratory Diseases
F. Substance Abuse
G. Infectious Diseases
Gestational Conditions
A. Hyperemesis Gravidarum
B. Ectopic Pregnancy
C. Gestational Trophoblastic Disease
D. Incompetent Cervix
E. Spontaneous Abortion
F. Placenta Previa
G. Abruptio Placenta
H. Disseminated Intravascular Coagulation
I. Premature Rupture of Membranes
J. Pregnancy-Induced Hypertension
K. HELLP Syndrome
L. Multiple Pregnancy
M. Oligohydramnios & Polyhydramnios
N. Isoimmunization
O. German Measles / Rubella
REFERENCE: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal &
child health nursing: Care of the Childbearing & Childrearing
Family (Eight ed., Vol. 1).
HIGH-RISK PREGNANCY
- A concurrent disorder, pregnancy-related complication, or
external factor that jeopardizes the health of the woman, the
fetus, or both.
- Certain pre-existing conditions may affect the developing
pregnancy by altering the fetal development and maternal
well-being.
- Environmental and psychological factors that needs to be
considered, as this may put the woman at risk:
➢ Poverty
➢ Unemployment
➢ Lack of education
➢ Occupational exposure to teratogens
➢ Victims of abuse or domestic violence
➢ Single or separated mothers
- The term “high risk” rarely refers to just one causative factor,
but includes psychological and social, as well as physical
aspects that help in the planning of holistic, ultimately
effective nursing care.
Ex. The pregnancy of a woman with diabetes, is automatically
considered as having a greater-than-normal risk because it forces
a fetus to grow in an environment in which hyperglycemia
(increased serum glucose levels) becomes the rule.
Indicators of High-Risk Pregnancy
● Demographic Factors
○ Age - ↓16 yrs. Old & ↑ 35 yrs. Old (Optimal
age of child bearing is 20-35 yrs. old)
○ Weight (overweight or underweight before
pregnancy)
○ Height - less than 5ft.
● Socioeconomic Status
○ Inadequate finances
○ Overcrowding
○ Poor standards of housing
○ Poor hygiene
○ Nutritional deprivation
○ Severe social problems
○ Unplanned and unprepared pregnancy
especially among adolescents
○ With the root of the problem → POVERTY &
LOW EDUCATIONAL STATUS
● Obstetric History
○ History of Fertility
○ Multiple Gestation
○ Grand Multiparity
○ Previous Abortion
○ Ectopic Pregnancy
○ Previous Losses (fetal death, stillbirth,
neonatal or perinatal death)
○ Previous operative obstetric such as (Forceps
delivery, Cesarean delivery
○ Previous cervical or uterine abnormality
○ Previous abnormal labor (Premature labor or
postmature labor or prolonged labor)
○ Previous high-risk infants ( LBW, Macrosomic
or LGA, w/ neurologic deficits, birth injury or
malformation and previous hydatidiform
mole)
● Current OB Status
○ Late or no prenatal care at all
○ Maternal anemia
○ RH sensitization
■ Antipartal bleeding
■ Placenta Previa
○ Pregnancy Induced HPN
○ Multiple Gestation
○ Premature or Postmature Labor
○ Polyhydramnios
○ PROM
○ Fetus inappropriately large or small
○ Abnormality in test for fetal well-being
○ Abnormality in presentation
● Maternal Medical History
○ Cardiac or pulmonary diseases of the mother
○ Metabolic diseases (diabetes and thyroid
diseases)
○ Endocrine disorders (pituitary and adrenal)
○ Chronic Renal diseases with repeated UTI and
bacteriuria
○ Presence of chronic hypertension
○ Venereal and other Infectious diseases
○ Major Congenital disease (anomalies on
reproductive tract)
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 1 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
●
○ Hemoglobinopathies
○ Seizure disorders
○ Malignancies
○ Major Emotional Disorders and mental retardations
Habituation
○ Smoking
○ alcohol
○ Drug use and drug abuse
Assessment for High-Risk Pregnancy
✓ Health history (Demographic data, chief concern, social
profile , past medical history, gynecologic history, LMP,
menarche, duration of menstruation, OB history, review of
systems)
✓ Determine if the client belong to the vulnerable group
(women with identified risk factors)
✓ Physical assessment (weight, height, v/s, fundal height
measurements if the px is 12 wks. AOG or FHD, full physical
examination, pelvic examination by doing bi-manual
examination estimating pelvic measurements and pap
smear which would include culture for chlamydia,
gonorrhea, and group B streptococcus)
✓ Laboratory Assessment
● CBC
● Blood typing & RH Factor
● Alpha-feto protein (to check for neural and
abdominal defect)
● Hepatitis B (check if Hep B surface antigen is
present; HBsAg test)
● Gonorrhea culture & syphilis screening (VDRL or
Rapid plasma Region test to diagnose syphilis)
● Rubella titer
● Papanicolau smear (done during the initial prenatal
exam to test for cervical neoplasia or possible STIs.)
PREGESTATIONAL CONDITIONS
CARDIOVASCULAR DISEASE
- Cardiovascular disease (even with hypertension included),
was once a major threat to pregnancy, now complicates only
approximately 1% of all pregnancies. It is still a concern in
pregnancy, however, because it can lead to such serious
complications.
- Responsible for 5% of maternal deaths during pregnancy.
- The cardiovascular disorders that most commonly cause
difficulty during pregnancy are valve damage concerns
caused by Rheumatic fever or Kawasaki disease and
Congenital anomalies such as atrial septal defect or
uncorrected coarctation of the aorta.
- ↑Age of Women or delayed 1st pregnancy ↑ incidence of
coronary artery disease and varicosities during pregnancy.
- A woman with cardiovascular disease needs a team
approach to care during pregnancy, combining the talents of
an internist, obstetrician, and nurse. Ideally, a woman should
visit her obstetrician or family physician before conception
so the healthcare team can become familiar with her state
of health when she is not pregnant and establish baseline
evaluations of her heart function, such as with an
echocardiogram.
-
A woman with cardiovascular disease should begin
prenatal care as soon as she suspects she is pregnant (1
week after the first missed menstrual period or as soon
as she has a positive home pregnancy test), so her
general condition and circulatory system can be
monitored from the beginning of pregnancy.
Pregnancy taxes the circulatory systems of every
woman, even without cardiac disease, because both
blood volume and cardiac output increases
approximately 30% (and up to as much as 50%) during
pregnancy. Half of this increase occurs by 8 weeks; it is
maximized by midpregnancy.
Increased blood flow past valves → functional murmurs
(innocent) or transient murmurs can be heard in many
women w/o heart disease during pregnancy. Heart
palpitations on sudden exertion are also usual.
The danger of pregnancy of a woman w/ Cardiac
Disease is because of this increase in circulatory
volume.
Most dangerous time → 28-32 weeks, just after
volume peaks. However, if the disease is severe,
symptoms can appear at the beginning of pregnancy.
Towards the end of pregnancy, her heart may become
overwhelmed by the increase in blood volume that her
cardiac output falls to the point vital organs (including
placenta) can no longer be perfused adequately →
oxygen and nutritional requirements of her cells and
those of the fetus are not met.
To predict a pregnancy outcome, a heart disease is
divided into four categories based on criteria:
-
-
-
-
New York Heart Association Functional Classification of Heart Failure
Class
Description
Class I (Mild)
No limitations of Physical activity
No heart failure symptoms; doesn’t cause undue fatigue,
rapid/irregular heartbeat (palpitation) or dyspnea
Class II (Mild)
Mild limitation of physical activity
Heart failure with symptoms with significant exertion(fatigue,
rapid/irregular heartbeat or dyspnea); comfortable at rest or
with mild activity
Class III
(Moderate)
Marked limitation of physical activity
Heart failure symptoms with mild exertion; only comfortable
at rest.
Class IV
(Severe)
-
Discomfort with any activity
Heart failure symptoms occur at rest
Women with Class I & II heart disease can expect to
experience a normal pregnancy and birth.
Class III can complete pregnancy by maintaining
special interventions (ex. bed rest)
Class IV usually advised to avoid pregnancy because
they are in cardiac failure even at rest and when they
are not pregnant.
a. Left-Sided Heart Failure - Pulmonary
- Occurs in conditions such as mitral valve stenosis, mitral
insufficiency and aortic coarctation. In these instances,
the left ventricle can’t move the large volume of blood
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 2 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
forward that it has received by the left atrium from the
pulmonary circulation. → Back Pressure
- Back Pressure:
➢ the left side of the heart becomes distended
➢ Systemic blood pressure decreases in the face of
lowered cardiac output
➢ Pulmonary hypertension occurs
- Pregnant client with existing LSH manifestations is often
respiratory or pulmonary
- Pulmonary edema:
➢ Produces profound shortness of breath as it interferes
with oxygen-carbon dioxide exchange
➢ Fluid begins to pass from the pulmonary capillary
membranes into the interstitial spaces surrounding
the lung alveoli and then into the alveoli themselves
➢ If pulmonary capillaries rupture under pressure, small
amounts of blood leak into the alveoli and the woman
develops a productive cough with blood-speckled
sputum.
➢ Limited oxygen exchange → high risk for spontaneous
miscarriage, preterm labor, maternal death
➢ Severe pulmonary edema could lead to orthopnea
- Orthopnea → a woman can’t sleep in any position except
with her chest and head elevated, as elevating her chest this
way allows fluid to settle to the bottom of her lungs and frees
space for gas exchange.
- Paroxysmal Nocturnal Dyspnea→ suddenly waking at night
with shortness of breath. This occurs because heat action is
more effective when she is at rest. With the more effective
heart action, interstitial fluid returns to the circulation. This
overburdens her circulation, causing increased left-side
failure and increased pulmonary edema.
Thrombus
formation
Anticoagulants with low-molecular-weight heparin may
be prescribed during early pregnancy as this doesn’t cross
the placenta.
Strain on
the Aorta
Antihypertensives may be prescribed to control blood
pressure;
Diuretics to reduce blood volume;
𝜷-blockers to improve ventricular filling
-
-
b. Right-Sided Heart Failure - Circulatory
Occurs when the output of the right ventricle is less than the
blood volume received by the right atrium from the vena cava.
Back-pressure from this results in congestion of the systemic
venous circulation and decreased cardiac output to the lungs.
Can be caused by unrepaired congenital heart defect such as
Pulmonary Valve Stenosis
Circulatory or systemic manifestations
Liver and spleen become distended
Liver enlargement can cause extreme dyspnea and pain in a
pregnant woman because the enlarged liver, as it is pressed
upward by the enlarged uterus, puts extreme pressure on the
diaphragm.
Distention of abdominal vessels can lead to exudate of fluid
from the vessels into the peritoneal cavity (ascites)
Fluid also moves from the systemic circulation into lower
extremity interstitial spaces (peripheral edema)
Eisenmenger Syndrome:
➢ The congenital anomaly most apt to cause rightsided heart failure in women of reproductive age
➢ A right-to-left atrial or ventricular septal defect
with an accompanying pulmonary valve stenosis.
➢ Women who have an uncorrected anomaly of
this type may be advised not to become
pregnant.
➢ If pregnancy occurs:
✓ Oxygen administration
✓ Frequent arterial blood gas assessment
to ensure fetal growth
✓ They can also expect to be hospitalized
for at least some days during last parts of
pregnancy
✓ During labor → they may need a
pulmonary artery catheter to monitor
pulmonary pressure. Extremely close
monitoring after epidural anesthesia to
minimize the risk of hypotension.
- Complications:
➢ Congestion of systemic venous circulation
➢ Decreased cardiac output to the lungs
➢ Blood pressure decreases due to less blood is able
to reach it
➢ Pressure is high in the vena cava from back
pressure of blood
➢ Both jugular venous distention
➢ Increased portal circulation
➢ Liver and spleen become distended
➢ Extreme liver enlargement leading to pain and
dyspnea
➢ Distention of abdominal and lower extremity
vessels leading to exudating of fluid from the
vessels into the peritoneal cavity or peripheral
edema
Assessment of a Woman with Cardiac Disease:
● Thorough health history to document prepregnancy
cardiac status
● Document a woman’s level of exercise performance
(i.e what level she can do before growing SOB, and
what physical symptoms such as cyanosis of the lips
and nail beds)
○ Refer to the New York Heart Association
Functional Classification of Heart Failure
Table
● Ask if she normally has a cough or edema (pulmonary
edema from heart failure may first manifest itself as a
simple cough)
● Never asses edema in women with heart disease
lightly as the normal edema of pregnancy (innocent)
must be distinguished from the beginning or
pregnancy-induced hypertension (serious) or the
edema of heart failure (also serious)
● Normal edema of pregnancy involves only the feet and
ankles, but edema of either pregnancy-induced
hypertension or heart failure also begins this way
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 3 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
○
●
●
●
●
●
●
Edema of pregnancy-induced hypertension usually
begins after week 20
If the edema is a sign of heart failure, it can begin at any
time and other symptoms will probably also be present:
○ Pulse → irregular?
○ Respirations → rapid/difficult
○ Chest pains on exertion
Record v/s in either sitting or lying position at the first
prenatal visit
○ For future health visits, always take these in the
same position for the most accurate comparison
Comparison assessments for capillary refill test (should be
<5 seconds) and jugular venous distention
RHF → assess liver size at prenatal visits
○ Becomes difficult to assess and will probably
become inaccurate late in pregnancy because the
enlarged uterus presses the liver upward under
the ribs and makes it difficult to palpate
Additional cardiac status assessments:
○ Electrocardiogram (ECG)
○ Chest radiograph or echocardiogram
Assure the client that an ECG merely measures cardiac
electrical discharge and so cannot harm her fetus in any
way. Echocardiogram uses ultrasound and so will also not
harm her fetus.
Fetal Assessment:
● Cardiac failure can affect fetal growth at the point at which
maternal blood pressure becomes insufficient to provide an
adequate supply of blood and nutrients to the placenta
● For this reason, the infants of women with severe heart
disease tend to have low birth weights because not enough
nutrients can be furnished to them.
● A poor perfusion level may also lead to an acidotic fetal
environment if the blood flow becomes inadequate for
carbon dioxide exchange. Preterm labor may also occur.
● This exposes an infant to the hazards of immaturity as well
as low birth weight.
● An infant may not respond well to labor (evidenced by later
deceleration patterns on a fetal heart monitor) if cardiac
decompensation has reached a point of placental
incompetency.
-
-
ENDOCRINE DISORDERS
Diabetes Mellitus
Chronic metabolic disorder characterized by a deficiency in
insulin production by the islets of Langerhans resulting in
improper metabolic interaction of carbohydrates, fats,
protein, and insulin.
This may be a concurrent disease of pregnancy, or this may
have a first onset on pregnancy which is Gestational Diabetes
Mellitus.
Type 1 DM is common on young people, even children
Type 2 DM is common on elderly or 40 yrs. Old and above
After delivery, the woman’s blood glucose level is expected to
return to normal
Risk factors:
➢ Family History
➢ Rapid hormonal change in pregnancy
➢ Tumor/infection of the pancreas - alters the
production of insulin
➢ Obesity and stress
Diagnostic Tests
➢ Oral Glucose Challenge Test
● 24-28 wks. AOG
● 50g oral Glucose
● Finding: Plasma glucose of >140 mg/dl =
perform OGTT
➢ Oral Glucose Tolerance Test (OGTT)
● Having 2/4 abnormal result > GDM
● FBS > 100 g oral glucose > venous blood
sample taken 1, 2, and 3 hours
● 4 blood samples, NPO-PM
➢ Glycosylated Hemoglobin (HbA1C)
● Maternal hemoglobin irreversibly bound to
glucose
● Measures long-term up to 3 months
compliance to treatment
● Normal value of 4%-8% a woman’s
hemoglobin increasing during hypoglycemia
-
This basis blood sugar to be taken needs to have 4
venous blood samples:
1. After 8 hours of fasting - after fasting, the px
needs to take 100g of oral glucose
2. After 1 hour of fasting
3. After 2 hours of fasting
4. After 3 hours of fasting
Effects of DM:
- Both can affect the mother and the baby
- When DM is well controlled effects on pregnancy
may be minimal. If control is inadequate, there may
be maternal, fetal, newborn complications.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 4 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Effects of DM
Mother
-
Baby
Infertility
Spontaneous abortion
Pregnancy induced hypertension
Infections: moniliasis, UTI
Uteroplacental insufficiency
Premature labor
Dystocia - difficulty in labor
Uncontrolled DM: Hypoglycemia
or hyperglycemia
Cesarean section often is
indicated
Uterine Atony → PP hemorrhage
-
-
-
-
Congenital anomalies
Polyhydramnios
Macrosomia (LGA)
Fetal hypoxia leading to
Intrauterine Fetal Death (IUFD)
and stillbirths
Increased perinatal mortality
Neonatal Hypoglycemia →
common afterbirth
Prematurity
Respiratory Distress Syndrome
→ 6th hour after birth
Hypocalcemia
Diabetic Women tend to have increased glomerular
filtration of glucose causing massive Glycosuria and
Polyuria.
Because of hormones Human Placental Lactogen (i.e,
chorionic somatomammotropin) and high levels of
Cortisol and there will be an increase rate of:
➢ Insulin secretion
➢ Glucose Production
➢ Insulin Resistance
This will result to:
➢ Hydramnios or excessive amount of amniotic fluid
(because a high glucose concentration causes extra
fluid shift and enlarge the amount of amniotic fluid)
➢ Macrosomic baby or LGA
➢ Pregnancy induced hypertension
➢ Microvascular changes: Necropathy & Retinopathy
➢ Macrovascular changes: Heart Problems & Candidal
Infections
This will put the woman at great risk of infection
Diabetes Mellitus - Type 1
Signs & Symptoms:
Polyuria - ↑ Urination
Polydipsia - ↑ Thirst
Polyphagia - ↑ Hunger
-
-
Weight loss
Fatigue
↑ Frequency of Infections
Rapid onset
Insulin Dependent
Familial Tendency
Peak Incidence from 10-15 years
DM is more difficult to control and maintain the sugar.
Insulin shock and Ketoacidosis (caused by the constant
use of glucose by the fetus) are also common.
Discomforts, nausea and vomiting predisposed to
Ketoacidosis, is a medical emergency
Medical Management:
- Insulin requirement should adjust based on the AOG
- Insulin Requirement: Regular and NPH
➢ 1st trimester - Insulin is kept at a stable dose
➢ 2nd trimester - Rapid Increase
➢ 3rd trimester - Rapid Increase
➢ Labor: IV Regular Insulin (long-acting insulins are
not enough to prevent Ketoacidosis)
-
➢ Postpartum - Rapid decrease to prepregnancy level (may not need insulin for the
first 24 hours after delivery if the client was
placed on a long NPO)
Early labor induction or cesarean section especially if
the fetus has gone macrosomic
Nursing Management:
- Early detection and regular prenatal visits (history
taking, symptomatology and prenatal screening)
➢ Encourage early prenatal assessment and
supervision as frequent prenatal visits are very
important
➢ Record diet intake
➢ Monitor blood glucose level several times
daily (Maintaining maternal glucose within the
normal range during prenatal and intranatal
period prevents stimulation of the fetal
pancreas that results in fetal or neonatal
hypoglycemia.)
- Dietary modification: 1800-2000kcal/day
➢ Carbohydrates → 200 mg/day
➢ Protein → 70g/day
➢ Unsaturated Fat
➢ Regular time in taking in food
➢ Promote adherence to dietary regimen
- Insulin administration → in times of oral anti-diabetic
pills are contraindicated, insulin is a cornerstone of
management.
➢ Increased need of insulin in the 2nd and 3rd
trimester should be managed well especially
on the 3rd trimester needs may be tripled →
increasing the tendency to Ketoacidosis.
➢ Prevent infection → Stressor which causes
hyperglycemia and increases the need for
insulin
- Serial UTZ → fetal growth evaluation & surveillance
beginning at 28-34 weeks AOG; earlier than 26 wks.
AOG only with poorly controlled GDM or with
additional complications
➢ Hospitalization is recommended to poorly
controlled GDM and concomitant HPN, &
treatment of infection
- Provide teaching on signs and symptoms of hypo &
hyperglycemia, regular exercise, self-administration
of insulin ang prompt reporting of danger signs and
signs of infection.
- Teach px on infection prevention and stress
management
- Continued monitoring on mother and fetus during
intra-partal period
➢ Early labor induction or cesarean section with
the presence of fetal distress will be indicated.
➢ Delivery timing is individualized; ideally at
term
➢ Terminating pregnancy depends on fetal and
maternal well-being surveillance
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 5 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
-
-
-
➢ When Macrosomia complicates pregnancy &
potentially causes CPD → induction of labor may be
done usually around 37-26 weeks, depending on
the UTZ monitoring, fetal size and pulmonary
maturity
➢ Monitoring: position the px to left lateral
recumbent to prevent supine hypertensive
syndrome
➢ Fluid electrolyte balance is important so D5 water
is needed to maintain glucose.
➢ Regular insulin added to IV of 5% -10% D5 water
titrated to maintain glucose between 100 to 150
mg/dl
Monitor maternal need for post-partal insulin
➢ Increased insulin resistance is usually resolved a few
hours after delivery
➢ IV insulin is generally discontinued
➢ Decrease insulin requirement during the first 24
hours necessitates monitoring of the insulin dose
which is titrated to measure blood glucose level in
the immediate postpartum period
➢ Decrease in insulin need to ½ to ⅔ pregnant dose
on 1st postpartum day if on cold diet
Encourage breastfeeding
➢ Known to have an anti-diabetogenic effect
➢ Hypoglycemia raises adrenaline level resulting in
decreased milk supply and letdown reflex
➢ Be
alert
for
postpartum
complications
(hemorrhage,
infections,
Insulin
shock,
hypoglycemia - wet cold clammy skin, pallor,
tremors and hunger, insulin reactions such as
hypoglycemic shock which occurs in peak action of
insulin
➢ Regular Insulin → peak action is usually 3-4 hours
after administration
➢ Encourage to have 1hour OGTT 3-8 weeks
postpartum to ensure normal return of glycemia.
Teach px on how to monitor their own blood sugar with the
use of Glucometer
➢ DM doesn’t only refer to high levels of insulin, but
as well as hypoglycemia
Ketoacidosis
- Is diagnosed when glucose levels are greater than 300mg
per 100ml, and with the presence of ketones in the blood
- Rapid acting insulin intravenously along with IV glucose
infusion is used in labor
- Frequent check of blood glucose and adjustment and
additional boluses of insulin as needed.
- The only insulin that can be given intravenously is the
regular insulin.
HEMATOLOGIC DISEASE
- Because the blood volume expands during pregnancy
slightly ahead of the red cell count, most women have
a pseudo-anemia of early pregnancy.
- Pseudo-anemia vs. True Anemia
➢ True anemia: (Hgb < 11g/dl; Hct < 33%) in the
first or third trimester of pregnancy or (Hgb <
10.5 g/dL; Hct < 32%) in the second trimester
- However, physiologic anemia of pregnancy is
considered hemodilutional. There will be an increase
in blood volume of 30%-50% higher before labor
causing disproportionate increase in blood volume and
blood cells resulting to the physiologic anemia of
pregnancy
Iron-Deficiency Anemia
- Most common anemia of pregnancy
- Many women enter pregnancy with a deficiency of
iron stores resulting from:
➢ Diet low in iron
➢ Heavy menstrual periods
➢ Unwise weight-reducing programs
- Iron stores are apt to be low in women who were
pregnant less than 2 years before the current
pregnancy or those from low socioeconomic levels
who have not had iron-rich diets.
- When the hemoglobin level is below 12 mg/dL
(hematocrit < 33%), iron deficiency is suspected
- Iron supplementation = 60 mg/day or 120-200
mg/day
Other Hematologic Diseases
- Folic Acid - Deficiency
Anemia
➢ Occurs most often
in multiple
pregnancies
- Thalassemia
- Malaria
- Coagulation disorders
RENAL AND URINARY DISEASES
- Adequate kidney function is important to a successful
pregnancy outcome because a woman is excreting
waste products not only for herself but also for her
fetus.
Urinary Tract Infections (UTI)
Etiology
- In a pregnant woman, because the ureters dilate from
the effect of progesterone, stasis of urine occurs.
- The minimal glucosuria that occurs with pregnancy
allows more than the usual number of organisms to
grow
➢ This causes asymptomatic urinary tract
infections (UTIs) in as many as 10% to 15% of
pregnant women
- Asymptomatic infections are potentially dangerous
because they can progress to pyelonephritis (infection
of the pelvis of the kidney) and are associated with
preterm labor and premature rupture of membranes.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 6 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
- Women with known vesicoureteral reflux (backflow of urine
into the ureters) tend to develop UTIs or pyelonephritis more
often than others
- Bacteria:
➢ Escherichia coli - from an ascending infection
➢ Streptococcus B - vaginal cultures should be obtained
because streptococcal B infection of the gential tract
is associated with pneumonia in newborns
➢ A UTI can also occur as a descending infection, or
begin in the kidneys from the filtration of organisms
present from other body infections
Assessment:
- Frequency and pain on urination (dysuria)
- Pain in the lumbar region usually on the right side that
radiates downward (pyelonephritis)
- The area feels tender to palpation
- Nausea and vomiting, malaise, dysuria, mild fever
- Urine culture
- The infection usually occurs on the right side because there
is greater compression and urinary stasis on the right ureter
from the uterus being pushed that way by the large bulk of
the intestine on the left side.
- A urine culture will reveal over 100,000 organisms per
milliliter of urine, a level diagnostic of infection
Medical management:
- Obtain a clean-catch urine sample for culture and sensitivity
from women with possible symptoms of UTI
- A sensitivity test after a culture will determine which
antibiotic will best combat the infection
- Antibiotic:
➢ Amoxicillin, ampicillin, and cephalosporins are
effective against most organisms causing UTIs and
are safe antibiotics during pregnancy. Should be
ordered by the doctor
➢ Sulfonamides can be used early in pregnancy but not
near term because they can interfere with protein
binding of bilirubin, which then leads to
hyperbilirubinemia in the newborn
➢ Tetracyclines are contraindicated in pregnancy as
they cause as they cause retardation of bone growth
and staining of the fetal teeth
Nursing Considerations:
- Void frequently (at least every 2 hours)
- Encourage the client to make it a habit to urinate as soon as
it is needed and to empty the bladder completely
- Wipe front to back after voiding and bowel movements
- Wear cotton, not synthetic fiber, underwear
- Void immediately after sexual intercourse
- Increase oral fluids
➢ To flush out the infection from the urinary tract
➢ Do not merely tell her to “drink lots of water”. Give
her a specific amount to drink every day (up to 3 to 4L
per 24 hrs)
- Assume a knee-chest position for 15 minutes morning and
evening. In this position, the weight of the uterus is shifted
forward, releasing the pressure on the ureters and
allowing urine to drain more freely
- Ensure compliance of antibiotic treatment
RESPIRATORY DISEASES
- Any respiratory condition can worsen the pregnancy
because the rising uterus compresses the diaphragm,
thus reducing the size of the thoracic cavity and
available lung space.
- Any respiratory disorder can pose serious hazards to the
fetus if allow to progress to the point where the
mother’s oxygen-carbon dioxide exchange is
compromised, or the mother and/or fetus can’t receive
enough oxygen
- Mild → e.g common cold; Severe → e.g Pneumonia;
Chronic → e.g TB or COPD
Nursing Considerations:
● Instruct px to get enough rest and sleep
● Foods rich in vitamin C (orange juice and fruits to help
boost the immune system)
● Room humidifier especially at night to moisten nasal
secretions and help mucus drain
● Antibiotic (Category A)
○ Check with the HCP the OTC of cough drops
or decongestants to ensure that any
medication taken by the px is safe during
pregnancy
● Oxygen therapy - for severe diseases
● Keep away from allergens if asthmatic
● Nebulization may be done as ordered by the doctor
● TB: R-I-E (Rifampicin, Isoniazid, Ethambutol)
SUBSTANCE ABUSE
- This refers to the misuse or overuse of substances
- Substances tend to interfere with organogenesis
especially during the first trimester
Assessment Findings:
● Parental neglect
● Malnutrition
● Presence of other infectious diseases or STIs
Management:
● Therapy depending on the substance used
● Counseling and rehabilitation
INFECTIOUS DISEASES
Hepatitis B
- Caused by the Hepatitis B virus that was transmitted
through blood and body fluids
- Acute infection affects permanent liver damage or
carcinoma
➢ In pregnancy, there is a possibility of maternal
to infant transmission which is done through
transplacental transmission
- Transplacental transmission
➢ Causes spontaneous abortion or preterm
labor
- During the intranatal and postnatal part of pregnancy,
transmission can occur through contaminated
surfaces and breast milk/colostrum
- The fetus can be exposed if mother is positive for the
infection
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 7 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Treatment:
1. Hepatitis B Immunoglobulin - antibodies
2. First of the three injections of the Hepatitis B vaccine before
discharge from the hospital
➢ Upon birth, hep b vaccine and hep b
immunoglobulin is given to the newborn
HIV-AIDS
- This is caused by a retrovirus, the human immunodeficiency
virus (HIV) that infects helper T lymphocytes and presents in
infected persons in blood, semen, and other body fluids
- Modes of transmission:
➢ Sexual contact
➢ Contaminated blood and blood products
➢ Placental transfer, possibly through breast milk
- The infant born from an HIV positive mother should be cared
for with strict attention to standard precaution to prevent the
transmission of HIV
- Standard precaution:
➢ Wear gloves, fluid-resistant gown, mask and
goggles
➢ Wear gloves to prevent the transmission of
bloodborne infections when there is risk of coming
into contact with blood or amniotic fluid. Change
gloves between patients.
➢ Wear a fluid-resistant gown, mask, and face shield
in all situation in which splashing of bodily fluids is
likely
➢ Wear a gown and gloves when handling newborns
until after a full bath to remove all blood and
amniotic fluid
➢ No mouth-to-mouth contact during resuscitation
and suctioning
➢ Use protective equipment
- No breastfeeding if mother is positive
Diagnosis:
● Based clinical criteria and positive HIV antibody test
● ELISA
PREGESTATIONAL CONDITIONS
● Rheumatic heart disease
● Diabetes mellitus
● Substance Abuse
● HIV/AIDS
● Rh sensitization
● Anemia
-
GESTATIONAL CONDITIONS
HYPEREMESIS GRAVIDARUM
Prolonged n/v past 16th wk. of pregnancy
Unknown cause
Extensive that can cause dehydration, ketonuria and
significant weight loss which can occur within the first 12
weeks in pregnancy
Women with the disorder have increased thyroid function,
because of the thyroid stimulating properties of HCG.
Some studies reveal that it is associated with Helicobacter
Pylori (the same bacteria that causes Peptic Ulcer)
Signs and Symptoms:
✓ Severe weight loss, nausea & vomiting (inability to
provide nutritional need)
✓ Ketonuria - ketones in urine (evidence on breaking
down of protein for cell growth)
✓ Elevated HCT concentration (inability to retain
fluid had resulted hemolytic concentration)
✓ Dehydration for untreated cases
■ May no longer provide nutrients for the
growth of the fetus
✓ Electrolyte imbalance
■ Concentration of sodium, potassium and
chloride may be reduced because of a
woman’s low intake
■ Hypokalemic alkalosis may develop from
loss of Hydrochloric acid from the stomach
■ Ataxia and confusion caused by decreased
Vit. B1 or Thiamine may also develop if left
untreated.
Medical management:
● IV hydration, NPO
○ Women may need to be hospitalized for
about 24 hours for the administration of IV
fluids. This is also to monitor their I/O, blood
chemistries and to restore dehydration.
○ Oral fluids and food are withheld for 24 hours
○ PLR with Vit. B1 may be administered to
increase hydration.
● Antiemetic
○ Reglan (Metoclopramide) → Class B, may be
prescribed to control vomiting
Nursing Management:
● Taper diet from NPO to clear fluids then small
quantities of dry toast, cracker or cereal. Soft diet to
regular diet afterwards.
○ If there is no vomiting after the first 24 hours
of oral restriction, small ounces of clear fluid
may be given, and the woman may be
discharged with the prescription of home
care.
○ If vomiting reoccurs, enteral or total
parenteral nutrition may be prescribed to
ensure that she is getting adequate nutrition,
together with the fetus.
● Monitor I/O to monitor dehydration
● Provide pleasant and small portion of foods
ECTOPIC PREGNANCY
- Condition where pregnancy happens outside the
uterine cavity
Types:
● Tubal - most common; 90-95% of cases, could lead
to tubal rupture before 12 weeks
● Cervical
● Abdominal
● Ovarian
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 8 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Risk factors:
● Constriction or narrowing of fallopian tube
● Pelvic Inflammatory Disease: Salpingitis, Endometriosis
● Puerperal and postpartum sepsis
● Surgery or congenital anomalies of the fallopian tube
● Adhesions, spasms, tumors
● Use of IUD - prevents normal implantation
Signs and Symptoms:
✓ Amenorrhea or abnormal menstrual period
✓ Tubal rupture: sudden sharp, low abd. pain radiating to
shoulder (Kehr’s sign)
✓ Neck pain
✓ N/V, positive pregnancy test
✓ Cullen’s sign
■ bluish navel due to blood in the peritoneal cavity
■ Characterized by edema, bruising, bluish
discoloration of the fatty tissue surrounding the
umbilicus or navel
■ Can arise due to pancreatitis, cancer of the
pancreas, ectopic pregnancy, liver problems,
thyroid cancer, or other source internal bleeding
of the abdomen
✓ Rectal pressure - due to the blood in the cul de sac
✓ Shock or circulatory collapse
✓ Positive pregnancy test
✓ Sharp or localized pain when cervix is touched
Laboratory:
● Low Hgb, Hct & HCG due to bleeding
● Elevated WBC
Diagnosis Tests:
● Pelvic UTZ - no embryonic sac inside the uterine cavity
● Culdocentesis - aspiration of non clotting blood in the cul
de sac of douglas, which means + Tubal Rupture
● Laparoscopy is not common and needs direct
visualization.
Medical Management:
● Methotrexate
○ Unruptured ectopic pregnancy can be
treated medically by the administration of
oral methotrexate
○ It is a folic acid antagonist, chemotherapeutic
agent which attacks and destroys fast
growing cells
○ Because trophoblast and zygote growth are
so rapid it is drawn to the site of ectopic
pregnancy, it could be administered directly
○ Advantage: the tube is left intact with no
surgical scarring that can cause a 2nd ectopic
pregnancy
○ dissolves the fetus
● Salpingectomy - surgical removal of the ruptured
fallopian tube
● Blood transfusion - management of shock from
ruptured tube
● Antibiotics
Nursing Management:
● Assess for shock
● Implement promptly shock treatment
● Position on Modified Trendelenburg (shock position)
● Infuse IV fluids (D5LR for plasma administration,
blood transfusion or drug administrations) as
ordered
● Monitor v/s and I/O
● Provide physical and psychological support (pre-op
and post-op)
● Anticipate grief, possible guilt responses, fearrelated potential disturbance in childbearing in the
near future
-
GESTATIONAL TROPHOBLASTIC DISEASE
Also known as Hydatidiform Mole or H-mole
The benign neoplasm of the chorion
The chorion fails to develop into a full-term placenta
and instead degenerates and become fluid-filled
vesicles
Common in the Orient and in people with low
socioeconomic status
The cause is unknown
Risk Factors:
● Increased or decreased maternal age
● Low socioeconomic status, low protein diet
● History of abortion and Clomiphene therapy
○ Clomiphene is used to induce ovulation or
treat infertility
○ Used by women who cannot produce eggs
and wish to become pregnant
○ An ovulatory stimulant that works similarly to
estrogen, a hormone that causes eggs to
develop in the ovaries and be released
(Cullen’s sign)
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 9 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Signs and Symptoms:
✓ Brownish or reddish, intermittent or profuse vaginal
bleeding by 12 weeks
✓ Spontaneous expulsion of molar cyst which usually
occurs during the 16th-18th week of pregnancy
✓ Rapid uterine enlargement inconsistent with AOG
✓ Symptoms of pregnancy-induced hypertension (PIH)
may appear before 20 weeks
✓ Excessive HCG → excessive N/V which could reach 1-2
million IU/L per 24 hrs
✓ Positive pregnancy test
✓ No fetal signs such as heart tones and movement
✓ Abdominal pain
○
●
●
●
Contraception is a must because signs of
pregnancy can mask early signs of
choriocarcinoma
Medical replacement of blood, fluid, and plasma is
indicated
Chemotherapy for malignancy with the use of
methotrexate which is the drug of choice
Chest x-ray - detect early lung metastasis
This is how the H-mole would look like. The uterus is distended
by thin-walled, translucent, grape-like vesicles of different sizes.
These are the degenerated chorionic villi filled with fluid. This
enlarges overtime and thus the woman may think that she is
pregnant with a fetus and not the H-mole.
Nursing management:
● Advice Bedrest
● Monitor v/s, I/O, blood loss, molar/tissue passage
● Maintain fluid and electrolyte balance, plasma, and
blood volume through replacements as ordered
● Prepare for D&C, hysterectomy or hysterotomy as
indicated
● Provide psychological support
● Anticipate fear-related to potential development of
cancer and disturbances to self-esteem for carrying an
abnormal pregnancy
● Prepare for discharge.
○ Emphasize the need for follow-up HCG
determination for one year - series of UTZ
○ Reinforce instructions on no pregnancy for one
year
○ Teach patient on contraceptive use especially
for one year
Diagnosis:
● Passage of vesicles
● Triad signs:
○ Enlarged uterus
○ Vaginal bleeding - Brownish and intermittent
discharges
○ HCG > 1 million compared to the normal value which
is 400,000 IU/L per 24 hrs
● UTZ
○ Findings: no fetal sac and no fetal parts
● Flat plate of the abdomen done after 15 weeks showed no
fetal skeleton
INCOMPETENT CERVIX
This is a condition characterized by a mechanical
defect of the cervix causing cervical effacement and
dilation and expulsion of the product of conception in
midtrimester of pregnancy.
Habitual aborters
Normal Cervix → there is a presence of a mucus plug
to keep the fetus and products of conception intact
inside the uterine cavity
Incompetent Cervix → has an absent mucus plug and
the cervix would easily efface and dilate causing
preterm or premature labor
-
-
Prognosis
● 80% remission after D&C (dilatation and curettage) and
may progress cancer of the chorion or choriocarcinoma
Complications:
● Choriocarcinoma - most dreaded
● Hemorrhage - most serious during the early treatment
phase
● Uterine perforation and infection
Medical Management:
● Methotrexate
● Evacuation: D&C (dilatation and curettage) or hysterectomy
if no spontaneous evacuation
○ Hysterectomy if above 45 years old and no future
pregnancy is desired or with increased chorionic
gonadotropin levels after D&C
● hCG titer monitoring for 1 year
○ No pregnancy for 1 year
Risk Factors:
● Increased maternal age
● Congenital defect of the cervix - short trauma of the
cervix, forceful dilatation and curettage, difficult
delivery, cervical lacerations such as conization and
cauterization.
● Trauma
● Cervical lacerations
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 10 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Signs and Symptoms:
✓ Painless contractions resulting of a dead or nonviable fetus
✓ Pink-stained show
✓ Relaxed cervical os on pelvic examination
✓ History - abortions
Medical Management:
● Cerclage - done 14-16 wk. AOG or prior to next pregnancy;
suturing the os to hold the fetus tight inside the uterus
○ Shirodkar - permanent; subsequent delivery is done
through cesarean section
○ McDonald - temporary closure of the cervix; sutures
are removed at term in preparation for pregnancy
Nursing Management:
● Provide psychological support especially to px with
negative feelings, low self-esteem, fear related to
complete pregnancy, guilt or anticipatory grief related to
expected loss of the baby
● Provide post-cerclage care
● Advise limitation of physical activities within two weeks
after treatment
● Routine prenatal care
○ Maternal and fetal growth monitoring should be
done
● Instruct client to report promptly signs of labor
● Assess for signs of labor, infection or premature rupture of
membranes
● Post-McDonald Cerclage - prepare stitch removal set in
addition to delivery set during labor, if px had Mcdonald
Surgery
Types:
● Induced Abortion
○ termination of pregnancy with medical or
mechanical interventions
● Spontaneous Abortion
○ without medical or mechanical interventions
Etiology:
● Defective ovum
● Maternal causes
○ Presence of congenital defects of the maternal
tract (most common)
○ Unknown cause (2nd leading cause)
● Maternal factors:
○ Viral infection
○ Malnutrition
○ Trauma - physical & mental
○ Incompetent cervix - most common cause of
habitual abortion
○ Hormonal or decreased progesterone
production
○ Increased temperature - febrile condition
○ Systemic disease of the mother: DM, Thyroid
dysfunction, severe anemia
○ Environmental hazards
○ Rh incompatibility
Signs and Symptoms:
✓ Vaginal bleeding (mild to severe)
✓ Uterine/abdominal cramps
✓ Passage of tissues products of conception
✓ Signs related to blood loss: Shock, pallor, clammy
skin, tachycardia, restlessness oliguria, air hunger,
hypotension
TYPES
BLEEDING
ABDOMINAL
CRAMPS
CERVICAL
DILATION
TISSUE
PASSAGE
FEVER
THREATENED
Slight
May or not
be present
None
None
No
INEVITABLE
Moderate
Moderate
Open
None
No
COMPLETE
Small to
negative
Moderate
Close or
partially
open
Complete
placenta
with fetus
No
INCOMPLETE
Severe
(bleeds the
most)
Severe
Open with
tissue in
cervix
Fetal or
incomplete
placental
tissue
No
MISSED
None to
severe
incoagulopat
hy
None no FHT
with
ultrasound
None
None
No
HABITUAL: 3
OR MORE
CONSECUTIVE
SPONTANEOUS ABORTION
ABORTION:
- Termination of pregnancy before age of viability:20-24
weeks AOG
SEPTIC
●
●
●
May represent signs of any of the above;
Usually detected in the threatened phase;
Cervical closure (McDonald and Shirodkar cerclage) may be
employed.
Mild to
severe
Severe
Close or
Open with
or without
tissue
Possible,
foul
discharge
Yes
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 11 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Medical Management:
● Surgery: Dilatation and curettage
● Antibiotic
● Fluid replacement: blood and plasma
● Habitual abortion: cerclage
Nursing Management:
a. Threatened Abortion
➢ Characterized by scant, bright red vaginal bleeding
and slight cramping
➢ Advised on complete bed rest for 24 to 48 hours
➢ Teach to save all blood clots passed and perineal
pads used
➢ Advice prompt reporting to the hospital if bleeding
persists or increases
➢ Prevention of abortion: avoid coitus or orgasm for 2
weeks especially around normal time of menstrual
period
➢ Advised to avoid strenuous activity 24-28 hours
b. Inevitable or Imminent Abortion
➢ Characterized by threatened miscarriage with labor
➢ Save or monitor clots, pads, and tissues for correct
diagnosis in histopathology
➢ Instruct women to save any tissue fragments and
bring to the hospital for examination
➢ The px may undergo Dilatation and Evacuation and
continue to monitor products of conception, and
severity of bleeding
➢ Monitor VS, blood loss, I&O, change in status and
signs of infection and refer any deviation
➢ Institute measures to treat shock as necessary:
replace blood, plasma, and fluids as ordered
➢ Prepare for surgery
➢ Provide psychological support
➢ Prevent isoimmunization: administer RhoGAM as
offered if:
■ Mother is Rh negative; abortus is Rh positive
■ Coomb’s test result is negative (no iso
immunization yet → no antibodies formed
yet)
➢ Observe client for 48 to 72 hours; provide
psychological and physical support care
c. Complete Abortion
➢ Entire products of conception expel spontaneously
without assistance
➢ No specific treatment
➢ Monitor bleeding
d. Incomplete Miscarriage
➢ Part of the conception is expelled but the
membranes are retained
➢ The woman is at risk for hemorrhage
➢ Treatment: Dilatation and curettage, or suction and
curettage
e. Missed Miscarriage
➢ Early pregnancy failure
➢ The fetus died in the uterus but not expelled
➢ May have no signs and symptoms
f.
g.
-
-
➢ Diagnosed through UTZ where there is no FHR
detected
➢ Treatment: D&C or D&E
➢ May be induced for labor if the px is more than
14 weeks pregnant.
Habitual or Recurrent Pregnancy Loss
➢ Pregnancy loss where there is 3 or more
consecutive abortion
➢ Habitual aborters
➢ Cause: Autoimmune, uterine infection and
deviation, hormonal, defects on the sperm or
ovum
Septic Abortion
➢ Caused by any infection resulting to the
termination of pregnancy
➢ Upon passage of products of conception there
could also be foul-smelling discharges
PLACENTA PREVIA
This is the premature separation of an abnormally low
implanted placenta
Most common cause of bleeding in the 3rd trimester
Lower Uterine Implantation/ Placenta Previa: Possible
cervix obstruction or the passageway for fetal
delivery. Usually detected late; cesarean
The unusually deep attachment of the placenta to the
uterine myometrium, that the placenta will not loosen
and deliver
IE is contraindicated
Bleeding is caused by pressure
Risk Factors:
● Multiparity - single most important factor
● Scarring and tumor in the upper uterine segment decreased vascularity in the upper uterine segment
● Increased maternal age - above 35 yrs. Old
● Multiple pregnancy
Signs and Symptoms
● Painless vaginal bleeding - fresh, bright red, external
in the 3rd trimester or 7th month
● Flaccid and soft uterus
● Intermittent pain - happens in labor secondary to
uterine contractions
● Intermittent hardening if in labor
● Profuse or slight bleeding - may come after an activity,
coitus or IE
Diagnosis:
● Ultrasound - 95% accurate result and detects the site
of the placenta
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 12 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
○ Progress of labor
○ FHT
Complications:
● Hemorrhage
● Prematurity
● Obstruction of birth canal
Four types of Placenta Previa
A. Complete/total - placenta totally covers the internal OS
B. Partial - placenta partly covers the internal OS
C. Marginal - w/c may be considered as low-lying type;
placenta lies over the margins of the internal OS
D. Low-lying - placenta at the lower third of the uterus and
does not cover the internal OS
Medical Management:
● Watchful waiting
○ Expectant management and conservative if:
✓ Mother is not in labor
✓ Fetus is premature and not in distressed
✓ Bleeding is not severe
● Amniotomy
○ Artificial rupture of the bag of water, w/c causes the
fetal head to descend causing mechanical pressure at
placental site controlling bleeding
● Double Set-up
○ Setting up for vagainal delivery and classical CS
○ To prepare for IE in suspected placenta previa in the
following conditions:
✓ Term gestation
✓ Mother in labor and progressing well
✓ Mother and fetus are stable
✓ Mother is not in labor or in shock, and/or the
fetus is distress only one set-up is to be
prepared, an emergency classical CS set-up
● Classical Cesarean section
● Delivery
○ If conditions for watchful waiting are absent or birth
canal is not obstructed, vaginal delivery could be done
○ CS if placenta placement prevents vaginal birth
✓ In previa, classical CS is indicated, as the lower
uterine segment is occupied by the placenta
✓ Future pregnancies will then be terminated by
another CS due to presence of classical CS
scar, as it is contraindication to vaginal
delivery; leading cause of uterine rupture
Nursing Management:
● Bed rest - Left lateral recumbent w/ a head pillow
● NO I.E.
● Monitor for profuse bleeding
● Provide psychological and physical comfort
● Monitor for postpartum bleeding
● Prepare client for diagnostic ultrasonography
● Prepare for conservatve management
● Institute shock measures as necessary
● Careful assessment
○ Vital signs
○ Bleeding
○ Onset
-
ABRUPTIO PLACENTA
Complication of late pregnancy characterized by
premature or complete separation of the normally
implanted placenta
A.k.a. accidental hemorrhage and ablatio placenta
Leading cause of bleeding in the 3rd trimester
Occurs in 1 out of 300 pregnancies
Occurs when the placenta separates from the inner
wall of the uterus before birth. → oxygen deprivation
Risk Factors:
● Maternal HPN
● Sudden uterine decompression
● Advance age, multiparity
● Short umbilical cord
● Trauma
Signs and Symptoms:
✓ Painful, vaginal bleeding in the 3rd trimester
✓ Rigid, board-like and painful abd.
✓ Enlarged uterus due to concealed bleeding
✓ Tetanic contractions with the absence of alternating
contraction and relaxation of uterus - if in labor
Complications:
● Hemorrhagic shock
● Couvelaire uterus - bleeding behind the placenta may
cause some of the blood to enter the uterine
musculature
● Disseminated Intravascular Coagulopathy (DIC)
● Cerebrovascular Accident (CVA)
● Renal failure
● Prematurity or IUFD
● Infection
Type 1 (A): Concealed/ Covert/ Central/ Classic Type
- Bleeding happens under the placenta
- Placenta separates at the center causing it to
accumulate behind the placenta.
- External bleeding is not evident.
- Signs of shock are not proportional to the amt. of
external bleeding
Type 2 (B): Marginal/ Overt/ External Bleeding Type
- Placenta separates at the margin and bleeding is
external
- Usually proportional to the amt. of internal bleeding
- May be complete or incomplete depending on the
degree of detachment
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 13 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Management:
● Maintain bedrest - Left Lateral Recumbent
● Careful monitoring
● Administer fluids through a large-bore needle for faster
infusion to replenish fluid loss or shock
● Prepare psychological support
● Prepare for emergency birth
● Observe for postpartum complications (after delivery such
as poorly contracted uterus, couvelaire uterus or
postpartum hemorrhage, disseminated intravascular
coagulation or DIC, neonatal distress)
BLEEDING DURING PREGNANCY
Time
1st & 2nd Trimester
2nd Trimester
3rd Trimester
Cause
IMMEDIATE ASSESSMENT OF VAGINAL BLEEDING DURING
PREGNANCY
Assessment Factor
Confirmation of
pregnancy
Specific Questions to Ask
Does the woman know for certain that she is
pregnant (positive pregnancy test or
physician/nurse-midwife confirmation)? A
woman who has been pregnant before and
states that hse is sure she is pregnant is
probably right, even if she has not yet had this
confirmed.
Pregnancy length
What is the length of the pregnancy in weeks?
Duration
How long did the bleeding episode last? Is it
continuing?
●
●
Miscarriage
Ectopic pregnancy
Intensity
●
●
●
H-mole
Premature cervical
Dilatation
How much bleeding occurred? (Ask the woman
to compare it to a common measure [e.g., a
tablespoon, a cup].)
Description
●
●
●
Placenta previa
Abruptio placenta
Preterm labor
Was blood mixed with amniotic fluid or mucus?
Was it bright red (fresh blood) or dark (old
blood)? Was it accompanied by tissue
fragments? Was it odorous?
Frequency
Steady spotting? A single episode?
Associated
symptoms
Cramping? Sharp pain? Dull pain? Has she ever
had cervical surgery?
Action
What was happening when the bleeding
started? What has she done (if anything) to
control bleeding?
Blood type
Does she know this? (Rh-negative women will
need Rh immune globulin to prevent
isoimmunization)
Nursing Management:
● Monitor signs of shock. Signs include:
○ Normal BP but heart rate increase
○ Skin color be normal
○ Temp. cool or moist
○ Patient is anxious
○ RR increased
● Late signs:
○ Hypotension
○ Tachycardia
○ Paleness
○ Cold skin
○ Px may be in coma
○ Increase urination
DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
- Rare life-threatening condition
- Early stage: DIC causes the blood to clot excessively
- Blood clot may reduce blood flow and further bleeding
on other parts
- As condition progresses: Platelets and clotting factor,
the substances in the blood that are responsible for
forming clots are used up. When this happens, the
person experience excessive bleeding
- Can lead to death
Signs and Symptoms:
✓ Bleeding
✓ Presence of blood clots
✓ Hypotension
✓ Easy bruising
✓ Rectal or vaginal bleeding
✓ Petechiae
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 14 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
●
●
Administer betamethasone x 2 doses as ordered
Antibiotics as prophylaxis bc mother is at risk for
having chorioamnionitis (started after 6 hrs from the
time of rupture)
Prepare for delivery (CS or NSVD)
●
Diagnosis
● Blood: CBC, PLT count
● Partial thromboplastin time (PTT)
● D-dimer test
● Serum fibrinogen
● Prothrombin time
Complications:
● Blood clot
● Stroke
● Excessive bleeding that leads to death
Management:
● Halt the source of bleeding
● Heparin- reduce and prevent clotting; may not be
administered if px is lack of platelets or is bleeding too
excessively. If sudden DIC = requires hospitalization, often
in ICU
● Blood transfusion- replace the platelets missing
PREMATURE RUPTURE OF MEMBRANES
- Happens beyond 37 weeks of gestation
- Rupture of bag of water before labor started
◪ PPROM - Preterm premature rupture of membrane (prior
to 37 weeks gestation)
◪ SPROM - Spontaneous preterm rupture of membrane (after
or with onset of labor before 37 weeks)
◪ Prolonged rupture of membrane (persists for more than 24
hrs and prior onset of labor)
Complications:
● Chorioamnionitis - most common
● Fetal sepsis
● Cord prolapse
Diagnosis:
● Vaginal speculum - pooling amniotic fluid
● Nitrazine paper (yellow to blue which shows that an
alkaline amniotic fluid is present), ferning test
Management:
● Bed rest (do not allow px to ambulate to prevent prolapse
of umbilical cord)
● Monitor FHR (fetal vital sign) and initiation of labor
● Labor induction
● Administer IV fluids as ordered
PREGNANCY-INDUCED HYPERTENSION (PIH)
Characterized by 3 symptoms of hypertension, edema
and proteinuria
Occurs after 20-24th week of pregnancy; disappears
6th weeks after delivery
One of the major causes of maternal and fetal
mortality
Etiology
● Nulliparity with extremes of age (17 y.o. below or 35
y.o. above)
● Severe nutritional deficiency (low protein diet and
calories)
● Presence of co-existing conditions (DM, multiple
pregnancy, chronic hypertension, renal disease)
Signs and Symptoms
● Kidneys: (Triad)
✓ Proteinuria, hypoproteinemia
✓ Edema
✓ HPN, Vasospasm
● Brain
✓ Visual disturbances
✓ Hyperreflexia/hyperirritability
✓ Convulsion and coma
● Uterus
✓ Decreased placental perfusion → Small for
Gestational Age (SGA)
✓ Generalized vasoconstriction
✓ Abruptio placenta
SIGNS
MILD PRE-ECLAMPSIA
SEVERE PRE-ECLAMPSIA
HPN
140-170/90 - 105 mmHg
>160/110 on two readings
taken 6 hours apart after bed
rest
PROTEINURIA
1+ or 1 g/day
3+ - 4+ or 5 g/day or more
EDEMA
Generalized, confined to
face (periorbital) and
fingers
Weekly weight gain: 1
lb/wk
Generalized, severe facial
puffiness, severe swelling of
face
Excessive weight gain: 5 lbs/wk
Epigastric pain
Cerebral disturbances
OLIGURIA
Absent
Present
IUGR
(Intrauterine
growth
retardation)
Absent
Present
OTHERS
Hypoproteinemia
Hemoconcentration
Hypernatremia
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 15 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Eclampsia
- 3rd type of PIH
- Convulsion and coma: check BP
- Severe headache and epigastric pain may tell incoming
convulsion
- First sign of convulsion: rolling of the eye balls
- Px are admitted in the labor room near the nurses’ station
with dim lights and lesser noise with a maximum of 2
patients inside the room.
- Environmental stimuli could be a factor to have eclampsia
Management:
● Diet: high protein, moderate sodium & supplemental iron
➢ Iron: 30-60 mg/day in 2nd and 3rd trimester until 2
to 3 months postpartum in lactating mothers
➢ Increase caloric intake by 10% in pregnancy
➢ Sodium restriction in pregnancy is harmful bec it
can decrease circulating volume and result in fluid
and electrolyte imbalance and elimination of vital
nutrients
➢ Provide a high protein diet with moderate sodium:
no total restriction of sodium
➢ Retain fluid with no added salt
● Promote adequate rest and sleep in LLR to promote in
tissue perfusion and induce diuresis
● Regular prenatal care and report danger signs such as visual
disturbances severe persistent headache and dizziness,
irritability, epigastric pain, and edema
● Teach the client in monitoring his own BP.
● Monitor I/O strictly
➢ Maternal and fetal VS need to be taken regularly
➢ Oliguria: bad(?); Diuresis: good sign
● Weigh daily
● Monitor DTR, onset of labor or abruptio placenta
● Administer Magnesium sulfate as ordered
● Seizure precaution:
- Reduce environmental stimuli of room at near
nurse's station (dim and no noise)
- Restrict visitors (2 patient/room)
- Monitor for signs of impending convulsion
- Have on bedside: airway, urinary catheter set, IV
fluids and emergency drugs
Pharmacologic Management:
1. Magnesium sulfate - MgSO4 (prevents convulsion; decrease
BP)
a. Before:
● Assess RR (12-20
cpm), DTR (check
before giving the 2nd
dose of the drug) and
BP
● Antidote on standby: 10% Calcium
Gluconate
● Procainamide
hydrochloride or Lidocaine cocktail - minimize pain
by numbing the area (administer through Z-track
method)
b. During:
● Given through gluteus medius (not painful)
c.
After:
● Monitor BP, RR (not less than 12 bpm), DTR
I&O & FHT
● BURP - BP, URINE, RR, Patellar Reflex q 4
hours
● Calcium Sulfate - Antidote
2. Hydralazine (Apresoline)
- Alpha blocker
- Given IVTT
3. Diazepam (Valium)
- Anticonvulsant given to clients who are having
seizures
4. Blood volume expanders
- Clients who are bleeding
-
HELLP SYNDROME
Life
threatening
disorder
associated
with
preeclampsia
Severe PIH
Disorder of the liver and blood that can be fatal if left
untreated
Rare disorder affecting less than 1% of all pregnancies
Develops on the last trimester of pregnancy but may
occur earlier or even present postpartum
H (Hemolysis)
● Break down of RBC
● In people w/ hemolysis, the RBC get broken down too
soon and rapidly w/c may result to low RBC level and
can lead to anemia
Diagnosis requires >2 of the ff.:
● Abnormal peripheral blood smear (schistocytes, burr
cells)
● Elevated serum bilirubin ( > 1.2 mg/dL )
● Low serum haptoglobin
● Significant drop in Hgb level unrelated to blood loss
E (Elevated)
L (Liver Enzymes)
● Indicate the liver is not functioning properly
● Inflamed or injured liver cells leak high amount of
certain chemicals including enzymes into the blood
● AST or ALT > upper limit of normal
● LDH > 2x upper limit or normal
L (Low)
P (Platelet count)
● Components of the blood that help with clotting,
when platelet levels are low the client may develop
increase risk of excessive bleeding
● < 100,000/mm³
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 16 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Risk Factors:
● Maternal age of greater than 34.
● Multiparity
2.
3.
Dizygotic Twins - fraternal, 2 separate ova
Supertwins - 3 or more fetuses on 1 pregnancy
Signs & Symptoms
- Wide ranging and vague, and are often difficult to diagnose
- Cause of symptoms are unknown
➢ Malaise, n/v
➢ Edema with secondary weight gain
➢ Epigastric or right upper quadrant pain (due to the
edema of the liver)
➢ Dyspnea (if pulmonary edema present)
➢ Jaundice
➢ Signs of dehydration including sunken eyes
➢ Edema leading to puffy eyes
➢ Dry mucous membranes
Class 1
(Severe)
Class 2
(Moderate)
Class 3
(Mild)
Platelets
< 50,000/uL
50,000 100,000/uL
100,000 150,000/uL
AST or ALT
> 70 IU/L
> 70 IU/L
> 40 IU/L
LDH
> 600 IU/L
> 600 IU/L
> 600 IU/L
Incidence of
bleeding
13%
8%
No increased risk
Management:
● Intravenous fluids should be given cautiously.
● Treat HPN
● Delivery (either vaginal delivery or cesarean section) is
indicated if HELLP syndrome occurs close to 34 weeks'
gestation
● Monitor bleeding
-
MULTIPLE PREGNANCY
Gestation of 2 or more fetus
Carrying multiple fetus during the same pregnancy
Risk Factors:
● Infertility management
● Advanced maternal age- result of delaying pregnancy by
choice and infertility which lead to major risk to multiple
gestation: prematurity and low birth weights
● Use of Clomiphene citrate- to increase maturation of
ovarian follicle
● Multiparity
Types:
1. Monozygotic Twins- develops from single ovum that
divides forming identical twins, 1 amnion, different
umbilical cord
a. Diamnionic Monozygotic - have their own
amnion, 2 chorion, 2 placentas
b. Monochorionic Monozygotic- the same chorion
and amnion
Manifestation:
➢ Positive history of twinning (within family or past
pregnancy)
➢ Large uterus
➢ Two or more FHT - asynchronous
➢ Palpation of 3 or more large parts
➢ Two fetal outlines by UTZ
➢ Increased maternal weight and discomforts
Diagnosis:
● UTZ and palpation
● High Serial Estriol
Complications:
A. Maternal
● Iron Deficiency Anemia (IDA)- most common
● Threatened abortion
● Preterm Labor/ PROM
● PIH
● Uterine atony after delivery or postpartal
hemorrhage
● Hyperemesis gravidarum
● Potential anxiety and depression
B. Fetal
● Prematurity
● Respiratory Distress Syndrome (RDS)- leading
cause of death
● Conjoining abnormalities- from incomplete
separation
● Stillbirth and Birth injuries
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 17 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Medical Management:
● Early diagnosis - comprehensive prenatal care
● Frequent monitoring of the maternal and fetal well being
➢ Laboratory assessment
➢ Fetal sonography (?)
➢ NST-biophysical profile
- 30-34 weeks
● Nutritional support
Non-pregnant kcal: 1800kcal - 2,300kcal
Singleton: Non pregnant kcal + 300kcal
Multiple: Non Pregnant kcal + 300kcal + 300kcal
Iron: 60-100 mg/day of iron (increase from 60mg - singleton)
Folate:1 gram/day of folate
●
●
Cervical assessment
Delivery: Vaginal or Cesarean section
Nursing Management:
● Teach the client on frequent prenatal care and balance diet.
○ Every 2 weeks in the 2nd trimester
○ Twice a week in the last 4 weeks
○ Increase calories and iron and vitamin
supplementation
○ Folic acid is important taken one month prior to and
throughout first 3 months of pregnancy
● Emphasize importance of frequent rest (left lateral
position) and prompt reporting of danger signs.
● Psychosocial assessment & support referral is needed to
social services, postpartum caregivers and lactation support
people)
● Intranatal:
○ Strict asepsis- prevent infection
○ Label babies as Baby A, B,...
○ Assist safe delivery of the second child (optimum
time of delivery of 2nd child: 5-20 mins.)
● Prevent bleeding:
○ Administer oxytocin after delivery of last baby.
○ Palpate fundus and do not massage the uterus until
delivery of placenta.
○ Gently massage and elevate fundus for 15-30
minutes
○ Promote bonding & psychological support.
OLIGOHYDRAMNIOS & POLYHYDRAMNIOS
Movements of amniotic fluid:
1. Swallow
- Swallows amniotic fluid then moves in the amniotic sac
into the baby's body
- Decreases amniotic fluid
2.
-
POLYHYDRAMNIOS
OLIGOHYDRAMNIOS
Too much amniotic fluid in
the amniotic space
Too little amniotic in the
amniotic space
1 ↓SWALLOWING
Decreased swallowing due
to:
a. TE Fistula
b. Duodenal Atresia
c. Esophageal Fistula
2 ↑URINATION
Increased urination
- Hyperglycemia
baby
(pisses
nonstop)
-
1 SWALLOWING
N/A
2 ↓URINATION
Bladder outlet obstruction
(PCKD:
Polycystic
Kidney
Disease)
+ Pulmonary
Hypoplasia
+ Potter sequence
Without amniotic fluid in the lung: results to
Pulmonary Hypoplasia
POTTER sequence
➢ Pulmonary hypoplasia
➢ Oligohydramnios
➢ Twisted face
➢ Twisted Skin
➢ Extremity Deformities
➢ Renal Agenesis → decreased urination
If the baby cannot urinate:
(Renal agenesis: decrease urination)
- less amniotic fluid goes out into the amniotic space
→ Oligohydramnios, which means that you have
Pulmonary Hypoplasia.
Effects: TTE = Twisted face, Twisted skin, Extremity
deformities
-
ISOIMMUNIZATION (RH INCOMPATIBILITY)
Different RH factor mom and baby
Occurs when an RH (-) mother carries a fetus with an
RH (+) blood type
The father of the child must either be homozygous or
heterozygous RH (+)
If the father of the child is a homozygous, for the
factor 100% of the couple's children will be RH (+)
If the father is heterozygous, for the trait, then 50% of
their children can be expected to be RH (+).
Although, this is basically a problem that affects the
fetus, it causes such concern and apprehension in a
woman during pregnancy and can be a maternal
problem as well.
Urinate
Increases amniotic fluid
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 18 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
○
Mother - Rhesus negative
Baby - Rhesus positive
- Mother and baby have different blood types
- The baby has its own unique blood type bc it inherits half of
its genetic make up from his father.
- The blood and baby’s blood don’t mix, but come in very
close contact w/ each other across the placental membrane
- If one has Rhesus Antigen (+), the body learns to recognize
antigen as part of the body, but if one has Rhesus Antigen
(-), the body thinks that it’s a pathogen.
- If the mother has Rhesus (-) and the baby has Rhesus (+),
anytime the baby’s blood gets into the mother’s
bloodstream, its gonna create the Anti-Rhesus Antibodies
- In future pregnancies, the antibodies that the mom has
developed will be able to cross the placental barrier due to
very small proteins and will get into the bloodstream of the
baby and start attacking the baby's blood cell.
- The baby’s blood cell will be hemolyzed or destroyed, it
releases chemicals into the baby’s body, called bilirubin w/c
is responsible for creating jaundice.
●
●
-
Sensitising Events - baby’s blood gets into the mother’s
bloodstream
● Miscarriage > 12 weeks
● Abdominal trauma
Assessment:
● Anti-D antibody titer (mother)
○ 1st pregnancy visit
○ If the result is normal or
minimal (0), the test is repeated
at 28 wks.
○ No therapy is needed if it’s also
normal
○ If the woman’s Antibody Titer is
elevated at the first assessment
showing RH sensitization, the
well-being of the fetus will be
monitored q 2 wks. (fetal
doppler)
● Anemia - RBC are destroyed faster than they are made
● Jaundice
● Swelling of the baby’s body, which can lead to heart failure
or breathing problems
● Baby could look edematous
Shot contains antibodies collected from
plasma donors that stop the immune system
from reacting to the baby’s RH positive blood
cell
○ Keeps the mother and the baby’s blood RH
incompatibility from causing any possible
problems, wherein the blood types mix at any
point during the pregnancy or delivery
○ If the mother and the baby maybe RH
incompatible, the shot of RhoGAM will be
given between 26-28 weeks AOG and given at
IM 20-72 hours after birth (to ensure that
future pregnancies are safe)
○ If the client undergoes Chorionic Villi Sampling
or Amniocentesis or if the mother experiences
bleeding during pregnancy or any trauma ,
where there could be exposed to fetal self ,
the doctor may shot another RhoGAM at any
point during pregnancy
Abortion → still needs to receive Rhogam
HYDROPS FETALIS - fetal complication where the baby
becomes edematous and the liver swells due to
insufficient albumin
-
GERMAN MEASLES / RUBELLA
Acute viral infection caused by a myxovirus
The maternal infection is mild but effects on the
fetus are severe
Considered a teratogen during pregnancy
IP: 2-3 weeks
Communicability happens within 7 days to 5 days
after rash appears
Transmission: Direct and Indirect contact
1st Trimester
●
●
●
●
Deafness
Eye defects
CNS defects
Cardiac
malformation
2nd Trimester
●
●
●
●
●
Premature labor
IUFD
DM
Thyroid problem
Progressive
panencephalitis
Other anomalies: (1st trimester)
● Microcephaly
● Mental retardation
● Susceptibility to pneumonia
● Enlarged liver
● Blood dyscrasia
● Hemolytic anemia
● Thrombocytopenia
Management:
● Rh (D) antibodies (RhIG) - arm or backside
● RhoGAM injection
○ Use to treat RH incompatibility during pregnancy
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 19 .
MCHN 2 - LECTURE Week 1 High Risk Pregnancy
Assessment Findings:
● Pink maculo-popular rash all over the patient, starts on the
face and spreads caudally on 3-5 days
● Slight fever, malaise
● Nasal congestion
● Anorexia
● Posterior auricular and occipital adenopathy
● Arthritis/ arthralgia
Management: Symptomatic
● Rubella Vaccine is given immediate postpartum or 1-3
months before pregnancy
● Supportive treatment
● Immune serum globulin given to exposed women to
prevent aggravation of maternal symptoms
● Immunization- cornerstone of therapy
○ Rubella vaccination
■ to all non-pregnant non-immune women of
childbearing age
■ should avoid pregnancy for at least 1
month/4 weeks after immunization
■ not contraindicated for breastfeeding
■ all children should receive MMR at age 15
months old and pregnant non-immune
women should receive be immunized in the
immediate postpartum confinement; never
during pregnancy because defects may be
delayed for up to 21 days
● Pregnant non-immune women should be immunized
IMMEDIATE POSTPARTUM
● Breastfeeding is not contraindicated
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 20 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
NURSING CARE OF THE HIGH-RISK PREGNANT CLIENT
DURING LABOR & DELIVERY
OUTLINE:
COMPONENTS OF LABOR
I.
Passenger
A. Fetal Malposition
B. Fetal Malpresentation
C. Fetal Distress
D. Prolapsed Umbilical Cord
II.
Passageway
A. Abnormal Size or Shape of the Pelvis
B. Cephalopelvic Disproportion
C. Shoulder Dystocia
III.
Powers
A. Dystocia
B. Premature Labor
C. Precipitate Labor & Birth
D. Uterine Prolapsed
E. Uterine Rupture
IV.
Operative Obstetrics
V.
Psyche
A. Fear & Anxiety on Labor Progress
REFERENCE: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal
& child health nursing: Care of the Childbearing &
Childrearing Family (Eight ed., Vol. 1).
PASSENGER (FETUS)
- Although the fetus is basically passive during birth,
complications may arise if an infant is immature or
preterm or if the maternal pelvis is so undersized that its
diameters are smaller that the fetal skull, such as occurs
in early adolescence or in women with altered bone
growth from a disease such as rickets.
- Can also occur if the umbilical cord prolapses, if more than
one fetus is present, or if the fetus is malpositioned or
large for the birth canal.
- Ideally for labor, the baby is positioned head down, facing
the mothers’ back with the chin tucked to its chest, and
the back of the head ready to enter the pelvis, called
Cephalic presentation.
- Most babies settle into this position within the 30 second
to 36 week of pregnancy.
Different sutures and fontanelles present in the fetus:
● Diamond shape fontanelle
- Anterior fontanelle
● Triangle shape fontanelle
- Posterior fontanelle
Risk Factors:
● GDM
● Multiple Pregnancy
● Malpositioned Fetus
● Immature or preterm
Risk Factors:
● GDM
● Multiple Pregnancy
- It could alter the position and the lie.
○ Additional personnel are needed for the birth,
including as many nurses to attend to possibly
immature infants as there are infants, plus additional
persons skilled in newborn resuscitation.
○ Be certain to focus on the mother’s needs as well as
those of her babies so she isn’t neglected
○ Twins may be born by cesarean birth to decrease the
risk of the second fetus experiencing anoxia; this is
also the situation in multiple gestations of three or
more because of the increased incidence of cord
entanglement and premature separation of the
placenta.
○ Anemia and Gestational HPN occur at higher than
usual incidence during multiple gestations
○ Be certain to assess the px’s hematocrit level and
blood pressure closely during labor or while waiting
for cesarean arrangements.
○ Vaginal birth:
■ The px is usually instructed to come to the
hospital early in labor and the first stage of labor
does not differ greatly from a single gestation.
■ Coming to a hospital this early in labor will make
labor seem long. Urge the woman to spend the
early hours engaged in activity, such as playing
cards or reading to make time pass quickly.
■ Multiple pregnancies often end before term, so
the woman may not yet have practiced
breathing exercises. The early hours of labor
may be used to practice.
■ During labor, support the woman;s breathing
exercises to minimize the need for analgesia or
anesthesia; this helps to minimize any
respiratory difficulties the infants may have at
birth because of their immaturity.
■ Be certain when taking FHRs by Doppler or a
fetal monitor, you are hearing two separate
beats as proof each infant is doing well, because
with multiple fetuses, abnormal fetal
presentation may occur.
■ Because the babies are usually small, firm head
engagement may not occur, thus increasing the
risk for cord prolapse after ROM.
■ Uterine dysfunction from a long labor, an
overstretched uterus, unusual presentation, and
premature separation of the placenta after birth
of the first child may also be more common.
○ Most twin pregnancies present with both babies
vertex. This is followed in frequency by vertex and
breech, breech and vertex, and then breech and
breech.
○ Multiple gestations of 3 or more have extremely
varied presentations.
○ After birth of the 1st infant, both ends of the baby’s
cord are tied or clamped permanently rather than
with cord clamps which could slip. This is to prevent
hemorrhage through an open cord end if additional
infants have shared the placenta.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 1 .
MCHN 2 - LECTURE
●
●
Week 2 High Risk Pregnancy During Labor & Delivery
○ Oxytocin administration is not done as to avoid
compromising the circulation of the infants not yet
born.
○ After the 1st birth, the lie of the 2nd fetus is
determined by external abdominal palpation or UTZ.
○ Often an Internal Podalic Version, where feet are
grasped by the delivering provided, is completed to
accomplish a breech delivery of the second twin.
○ Cold hypothermia is a concern for preterms, thus the
time parents are to inspect their child depends on the
infants’ weight and conditions.
○ Review measures used such as armbands to avoid
confusion with the infants.
○ Careful assessment to determine their true
gestational age and whether a phenomenon such as
twin-to-twin transfusion could have occurred.
○ If parents aren’t unable to inspect their babies
thoroughly after birth, be certain they have an
opportunity to do so as soon as possible to dispel any
fear they had.
○ Assess the woman carefully in the immediate
postpartum period because a uterus that was overly
distended because of multiple gestations may have
more difficulty contracting than usual, thus placing
her at risk for hemorrhage from uterine atony.
○ The risk for uterine infection increases if labor or
birth was prolonged.
Malpositioned fetus
○ Most common malposition - occipitoposterior
Immature or preterm
Ideal position for the fetus:
- Ideally the head or vertex should be on the anterior
portion of the maternal pelvis, meaning the fetus is
facing towards the back, as it would facilitate
successful cardinal movements during labor and
delivery.
● Right Occiput Anterior (ROA)
● Left Occiput Anterior (LOA)
-
-
FETAL MALPOSITION
Occipitoposterior → most common
Occurs when the occiput of the fetus, who is in vertex
presentation is rotated so that it is not oriented
anteriorly in the maternal pelvis.
Normal position and presentation should be well flexed
and the occiput should be in the anterior part of the
pelvis.
However, if the fetus’ occiput is towards the posterior
part of the pelvis, then it is considered an abnormal
position. Though the fetus can still position himself
correctly in the maternal pelvis allowing a successful
vaginal delivery.
As part of the cardinal mechanism that upon complete
extension, ideally the head should be facing downwards.
The symphysis pubis will serve as a joint, wherein the
head could pivot during complete extension.
However, if the fetus would maintain an abnormal
position, which is an occipito posterior tendency could
the fetus is facing upward causing problems during
complete extension.
Examples of Occipitoposterior position:
● Long rotation
- Ideally, if the fetus is about to be delivered, it needs
to have a long rotation, meaning the fetus needs to
rotate ⅜ of the total circumference of the pelvis,
considered a long rotation, which would lead to a
successful vaginal delivery.
- The anterior portion which has the diamond
fontanelle would be on the back portion of the mother
having a successful extension.
● Short anterior rotation
- Wherein as it tries to rotate to the ideal position it
would stuck up into a transverse position and this
could lead to a problem during the delivery.
● Nonrotation
- If it's not rotated at all, thus the fetus will not position
into a successful extension.
● Short posterior rotation
- Maintains to the posterior part of the maternal pelvis,
thus it will be facing upright during extension.
Risk
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 2 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
Factors:
● Common among women with android, anthropoid or
contracted pelvis
-
Assessment Findings:
● The mother would complain the pressure and pain in the
lower back
-
Management: A
● Provide back rub
● Keep the bladder empty - to allow descent of the fetus
● Provide IV glucose for prolonged labor - to prevent
hypoglycemia
● Cesarean delivery
○ Arrest in transverse position
○ Any signs of fetal distress
○ Presence of obstruction
● Induce of Augment labor for possible NSVD (vacuum may
be use)
○ Intact Bag of water (BOW)
○ Fully dilated to 10 cm with no signs of obstruction.
■ However, vacuum extraction could be used to
assist the delivery. Delivery may be
complicated by perineal tears or extension of
an episiotomy.
■ If there are signs of obstruction or the FHR is
abnormal, w/c would mean there is fetal
distress, cesarean delivery could be done.
However, if intact there could be amniotomy
done by the doctor and allow labor to
continue.
■ If the cervix is not fully dilated, then oxytocin
could be used to augment or induce the labor.
■ If the cervix is fully dilated, but there is no
descent in the expulsive phase, then assess for
signs of obstruction. Possibly the fetus could
be rested in a transverse position.
■ If no signs of obstruction, the woman could
still continue with the labor.
■ If the cervix is fully dilated and fetal head is ⅗
palpable above the symphysis pubis or the
bony prominence of the head is above -2
station,
the
CS
could
be
done.
-
-
Descent and delivery of the head by flexion may occur in
the chin anterior position.
Chin anterior position could still have normal vaginal
delivery.
However, a chin posterior position with a fully extended
head, as it is blocked by the sacrum prevents descent and
labor is arrested.
In most cases, chin posterior is delivered thru CS.
Always remember that in this presentation, though it
could be done thru normal vaginal delivery, vacuum
extraction should be used.
The newborn’s face could be edematous upon delivery,
especially the lips.
Diagnostic:
● Leopold's maneuver
● UTZ - could confirm the presentation
● Internal examination - the examiner will feel the chin
instead of the occiput.
Chin anterior is more conducive to vaginal delivery
-
2. Breech Presentation
The frequency of breech presentation falls at pregnancy
advances.
At the 30th week of pregnancy, 15% of the fetuses
present as a breech. By the 36th week the proportion has
fallen to 6% . By term, only 3% present as breech.
Most of the baby turns as cephalic.
The presentation is not important before the 32nd to
36th week. At this stage the finding can be found through
palpation.
Lower uterus: soft, irregular mass
Fundal area: firm, smooth, rounded mass
Auscultation: Fetal heartbeat is loudest at above the
umbilicus
Types of Breech Birth Position:
-
FETAL MALPRESENTATION
1. Face & Brow Presentation
The chin serves as the reference point in describing the
position of the head.
It is necessary to distinguish only chin anterior position, in
w/c the chin is anterior in relation to the maternal pelvis.
Chin posterior, the chin is rapid towards the back portion
of the mother.
Prolonged labor is common.
1.
2.
3.
Frank breech position: Breech with extended leg
Complete breech position: Breech with flexed leg; Hips
and knee are flexed
Footling breech position: Could be single or double
footing; both legs could be dropped into the maternal
cervix
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 3 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
Risk Factors:
● Gestational age of <40 wks. (could be managed)
● Fetal abnormality
● Polyhydramnios
● Midseptum in the uterus
● Tumor growth in the uterus (prevent fetus to position
correctly)
● Pendulous abdomen
● Multiple gestation
Assessment:
● FHR - palpate at higher
portion
in
the
abdomen
● UTZ - confirmatory
●
Complications:
● Hip dysplasia
● Anoxia from cord prolapse
● Head trauma
● Arm or supine fracture
● Early rupture of membrane
● Meconium staining - does not mean fetal distress
common w/ breech presentation because of the pressure
applied to the rectum or to the anus of the fetus
producing its meconium
Management:
● External Cephalic Version
- procedure that externally rotates the fetus from a
breech to cephalic presentation
- successful version of a breech into cephalic presentation
allows women to avoid cesarean delivery
- Examples of anatomical restraints that may restrict fetal
movement into the vertex presentation:
➢ Extended fetal leg
➢ Placental implantation
➢ Contracted maternal pelvis
➢ Tumor certain fetal anomaly (hydrocephaly)
➢ Teratoma
➢ Multiple Gestation
- Always remember that there are certain criteria that we
need to consider before attempting an external version.
In the external version you need to use anesthesia for this
because it's painful. Make sure that the uterus is not
contracting to allow free movement of the fetus and also
there should be enough amniotic fluid.
- Only attempt external presentation if breech
presentation is present at/ after 37 week. Because before
37 weeks a successful version is more likely to
spontaneously revert back to breech presentation.
- Vaginal delivery is possible making sure that the woman:
➢ does not have a history of CPD
➢ no complications such as fetal growth
restriction
➢ uterine bleeding
➢ previous cesarean delivery
➢ fetal abnormalities
➢ twin pregnancy
➢ hypertension
➢ fetal death
If the external version is successful then normal
childbirth could be preceded. If it fails, c-section is
needed.
-
●
-
Breech birth - not common; done by skilled health
care provider with safe condition; there should be
complete or frank breech presentation (only position
that could be done)
Cesarean section
The woman should not push until the cervix is fully
dilated.
Full dilation should be confirmed by a vaginal
examination.
Head is born last and should be facing downward.
C-section is ideal for breech presentation especially
for:
○ Double foot
○ Small or malformed pelvis
○ Very large fetus
○ Previous caesarean section for CPD
○ Hyperextended or deflexed head
3. Shoulder Presentation
Risk Factors:
● Pendulous abdomen
● Uterine fibroid tumors
● Congenital abnormality
in the uterus
● Premature infant
Management:
● Delivery
through
cesarean section
-
FETAL DISTRESS
Emergency pregnancy labor and delivery complication in
which the baby experiences birth asphyxia
Must be addressed immediately to avoid serious
complications such as HIE (hypoxic ischemic
encephalopathy), cerebral palsy and other birth injuries.
Prevention: deliver the baby allowing nurses to
administer medical care and usually c-section.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 4 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
Risk Factors:
● Dystocia
● Cord coil or compression or
prolapse
● Improper use of oxytocin
(hyperstimulation)
● Co-existing conditions of the
mother
● Bleeding
● PIH
● Supine Hypotension
Syndrome
Assessment Findings:
● FHT > 160 or <120 bpm
● Meconium-stained amniotic fluid
● Fetal hypermobility or hypomobility
Management:
● Position in LLR (relieves pressure in inferior vena cava)
● Stop the oxytocin drip
● Administer oxygen (6-7 L/min)
● Correct hypotension
➢ elevating the leg
➢ increase IV rate or increase hydration
➢ no oxytocin
➢ turn the mother to her left if it’s case of vena
cava syndrome
● Monitor FHT
● Notify the physician
● Prepare for emergency CS if indicated
UMBILICAL CORD PROLAPSE
-
-
Readily slips down at the vaginal; palpable at IE
Assessment findings:
● Felt
upon
vaginal
examination
● Visible at the vulva
● Deceleration of FHR
Management:
● Assess FHR every
after rupture of
membrane
● Place gloved hand
into the vagina and
elevate fetal head
off the cord
● Position woman in
knee-chest
or
Trendelenburg position (shock position)
● Administer oxygen (10 L/min)
● Amnioinfusion - relieves pressure on the cord;
isotonic fluid is instilled into the uterine cavity
● Do not push back the cord into the vagina this could
add to the pressure; instead push the fetus head away
from the cord
● Cover any exposed cord with gauze wet with sterile
saline to prevent drying
● Cesarean section
PASSAGEWAY
Risk Factors:
● Bony pelvis:
○ Contracted (due to malnutrition of the mother)
○ Deformed (due to trauma or polio)
● Soft tissue:
○ Tumor in the pelvis (that could alter the passage of
the passenger)
○ Viral infection in the uterus or abdomen
○ Scars
A loop of umbilical cord slips down at the presenting
fetal part.
Prolapse may occur after the membrane's rupture if
the presenting fetal part is not fitted firmly into the
cervix.
Risk Factors:
● PROM
● Malpresentation
● Placenta previa
● Intrauterine tumors
● Small fetus
● CPD (preventing firm engagement)
● Polyhydramnios
● Multiple gestation
-
The incidence is about 0.5% of cephalic birth but can
rise as high as 10% or higher with breech or transverse
lie.
Cord prolapse can be discovered after the membrane
has ruptured.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 5 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
Shapes/ Kinds of Pelvis:
1. Gynecoid
a. Most favourable/ ideal passage for childbirth because the wide-open shape lets the baby have
plenty of room during delivery
2. Android
a. Its narrowness restricts the baby from moving
b. C-section required to some
3. Anthropoid
a. Narrower than gynecoid
b. Longer labor
4. Platypelloid
a. The shape of this can make labor difficult.
b. C-section required
CEPHALOPELVIC DISPROPORTION (CPD)
-
Mismatch between the mother’s pelvis and the baby's
head
The baby's head is proportionally too large or mother's
pelvis too small to easily allow baby to enter the pelvic
opening
Make vaginal delivery impossible
Treatment for CPD varies based on severity and when it is
diagnosed
If it is severe and diagnosed early: planned C-section is
indicated or scheduled C-section
Other cases: Symphysiotomy - surgical division of pubic
cartilage; Emergency C-section
Risk Factors:
● Infertility treatment
● Maternal obesity
● Previous cesarean
delivery
● Polyhydramnios
● Gestational diabetes result to macrosomic baby
● Postmaturity
● Multiparity
● Advanced maternal age
● Short stature
● Transverse diagonal measurement of < 9.5 cm
● History of childhood calcium deficiency or rickets
Assessment:
● High station or floating
even after a significant
amount of contractions
● Prolonged and arrest of
labor - results to oxygen
deprivation
● Signs of fetal distress
Diagnosis:
● History of vaginal delivery rules out CPD
● Pelvimetry
Complications:
● Hyperstimulation of oxytocin
● Prolonged labor
● Shoulder dystocia
● Umbilical cord compression
Management:
● Scheduled cesarean section
● Emergent cesarean section after trial of labor
-
SHOULDER DYSTOCIA
Occurs when the baby's head passes through the birth
canal and shoulders become stuck during labor
Obstruction during fetal delivery
Considered a medical emergency; doctor must address
quickly
Other mother has shoulder dystocia without having risk
factors
Risk Factors:
● GDM
● History of macrosomic baby (large birth weight)
● History of shoulder dystocia
● Labor induced
● Obesity
● Post-term
● Multiple gestation
Assessment:
● Turtle
sign
crowning
but
retracts
during
contractions; fetal head first comes out into the body
but will then seem to go back into the birth canal
● Prolonged second stage of labor due to the obstruction
● Arrest of descent
Complications:
● Hemorrhage
● Vaginal or cervical tears, Rectum tears
● Cord compression
● Fractured clavicle of newborn
● Brachial plexus injury
● Rare:
○ Excessive internal bleeding in the mother
Management:
HELPERR
for Shoulder Dystocia
H Call for Help (ask for assistance)
E Evaluate for Episiotomy (incision in the perineum)
L Legs: McRoberts Maneuver (pulling of legs towards the
mother’s chest)
P External Pressure - suprapubic pressure (doctor will place
pressure on a certain area of the pelvis to encourage the baby's
shoulder to rotate on the oblique(?) direction)
E Enter: rotational maneuvers (helping to rotate baby's
shoulder to where it can pass more easily; Internal Rotation)
R Remove the posterior arm
R Roll the patient to her hands and knees (helps pass the baby
more easily through the birth canal)
*These don't have to be performed in the order listed to be
effective.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 6 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
Risk Factors:
● Primigravida
● Pelvic bone contraction
● Posterior fetal position or extension of fetal head
● Failure of uterine muscle to contract
● Nonripe cervix
● Full rectum or bladder
● Exhaustion from labor
● Inappropriate use of analgesia
Delivery of the posterior arm. By passing one hand into the
vagina along the posterior arm, the practitioner may flex the
fetal arm until the forearm may be gripped and swept across
the fetal chest, delivering the posterior arm and shoulder.
-
-
-
-
-
POWER
Contraction phase consists of a descending gradient. The
wave begins in the fundus wherein there is the greatest
number of myometrial cells. Then, moves downwards
through the corpus of the uterus.
Intensity of the contraction diminishes from fundus to
cervix. That's why when you do your labor watch, your
hands should be placed on the fundal area to feel the
utmost contractions.
Retraction phase:
➢ Which is throughout the labor, the upper uterine
segment is more active, contracting more
intensely and for a longer time than the lower
uterine segment.
➢ The second part of the contraction phase.
➢ After the muscle has contracted, it refracts as it
relaxes by pulling up the cervix and lower uterine
segment.
➢ The upper uterine segment becomes thicker in
time, while the more passive lower segment
becomes thinner.
The synchronous nature of the contraction is necessary
for efficient dilatation and effacement of the cervix.
Women who are dehydrated frequently experience
preterm labor that can be stopped by hydration.
Normal uterine contractions are like waves composed of:
➢ Increment - building up or ascending portion
➢ Acme - peak
➢ Decrement - coming down or descending
portion
Remember: A normal or an ideal contraction should have
a maximum duration of 80 secs. and with a minimum
relaxation of 2 mins.
Any alteration with power may bring about a deep OB
score or OB history of a pregnant woman.
DYSTOCIA
- Prolonged or difficult labor/delivery because of
problems with the factors of
labor.
Etiology:
● Hypotonic Uterine
Contractions
● Hypertonic Uterine
contractions
● Dysfunctional Labor
● Pathologic Retraction Ring
- Hypotonic has a late onset and it is usually in the active
phase.
- Hypertonic happens during the early as the latent
phase
Hypotonic
Hypertonic
Onset
Late onset; active phase
Early onset; latent phase
Contractions
Weak, painless, tension not
synch
Strong, painful,
uncoordinated, increased
contractions but ineffective
in bringing further dilation
Causes
Overdistention, advanced
aged, increased parity,
contractures, fetal
malposition, analgesia/
anesthesia
Primigravidity, young age,
injudicious use of oxytocin
Treatment
Enema, walking, amniotomy,
oxytocin
Sedation
CTG Strips
A = normal
B = hypotonic uterine inertia
C = hypertonic uterine inertia
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 7 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
First CTG strip : Ideal uterine activity during an active labor
Second CTG strip: Hypotonic uterine inertia
- The resting tone of the uterus remains less than 10
millimeters mercury and the strength of contractions does
not rise above 25 millimeters mercury.
- Hypotonic contractions are most opt to occur during the
active phase of labor, they may occur after the
administration of analgesia, especially if the cervix is not
dilated to 3-4 cm or if bowel or bladder distention prevents
descent or firm engagement.
- That’s why it is best that pain relievers such as sedatives
should be given if the mother is greater than 3-4 cm cervical
dilated.
- They may occur in a uterus that is overstretched by multiple
gestation. A larger than usual single fetus, hydramnios or in
a uterus that is relaxed from a grand multiparity. Such
contractions are not exceedingly painful because of their
lack of intensity.
- Keep in mind that, however, that the strength of a
contraction is a subjective symptom. Some women may
interpret this contraction as very painful.
- Hypotonic contractions increase the length of labor because
more of them are necessary to achieve cervical dilatation.
- This can cause the uterus to not contract as effectively
during the postpartum period because of exhaustion
increasing a woman’s chest for postpartum hemorrhage.
- In the first hour after birth, following a labor of hypotonic
contractions, palpate the uterus and assess lochia every
15 mins. to ensure that postpartum contractions are not
also hypotonic and therefore inadequate to halt bleeding.
Third CTG strip: Hypertonic uterine inertia
- These are marked by an increase in resting tone to more
than 15 millimeters mercury. However, the intensity of
the contraction maybe no stronger than that associated
with hypotonic contractions.
- In contrast to hypotonic contraction, hypertonic ones
tend to occurs frequently and are most commonly seen
in the latent phase of labor
- This type of contraction occurs because the muscle
fibers of the myometrium do not repolarize or relax
after a contraction, thereby wiping it clean to accept a
new pacemaker stimulus.
- They may occur because more than one pacemaker is
stimulating contractions.
- They tend to be more painful than usual because the
myometrium becomes tender from constant lack of
relaxation and the anoxia of uterine cells that results.
- A woman may become frustrated or disappointed with
her breathing exercises for childbirth because such
techniques are ineffective with the type of contraction.
- A danger of hypertonic contractions is that the lack of
relaxation between contractions may not allow optimal
uterine artery filling; this could lead to fetal anoxia early
in the latent phase of labor.
- Any woman who has pain sense is out of proportion to
the equality of her contractions should have both a
uterine and fetal external monitor applied for at least 15
minutes to ensure that the resting phase of the
contraction is adequate and that the fetal pattern is not
showing late deceleration.
-
If deceleration in the fetal heart rate (FHR) or an
abnormally long first stage of labor or lack of progress
with pushing occurs, cesarean birth may be necessary.
Both the woman and her support person need to
understand that although the contractions are strong,
they are ineffective or not achieving cervical dilatation.
Dysfunctional Labor
Stage of
Labor
1st
stage
Dysfunction
Nullipara
Multipara
Prolonged Latent Phase
20 hrs
14 hrs
Protracted Active Phase
1.2 cm/hr
1.5 cm/hr
Prolonged Deceleration
Phase
> 3 hrs
> 1 hr.
Secondary Arrest of
Dilatation
2nd
stage
>2 hrs.
Prolong Descent
< 1.0cm/hr
< 2.0cm/hr
Arrest of Descent
2 hrs.
1 hr.
1st Stage:
Prolonged latent phase
- Latent phase that lasts longer than 20 hours in nullipara
or 14 hrs. in multipara.
- Occurs if the cervix is not ripe at the beginning of labor. It
may occur if there is excessive use of analgesia early in
labor.
- Uterus is in a hypertonic state.
- Relaxation between contractions is inadequate and
contractions are only mild, therefore ineffective.
- One segment of the uterus may be contracting with more
force than the other segment.
- This is managed by helping the uterus to rest, provide
adequate fluid for hydration and pain relief with a drug
such as morphine sulfate.
Protracted Active Phase
- Usually associated with fetal malposition/CPD although it
may reflect ineffective myometrial activity.
- This phase is prolonged if cervical dilatation does not
occur at a rate of at least 1.2cm in nullipara and 1.5 cm in
multipara or if the active phase lasts longer than 12 hrs in
primigravida or 6 hrs in multigravida.
- If the cause of delay is malposition or CPD, cesarean birth
may be necessary.
Prolonged deceleration phase
- When it extends beyond 3 hrs. in nullipara or 1 hr. in
multipara
- If it most often results from abnormal head position.
- Cesarean birth is frequently required
Secondary arrest of dilatation
- Occurred if there is no progress in cervical dilatation for
longer than 2 hrs.
- CS birth may be necessary
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 8 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
2nd Stage:
Prolong descent
- Occurs if the rate of descent is less than 1 cm/hr in
nullipara or 2 cm/he in multipara.
- It can be suspected if the second stage lasts for than 2 hrs
in a multipara
Arrest of descent
- No descent has occurred for 2 hrs in nullipara or 1 hr in
multipara
- Failure of descent occurs when expected descent of fetus
does not begin or engagement or movement beyond 0
station does not occur
- Most likely the cause is CPD, cesarean is necessary
- No contraindication to vaginal birth, oxytocin may be
used to assist labor
Pathologic Retraction Ring
- AKA Bandl’s Ring
- Appears during the second stage of labor
- Indentation across the abdomen due to excessive
retraction of the upper uterine segment
- Upper part has thicker myometrium
- Fetus might be stuck
- Abnormal junction between the two segments of the
uterus which is a late sign associated with obstructed
labor.
- Prior to the onset of labor, the junction between the
lower and the upper uterine segment is a slightly
thickened ring.
- Ideally it should be on the lower part of the uterus,
however, Bandl’s ring is apparent in the upper part of the
uterus.
- In abnormal and obstructed labor, after the cervix has
reached full dilatation further contractions cause the
upper uterine segment muscle fibers to shorten so the
actively contracting upper segment becomes thicker and
shorter.
- The ridge of the pathologic ring of the Bandl’s can be felt
or seen rising as far as high up the umbilicus.
- So upon assessment, there could be the retraction ring
inspected along the umbilicus level.
- The lower segment becomes stretched and thinner and if
neglected may lead to uterine rupture.
- Major pathology behind obstructed labor: a circular
groove encircling the uterus is formed between the active
upper segment and the distended lower segment. Due to
pronounce retraction there is fetal jeopardy or even
death.
Management:
● Administration of Morphine sulfate or amyl nitrate to
alleviate pain
● Tocolytic agent to stop the contractions
●
-
CS delivery may be done
PRETERM LABOR
Initiation of labor
Occurs after 20 weeks and before 37 weeks AOG
Dilatation and effacement are happening
Risk Factors
Maternal Factors
Fetal Factors
Placental
Factors
● Maternal infection (leading
cause)
○ May be accompanied with
renal or cardiac diseases
and diabetes
● PROM
● Bleeding
● Uterine
abnormalities
or
overdistention
● Incompetent cervix
● History of:
○ Preterm labor
○ Spontaneous or induced
abortion
○ Pre-eclampsia
○ Short interval of less than 1
year b/t pregnancies
● Trauma
● Poor nutrition (probably due to
low socioeconomic status)
● No prenatal care
● Lack of childbirth experience
● Extremes of age (decreased
weight and less height)
● Excessive fatigue
● Smoking
● Extreme emotional stress
● Multiple
pregnancy
● Infections
● Polyhydram
nios
● Congenital
adrenal
hyperplasia
● Fetal
malformatio
ns
● Placental
separation
● Placental
disorders
Complications:
● Prematurity
● Fetal death
● SGA (Small for Gestational Age)/IUGR (Intrauterine
Growth Restriction)
● Increase in perinatal morbidity and mortality
Management:
● Once labor is suspected during the preterm period,
hospitalization is advised to the mother to prevent
premature delivery
● Mother kept on bed rest on left lateral recumbent (LLR)
● Adequate hydration through oral and parenteral route
● Monitor:
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 9 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
○
Uterine Contractions and irritability q 1-2 hrs to
determine increasing or decreasing contractions
○ V/S (major drugs employed can alter them)
○ I/O
○ Signs of infection
○ Cardiac & respiratory status and distress signs
○ Cervical consistency, dilation & effacement
○ Fetal well-being
○ Early signs of edema (such as pulmonary edema
is a possible complication of tocolytics)
Promoting physical & emotional comfort is important
○ Keep the client informed of the progress
Administer Tocolytics (e.g. Magnesium sulfate (MgSO4),
Terbutaline, Ritodrine) to arrest labor by causing
relaxation of the uterus
○ Toco - (childbirth) & -lysis (halting or stopping)
Administer corticosteroid [(e.g betamethasone (IM
route)] to enhance maturation of the fetal lungs to
stimulate production of surfactant when there are
contraindications in attempting to arrest preterm labor.
Administer the ordered drugs according to protocol.
Assess the effect of drugs on labor and fetus and monitor
for side effects of drugs.
Client may be discharged once contractions have stopped
and maternal and fetal conditions stabilized
●
●
●
●
●
Contraindications to arresting labor:
● Advanced pregnancy
● Ruptured BOW
● Maternal diseases
○ Bleeding
○ Complications
○ Pregnancy-induced Hypertension (PIH)
○ Cardiovascular disease
● Fetal distress
● Rh Isoimmunization
Health teachings:
● Maintain bed rest on a LLR position
● Well-balanced diet: high in iron, vitamins, and important
minerals
● Continuation of oral medications as ordered
● Frequent prenatal visits every week
● Activity restrictions
● Chronic illnesses should be monitored while acute cases
should be treated immediately
● Teach client on the observable signs and symptoms of
preterm labor and importance of prompt reporting to
the physician when present. Also, provision of
psychological support and encouragement should be
established.
-
PRECIPITATE LABOR
Short labor that last 2-3 hours or less; Fast labor;
Deliveries that happen at home, taxis
Common on multigravida women
Fetus will be at risk for infection or sepsis
Mother is at risk for chorioamnionitis
Risk Factors:
● Multiparity - most common and most important
factor
● Trauma
● Large pelvis and lax soft tissues
● Small fetus
● Labor induction by oxytocin and ROM
● Severe emotional stress
Complications
Maternal
● Laceration
● Hemorrhage secondary to the separation
of placenta
● Infection
● Uterine rupture if the birth canal is not
readily distensible.
● Hypotonic Contractions which can cause
hemorrhage especially PP.
Fetal
●
●
●
●
Hypoxia
Anoxia
Sepsis
Intracranial
hemorrhage
Treatment:
● Episiotomy
● Facilitate delivery
Assessment Findings:
● Tetanic-like contractions
● Rapid labor and delivery
○ Nullipara - 5 cm/hr.
○ Multipara - 10 cm/hr.
● S/S of Impending delivery:
○ Desire to push
○ Strong contractions
○ Ruptured membranes
○ Heavy bloody show
○ Bulging rectum
○ Severe anxiety
Management:
● Never leave client
● Monitor FHT q15 mins to detect fetal distress from fetal
hypoxia secondary to tetanic contractions
● Provide emotional support
○ Reassuring that you will stay
○ Explaining precipitate labor in simple terms
○ Explain to the px what is happening
○ Provide care until the physician or help arrives
○ Assist the client on retaining self-control over
what is happening
● Assist with delivery
○ Never hold the baby back
○ Put on sterile gloves if possible
● Instruct client to pant and not to push
● Rupture the membranes when head crowns
○ Gently slip the cord over the head with free hand
if the cord is draped around the neck
○ Use gentle pressure to fetal head upwards
towards the vagina to prevent damage or injury
to fetal head, and vaginal lacerations
● Deliver head in between contractions
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 10 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
○
●
●
●
●
-
Shoulders are usually born spontaneously after
external rotation. If not, use gentle pressure
downward to move anterior shoulder under
symphysis pubis, and use upward pressure for
the delivery of the posterior shoulder.
○ Right after the head is delivered and the
shoulders are out, suction the mouth and the
nose using a bulb syringe if available, if not use a
towel to wipe the blood and mucus from the
mouth and nose.
Support the fetal body during expulsion
Perform cord care
○ If materials are available: Clamp cord in 2 places,
and cut between with a clean knife or scissors.
○ If materials are not available: Double tie with the
possible cleanest cloth or string
○ Ensuring that there is no pulsation between the
2 ties to prevent transfusing newborn blood to
the outside which will lead to neonatal
hemorrhage and shock.
Allow placenta to separate naturally
○ Wrap placenta, cord and baby together
○ Have the fetal side near the newborn
Perform Unang Yakap
○ Encourage mother to breastfeed to induce
uterine contractions, for reassurance that all is
well.
○ Institute measure that is prescribed for the 3rd
and 4th stage of labor
○ Handle the delivery gently to prevent injury to
the mother and the baby
UTERINE RUPTURE
Rupture of the uterus because of the stress in labor with
extrusion of uterine contents into the abdominal cavity
This is common in women who have a history of cesarean
section and happens along the incision of the previous
cesarean delivery
Puts women at high risk for bleeding
Shock Position: Tredelenburg → to save the organs; to
●
●
Assessment Findings:
● Sudden acute abdominal pain
and tenderness
● Cessation of contractions & FHT,
with rescinding part no longer
felt on cervix
● Feeling
of
mother
that
something happened inside her
● Signs of external bleeding
● Signs of Shock and predisposing factors
Complications:
● Shock or hemorrhage
● Maternal and fetal mortality
● Infection from traumatized tissue
Management:
● Laparotomy to deliver the fetus
● Hysterectomy for complete rupture although in most
cases, the uterus may be sutured left in.
● Blood transfusion
● IV fluid replacement
● Antibiotics as ordered
● Stay with the client and call for assistance if uterine
rupture is suspected
● Positioning on a trendelenburg position
● Provision of warm
● Notify physician
● Inform support person
● Prompt IV infusion
● Prepare for immediate surgery
● Provide psychological support
perfuse blood & oxygen to the brain, giving off oxygen to
the organs → perfuse fluids
Risk Factors:
● Previous CS Scar - most common cause
● Improper use of oxytocin
● Overdistention of the uterus
● Strong contractions with non-progressive labor
● Abnormal presentation
● Trauma
Injudicious obstetrics
○ Application of forceps when the cervix is not fully
dilated
○ 2nd stage of labor, fundal pressure and force
delivery of fetus would result to abnormality such
as hydrocephalus
Ill-advised podalic version
UTERINE INVERSION
It is the potentially life-threatening complication of
childbirth.
Normal placenta detached from the uterus and exits from
the vagina around half an hour after the baby is delivered.
Uterine inversion means the placenta remains attached
and its exit pulls the uterus inside out. In most cases, the
doctor can manually detach the placenta and push the
uterus back into
position.
Occasionally,
abdominal surgery is
required
to
reposition
the
uterus.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 11 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
- Can cause severe bleeding
1st Degree Inversion: Incomplete Inversion
- When the top of the uterus or fundus has collapsed
but the uterus hasn't come through the cervix.
2nd Degree Inversion: Complete Inversion
- When the uterus is inside out and coming out through
the cervix.
3rd Degree Inversion: Prolapsed Inversion
- The fundus of the uterus is coming out of the vagina.
4th Degree Inversion: Total Inversion
- Both the uterus and vagina protrude inside out.
- This occurs more commonly in cases of cancer than
childbirth
Risk Factors:
● Prior delivery of long labor
● Use of muscle relaxing (magnesium sulfate) during
labor
● Short umbilical cord
● Pulling too hard of the umbilical cord to
● hasten the delivery of placenta especially if it’s
attached to the fundus
● Placenta accreta or when the placenta had invaded
to deeply to the uterine wall
● Presence of congenital abnormalities or weaknesses
of the uterus
Management:
● Administer IV fluid replacement
● Stop oxytocin and replace uterus back
● Flashing the vagina with saline water so that water
pressure inflates the uterus and props it back into
position.
● Abdominal surgery - to reposition the uterus if all
other attempts to reinsert have failed
● Blood transfusion
● Emergency hysterectomy
● Antibiotics - to reduce the risk of infection
Take note that oxytocin should be administered after placing
the uterus back and it should not be given before or during the
replacement of the uterus. Close monitoring in intensive care
for few days may be necessary
Manual Replacing of the Uterus
AMNIOTIC FLUID EMBOLISM
Escape of amniotic fluid into the maternal circulation
through the placental site and into the pulmonary
arterials.
This is common among premature or normal rupture of
membranes when there is amniotic fluid embolism starts
from the moment the bag of water rupture, abruptio
placenta, and difficult labor
This is rare but usually fatal. Mortality in the first hour in
25% of pregnant women with amniotic fluid embolism is
usually fatal for both the mother and baby, and this is
considered an obstetric emergency.
-
-
Assessment Findings:
● Acute dyspnea
● Cyanosis
● Sudden chest pain
● Pulmonary shock &
edema
● Circulatory collapse sign of shock
● Disseminated
Intravascular
Coagulation (DIC)
Management:
● Cardiorespiratory support; CPR
● Oxygenation
● Hydration - IV fluids and plasma monitoring
● Heparin
● Deliver: forceps if cervix is fully dilated
● Deliver vaginal if cervix is fully dilated
● ICU once stabilized
In the institution of the measures to support life:
➢ Place the mother in a shock position as indicated
which is Trendelenburg position and also still turn the
mother towards the left to facilitate the perfusion of
the blood towards the fetus.
➢ Oxygenate promptly.
➢ Maintain and monitor fluid and blood transfusion
➢ Provide the administered drugs
➢ Inform family of the woman's conditions
➢ Provide support
➢ Transfer to ICU when stabilized for close monitoring
and intensive care
-
-
Using the glove hand of the practitioner it will push
back into its original position in making a fist to apply
pressure maintaining its original position.
Make sure not to administer oxytocin or any oxytocin
drugs during this process and it should be given after
repositioning the uterus.
OPERATIVE OBSTETRICS
FORCEPS DELIVERY
It is the delivery of the
baby using obstetrics
instruments such as
forceps which consist of
the
blade,
shank,
handle, and a lock
Indications:
● Second stage of labor fetal distress & shorten
of the labor
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 12 .
MCHN 2 - LECTURE
●
●
●
➢
➢
➢
●
Week 2 High Risk Pregnancy During Labor & Delivery
Abnormal presentation or arrested descent
Preterm labor - to protect fetal head from injuries
Maternal exhaustion
To shorten the 2nd stage of labor
Ineffective expulsive effort or poor progress
Exhaustion
Medical diseases (cardiac disease)
Criteria:
● Fully dilated
● Ruptured BOW
● Engaged head
● Empty bowel and bladder
● No CPD
● Episiotomy
● Anesthesia
2 Types of Forceps Delivery
● Low or Outlet Forceps Delivery
- This is the application of forceps on the fetal head
which is on the perineal floor
● Mid Forceps Delivery
- Wherein the fetal head is at the level of ischial spines.
Complications:
● Maternal Laceration/hemorrhage
● Uterine rupture
● uterine prolapse
● Cystocele, rectocele
● Facial paralysis of the newborn (temporary)
● Intracranial hemorrhage
● Skull fracture - problem w/c should be managed directly
● Tissue Trauma
-
-
VACUUM EXTRACTION
It is a procedure sometimes done during the course of
vaginal child birth. During vacuum-assisted vaginal
delivery, the health care provider applies the vacuum,
which is a soft or rigid cup with a handle and a vacuum
pump to a baby’s head to help guide the baby out of the
birth canal.
This is typically done during a contraction while the
mother pushes.
Indications: (largely similar to forceps delivery)
● Prolonged second stage of labor
● Abnormal presentation or arrested descent
● Preterm labor
● Maternal exhaustion
● Medical diseases
Criteria:
● Fully dilated:
➢ Fully dilated, and if the doctor attempts vacuum
extraction that it is not fully dilated there is a
significant chance of injury or tearing of cervix,
Cervical injury requires surgical repair and may lead
to problems in future pregnancies.
➢ The exact position of the baby’s head must be
known and the vacuum should never be placed on
the baby’s face or brow. The ideal position of the
vacuum cup is directly over the midline on top of the
baby’s head.
➢ ● Vacuum delivery is less likely to succeed if the baby
is facing straight up and when the client is lying on
her back. The baby’s head must be engaged within
the birth canal. The position of the baby’s head in
the birth canal is measured in relation to the
narrowest point of the child birth canal. The baby
should be in the lower position.
➢ Before vacuum extraction is attempted, the top of
the baby’s head is even with the ischial spine.
Preferably the baby’s head has descended 1 to 2 cm
below the spine. So the chances for the success of
vacuum delivery increase. It also increases when the
baby’s head can be seen at the vaginal opening
during.
➢ The membrane should be also ruptured to apply the
vacuum cup to the baby’s head, the amniotic
membranes must be ruptured. This usually occurs
well before vacuum extraction is considered.
➢ The baby should smugly fit to the birth canal there
should be no CPD. There are times when the baby is
too big or the birth canal or the birth canal is too
small for a successful delivery. Attempting a vacuum
extraction in this situation will not all be
unsuccessful, but may result in complications.
➢ The pregnancy must be termed or near term. The
risk of vacuum extraction is increased in premature
infants. Therefore, it should not be performed
before 34 weeks in pregnancy.
● Ruptured BOW
● Engaged head
● Empty bowel & bladder
● No CPD
● Episiotomy
● Anesthesia (lesser than forceps delivery)
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 13 .
MCHN 2 - LECTURE
Risks:
●
●
●
●
●
●
●
●
●
●
●
●
-
Week 2 High Risk Pregnancy During Labor & Delivery
Pain in the perineum
Vaginal tears
Dysuria
Temporary urinary or fecal
incontinence; long term
fecal
or
urinary
incontinence
Fetal scalp wounds
High risk of getting the baby’s shoulder stuck
after the baby’s head has been delivered (Shoulder
dystocia)
Skull fracture
Bleeding within the skull
Serious infant injuries after vacuum
extractions are rare
Caput formation (most common) due to the suction
applied to the fetal head
CESAREAN SECTION
Cesarean Delivery might be scheduled by the doctor in
advance by the due date or it may become necessary
during labor because of an emergency.
Types:
1. Scheduled elective CS
- Common in women who have history with CPD,
transverse lie, breech presentation
2. Emergent CS
- Common in women who have tried trial of labor or
with complications while in delivery
Indications:
● Prolonged labor - it happens when a primigravida is in
labor for 20 hours or more or 14 hours or more for
mothers who have given birth before. Also, for baby’s
who are too large for birth, slow cervical thinning, and
caring multiple which can cause prolonged labor
● Abnormal positioning - it does not follow the ideal
position which is head first near the birth canal
● Fetal distress
● Birth defects - to reduce complications
● History of CS
● Chronic health condition
● Cord prolapse
● CPD
● Placental issues - esp. placenta abruptio
● Multiple pregnancy
● Vaginal infection: Herpes
Types of Incision:
Classical incision:
- Used on emergency cases such as cord prolapse, px
with seizure and eclampsia, and placenta previa
- vertical line from below the umbilicus down to the
hypogastric area
Low transverse incision: Pfannenstiel (fan-nen-stayl)
- Most common
- Faster healing; lesser blood loss
- done transversely on the lower segment of the uterus
Anesthesia
1. Regional Anesthesia
a. Epidural
- Short
duration
of
anesthesia
- A fine tube is inserted to
a woman’s back, into a
space between the spinal
cord and its outer
membrane.
- The
anesthesia
medication moves through the tube into the woman’s
back, and the flow of the medication can be
controlled. And it is usually maintained hours after or
hours during postpartum.
b. Spinal
- Directed once into the spinal space
- In one time; 1-2 hrs anesthetic effects; spinal
headache side effect
- Anesthesia medication is injected in one single dose,
into a part of a woman’s spinal column. For this
medication given can give a longer effect compared to
epidural anesthesia.
- The pain-relieving effects of a spinal block are almost
instant and they last about 1-2 hours, after the
injection, which could cover the whole procedure of
c-section.
2. General Anesthesia
- Puts the woman to sleep and is frequently used for
emergency CS such as cord prolapse.
- Inhalation is used and then after the inhalation of
anesthesia, the mother needs to be intubated for
continuous sedation
- Fast acting anesthesia
- Used in cases of eclampsia & cord prolapse
- 1-2 hours
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 14 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
Management:
➢ Pre-operative
● Deep breathing
● Incentive Spirometry
● Turning
● Ambulation
● Informed consent
● GI Prep
➢ Intra-operative
● Skin preparation to ensure the prevention of infection
● Assist birth of infant
● Newborn care
➢ Post-operative
● Ensure patent airway and prevent respiratory
obstruction. Equip the recovery room with suction and
oxygen. If under anesthesia, position the patient on
her side, to promote drainage of secretions.
● Monitor V/S & I/O q5 mins until stable, q15 minutes
for 1 hour & every 30 mins until discharge to the postpartum floor & I/O observe urine for bloody tinge
which is a dangerous sign of trauma to the bladder
during surgery.
● Monitor uterine firm gently to ensure that it is form
● Regularly check dressing and perineal pad
● Maintain fluid & electrolyte balance
● Clear fluid after passage of flatus which is requirement
to oral intake and early resumption of solids
● Provide assistance during mother/ father-infant
interaction
○ Provide emotional support
○ Promote bonding
○ Be present during the entire initial breastfeeding
time
● Administer medications as ordered:
➔ Oxytocin to ensure firm fundus
➔ Analgesics to provide relief of postoperative pain
➔ Antibiotics to prevent puerperal sepsis
● Assess for symptoms of complications such
hemorrhage, infection, and leg thrombophlebitis
● Assist in regular turning or positioning in bed
● Assess for danger signs such as local redness, swelling,
and pain
● Validate eliciting the homan’s sign of calf pain upon
dorsiflexion of the leg
● Encourage early exercises by following CS section;
passive to active exercises
Exercise
Time to Start
Foot & leg exercise
As soon as possible, especially after epidural
anesthesia, as peripheral circulation is sluggish- risk
for DVT.
To improve circulation, reduce edema, & prevent
DVT.
Abdominal
tightening, pelvic
tilting/rocking,
knee, rolling
Can be practiced gently after 24 hours.
To ease back ache and flatulence
To help prevent back ache
Pelvic floor
exercise, curls-up,
hip hitching
After 4-5 days when the woman is more comfortable.
To prevent stress incontinence.
Strenuous keep-fit
exercises, aerobics,
competitive sports
●
●
10-12 weeks after surgery and only after ensuring
that pelvic floor muscles are functioning effectively.
To keep fit and help regain strength.
Ensure that the exercises double-leg lift and sit ups
should never be performed.
Lifting should be avoided and if inevitable keep the
object as light as possible and close to the body, bend
knees, and straighten back.
TRIAL OF LABOR
■ Trial of labor after Cesarean Section
- It is often those successful which could lead to
Vaginal Birth After CS (VBAC)
- It provides shorter recovery period for the woman
- Could also lead to fewer health risks such as
bleeding, infection, and death
Indications:
● Low-transverse section or side-to-side incision in the
uterus which was used for all CS birth
● No health problems that would prevent VBAC
● The baby is in normal head down position and
presentation
Contraindications:
● Classical incision
● History of uterine rupture & surgeries
● Previous delivery within 18 months
● History of 2 or more CS
● Pre-eclampsia
● Post -term
Management:
● Monitor FHT & contractions frequently
● Urge women to empty bladder q2hrs so her urinary
bladder is as empty as possible allowing the fetal head
to use the space available
● If after a definite period 6-12 hrs adequate progress in
labor cannot be documented or if at anytime fetal
distress occurs a trial of labor will be discontinued and
the woman will be schedule for CS birth
● Provide psychological support
● Emphasize to do not overstress as it is best for their
baby to be born vaginally. If the trial of labor fails, a CS
birth is scheduled. Provide an explanation as to why
CS birth is necessary and why it has come the best
route for the birth of their baby.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 15 .
MCHN 2 - LECTURE
Week 2 High Risk Pregnancy During Labor & Delivery
PSYCHE
-
-
A pregnant woman’s general behavior and influences
upon her affect labor progress
Fear and anxiety affect labor progress
A woman who is relaxed, aware of, and participating in
the birth process usually has a shorter intense labor
Other factors that affect psychological response of the
mother
➢ Childbirth preparation process and prenatal
classes. Considered as a valuable tranquilizer
during the birth process which leads to a
decreased need for analgesics in labor.
➢ Support system. Husband’s presence in the labor
and delivery unit can provide emotional support,
which could lead to less anxiety, less emotional
tension, and less pain perception
➢ The attending nurse should provide a supporting
and caring environment by respecting the client
and family’s needs and attitude. This could lead
to therapeutic communication.
➢ Previous
experiences.
Facilitate
good
psychological response to labor and delivery
➢ Anticipation of pain can increase emotional
tension which could increase the pain
perception. Even though pain perception is
greatly influenced by a lot of factors such as
psychological and psychosocial factors. There is a
physiologic basis discomfort labor.
Some factors that make labor a meaningful positive or
negative event were identified:
➢ Cultural influences integrating maternal
attitude
➢ How a particular society views childbirth
➢ Expectations and roles for the labor process
➢ Feedback from people participating in the
birth process
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 16 .
MCHN 2 - LECTURE
Week 3 High Risk Pregnancy Postpartum
NURSING CARE OF THE HIGH-RISK POSTPARTAL CLIENT
OUTLINE:
I.
II.
III.
IV.
●
-
Postpartal Hemorrhage
Puerperial Infection
A. Endometritis
B. Urinary Tract Infection
C. Wound Infection
Thrombophlebitis
Postpartal Psychologic Maladaptation
●
●
●
●
REFERENCE: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal
& child health nursing: Care of the Childbearing &
Childrearing Family (Eight ed., Vol. 1).
-
POSTPARTAL HEMORRHAGE
It is the excessive bleeding which reaches about
500ml or more from the genital tract at any time
following delivery up to 6 weeks.
The most important thing we need to monitor
Could be early or late:
- Early
- Delayed → usually caused by infection
wherein it could cause couvelaire uterus and may
prevent normal uterine contractility; could also cause
incomplete placental separation
Lacerations
brought about operative obstetrics such as forceps,
poor management of the second stage of labor, large
size of the fetus, precipitate labor, and abnormal
positions
Retained placental fragments
which is cause by the injudicious 3rd stage of labor and
to adherent placenta which could cause some part of
the membranes to be retained
Polyhydramnios
Diabetic pregnancy
Multiparity
Assessment:
● Copious vaginal bleeding
● Soft, boggy, non-palpable uterus → indicating uterine
atony
● Incomplete placenta
● Obvious lacerations
● Bleeding from the wound
POSTPARTUM BLEEDING
What to Expect
1.
2.
Early or Primary Postpartal Hemorrhage
- Third stage up to 24 hours PP
- Refers to the bleeding during the first stage of labor or
first 24hrs of delivery
Later or secondary Postpartal Hemorrhage - after 24
hours until 6th wk. PP.
Risk Factors:
● Uterine atony
- most common cause of postpartal hemorrhage
● Over distention
- brought about multiple pregnancy
● Effect of anesthesia, general anesthesia
- that causes the uterus to be atonic
● Precipitate labor
which brings about excessive contraction in less than
1 hr causing uterine muscles, insufficient opportunity
in strength to retract
● Prolonged difficult labor
- resulting in uterine inertia
● Placenta previa
- which is the lower uterine segment that is not
contractile as the upper fundal portion
● Abruptio placenta
0-4 Days
Bright Red
Heavy like a period
Small/Medium clots
5-8 Days
Red/Pink
Less bleeding
Heavier when active
Small clots
9-14 Days
Pink/Brown
Minimal loss
No clots
3-4 Weeks
White/Cream
Blood changes to discharge
No clots
Managing the blood
Do’s
●
Use large and soft sanitary
pads
Use Adira Period Panties
to keep you from staining
●
-
Don'ts
●
●
Use tampons
Use same pad for over 4 hours
to prevent infection
There should be no blood clots as this indicates
bleeding
If there is a deviation in lochia: blood clots on 10 days,
it may be a sign for PP bleeding → assess for shock
(lightheadedness, confusion)
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 1 .
MCHN 2 - LECTURE
Week 3 High Risk Pregnancy Postpartum
●
●
●
A
B
●
●
●
●
●
C
D
Four degrees of vaginal tears:
- This occurs when the baby’s head is coming through the
vaginal opening and is either too large for the vagina to
stretch around or the head is in normal size but the vagina
doesn’t stretch easily.
- These kinds of tears are relatively common
A. 1st degree
- Involves only the perineal skin; the skin between the
vaginal opening and rectum and the tissue directly
beneath the skin
- The client may manifest mild pain or stinging during
urination
- This tears might or might not require stitched and
typically heal within a few weeks
B. 2nd degree
- Involves the skin and the muscle of the perineum and
might extend deep into the vagina
- Typically require stitches
- Heal within a few weeks
C. 3rd degree
- Extend into the muscle that surrounds the anus or the
anal sphincter
- This tears sometimes require repair with anesthesia in
an OR rather than in the DR and might
- Take a longer to heal than a few a weeks
- Complications such as stool leakage and painful
intercourse are possible
D. 4th degree
- Most severe and extends through the anal sphincter into
the mucous membranes that lies the rectum
- Usually requires repair with anesthesia inside the
operating room
- This could also lead to PP bleeding especially if it is not
dealt immediately
Management:
● Fundal massage until firm
○ First nursing action for uterine atony
○ Not too long as this can exhaust the muscle and have
rebound contractions)
● Provide oxytocic drugs (e.g. oxytocin, methergine,
carboprost)
●
●
●
●
●
Apply ice pack over hypogastric area and perineum
○ To reduce swelling, pain and bleeding
Promote bladder emptying
○ To keep the uterus contracted
○ Let the mother void on her own, if capable. If not,
use straight catheterization
Initiate early breastfeeding
○ Perform nipple stimulation to stimulate oxytocin
secretion by the posterior pituitary gland
Assess and estimate blood loss frequently
Check the V/S and fundus q 5-15 mins
Keep all pads and linens to assess the volume of blood
clots
Notify the physician for repair of laceration
Maintain asepsis since hemorrhage predisposes the
mother to infection
Monitor I/O. Fluid and blood replacement and oxygen
administration
Be alert for blood reactions
Provide psychological support. Explain test procedures to
help deal anxiety
Increase iron diet
Teach to adhere to follow up care schedule
PUERPERIAL INFECTION
- Any infection of the reproductive organ within 6 weeks
after childbirth or 1st weeks after abortion
- This is usually localized in the endometrium causing
endometritis.
- Leading cause of nosocomial infection and maternal
mortality
- Kind of infection would vary depending on the area where
infection is present or its manifestation, it could be on
the;
○ Fallopian tube
○ Ovaries
○ Within the uterus
○ Within the cervix, w/c could result to cervicitis
Criteria:
● Fever on any 2 of the first 10 days postpartum, excluding
the first 24 hours after delivery which is more or less
brought about by dehydration
Etiology:
● Can be aerobic or
anaerobic
● Bacterial
● E.coli
Risk Factors:
● Duration of labor
which last more than
18 hrs
● Route of delivery
● CS over NSVD
● Invasive procedures in prolonged labor with frequent IE.
● Prolonged delivery after ROM which is greater than 24 hrs
● Internal fetal monitoring
● Positive amniotic fluid culture of E. Coli and Klebsiella
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 2 .
MCHN 2 - LECTURE
Week 3 High Risk Pregnancy Postpartum
●
History of infection
○ UTI, STDs, prenatal factors such as obesity, anemia
and malnutrition
Take Note:
- The bacteria could be coming from the vagina and it goes
up through the uterus and it could affect the fallopian
tube and lastly the ovary.
Postpartum Fever:
1. Dehydration
2. Breast engorgement
3. PP sepsis
-
ENDOMETRITIS
Inflammation and the infection of the endometrium (the
lining of the uterus) and is usually due to infection
postpartum.
Not life threatening but it's important to get it treated as
soon as possible.
Generally, go away when treated with antibiotics
It occurs at the same time with other condition on the
pelvis area
Signs & Symptoms
● Pelvic and abd. pain
● Dysuria, polyuria
● Foul odor urine
● Chills, fever, and fatigue
● Inflamed bladder and urethra
● Strong urge to urinate but may urinate only few drops
● Frequent urination
● Burning sensation while urinating
● Unpleasant smelling urine or foul odor urine
● General body pain
-
Signs & Symptoms
● Abdominal swelling
● Abdominal vaginal discharges
● Abnormal vaginal bleeding
● Discomfort during bowel movement
● Fever
● General feeling of weakness
● Pelvic pain or in the lower abdominal area or rectal area
● Constipation
-
-
URINARY TRACT INFECTION
Pregnancy may bladder lose its tone
The pelvic floor muscles help keep the urethra close so
the urine doesn’t leak out.
During labor, these muscles go into the overdrive along
with the ligaments, nerves, and muscles of the lower
abdomen.
Excessive tear during the delivery can lead to injury or
trauma to these sets of muscles and ligaments. These
subsequently might fail to do their job as in labor.
Pregnancy may cause its bladder to lose its stones making
it difficult for women to complete emptying the bladder.
This makes the uterine more susceptible to flow back up
to the urethra and the longer urine stays in the urinary
tract, the higher the chances the bacteria will multiply
enhanced higher to vulnerability to infection.
If the woman is in pain after delivery or does not void due
to activity restrictions then the mother could suffer from
UTI PP.
WOUND INFECTION
May happen on incisions done after CS or on
episiotomies with NSVD
Risk Factors:
● Obesity
● DM
● Immunocompromised disorder
○ HIV, chorioamnionitis, taking long-term steroids
(oral or IV), poor prenatal care
● Previous CS delivery
● Lack of cautionary antibiotics
● Long labor or surgery
● Excessive blood loss during delivery or surgery
Signs & Symptoms:
● Abdominal pain
● Redness and swelling in the incision site
● Pus Drainage and pain on the incision site
● Foul-smelling discharges
● Bleeding that soaks the dressing
● Bleeding that contains blood clots
● Fever
● Painful urination
● Leg pain or swelling
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 3 .
MCHN 2 - LECTURE
Week 3 High Risk Pregnancy Postpartum
Assessment Findings:
● Fever, chills, and tachycardia
● Changes in lochia, color, amount or odor, and consistency
of lochia
● Painful/tender uterine fundus
● Delayed uterine involution
● Body malae
● Anorexia
● Headache
● Dysuria
● Burning sensation on urination
● Costovertebral tenderness
● Subinvolution
Management:
● Antibiotics
○ First line treatment for puerperal sepsis
○ Prevention in early treatment of anemia in
pregnancy
○ Start with ordered antibiotics immediately after
appropriate specimen is obtained
○ Adequate treatment of dystocia in PROM (?) with
antibiotics
● Prevention of lacerations as much as possible
● Administer analgesics as ordered
● IV fluid containing calories and electrolytes in CS when
appropriate
● Maintain bedrest and isolate mother from the newborn if
necessary
● Strict asepsis in handling labor and delivery
● Perineal cleanliness
● Observe standard precaution and careful handwashing
○ Hygiene and proper attire of personnel is
important and personnel with s/s should be
assigned to render direct care
● Monitor V/S and I/O.
○ Force fluids up to 3000-4000ml
○ Increase oral fluids
● If not contraindicated encourage frequent voiding
● Promote drainage of secretions
● Position: Fowler’s or semi-fowler’s
● Teach regarding perineal hygiene
○ Handwashing before and after touching the
perineum
○ Front to back removal of sanitary napkins
○ Frequent changing of napkins
● Diet modification
○ Provide nutritious high calorie, high protein and
high iron diet
● Promote comfort
○ Positioning
○ Make sure that the client doesn't feel cold, use
heat or cold as indicated to relieve localized pain
○ Prevent or relieved common discomforts of the
puerperium
○ Find a restful environment
Evaluation of Episiotomy Healing
- Instrument designed to assess the healing process of the
perineum following an episiotomy and/or lacerations
during delivery
- Can be implied to any incision (e.g. cesarean incisions)
- Each part of the REEDA should be assessed accurately and
regularly for the medical healthcare team to monitor for
involution or recovery of the woman PP
REEDDA
-
R
Redness
E
Edema
E
Ecchymosis
D
Discharges
D
Drainage
A
Approximation
THROMBOPHLEBITIS
Inflammation of the vein resulting in vascular
occlusion of vessels, pelvis, or lower extremities.
Signs & Symptoms
Superficial Thrombophlebitis
●
●
●
●
●
●
Common from 4-10 days PP
Mild fever or slight pyrexia
Tender varicose vein
Swelling
Hardness
Redness
Deep Vein Thrombosis
● Manifest during the 1st 2
weeks after delivery
● Calf pain/Positive Homan’s
sign
● Edema and swelling of the
leg 2-3 cm larger than the
non-affected leg
● Pain, fever & chills
Etiology:
● Infection from the uterine cavity or the placental site
into the pelvic and femoral vein
● Circulatory stasis esp. if mother tends to be bed ridden
or stays non-ambulatory PP
● Hypercoagulability
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 4 .
MCHN 2 - LECTURE
●
●
●
●
Week 3 High Risk Pregnancy Postpartum
Trauma of childbirth
Lack of activity
Clot formation in pelvis veins following by CS
Clot formation if calf of leg due to poor circulation
Risk Factors:
● Bedrest or prolonged immobility
● CS
● Multiparity and advanced age > 30 yrs. old
● Obesity
● Estrogen therapy
● History of thrombophlebitis
Complications:
● Pulmonary embolism or the passage of thrombus
usually originating in one of the uterine or other pelvic
veins into one of the lungs where it disrupts the
circulation of blood causing embolism and death
Management:
● Early ambulation
● Avoid pressure behind the knees
● Avoid crossing of the legs
● Avoid constricting garters
● Maintain bedrest if using bed cradle to support linens
and beddings by elevating affected leg or hip
● Apply heat or warm compress for 15-20 mins
● Use support bandage or stockings
● Administer antibiotics or anticoagulant as ordered
- Heparin
(most
commonly
used
anticoagulant)
● Analgesia for pain except for aspirin as it alters
coagulation and results in bleeding
● Do not massage the affected area
● Allow clients to express feelings (fears and concerns).
Provide support
● Monitor for signs of pulmonary embolism
○ Sudden intense chest pains
○ Marked distress
○ Severe dyspnea
○ Apprehension
○ Thready pulse
○ Sudden shock
● If the client undergoes heparin therapy it is important
to monitor for signs of bleeding
● Ensure protamine sulfate
-
-
POSTPARTAL PSYCHOLOGIC MALADAPTATION
A demanding period characterized by overwhelming
biological, physical, social, and emotional changes.
It requires significant personal and
interpersonal
adaptation, esp. in case of primigravida
Pregnant women and their families have lots of
aspirations from PP period which is followed by the joyful
arrival of the baby. Unfortunately, women in the PP can
be vulnerable to a range of psychiatric disorders.
Perinatal mental illness is largely underdiagnosed and
can have far reaching ramification for both the mother
and the infant.
POSTPARTUM
BLUES
POSTPARTUM
DEPRESSION
POSTPARTUM
PSYCHOSIS
Manifestations
Fluctuating
mood, sadness,
crying,
irritability and
tearfulness
Depressed
mood
Feeling loss
Depressed and
manic
Delusions/
hallucinations
Onset
Within 2 weeks
PP
2 wks. PP up
to 3-6 months
2-3 days PP up to
a one month
Etiology
Hormonal
changes
Lack of
support
Reactivation of
psyche disorder
Postpartum Blues
- Also known as baby blues
- More on hormonal
- Most common but self-limited condition that begins
shortly after childbirth and can present a variety of
symptoms.
Postpartum Depression
- Gradual and may occur 2 weeks postpartum
- May last up to 3-6 months
Acute Postpartum Psychosis
- Low incidence
- Divided into depressed and manic types
- Symptoms begin 2-3 days after delivery
- Period of developing is within the first month after
delivery
Risk Factors:
● Prior emotional or mental illness
○ Separation due to neonatal problems
○ Self-concepts
● Stresses of pregnancy or delivery and stresses of new
responsibilities of parenthood
● Physical problems
● Social factors
○ Low socioeconomic status
○ Lack of support system
○ Disturbed family relationship
Management:
● Execute early recognition of the problem
● Explore potential resources that client or family might use
to reduce the stress of parenthood
● Maintain contact with the infant
● Support positive parenting behaviors
● Administer psychotropic medications as ordered
● Offer positive feedback to improve self-esteem
● Teach client and family parenting skills
● Refer to other health team members
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 5 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
NURSING CARE OF THE HIGH RISK NEWBORN
OUTLINE:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
Priorities in the First Days of Life
Birth Asphyxia
Altered Gestational Age
A. Preterm Infant
B. Low Birth Weight
C. Post Term
Large for Gestational Age (LGA)
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
Sudden Infant Death Syndrome
ABO/RH Incompatibility
Acquired Maternal Infection
Infant of Mother with DM
Infant of Drug Dependent Mother
Infant with Fetal Alcohol Exposure
REFERENCE: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal
& child health nursing: Care of the Childbearing &
Childrearing Family (Eight ed., Vol.
1.
-
-
2.
-
-
3.
-
PRIORITIES IN THE FIRST DAYS OF LIFE
Initiation and maintenance of respirations
It’s important to establish the airway and maintain
respiration, since most death occurring during the first 48
hours after birth, results from the newborn in the
inability to establish or maintain adequate respiration.
An infant who has difficulty in accomplishing respiratory
actions in the first hour of life, and yet survives, may
experience residual neurologic dysfunction due to
Cerebral Hypoxia.
We need to be prompt, and thorough care is necessary
for effective intervention.
Establishment of extrauterine circulation
Although establishing respiration is the usual priority of
high risk infants, birth & lack of cardiac functions may be
present concurrently, or may develop if respiratory
function can’t be quickly initiated & maintained.
If an infant has no audible heartbeat, or if the cardiac
beat is below 80 bpm, Closed Chest Massage should be
started and a combination with Lung Ventilation at a rate
of 30/minute should be continued and interchanged with
cardiac massage at a ratio of 1:5
There is a need to monitor transcutaneous oxygen or
pulse oximeters to evaluate respiratory function &
cardiac efficiency.
Maintenance of fluid and electrolyte balance
After initial resuscitation attempts, hypoglycemia may
result from the effort of the newborn expending to begin
breathing
Dehydration may result from increased, insensible water
loss from rapid respirations.
Fluids such as lactated ringers or ringer's lactate, 5%
dextrose in water are commonly used to maintain fluid
and electrolyte levels.
Electrolytes, particularly sodium, potassium & glucose,
are added as necessary, depending on the electrolyte
analysis.
-
4.
-
-
-
5.
-
-
6.
-
7.
-
-
Fluid demand or the fluid administration, must be
carefully maintained because high fluid intake can lead
to heart failure.
The use of radiant warmer increases water loss from
convection & radiation. Newborns on a warmer and
those who are placed in double-walled incubators will
require more fluid.
Control of body temperature
Any high-risk infant may have difficulty in maintaining a
normal temperature, in addition from stress in an illness
or immaturity, an infant’s body is often exposed to
procedures such as resuscitation & blood drawing.
It is important to keep newborn in a neutral temperature
environment, not too hot or too cold as this place an
infant in less demand to maintain a minimal metabolic
rate necessary for effective body functioning.
To prevent newborn from being chilled after birth, wipe
the infant dry, cover the head with a cap, & place them
immediately in a prewarmed radiant warmer, warmed
incubator, or establish skin-to-skin contact.
Intake of adequate nourishment
Infants who experience severe asphyxia at birth, usually
receive intravenous fluid so they don’t become
exhausted by sucking.
There are times that because of temporary reduction of
oxygen of the bowel, this will result to Necrotizing
Enterocolitis - a condition of the bowel that we need to
prevent intake of fluids through the bowel
If an infant’s respiratory rate remains rapid, uneasy, &
neck has been ruled out, Gavage Feeding
(breastmilk/formula is given directly to the baby's
stomach through a tube on the baby’s nose) may be
introduced.
Preterm infants should be breastfed if possible. If not,
the mother can express breastmilk and use it to initiate
breastfeeding.
We need to increase the feeding of an infant according
to demand and caloric needs.
Establishment of waste elimination
Although most infants void within 24 hours after birth,
they may void later than term newborn, due to all the
procedures done that may be necessary for
resuscitation.
Their blood pressure may not be adequate to optimally
supply their kidneys.
We need to document any voiding that occurred during
resuscitation. This is proof that hypotension is improving
& the kidneys are being perfused.
Immature infants may also pass stool later than term
infants, due to meconium not yet reaching the end of the
intestine by birth.
Prevention of infection
Contracting an infection could drastically complicate a
high-risk newborn’s ability to adjust in extrauterine life
Infections such as chilling causes metabolic demand
which stresses the baby out. Newborns have an
immature immune system; thus, they are prone to
infection. Infections stresses the defense mechanism of
a newborn
The baby can be exposed to infection through prenatal,
perinatal or postnatal causes.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 1 .
MCHN 2 - LECTURE
-
8.
-
-
9.
-
-
-
Week 5 Nursing Care of the High-Risk Newborn
For premature rupture of membrane, an infection places
the infant in a high-risk category.
Common viruses can place an infant in the uterus at high
risk, such as Cytomegalovirus and toxoplasmosis virus. An
infant with this infection may be born with congenital
anomalies due to the viral infection
All persons in contact with the infant must observe good
handwashing technique & standard precautions to
reduce the risk of infection transmission.
Healthcare workers with infection have a professional &
moral obligation to refrain from caring newborns.
Establishment of an infant-parent relationship
Be sure that parents w/ high risk infants are informed of
what is happening during resuscitation at birth. They
should be able to visit the special nursing unit to which
the child is admitted, as often as they choose.
We need to inform them that they need to wash their
hands and gown, before they touch their child. This is to
make sure that their child’s birth is real to them.
If the baby wouldn’t survive, the interaction would make
the baby more real. Only the feeling of real birth and
death can make parents begin to work through their
feelings and acceptance.
Urge parents to spend time with the infant in the ICU or
nursery, as the infant improves.
Be sure that they have access to healthcare personnel,
after discharge, to help them care for the child
confidently at home.
Institution of developmental care
Most high-risk infants enjoy catching up with growth,
once they stabilize from the trauma of birth.
They quickly move to playing w/ age-appropriate toys.
Some parents may need support before & after their
infants are discharged, to begin them viewing infants well
and capable of doing all things
Anticipatory guidance helps parents to be ready for the
next developmental steps
BIRTH ASPHYXIA
Also known as Perinatal Asphyxia or Neonatal Asphyxia:
It is an insult to the fetus or newborn due to the lack of
oxygen or lack of perfusion to various organs.
The lack of oxygen can lead to brain suffering and in
prolonged periods, it can cause death to the baby
It can occur before delivery, before labor, during delivery,
and after delivery.
With the deprivation of oxygen, the cells cannot sustain
that status causing cells to have a buildup of waste
products and acids. This can result in temporary or
permanent damage to the brain of the baby.
In prolonged periods, this damage can often cause lifelong
disabilities to the baby like:
➢ Birth defects
➢ Seizures
➢ Cerebral palsy
➢ Developmental delays
➢ Permanent brain damage
➢ Death
Physiology of Asphyxia
- Before the baby becomes asphyxiated, he will undergo a
pattern:
1. Primary Apnea
2. Secondary Apnea
➢ If primary apnea is
not resolved
Primary Apnea
- When an infant is deprived of O2 initially, rapid breathing
occurs. If the asphyxia continues:
➢ Respiratory movements cease,
➢ HR begins to fall,
➢ Neuromuscular tone reduces.
- To counter primary apnea, tactile stimulation and
exposure to O2 will induce respiration
Secondary Apnea
- If primary apnea was not
resolved and asphyxia still
continues:
➢ The baby develops a
deep
gasping
response,
➢ HR will continue to fall,
➢ Significant bradycardia
➢ BP begins to fall
➢ The infant is now unresponsive to stimulation
and will not spontaneously resume respirations
unless positive pressure ventilation (PPV) is
initiated.
By the time the baby is delivered, we get their APGAR score
right away. As soon as we observe that the APGAR score is poor
(e.g., there is nasal flaring, bluish discoloration of the body,
absence of cry), within 2 minutes, we need to resuscitate the
baby:
1. Establish an airway
➢ Make sure there is no obstruction. Clear off all
secretions in the mouth and nose
2. Expand the lungs
➢ By being successful with establishing a patent
airway, we are helping the baby breathe, causing
the lungs to expand
3. Initiate and maintain effective ventilation
➢ If the baby has no effort in breathing, we need to
initiate positive pressure ventilation (PPV)
Nursing Management:
● Stimulate the NB (tactile stimulation)
○ Drying the baby can stimulate them to cry
○ Touching the baby
○ Try to wake them up
● Suction the secretions in the mouth and nose
● Position the newborn in a sniffing position - ideal
position in performing intubation
○ Head of the baby is extended and the neck is
flexed
● Attach to pulse oximeter to monitor the O2 saturation
● Continue APGAR scoring until there is a good score
● Airway management
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 2 .
MCHN 2 - LECTURE
○
○
Week 5 Nursing Care of the High-Risk Newborn
Set of maneuvers or medical procedures that is
performed to prevent and relieve airway
obstruction
Ensures an open pathway of gas exchange
between the patient’s lungs and the atmosphere
-
If a newborn has a total score less than 4 then he/she is in
serious danger and is in need of resuscitation.
If the score is from 4 to 6 then the infant's condition is
guarded and the baby may need clearing of airway and
supplemental oxygen.
If the score is from 7 to 10 then this is considered as good
which indicates the infant’s score is high.
Pulse Oximeter
- Some have a probe on it
which is attached to the
feet of the baby or the
arm of the baby.
- This detects heart rate
and O2 saturation of the
baby.
-
Sniffing Position
Glabella is the area in between the eyebrows of the
newborn
FETAL RESUSCITATION
- In the event that the baby does
not respond to any of the
stimulation being performed by
the doctors or the nurses, we need
to anticipate and be ready that the
doctor will perform fetal
resuscitation or the airway
management
- Laryngoscope, on the tip, has a
light which serves as a guide and
helps the doctor in viewing the
part where the endotracheal tube
is inserted so that one can establish a patent airway. This
is to gain access for the oxygen to go to the lungs.
- Anticipate that the tube will be connected to an oxygen
tank so this should be readily available. It should be warm
and humidified. Also ensure that O2 saturation is
established. Hook the baby to an O2 sat instrument.
Continuously monitor and auscultate the heart rate of the
baby. Anticipate that after insertion of the endotracheal
tube, a chest x-ray will be ordered to ensure that there is
a proper placement of tube.
- After airway management, the doctor will order for
insertion of the oral-gastric tube for feeding. One might
expect the baby will face stress and will have a problem in
thermoregulation.
APGAR SCORE
- Taken at 1 min and 5
min after birth.
- The newborn is
observed and rated
according to the
APGAR.
- Serves as a baseline
for future evaluation.
Take note of heart rate, respiratory effort , muscle tone,
reflex irritability and color of the infant.
- Has a rating of 0 , 1 , or 2. The scores are then added.
THERMOREGULATION
●
●
●
-
One might expect the baby will face stress during
resuscitation. This will cause a problem for infants in
thermoregulation.
Prepare a radiant warmer, a machine which can help
regulate the temperature of the baby.
○ Radiant Warmer is a standee which has a probe
that is attached to the baby to continuously
monitor the baby’s temperature.
○ Isolet or Incubator, not always available
nowadays and is considered as obsolete. Serves
as a good thermoregulating machine
Baby might undergo hypoglycemia so monitoring is
done specifically on the capillary blood glucose.
ALTERED GESTATIONAL AGE
Fetal growth abnormalities
● Term infants
● Preterm infants
● Post
term
infants
● AGA
● SGA
● LGA
Classification of Size
● SGA - small for
gestational
age;
weight below 10th
percentile
● AGA - appropriate for gestational age, weight between 10
and 90th percentiles (between 5lb and 12oz (2.5kg) and
8lb, 12oz (4kg)
● LGA - large for gestational age, weight above 90th
percentile
● IUGR - Intrauterine Growth Restriction; deviation in
expected fetal growth pattern, cause by multiple adverse
conditions, not all IUGR infants are SGA, failure to achieve
potential size.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 3 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
PRETERM INFANT
A preterm infant is usually
defined as a live born infant born
before the end of 37 weeks of
gestation.
Another criterion of a preterm
infant is the weight of the baby
(<2,500 grams; about 5 lbs. & 8
oz.)
Through Ballard Scoring - physical and neurological
assessment, we can determine if an infant is preterm,
term or posterm
Clinical Manifestations of a Preterm Infant:
● Disproportionate Large head
● Ruddy skin
○ The infant has less subcutaneous tissue
○ Veins are easily noticeable
● Large acrocyanosis
● Extensive lanugo
○ Will usually cover the back, forearm,
forehead, & the sides of the face
● Few or no creases on soles of feet and palms
○ Would feel very smooth and soft, because of
the little to no creases present
-
-
-
Nursing management:
● Emergency CS
○ In cases of fetal distress
● Oxygen - Pulmonary Edema & Retinopathy of
Prematurity
○ A lack of surfactant makes them extremely
vulnerable to Respiratory Distress Syndrome (RDS)
○ Surfactants are released at 34 weeks of gestation
○ Babies born before 34 weeks, will be attached to
supplemental oxygen
○ We should take note of the risk of having
Pulmonary Edema and Retinopathy due to a large
amount of oxygen given
● Monitor intake and output
○ I/O monitoring should be done q 2H in absolute
figures
● Calorie Requirement
○ A preterm infant has a small stomach capacity as
compared to term infants; they can’t take a large
feeding. Thus, feeding schedules are frequent with
smaller amounts.
○ Feedings may be 1-2 ml q 2-3 hours
Preterm
Term
Total
Calories
115 - 140 calories/kg of
body weight per day
100-110 cals/kg of body
weight per day
Protein
3 - 3.5 g/kg of body
weight
2 - 2.5 g/kg of body
weight
●
Feeding of the baby:
■ Born greater than 28 wks. → feeding is
addressed through IV Fluids
■ 28-32 wks. → feeding is done through OGT
■ 32-34 wks. → feeding is done through cup
■ 34 wks. & above → breastfeeding as tolerated
○ Feeding may be safely delayed until the infant
stabilizes their respiratory effort from birth
○
Preterm infants may be fed by total Parenteral
nutrition until they are stable enough for other
means (Gavage, OGT, Cup, etc.)
Thermoregulation
○ A baby’s skin has less fat, making them prone to
heat loss
○ Preterm infants’ temperatures are monitored
closely, and they should be placed under a radiant
warmer.
●
Goal of preterm labor:
- Hold the pregnancy so that the baby will be able to
survive in the extrauterine life, but in cases of fetal
distress, emergency CS will be performed.
LOW BIRTH WEIGHT
Intrauterine Growth Restriction (IUGR)
- IUGR babies are those who fail to reach potential size
- They fall below the 10th percentile
- Causes:
MATERNAL
●
●
●
●
Substance abuse
Diabetes mellitus
Hypertension
Exposed to TORCH infections
-
PLACENTAL
●
●
Insufficiency in the
placenta
Poor perfusion
Difference between IUGR and SGA
➢ IUGR has a pathologic cause
➢ SGA has no pathologic cause
Clinical manifestations:
● Overall wasted appearance
● Poor skin turgor
● Large head - due to the rest of the
body being small
● Skull sutures may be widely separated
from lack of normal bone growth
● Dull hair and lusterless
● Sunken abdomen and cord appear dry (may be stained
yellow)
● Small liver - cause difficulty in regulating glucose, protein
and bilirubin levels after birth
● Polycythemia > hyperbilirubinemia
○ High levels of Hct
○ There is lesser amount of plasma compared to the
RBC present due to lack of fluids in the intrautero
○ Polycythemia - increase in the total number of RBC
■ Due to the state of anoxia during
intrauterine life
■ Causes increase blood viscosity that puts
extra effort on the infant’s heart as it is more
difficult to effectively circulate thick blood
○ Acrocyanosis may be prolonged, persistent, and
more marked than the usual
○ If polycythemia is extreme, blood vessels may
appear black and thrombus formation may result
● Hypoglycemia
○ Due to the decreased glycogen stores
○ Infants may need intravenous glucose to sustain
blood sugar until they are able to suck vigorously
enough to take sufficient oral feeding
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 4 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
POST TERM
A post term infant is born after 42 weeks of pregnancy
Commonly, it is recommended to induce labor at 2-week
post term to avoid postmature birth
However, when gestational age has been miscalculated or
if for some other reason labor is not induce until 43 weeks
of pregnancy, this may result in a post term infant
An infant who stays in the utero past 42 weeks of pregnancy
is a special risk.
➢ Placenta appears to function effectively for only 40
weeks
➢ Beyond that, the placenta will lose its ability to carry
nutrients effectively to the fetus
Fetus who stays in utero with a failing placenta may die or
develop post term syndrome
-
-
Characteristics of post term syndrome:
● Small for gestational age (SGA)
● Dry, cracked, leather-like skin
○ Lack of fluids
○ Absence of vernix caseosa
● Light weight from recent weight loss
that occurred because of poor
placental function
● Less amount of amniotic fluid (may be
meconium stained)
● Long fingernails (growth is beyond the
fingertips)
● Alert (much more like a 2-week-old
baby than a newborn)
-
-
-
-
-
At birth, the post term baby is likely to have difficulty in
establishing respiration, especially if meconium aspiration
occurs
In the first hour of life, hypoglycemia may develop because
the fetus had to use stores of glycogen for nutrition or
nourishment in the last week of intrauterine life.
Subcutaneous fat levels may be low having been used in
utero
➢ It is important to prevent a post term infant from
becoming chilled at birth or during transport
Polycythemia may develop from decreased oxygenation in
the final week
➢ Hematocrit may be elevated because of
polycythemia and dehydration which lowers the
circulating plasma level
LARGE-FOR-GESTATIONAL-AGE (LGA)
Infant is LGA if the birth weight is above 90th percentile in
the intrauterine growth chart
They appear healthy at birth due to their weight
➢ A gestational age examination will reveal an
immature development
It is important that an LGA infant will be identified
immediately so that the infant is given special care
appropriate for their gestational age rather than being
treated as a term newborn
Macrosomia
Fetus is suspected of being LGA when a woman’s uterus is
unusually large for the date of pregnancy.
-
If the infant’s large size was not detected during the
pregnancy, it may be first recognized during labor when
the baby cannot descend through the pelvic rim.
At birth, LGA infants may show immature reflexes and low
scores of gestational age examination in relation to their
size
Etiology:
● Overproduction of growth hormones in the uterus
○ Often occurs in infants of mothers who have
diabetes mellitus and in obese mothers
○ Extreme macrosomia may result in diabetic
mothers whose symptoms are poorly uncontrolled
■ Fetus is exposed to high glucose levels and
so they grow big
● Multiparous women
○ Prone to delivering a large baby
○ In every succeeding pregnancy, their babies will
tend to grow larger
Complications:
● Cesarean section due to cephalopelvic disproportion
● Shoulder dystocia - the wide shoulder cannot pass
through the outlet of the pelvis
● Erb-Duchenne paralysis
○ At birth, the newborn may have extensive bruising
or injuries (e.g. broken clavicle)
○ This can cause trauma to the cervical nerve
resulting to Erb-Duchenne paralysis if born
vaginally
● Caput succedaneum, cephalohematoma, or molding
○ LGA infants have large heads and so they are
exposed to unusually high-pressure during birth
○ Molding occurs when there a change in shape of
the skull in order to allow it to pass through the
canal
○ Caput succedaneum appears in LGA infants
because of the unusually high pressure at birth
causing edema in the loose connective tissue which
can extend across a number of sutures
■ This will disappear within 24 hours
○ Cephalohematoma is the rupture of blood vessels
in the subperiosteal layer (buildup of blood
underneath the periosteum). This builds up does
not pass-through sutures.
■ Located in one location
■ Disappears after 2-3 days
● Rebound hypoglycemia
○ LGA infants needs to be carefully assessed for
hypoglycemia in the early hour of life because they
have used up nutritional stores readily to sustain
their weight
○ If the mother has DM that is poorly uncontrolled,
fetuses will have increased blood glucose level in
the uterus which causes the fetus to produce
elevated levels of insulin to counter the
hyperglycemic environment.
■ After birth, this increased insulin level will
continue for up to 24 hours of life.
■ This can possibly cause rebound
hypoglycemia
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 5 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
Nursing Management:
● Breastfeed the newborn immediately
-
-
-
-
-
RESPIRATORY DISTRESS SYNDROME (RDS)
Also called Hyaline Disease Membrane
Most common cause of respiratory distress in:
➢ Preterm infants
➢ Infants of diabetic mothers
➢ Infants born through cesarean delivery
➢ Any infant with decreased blood perfusion of the
lungs such as those who had meconium
aspiration
Pathologic feature of RDS is a hyaline like fibrous
membrane formed from an exudate of an infant’s blood
that begins to line the terminal bronchioles, alveolar
ducts, and alveoli.
This membrane prevents the exchange of O2 & CO2 at the
alveolar capillary membrane.
The cause of RDS is a low level or absence of Surfactant →
the phospholipids that normally line the alveoli; reduces
the surface tension upon expiration and inhalation, which
keep the alveoli from collapsing.
Due to structural and functional immaturity of lung
➢ Underdeveloped parenchyma
➢ Surfactant deficiency
Results in decreased lung compliance, unstable alveoli
SURFACTANT
- Produced normally until the 34th week of gestation
Functions of Surfactant
➢
➢
➢
➢
Decreases the surface tension.
To promote lung expansion during inspiration.
To prevent alveolar collapse and loss of lung volume
at the end of expiration.
Facilitates recruitment of collapsed alveoli.
Incidence or RDS:
● 60% - 80% - born 28 weeks AOG
● 15% - 30% - 32 - 36 weeks AOG
● Rarely in those above 37 weeks
➢ Term babies: have a storage pool of approx. 100
mg/kg of surfactant at birth
➢ Preterm Babies: Have a storage of pool approx. 4-5
mg/kg surfactant at birth.
Etiology:
● Prematurity
● Meconium aspiration
➢ Due to poor blood perfusion to the lungs
● Pneumonia
PATHOPHYSIOLOGY OF RDS
1.
Breathing
Due to high pressure that is required to fill the lungs
with air for the first time upon overcoming the pressure
of lung fluid, chances are the alveoli would collapse w/
each expiration as surfactant is deficient & forceful
inspirations are still required to inflate them.
2. Lung Damage
- Poor exchange of oxygen can lead to tissue hypoxia,
causing the release of lactic acid.
- Lactic acid combines with CO2 resulting in the
formation of a hyaline membrane on the alveolar
surface, leading to severe acidosis.
3. Hyaline Deposits
- Acidosis causes decreased pulmonary vasoconstriction
which limits the surfactant production
4. Surfactant Deficiency
- The ability to stop the alveoli from collapsing with each
expiration becomes impaired
- This vicious cycle continues until O2 & CO2 exchange in
the alveoli is no longer adequate to sustain life without
the ventilator
5. Respiratory failure / Death
-
Signs and Symptoms:
● Grunting
○ Due to the closure of the glottis, creating a
prolonged expiratory time
● Nasal flaring
● Central cyanosis in room air
● Tachypnea
○ More than 60 rpm
● Sternal and subcostal retractions
Diagnosis:
● Chest X-ray
○ Will reveal a diffused pattern of radiopaque areas,
that looks like a ground glass or haziness
● Arterial Blood Gas (ABG)
○ Blood studies are taken from an umbilical vessel
catheter which will reveal Respiratory Acidosis
Nursing Management:
● Surfactant
○ Through an endotracheal tube, surfactant is
administered at birth
○ Synthetic surfactant is sprayed into the lungs by a
syringe or endotracheal tube
○ Infant is positioned with the head held upright and
tilted downward
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 6 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
○
●
●
●
●
It is important to ensure that the infant's airway will
not be suctioned for a long as possible after
administering, to avoid suctioning the drug away.
Airway
○ We need to attach the baby on a ventilator through
an endotracheal tube
Oxygen administration
○ Necessary to maintain correction of PO2 & pH level
○ Continuous Positive Airway Pressure (CPAP) or
Assisted Ventilation with Positive & Expiratory
Pressure (PEP) will exert pressure on the alveoli at
the end of expiratory & will keep the alveoli from
collapsing.
○ This will improve the oxygen exchange
○ Complications with this therapy would be
Retinopathy of Prematurity
Extracorporeal membrane oxygenation (ECMO)
○ Was first developed as a means of oxygenating
blood during cardiac surgery
○ It has now expanded for management of Chronic
Severe Hypoxemia in newborn, with illnesses such
as Meconium Aspiration, RDS, Pneumonia &
Diaphragmatic Hernia
○ It is also used for near drowning victims or infants
with severe lung infections
○ With ECMO, blood is removed from the baby by
gravity using a venous catheter, advanced into the
right atrium of the heart, then the blood circulates
from the catheter to the ECMO machine, where it is
oxygenated and rewarmed. It is then returned to
the infant’s aortic arch by a catheter advanced
through the carotid artery.
○ ECMO is typically used for 4-7 days, with many
potential complications. Chief of which is
Intracranial Hemorrhage, possibly from the
anticoagulant therapy necessary to prevent
thromboembolism.
○ Constant nursing care is required for a child
receiving ECMO:
■ To ensure that their blood volume remains
adequate
■ Bleeding doesn’t occur
■ Oxygen is being supplied to the body tissue
Prevention
○ RDS rarely occurs in
mature infants.
○ Dating in pregnancy by
sonogram,
and
by
documenting the level of
Lecithin in surfactant
obtained from amniotic
fluid exceeds sphingomyelin (2:1), are important
ways to ascertain that an infant born by cesarean
birth, or has labor induced, is mature enough that
RDS would not likely to occur
○ Tocolytic agents such as MgSO4 or terbutaline can
help to prevent preterm birth for a few days,
because steroids appear to quicken the formation
of lecithin.
○ It may be possible to prevent RDS in infants by
administering 2 injections of glucocorticosteroids,
such as Bethamethasone to the mother at 12 and
○
○
-
-
-
24 hours during this time. It is most effective when
given 24-34 weeks of pregnancy.
Unfortunately, there is often no warning to
preterm birth. Only imminent hours before birth
Steroids don’t take effect before 24-48 hours
before birth. Some birth or labor will progress too
rapidly with this preventive measure to be
effective
MECONIUM ASPIRATION SYNDROME
Meconium is present at the bowel of an infant as early as
10 weeks’ gestation
Infants with hypoxia in the uterus experience Vagal Reflex
Relaxation of the rectal sphincter which then releases
meconium into the amniotic fluid.
Babies born through breech presentation may expel
meconium on the amniotic fluid due to pressure on the
buttocks.
In both instances, the appearance of amniotic fluid is
green to greenish black due to meconium.
Meconium staining occurs approximately 10%-12%
during pregnancy and doesn’t tend to occur on extremely
low birthweight infants, because the meconium hasn’t
passed far enough into the bowel for it to be at the
rectum.
An infant may aspirate meconium either in the uterus or
within their first breath after birth, which can cause
severe respiratory distress in 3 ways:
1. Causes inflammation of bronchioles because it
is a foreign substance.
2. It causes blockage of small bronchioles by
mechanical plugging.
3. It causes decrease in surfactant production
through lung cell trauma.
This causes hypoxemia, CO2 Retention, & intrapulmonary
and extrapulmonary shunting.
A secondary infection of injured tissue may lead to
pneumonia.
An infant with meconium aspiration syndrome will have
difficulty in respiration at birth.
Signs and Symptoms:
● Low apgar score
○ Almost immediately, Tachypnea, cyanosis and
retractions occur.
○ With meconium-stained fluid, an infant should be
suctioned with bulb syringe or catheter while at the
perineum, before the birth of the shoulder to avoid
meconium aspiration
○ Although there is some dispute as to whether all
infants with meconium-stained fluid needs
intubation, those with severe staining are
intubated & meconium is suctioned from their
trachea and bronchi
○ Do not administer oxygen under pressure or bag
and mask, until the infant has been intubated and
suctioned, so that the pressure of oxygen doesn’t
drive small plugs of meconium further down to the
lungs, worsening the obstruction.
● Retractions
● Barrel chest
● X Ray - bilateral coarse infiltrates
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 7 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
Management:
● Amnioinfusion
○ Can be used to dilute the amount of meconium in
the amniotic fluid
○ Reduces the risk of aspiration
● CS
○ Some infants are delivered through CS after
meconium-stained amniotic fluid becomes evident
during labor.
○ After birth and tracheal suctioning, infant may be
treated with oxygen administration or assistant
ventilation
○ Maintain a neutral temperature to have no increase
in metabolic demand
● Pharmacologic
○ Antibiotic therapy may be used to stall the
development on pneumonia – a secondary problem
○ Lung tissue may be noncompliant after aspiration,
which may necessitate high respiratory pressure.
This causes Pneumothorax.
○ Infant must be observed carefully for signs of
trapped air in the alveoli. Because alveoli may
highly expand that it will rupture, sending air into
the pleural space.
○ Because of this increased pulmonary resistance,
ductus arteriosus remains open, causing blood to
shunt from the pulmonary artery into the aorta.
This compromises cardiac efficiency and increases
hypoxia.
○ Observe for signs of heart failure (increased heart
rate or respiratory distress)
● Chest physiotherapy
○ With clapping and vibration may be helpful in
removing remnants of meconium from the lungs
● Extracorporeal membrane oxygenation (ECMO)
○ Some infants will remain on ECMO to ensure
adequate oxygenation
○ Although meconium aspiration is an insult to a
newborn, with therapeutic intervention the
systems of this
will begin to fade
in week’s time.
SUDDEN INFANT DEATH SYNDROME (SIDS)
Also known as Crib Death
Sudden, unexplainable death during 1st yr. of life
Etiology is unknown
Theories/possible contributing factors about its cause:
➢ Prolonged but unexplained apnea
➢ Viral respiratory or botulism infection
➢ Pulmonary edema
➢ Brain stem abnormalities
➢ Neurotransmitter deficiencies
➢ Heart rate abnormalities
➢ Distorted familial breathing pattern
➢ Decreased arousal response
➢ Possible lack of surfactant in the alveoli
➢ Sleeping in a prone position
Affected infants were well-nourished
Some parents reported that an infant may have had a
slight head cold after being put to bed
➢ Infant was found dead after a few hours later
➢ They did not make any sounds as they died which
indicates that they died with laryngospasm
Infants who died of SIDS were found to have bloodflecked sputum/vomitus in their mouth or in the bed
clothes.
➢ This seems to occur as the result of death and not
as the cause
Autopsy often reveals petechiae in the lungs & mild
inflammation and congestion in the respiratory tract.
However, these symptoms are not severe enough to
cause SIDS
-
-
-
-
Diagnosis:
● Diagnosis of exclusion (rule all other causes)
○ That is why autopsy is performed for SIDS cases
Risk factors:
BABY
MOTHER
● How they sleep
● Male neonates
- more prone to SIDS
than
female
neonates
● 2-4 months of age
- peak
age
of
incidence
● Formula feeding
● Premature baby
● Low birth weight
●
●
●
●
●
●
●
●
●
Little to no prenatal care
Teen mother
Closely spaced pregnancies
Smoking during pregnancy
Drinks alcohol during pregnancy
Twins
Native American infants
Alaskan Native infants
Economically
disadvantaged
Black infants
● Narcotic dependent mothers
*Shown but was not discussed
Meconium
Aspirator
à Deep suctioning is
observed
Safe Sleep Do’s and Don'ts
Do’s
●
●
●
●
●
●
ASTM Certified Crib
Baby on back
Firm crib mattress
Fitted pad & sheets
Mattress encasement
Swaddle newborns
Don’ts
●
●
●
●
●
Crib bumpers
Blankets
Pillows
Stuffed animals or toys
Cords near the crib
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 8 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
ABO/RH INCOMPATIBILITY
Etiology:
● Incompatible RH and ABO blood type of fetus and
mother
● Rh incompatibility is different from ABO
incompatibility
● HDN = Hemolytic Disease of the Newborn
RH HDN
ABO HDN
Less common
More common
Mother
Rh negative
O
Fetus
Rh positive
A, B, or AB
Pregnancy
affected
Usually, second
Usually, first
Severity
Severe
Mild
Blood smear
Erythroblastosis
Spherocytosis
Direct Coombs
Test (DCT)
Strongly positive
Weakly positive or
negative
Frequency
Blood group
-
Theoretically, there is no connection that exists between
the maternal and fetal circulation. Meaning, no fetal blood
cells can enter the maternal circulation.
In actuality, occasional placental villi breaks and a drop or
two of fetal blood does enter the maternal circulation. This
is where the problem begins.
Rh Incompatibility
- Mother is Rh negative and fetus is Rh positive (contains D
antigen)
- Introduction of the fetal blood causes sensitization to
occur and the mother begins to form antibodies against
the D antigen.
- Most form in the mother’s bloodstream in the first 72
hours after birth because there is an active exchange of
fetal-maternal circulation as placental villi is loosened and
as the placenta is delivered
- During the 2nd pregnancy, there will be a high level of antiD antibodies in the mother’s bloodstream in which this will
act to destroy the fetal RBC early in the pregnancy if the
fetus is Rh positive.
ABO Incompatibility
- Mother is Type O and fetus is Type A, B, or AB
- Reaction in infants with Type B is often most serious
- Hemolysis can become a problem in the first pregnancy in
which there is an ABO incompatibility because of the antiA and anti-B antibodies that are naturally occurring or are
present at birth in individuals whose RBCs lack these
antigens
- These antibodies are of large class and do not cross the
placental barriers. We are referring to the
immunoglobulin, IgM.
-
-
An infant of an ABO incompatibility is not born anemic
compared to an Rh sensitized child.
Hemolysis begins with birth when the blood and
antibodies are exchanged during the mixing of maternal
and fetal blood as the placenta is loosened
Destruction of RBC may continue up to 2 weeks of age
Preterm do not seem to be affected by ABO
incompatibility
➢ May be due to the receptor sites for anti-A and
anti-B antibodies do not appear in RBCs until later
in fetal life
➢ In mature newborn, direct Coombs test may be
only weakly positive because of few anti-A and
anti-B receptors sites present.
➢ Reticulocyte count (immature or newly formed
RBCs) is usually elevated as the infant attempts to
replace the destroyed cells
Signs and symptoms:
● Coombs test — direct and indirect
○ Indirect Coombs test in Rh incompatibility
■ Rising anti-Rh titer or rising levels of
antibody during pregnancy
○ Positive Direct Coombs test
■ Confirmed detecting antibodies on the
fetal erythrocytes in the cord blood by
percutaneous sampling at birth
● Enlarged liver and spleen
○ Due to the attempts to destroy the damaged RBCs
● Extreme edema
○ If the number of RBCs has significantly decreased,
the blood in the vascular circulation may be
hypotonic to interstitial fluid.
○ Fluid will shift from lower to higher isotonic
pressure by the law of osmosis
■ Causes the extreme edema
● Severe anemia
○ Result in heart failure
○ Heart has to beat fast to push the dilute blood
forward
● Hydrops fetalis
○ Old term for appearance of severely involved
infant at birth
○ Hydrops = edema; fetalis = lethal state
● Pathologic jaundice
○ With birth progressive jaundice usually occurring
within the first 24 hours of life will begin indicating
in both ABO and Rh incompatibility that a
hemolytic process is at work
○ Jaundice occurs because RBCs have been
destroyed and indirect bilirubin is released
■ Indirect bilirubin is fat-soluble and cannot
be excreted in the body
■ In normal circumstances, glucuronyl
transferase (liver enzyme) converts
indirect bilirubin to direct bilirubin
■ Direct bilirubin is water-soluble and
combines with bile for excretion from the
body with feces
■ Infants with extreme hemolysis, the liver
cannot convert indirect bilirubin to direct
bilirubin and so jaundice becomes extreme
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 9 .
MCHN 2 - LECTURE
●
●
Week 5 Nursing Care of the High-Risk Newborn
Hypoglycemia
○ Infant needs to use glucose stores to maintain
metabolism in the presence of anemia
■ Causes a progressive hypoglycemia,
compounding the initial problem
○ A decrease in the Hgb during the first week of life to
a level less than that of cord blood is a later
indication of blood loss or hemolysis
Green stool, dark urine- post-phototherapy
○ The stool of an infant under bilirubin lights is often
bright green. (often loose and may be irritating to
the skin)
■ This is due to the excessive bilirubin
excreted as a result of the therapy
○ The urine may be dark colored from urobilinogen
formation
■ The cause of the green stool and dark urine
●
Management: these may be immediate measures necessary to
reduce indirect bilirubin level in infants affected with ABO and
Rh Incompatibility
● Early breastfeeding
○ Since bilirubin is removed from the body by being
incorporated in the feces
○ Therefore, the sooner bowel elimination begins,
the sooner the bilirubin removal begins
○ Early feeding with breastmilk stimulates and
accomplishes bowel peristalsis
● Phototherapy
○ An infant's liver process little bilirubin in utero
because the mother's circulation does this for the
infant
○ Exposure to a light triggers the liver to assume this
function
○ Additional light supplied by phototherapy appears
to speed the conversion potential of the liver.
○ In phototherapy, the infant is continuously exposed
to a specialized light such as Quartz halogen, cool
white daylight or blue fluorescent placed at 12-30
inches above the bassinet or incubator.
○ Specialized fiber optic lights system incorporated
into the fiber optic blanket have been developed
and are ideal for home care
○ Infant is undressed except for the diaper. Skin is
exposed as much as possible.
○ Term newborns are generally scheduled for
phototherapy when total serum bilirubin level rises
to 15 mg/dL at 25-28 hours of age
■ Preterms have treatment begun at levels
for as low as 10-12 mg/dL
● Exchange transfusion
○ Intensive phototherapy in conjunction with
hydration and close monitoring of serum bilirubin is
the preferred method of treatment for neonatal
jaundice.
○ Despite if all of this is exhausted and still the
bilirubin level continues to rise, then exchange
transfusion may be necessary.
○ Before the transfusion procedure, the baby’s
stomach is aspirated to minimize risk of aspiration
from manipulation.
○ The umbilical vein is catheterized as the site of
transfusion. The procedures involve alternately
withdrawing small amounts of infant’s blood of
about 2-10 ml and then replacing it with an equal
amount of donor’s blood. The blood is exchanged
slowly to prevent alternating hypovolemia and
hypervolemia. This can make an exchange
transfusion a lengthy procedure at about 1-3 hrs.
○ Automatic pumps are helpful to perform the
exhausting repetitive ritual.
○ At the end of the procedure, using the last
specimen of the blood withdrawn Hct, bilirubin,
electrolyte, especially the calcium glucose are
determined and the blood culture is also taken.
○ Exchange transfusion may need to be repeated
because unconjugated bilirubin from the issue
moves the circulation after initial exchange.
Erythropoietin
Nursing Considerations:
● Protect eyes and genitalia
○ This can cause harmful effects to the baby’s retina
& genital area so we need to protect these areas.
○ Put on eye and genital patches. With the eye patch,
there’s a possibility of suffocation, so we need to
monitor the baby from time to time if the eye patch
is properly in place.
○ Removal of the eye patch while the infant is with
the mother, this gives the infant a period of visual
stimulation and can also promote mother and
infant interaction
● Feed frequently
○ The infant receiving phototherapy should be
removed from under the light for feeding so that
the baby continues to have interaction with the
mother and in addition to supplemental feeding.
○ Formula feeding may be recommended to prevent
dehydration.
● Promote mother-and-child interaction
● Thermoregulation
○ Continuously monitor the temperature of the
baby, as exposure to phototherapy can have
radiation and convection. So can be temperature
very crucial that's why we need to make sure that
thermoregulation is established.
●
ACQUIRED MATERNAL INFECTION
Group B Beta-hemolytic streptococcal infection (GBS)
○ Major cause of infection in newborn is GBS
○ Gram (+) bacterium is naturally inhibited in the
female genital tract.
○ May be spread from baby to baby if good
handwashing technique is not used in handling
newborns.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 10 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
○
If a mother is found to be positive in GBS during late
pregnancy, ampicillin administration is given
intravenously at 28 weeks and again during labor to
help reduce the possibility of newborn exposure.
● Ophthalmia neonatorum
○ This is an infection that occurs at birth during the
first month.
○ The most common causative agent is neisseria
gonorrhoeae and chlamydia trachomatis, an infant
contracted organism during birth from vaginal
secretion.
○ Neisseria gonorrhoeae infection is an extreme,
serious form of conjunctivitis because if left
untreated the infection progresses to corneal
ulceration and obstruction and resulting in opacity
to cornea and severe vision impairment.
● Hep B. virus - This can be transmitted to the newborn
contact with infected vaginal blood at birth with the
mother positive of the virus. It is a destructive illness
accounting to 70-90% of infective infants because they
become chronic carriers of the virus. Number of infants
will develop cancer later in life. To reduce the possibility of
its spread newborns must be routinely vaccinated at birth.
If the mother is identified as Hep. B positive, an infant
must also be administered with immune serum globulin
within 12 hours of birth to decrease the possibility of
infection.
● Generalized herpes virus infection (Herpes simplex virus
Type 2 infection) is most prevalent among women who
have multiple sexual partners. Can be contracted by a
fetus across the placenta if the mother is active or has
primary infection during pregnancy. The virus can be
contracted from vaginal secretions of a mother who has
active herpetic vulvovaginitis at the time of birth.
● HIV infection - Human Immunodeficiency Virus (HIV)
infection and Acquired Immunodeficiency Syndrome
(AIDS) can be caused by placental transfer or direct
contact with a maternal blood during birth.
● Newborns are susceptible to infection at birth because
their ability to produce antibodies is immature.
● There are many infections in newborns such as
toxoplasmosis, rubella, syphilis, cytomegalovirus, which
are spread to the fetus across to placenta in the uterus.
● Other infections are contracted from exposure to vaginal
secretions at birth.
Diagnosis:
● Blood culture
Signs and symptoms:
(Pneumonia like symptoms)
● Hypothermia
● Hypotonia - muscles are relaxed
● Tachypnea, paleness
Management:
● Prophylaxis (antibiotic therapy)
● Standard and contact infection precautions are observed
in order to not to transfer or spread the viruses from one
baby to another. To protect ourselves from the virus. You
need to wear a mask, gloves, and gowns in order to stop
the chain of infection.
● Eye irrigation - for apnea neonatorum
●
●
●
●
-
-
Bath baby immediately (HBsAg + mother) - to remove the
secretions and blood from the baby. Given vaccines and
immune serum globulin.
HBIG + HBV
Acyclovir (herpes simplex)
Antenatal prevention - in order to not to transfer the
infection to the baby
INFANT OF MOTHER WITH DM (Diabetes Mellitus)
An infant of a diabetic mothers whose illness is controlled
during pregnancy is typically longer and weighs more than
that of other babies. The baby has also a greater chance
of having congenital anomaly such as cardiac anomaly as
if hyperglycemia were direct to a rapidly growing fetus.
Most babies have cushingoid appearance or fat and puffy
appearance. They tend to be lethargic or limp at the first
day of life as a result of hyperglycemia.
Signs and symptoms:
● Macrosomia
○ Results from over stimulation of pituitary growth
hormone and extra fat deposit created by high
levels of insulin during pregnancy.
● Severe hypoglycemia
○ Immediately after birth, the infant tends to be
hyperglycemic because the mother is slightly
hyperglycemic and excess glucose transfers across
the placenta during pregnancy.
○ The fetal pancreas responds to this high glucose
level with islet cell hypertrophy resulting in the
matching high insulin level.
○ After birth, an infant's glucose begins to fall
because mother circulation is no longer supplying
the glucose.
○ Then the overproduction of insulin will cause the
development of severe hypoglycemia
● Hypocalcemia.
○ Also frequently develop because parathyroid
hormone levels are low in these infants due to
hypomagnesemia from excessive renal loss of
magnesium
● Hyperbilirubinemia
○ May also occur in these infants because of if
immature they cannot effectively clear bilirubin
from their system
Nursing considerations:
● Early feeding
○ Hypoglycemia is defined as serum glucose level of
less than 40 mg/dL in newborn
○ To avoid serum glucose levels from falling this low,
infants of diabetic mothers are fed early with
formula or administer a continuous infusion of
glucose.
○ It is important that the child be given only bolus of
glucose otherwise rebound hypoglycemia may
occur.
○ Some infants of diabetic mothers have smaller than
usual left colon. Apparently, this is another effect
of the uterine hyperglycemia which limits the
amount of oral feeding they can take in their first
day of life.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 11 .
MCHN 2 - LECTURE
Week 5 Nursing Care of the High-Risk Newborn
○
●
-
Signs of inadequate colon:
➢ Vomiting/ abdominal distention after the
first few feeding
Monitor bowel movement
INFANT OF DRUG- DEPENDENT MOTHER
Tends to be small for gestational age
If the mother is dependent on drug, an infant will show
withdrawal symptoms
Signs and symptoms: (Neonatal Abstinence Syndrome (NAS)) withdrawal symptoms shortly after birth
➢ Irritability
➢ Disturbed sleep pattern
➢ Constant movement possibly leading to abrasion of
elbows, knees, and nose
➢ Frequent sneezing
➢ Shrill
➢ High pitched cry
➢ Possible hyper reflection
➢ Neuromuscular irritability
➢ Convulsion
➢ Tachycardia
➢ Tachypnea - so rapid possibly so severe that leads to
hyperventilation and alkalosis
➢ Vomiting and diarrhea
○ which leads to large fluid loss and secondary
dehydration
○ Specific neonatal abstinence scoring tool may be
used to quantify infant's status
○ Occurs 24-48 hrs up to 2 weeks (signs showing
withdrawal)
Nursing considerations:
● Remove excessive stimuli
○ Keep them in a comfortable environment away or
free from excessive stimuli
○ In many infants of heroin addicted women, they suck
vigorously and continuously and seem to find
comfort and quite if given pacifier
○ Infants also with methadone and cocaine addiction
women may have extremely poor sucking ability and
may have difficulty getting enough fluid intake
unless given through the Gavage feeding
○ Specific therapy for infant is individualized according
to the nature and severity of the signs
○ Maintenance of electrolyte and fluid balance is
essential
○ If infant is vomiting and diarrhea then intravenous
administration of fluid may be indicated
● Avoid breastfeeding with narcotic-use of mothers
○ To avoid passing narcotic in the breast milk to the
child
○ Once the infant has been identified as having been
exposed to drug in utero, the mother needs
treatment to withdrawal symptoms and follow-up
care as much as the infant
○ Evaluation is necessary to determine before
discharge whether environment that allowed for
drug abuse will be safe for an infant at home
○
Infants who are exposed to drug in utero may have
long term neurologic problems
INFANT WITH FETAL ALCOHOL EXPOSURES
Fetal Alcohol Spectrum Disorder (FASD)
- Alcohol crosses the placenta in the same concentration as
is present in the maternal bloodstream this results in FAS
or exposure
- FAS appears in about 2 per 1000 newborns and is often
the most difficult to document than that of a recreational
drug exposure because it's unknown if there is safe
threshold of alcohol ingestion during pregnancy
Signs & symptoms: (Physical Features)
○ Microcephaly
○ Low nasal bridge
○ Epicanthal folds
○ Minor ear anomalies
○ Micrognathia (jaw is lower or undersized)
○ Small palpebral fissures
○ Smooth philtrum
○ Thin upper lip
-
-
All pregnant women are advised to avoid alcohol intake
to prevent any teratogenic effects on babies.
Newborn with FAS has a number of possible problems at
birth
A characteristic that marks the syndrome includes pre and
post-natal growth restriction there is CNS involvement
and cognitive challenges and cerebral palsy.
During neonatal period, the infant may be tremulous,
frigid, irritable & may demonstrate weak sucking reflex.
Sleep disturbance is common with the baby tending to
always be awake or asleep depending on the mother's
alcohol level close to birth.
Most serious long-term effects are cognitive challenges.
Behavior problems like hyperactivity in school age
children, growth deficiency throughout life and infant
need follow-up so any future problems may be
discovered.
Mother needs follow-up to reduce alcohol intake for
better overall health.
Nursing Considerations:
- Perform complete assessment of systems including heart
and lung auscultation; FAS often results in deformities of
the heart and lungs and may result in murmurs, heart
valve disorders or respiratory diseases such as asthma
- Obtain history of pregnancy from patient’s mother
- Determine how much alcohol was consumed throughout
pregnancy and frequency.
- Severity of symptoms may be determined by the amount
of exposure.
- Health teaching that NO amount of alcohol consumed is
considered safe during pregnancy.
KUAN, PADILLO, PEPITO, RELAMPAGOS, SEVILLA, TABOR 12 .
These are primary defects in the testis. From the word
primary, this concerns the shape and morphology of the
sperm.
●
UNIT 5: NURSING CARE OF CLIENTS WITH GENERAL
DISTURBANCE IN REPRODUCTION AND SEXUALITY
The inability to conceive a child or sustain a pregnancy to birth
that affects as many as 14% of couples who desire children.
Couples exploring fertility testing come in all different types:
many are married couples who are having trouble conceiving;
some are couples who have plans to marry and wonder if they
will have trouble conceiving; some desire to remain single or
partner with someone of their own sex and bear a child, through
an assisted fertility method; some are gay or lesbian.
When a couple first pursues fertility counseling, they usually
have fears and anxieties not only about their inability to
conceive but also about what this condition will mean to their
future lifestyle and family.
Infertility (Subfertility)
- Inability to conceive a child or sustain a pregnancy to
birth after at least 1 year of unprotected sex.
- There are two types of infertility or subfertility:
● Primary Subfertility
○ No history of conception, which
means that there has been no previous
conception at all.
● Secondary Subfertility
○ History of viable pregnancy but unable
to conceive at present.
Sterility
- Inability to conceive because of a known condition,
such as the absence of a uterus.
Causes of Infertility
Male - 35%
➢
➢
➢
➢
Sperm Production - Congenital anomalies, pubertal
complications, environmental factors
Sperm Transport
Sperm Motility
Erectile Dysfunction - Inability to achieve erection (Primary
& Secondary)
❖ Pretesticular
● These are problems or disorders concerning extragonadal
endocrine, such as those originating in the hypothalamus,
pituitary or adrenals, in which these affect spermatogenesis
(production of sperm cells). Pretesticular in other words are
problems concerning the amount of sperm or low sperm
count.
❖ Testicular
❖ Post-testicular
● These are factors affecting the ability of the sperm to travel
from the site of production, the testicle, to leave the body in
ejaculation.
● Sperm motility or the movement of sperm (develop due to
autoimmunity which immobilizes sperms)
● Problems in the ejaculation or deposition, preventing
spermatozoa from being placed close enough to a woman’s
cervix to allow ready penetration and fertilization.
Female - 35%
The factors that cause subfertility in women are analogous to those
causing subfertility in men: anovulation (faulty or inadequate
production of ova), problems of ova transport through the fallopian
tubes to the uterus, uterine factors such as tumors or poor
endometrial development, and cervical and vaginal factors that
immobilize spermatozoa.
➢
➢
➢
➢
➢
➢
➢
➢
Congenital Anomalies
Infections
Uterine Malpositions
Hormones
Gynecologic in origin
Anovulation
Sexual Practices, Timing of Sexual Act
Tubal Patency (Pelvic Inflammatory Disease, PID Related)
Both - 20%
❖ Environmental factors
● Exposure to radiation or chemicals
❖ Drugs
● Drug users or prolonged maintenance of a drug that can
lead to infertility
❖ Diet/Exercise
● Heavy exercises or faulty eating habits can also lead to
infertility
Unexplained - 10%
Assessment & Evaluation of Infertility:
➢ Health history and perform physical assessment
➢ Nurses often assume the responsibility for initial
history taking with a subfertile couple. Because
of the wide variety of factors that may be
responsible for subfertility.
➢
Most couples assume that subfertility is the woman’s
problem. Many women, even after careful explanation
that the problem is their male partner and not theirs,
continue to show low self-esteem, as if the fault did
rest with them. For a thorough women’s health history,
ask about:
○ Current or past reproductive tract problems,
such as infections
○ Overall health, emphasizing endocrine
problems such as galactorrhea (breast nipple
secretions) or symptoms of thyroid
dysfunction
○ Abdominal or pelvic operations that could
have compromised blood flow to pelvic
organs
○ Past history of a childhood cancer treated
with radiation that might have reduced
ovarian function
○ The use of douches or intravaginal
medications or sprays that could interfere
with vaginal pH
➢ Exposure to occupational hazards such as x-rays
or toxic substances
➢ Nutrition including an adequate source of folic
acid and avoidance of trans-fats. ● If she can
detect ovulation through such symptoms as
breast tenderness, mid cycle “wetness,” or lower
abdominal pain (mittelschmerz).
➢
Also obtain a menstrual history including:
○ Age of menarche
○ Length, regularity, and frequency of menstrual
periods
○ Amount of flow
○ Any difficulties experienced, such as
dysmenorrhea or premenstrual dysphoric
disorder (PDD)
○ History of contraceptive use
○ History of any previous pregnancies or
abortions
➢ A minimum history for the man should include:
○ General health
○ Nutrition
○ Alcohol, drug, or tobacco use
○ Congenital health problems such as
hypospadias or cryptorchidism
○ Illnesses such as mumps orchitis,
urinary tract infection, or sexually
transmitted diseases
○ Radiation to his testes because of
childhood cancer or another cause
○
○
○
○
Operations such as surgical repair of a hernia,
which could have resulted in a blood
compromise to the testes.
Current illnesses, particularly endocrine
illnesses or low grade infections
Past and current occupation and work habits
Sexual practices such as the frequency of
coitus and masturbation, failure to achieve
ejaculation, premature ejaculation, coital
positions used, and use of lubricants
○
Past contraceptive measures, and existence
of any children produced from a previous
relationship.
➢ For both, nurses have to check into the lifestyle,
use of contraception, STDs, smoking practices,
exercises and the type of occupation.
Diagnosis:
➢ To determine and diagnose problems of
infertility, the couple or an individual has to
undergo a series of diagnostic tests and
procedures.
➢ In male infertility, problems in spermatogenesis,
or inadequate sperm count are determined by
the diagnostic test semen analysis.
Semen Analysis
➢ After 2 to 4 days of sexual abstinence
➢ The man ejaculates by masturbation into a
clean, dry specimen jar. The number of sperm in
the specimen are counted and then examined
under a microscope within 1 hour, then their
appearance and motility are noted.
➢ An average ejaculation should produce 2.5 to 5.0
mL of semen and should contain a minimum of
20 million spermatozoa per milliliter of fluid (the
average normal sperm count is 50 to 200 million
per milliliter).
➢ Male should be instructed that a repeat is done
after 2 or 3 months, because spermatogenesis
is an ongoing process, and 30 to 90 days is
needed for new sperm to reach maturity.
➢ Have adequate rest, avoid fatigue and take
vitamins
➢ Do not use lubrication
➢ Note the time of collection
➢ Keep the specimen at body temperature en route
to lab
➢ Specimen must be examined within 1 hour
➢
➢
➢
Another male infertility factor is ejaculation problem or
sperm transport disorder, which includes erectile
dysfunction or impotence (inability to achieve
erection). This condition is primary if the man has
never been able to achieve erection and ejaculation
and secondary if the man has been able to achieve
ejaculation in the past but now has difficulty.
Solutions to the problem can include psychological or
sexual counseling as well as use of a drug such as
sildenafil (Viagra).
Premature ejaculation (ejaculation before penetration)
is another factor that may interfere with the proper
deposition of sperm. . It is another problem often
attributed to psychological causes. Adolescents may
experience it until they become more experienced in
sexual techniques.
➢
➢
➢
➢
➢
In females, monitor and check for the production of
ova. Anovulation (absence of ovulation), the most
common cause of subfertility in women, may occur
from a genetic abnormality such as Turner’s syndrome
(hypogonadism) in which there are no ovaries to
produce ova.
It may result from a hormonal imbalance caused by a
condition such as hypothyroidism that interferes with
hypothalamus-pituitary-ovarian interaction.
Ovarian tumors may also produce anovulation because
of feedback stimulation on the pituitary, thus ova is not
produced.
Chronic or excessive exposure to x-rays or radioactive
substances, general ill health, poor diet, and stress may
all contribute to poor ovarian function.
The most frequent cause, however, is naturally
occurring variations in ovulatory patterns or polycystic
ovary syndrome, a condition in which the ovaries
produce excess testosterone, lowering FSH and LH
levels.
Basal Body Temperature Charting
➢ Ovulation monitoring is the least costly way to
determine a woman’s ovulation pattern. Patient
is asked to record her basal body temperature
(BBT) for at least 4 months.
➢ To determine this, a woman takes her
temperature each morning, before getting out of
bed or engaging in any activity, eating, or
drinking, using a special BBT or tympanic
thermometer.
➢ She plots this daily temperature on a monthly
graph, noticing conditions that might affect her
temperature (e.g., colds, other infections,
sleeplessness).
➢ At the time of ovulation, the basal temperature
can be seen to dip slightly (about 0.5° F); it then
rises to a level no higher than normal body
temperature.
➢ Towards the end of the cycle, during the 24th
day, her temperature begins to decline,
indicating that progesterone levels are falling,
and that she did not conceive.
Post-coital Test (Sims-Huhner Test)
➢ Carried out to eliminate cervical abnormalities if
female is unable to conceive
➢ Doctors suggest test after other tests identify
the female is ovulating well and the semen
analysis of the male is normal
➢ With a speculum, a tiny amount of mucus is
taken from the cervix for testing
➢ Done with pelvic UTZ to make sure the test is
being carried out at the time of ovulation
➢ Cervical mucus is carefully examined under a
microscope to assess its quality, sperm quantity,
and sperm motility
UTZ (Sonohysterosalpingogram)
➢ Saline is injected through the cervix into the
uterine cavity to illustrate the inner shape of
uterus and degree of openness or patency of the
fallopian tube
➢ Can determine other problems such as cause of
abnormal uterine bleeding, repeated miscarriage
(able to detect abnormal growth inside the
uterus i.e. fibroids and polyps, scar tissue,
abnormal uterine shape, problems with the lining
of uters, and whether fallopian tube is open or
blocked.
Sonohysterography
➢
An ultrasound technique designed for inspecting the
uterus and fallopian tube. The uterus is filled with
sterile saline, introduced through a narrow catheter
inserted into the uterine cervix. A transvaginal
ultrasound transducer is then inserted into the vagina
to inspect the uterus for abnormalities such as septal
deviation or the presence of a myoma and assess the
patency of the fallopian tube. Because this is a
minimally invasive technique, it can be done at any
time during the menstrual cycle.
Tubal Insufflation Test (Rubin’s Test)
➢ Diagnostic method to determine whether
fallopian tubes are occluded or not.
➢ Consists of introducing CO2 into the uterus
through the fallopian tube
➢ The gas escapes into the abdominal cavity and
if the tube is not occluded = Positive Test,
causing referred shoulder pain
➢ The abdominal gas may be demonstrated by an
x-ray or fluoroscopy
➢ Insufflation: Gas pressure of <120 mmHg
○ Manometer reading decreases to 100
or less if tubes are clear
○ If reading is between 120 to 130 =
partial stricture
○ 200 and more = tubes are obstructed
➢
Hormonal Evaluation
● FSH, LH, and estradiol are measured on the 3rd
day of the menstrual cycle
● Measurements allow the doctors to access the
ovarian reserve or the ability to produce quality
eggs
Tubal patency
➢
➢
Both ultrasound and x-ray imaging can be used to
determine the patency of fallopian tubes and assess
the depth and consistency of the endometrial lining.
Nurses need to assess the tubal patency to determine
tubal transport problems. Difficulty with tubal transport
usually occurs because scarring has developed in the
fallopian tubes. This typically is caused by chronic
salpingitis (chronic pelvic inflammatory disease). It can
result from a ruptured appendix or from abdominal
surgery involving infection that spread to the fallopian
tubes and left adhesion formation in the tubes.
Transvaginal Hydrolaparoscopy
➢
➢
Allows direct visualization of the female peritoneal
cavity. A trocar is passed through the vagina, into the
pouch of douglas, and an optic scope is placed
through the trocar sleeve, allowing close examination
to the uterus, ovaries, fallopian tube, and peritoneum.
In this procedure, no abdominal incision is required.
The procedure can be accomplished in the office
setting.
Uterine Endometrial Biopsy
➢
➢
Used as a test for ovulation or to reveal an endometrial
problem such as a luteal phase defect.
Endometrial biopsies are done 2 or 3 days before an
expected menstrual flow (day 25 or 26 of a typical
28-day menstrual cycle). It will start with the induction
of a paracervical block or anesthesia, then a thin probe
and biopsy forceps are introduced through the cervix.
A woman may experience mild to moderate discomfort
from the maneuvering of the instruments. There may
be a moment of sharp pain as the biopsy specimen is
taken from the anterior or posterior uterine wall.
➢
Possible complications include pain, excessive
bleeding, infection, and uterine perforation.
This procedure is contraindicated if pregnancy is
suspected (although the chance that it would interfere
with a pregnancy is probably less than 10%) or if an
infection such as acute PID or cervicitis is present.
Caution a woman that she might notice a small
amount of vaginal spotting after the procedure. For
follow-up, she needs to call her primary care FIGURE
8.3 Insertion of dye for a hysterosalpingogram. The
contrast dye outlines the uterus and fallopian tubes on
radiographs to demonstrate patency. If she develops a
temperature greater than 101° F, has a large amount of
bleeding, or passes clots.
She also needs to call the health care agency when she
has her next menstrual flow. This helps “date” the
endometrium and the accuracy of the analysis.
Medical Management:
Pharmacologic:
✓ Sildenafil (Viagra)
➢ Treat male’s sexual function problems, like
impotence or erectile dysfunction disorder. This
is in combination with sexual stimulation.
➢ Phosphodiesterase inhibitor: It works by
increasing the blood flow to the penis, to help a
man get and keep an erection.
✓ Dapoxetine
➢ A selective serotonin reuptake inhibitor (SSRI)
which is specially developed for treatment of
premature ejaculation.
➢ Increases the time to ejaculate and can improve
the control of ejaculation. It starts to work very
quickly so it is taken when you anticipate having
sex, rather than taking it everyday.
➢ Taken 1-2 hours before an individual will engage
in sexual activity.
✓ Hormone Therapy
➢ For couples who are unable to have children, this
treatment can increase the chance of pregnancy.
➢ In many cases, inability to have children can be
attributed to hormonal imbalance. Usually
performed in women.
Hormone treatment, in women, aims to promote egg maturation
and triggers ovulation. So this increases the likelihood of
successful fertilization. Under hormone therapy we have
Clomiphene citrate or clomid. This is an oral medication that is
often used to treat certain types of women infertility.
-
Clomiphene citrate (Clomid)
-
○
Estrogen agonist; blocks estrogen
receptors. Stimulates the ovaries.
➢ Steroid Administration: (Tubal insufficiency due
to infection) To help in reducing adhesions
○
Clomid works by making the body think that
your estrogen levels are lower than they are,
which causes the pituitary gland to increase
secretion of FSH (follicle stimulating
hormone) and LH (luteinizing hormone). High
levels of FSH stimulate the ovary to produce
an egg cell or multiple follicles that would
develop and release during ovulation, while
high levels of LH stimulate ovulation.
Surgery:
❒ Canalization of Fallopian Tube
➢ Nonsurgical procedure to clear the blockage or
obstruction in the fallopian tube
➢ Obstructions such as myoma and fibrous tumor
can interfere with fertility
Letrozole (Femara)
○ Oral fertility medication used to induce
an egg to be developed and released in
women
○ Used in women who cannot ovulate or
to induce multiple eggs on women who
ovulate on their own
○
○
○
These hormones, FSH and LH, can cause the
development of ovulation in women who are
anovulatory or increase the number of eggs
developing in the ovaries of women who
already ovulate.
Used in women with breast cancer.
Aromatase inhibitor: Aromatase is an enzyme
that is responsible for the production of
estrogen in the body. It works by inhibiting
aromatase, thereby suppressing estrogen
production.
In both cases, the result is that the pituitary gland produces
more hormones needed to stimulate the ovaries.
-
Bromocriptine (Parlodel)
○
○
○
Ergot alkaloids: blocks the release of a
hormone called prolactin from the pituitary
gland. Prolactin affects the menstrual cycle
and milk production.
Used to treat certain menstrual problems like
amenorrhea in women and stop milk
production in some men and women who
have abnormal milk leakage.
Used to treat infertility in both men and
women that occurs because the body is
making too much prolactin.
○
To decrease increased prolactin levels
and allow for the rise of gonadotropins
○
Antibiotic therapy is given if the underlying
cause is brought about by infection, such as
in pelvic inflammatory diseases.
✓ Antibiotic (Infection)
➢ Given to manage any current infection
➢
➢
Performed through a speculum placed in the vagina,
and a small plastic tube is inserted into the cervix to
the uterus.
A liquid contrast agent is injected through a catheter
and examines the uterine cavity on a nearby monitor
using an x-ray camera.
○ If blockage is determined, and it is located on
one or both fallopian tubes, thread a small
catheter through the first catheter and then
into the fallopian tube to clear the blockage.
➢ Adhesiolysis must be done, obstructions can be
lysed through hysteroscopy.
❒ Adhesiolysis
➢
Adhesions can form from any type of trauma to the
abdomen.
➢ In adhesiolysis, this is the removal of adhesions
in any part of the abdominal cavity. In fertility
adhesion can cause female reproductive organ
problems by obstructing ovaries or fallopian
tubes.
➢
Also a cause of painful intercourse for some people.
➢ If a doctor suspects adhesions are causing the
reproductive issue, they may recommend
surgery to remove them through laparoscopy. A
laparoscope is a long thin tube that contains a
camera and light is inserted into an incision
which helps the surgeon find the adhesion to
remove them.
❒ Correction of Coital Habits
➢ Although frequent intercourse may stimulate
sperm production, men need sperm recovery
time after intercourse to maintain adequate
sperm count.
➢ Advise couples: Coitus every other day rather
than everyday, especially during fertile period.
➢ Male superior position: Best position for coitus
to achieve conception (Places sperm closer to
the cervical opening)
○ Male should try for deep penetration
(Ejaculation places sperm closer to the
cervix)
○
○
○
Elevating women’s hips and on a pillow
facilitates sperm collection near the
opening to the cervix
Woman should remain on her back with
knees drawn up for at least 20 minutes
after ejaculation to help sperm remain
near cervix
Do not use douching or lubricants
before or after intercourse to avoid
altering the pH of the vagina which
could interfere with sperm motility
❒ Surrogate Motherhood and Adoption
➢ Surrogate Mother: Woman agrees to carry a
pregnancy term for a subfertile couple.
➢ The surrogate may provide ova and be
impregnated by the man’s sperm. Other
instances, the couple may be donated by the
subfertile couple.
➢ Adoption: Alternative for subfertile couples.
Assisted Reproductive Techniques to Manage
Subfertility
Alternative Insemination (Therapeutic Insemination)
complete, underwent a vasectomy but now wish to have
children.
In the past, men who underwent chemotherapy or radiation for
testicular cancer had to accept being child free afterward as
they were no longer able to produce sperm.
Today, sperm can be cryopreserved (frozen) in a sperm bank
before radiation or chemotherapy and then used for
insemination afterward (cryopreserved sperm: sperm placed in
a sperm bank before radiation or chemotherapy).
One disadvantage of using frozen sperm is that it tends to have
slower motility than unfrozen specimens/sperm. However,
although the rate of conception may be lower from this source,
there appears to be no increase in the incidence of congenital
anomalies in children conceived by this method.
An advantage of cryopreserved sperm is that it can be used
even after years of storage.
To prepare for artificial insemination, a woman must record her
Basal Body Temperature (BBT), assess her cervical mucus, or
use an ovulation predictor kit to predict her likely day or
involution.
On the day after involution, the selected sperm are instilled into
the cervix using a device similar to a cervical cap or diaphragm,
or they are injected directly into the uterus using a flexible
catheter.
If therapeutic donor insemination is selected, the donors are
volunteers who have no history of disease or no family history of
possible inheritable disorder. The blood type, or at least the Rh
factor, can be matched with the woman’s to prevent
incompatibility. Sperm from sperm banks can be selected
according to the desired physical or mental characteristics.
The installation of sperm into the female reproductive
tract to aid conception. The sperm is instilled into the
cervix (intracervical insemination) or directly into the
uterus (intrauterine insemination). Either the husband’s
sperm (artificial insemination by husband) or donor
sperm (artificial insemination by donor or therapeutic
donor insemination) can be used.
Some couples have religious or ethical beliefs that prohibit them
from using artificial insemination. Some states have specific
laws regarding inheritance, child support, and responsibility
concerning children conceived by artificial insemination.
Artificial insemination takes an average of 6 months to achieve
conception, it may be a discouraging process for couples to
have to wait this long to see results.
Used if the man has an adequate sperm count or a
woman has a vaginal or cervical factor that interferes
with sperm motility.
In Vitro Fertilization
Donor insemination can be used if a man has a known
genetic disorder that he does not want transmitted to
children or if a woman has no male partner. It is a useful
procedure for men who, feeling their family was
One or more mature oocytes are removed from a
woman’s ovary by laparoscopy and fertilized by exposure
to sperm under laboratory conditions outside a woman’s
body. About 40 hours after fertilization, the laboratory
grown fertilized ova are inserted into a woman’s uterus,
where ideally one or more of them will implant and grow.
Most often used for couples who have not been able to
conceive because a woman has a blocked or damaged
fallopian tube. It is also used when a man has
oligospermia (very low sperm count). IVF may be useful
to help couples when an absence of cervical mucus
prevents sperm from traveling to or entering the cervix,
or antisperm antibodies cause immobilization of sperm.
In addition, couples who have unexplained infertility of
long duration may be helped by IVF.
A donor ovum, rather than a woman’s own ovum, also
can be used for a woman who does not ovulate (genetic
disorder) or carries a sex linked disease that she does
not want to pass on to her children (these are the
indications).
Before the procedure, a woman is given an
ovulation-stimulating agent (GnRH) such as Clomiphene
citrate (Clomid). Beginning about the 10th day of the
menstrual cycle, the ovaries are examined daily by
ultrasound to assess the number and size of developing
ovarian follicles. When a follicle appears to be mature, a
woman is given an injection of hCG, which causes
ovulation in 38-42 hours.
In the harvesting procedure, a needle is introduced
intravaginally, guided by ultrasound and the oocyte is
aspirated from its follicle. Many oocytes may ripen at
once and perhaps as many as 3 to 12 can be removed.
The oocytes are incubated for at least 8 hours to ensure
viability. In the meantime, the husband or donor supplies
fresh semen specimens. The sperm cells and oocyte are
mixed and allowed to incubate in a growth medium.
After sterilization of the chosen oocyte occurs, the
zygotes formed almost immediately begin to divide and
grow. By 40 hours after fertilization, they will have
undergone their first cell division. The fertilized eggs are
then
examined through genetic analysis for
abnormalities, if it is normal, and it is transferred back to
the uterine cavity through the cervix by means of a
urinary catheter.
In some instances, progesterone may be given to a woman if it
is believed that she will not produce enough on her own to
support implantation. Once a pregnancy has been successfully
established, a woman’s prenatal care is the same as that for any
pregnancy.
Part of the nursing consideration, we nurses need to supply
support and counseling to sustain the couple through this
process. Also couples need emphatic support from the health
care providers through these difficult times.
Infertility (Subfertility)
Nursing Management:
● Change in lifestyle.
● Educate couples on a variety of tests.
○ As we all know couples have to undergo
diagnostic testing procedures in order to
determine problems of infertility. Prior to
availing those tests, we need to inform
this couple how these procedures are
being performed and what is expected
of that.
● Allow couples to express thoughts on subfertility
or sterility.
○ Infertility causes anxiety and emotional
stress to individuals or couples.
● Listen to them.
● Express their concerns.
● Let them ventilate their feelings and anxiety.
○ This way it relieves tension and airs out
feelings
of
frustrations
and
disappointments.
● Reinforce options on alternative childbirth
techniques.
○ Surrogate mothers
■ Women who agrees to carry a
pregnancy to term for a infertile
couple
○ Adoption
■ Once a ready alternative for
infertile couple
○ Child-free Living
■ An alternative lifestyle available
for both fertile and infertile
couple couples who have been
through rigors and frustrations
of subfertility testing and
unsuccessful
treatment
regimens, child free living may
emerge as the option they finally
wish to pursue.
● Self care awareness regarding fertility:
● Avoid douching
○ Can alter the pH of vaginal secretion
● Promote retention of sperm after coitus
○ Right positioning
● Maximize the potential for fertilization
■ Intervention:
Monitoring
of
ovulation and right timing of
coitus.
○ Avoid anxiety and stress.
○ Maintain adequate nutrition.
Client Education:
1. Provide information of the different tests and procedures and
possible outcomes.
2. Self care awareness regarding fertility
3. Empowering realistic expectations.
● Most infertility interventions have advantages and
disadvantages and not all of the outcomes favors the
couple’s desires. Help them set realistic goals to
prevent devastations.
4. Provide emotional support.
● With all of the anxiety and stress they are going
through, we uplift them, offer genuine encouragement,
reassurance and compassion.
5. Create or refer to support groups.
● Couples with infertility are described to be extremely
isolating. They may feel like they are the only couple
going through this. To help them, let them talk to
others who are in similar situation
6. Promote a positive self image
● We help them recognize their own assets and
potential while being realistic liabilities and limitations.
Negative self-image focuses on faults, distorting
image and imperfections. A positive self image can
boost our physical, mental, social, spiritual well being.
Pelvic Floor Dysfunction
The inability to control the muscles of the pelvic floor.
Pelvic floor acts like a sling that supports the
organs of the pelvic region
Contracting and relaxing the pelvic floor allows
us to control bowel movement and urination
In women = sexual intercourse
Childbirth can result in tears of the
sling/musculature of the pelvic floor = structural
weakness
Cystocele - (Anterior Vaginal Prolapse)
➔ Downward displacement of the bladder towards
the vaginal orifice, resulting in the damage of the
vaginal support structure.
➔ Bladder falls down into the vagina
Clinical Manifestations:
● Reports of sense of pelvic pressure, fatigue,
urinary problems (incontinence, frequency and
urinary urgency), back pain, pelvic pain
Rectocele - (Posterior Vaginal Prolapse)
➔ Wall separating the rectum from the vagina
weakens
➔ Allowing the rectum to bulge into the vagina
Clinical Manifestations:
● Reports of sense of pelvic pressure, fatigue,
rectal pressure, constipation, uncontrollable gas,
fecal incontinence (with complete tears)
Both rectocele and perineal lacerations which occur
because of muscle tears below the vagina during
delivery may affect the muscles and tissues of the pelvic
floor. Some lacerations may completely sever the
muscle fibers of the anal sphincters.
Uterine Prolapse
Vaginal Prolapse
Structures that support the uterus weaken (due to
childbirth), the uterus may work its way down to the
vaginal canal, and may appear outside the vaginal
orifice.
Weakening of the vaginal wall, allowing the pelvic organs
to protrude to the vaginal canal
Found in older women
Risk Factors:
● Age
● Parity
● Vaginal delivery
● Familial predisposition
●
Normal Anatomy: Uterus and cervix lie at the
right angle to the long axis of the vagina with the
body of uterus slightly inclined forward; freely
movable upon examination
Signs and Symptoms:
● Pelvic heaviness or pulling
● Vaginal bleeding or an increase in vaginal
discharge
● Difficulties with sexual intercourse
●
●
●
●
●
Stress incontinence, urinary problems - pressure
on the bladder
Constipation
Lower back pain
Sensations of sitting on a ball or that something
is falling out of the vagina
Coughing aggravates S/S
Etiology:
● Pregnancy and delivery
● Menopause
● Frequent heavy lifting,
coughing
● History of pelvic surgery
○
●
●
Estrogen is vital in maintaining muscle
strength
Rest
Pessary Use
○ Clean daily, change q3 months, perineal
hygiene
Sexual Dysfunction
straining,
chronic
Management:
✓ Surgery (Colporrhaphy, vaginal hysterectomy)
Uterus is sutured back into place and repaired to
strengthen and tighten the muscle
❖ Anterior colporrhaphy - repair of cystocele
❖ Posterior colporrhaphy - repair of rectocele
➢ A laparoscopy is inserted through a
small abdominal incision, pelvis is
visualized, and surgery is performed.
❖ Vaginal Hysterectomy - removal of uterus (For
post menopausal women)
✓ Stool softener
✓ Pessary application
Treatment of choice for elderly women or too ill
women who cannot tolerate surgery
Pessary: ring-shaped, doughnut-shaped, made
of various materials (rubber or plastic)
Device is inserted into the vagina, positioned to
keep an organ properly aligned when a prolapse
has occurred
Nursing Management:
● Pelvic exercise (Kegel exercise - to help
strengthen weakened muscles in the pelvic
cavity; effective in the early stages of prolapse)
● Increase fluid intake and correct misconceptions
about fluid restrictions to reduce incontinence
● Vaginal estrogen
This can happen at any phase of sexual response cycle,
and it prevents an individual from experiencing
satisfaction from sexual activity.
1. Desire disorders
Lack of sexual desire or interest in sex
Effect of the medicine or chronic disease such
as peptic ulcer or chronic pulmonary disorder
that causes frequent pain and discomfort. This
may interfere with the man and women’s overall
wellbeing and interest in sexual activity.
2. Arousal disorders
Inability to become physically aroused or excited
during sexual activity.
Can be caused by physical or psychological
factors or both. Needs careful assessment to
help clarify the cause of the problem.
3. Orgasm disorders
Delay of absence of orgasm
The failure of women to achieve orgasm can be
a result of poor sexual technique, or
concentrating too hard on achievement or
negative attitude toward sexual relationships.
Treatment is aimed to relieve the underlying
cause and it may include instruction and
counseling for the couple about sexual feelings
and needs. Like the arousal disorder, disorder of
orgasm occurs in both men and women.
4. Pain disorders
Pain during intercourse (dyspareunia)
Because the reproductive system has sensitive
nerve supply when pain occurs in response to
sexual activities it can be acute or severe and
impairs a person’s ability to enjoy this segment
of life.
Examples of a condition under pain disorder:
Vaginismus, dysporonea, vestibulitis,
Vaginismus
●
■ Involuntary contraction of muscles at the outlet of
vagina when coitus is attempted. This muscle
contraction prohibits penile penetration.
■ This can occur in women who have been raped and
also a result of early learning pattern in which sexual
relations are viewed as bad and sinful.
■ In other sexual problems, psychological counseling
is needed to reduce this response
Dysporonea
■ Pain during intercourse
■ Caused by endometriosis (abnormal placement of
endometrial tissue), vestibulitis (inflammation of the
vestibule), vaginal infection, hormonal changes.
Vestibulitis
■ Inflammation of the vestibule. This condition occurs
due to endometriosis or abnormal placement of
endometrial tissue, vaginal infection, hormonal
changes that occur with menopause and causes
vaginal drying.
■ A psychological condition may be present, treatment
is aimed at the underlying cause, encouraging open
communication between the sexual partners is
necessary.
5. Premature Ejaculation
Ejaculation before penile-vaginal contact
This term is also used to mean ejaculation
before the sexual partner achieved satisfaction.
This can be unsatisfactory and frustrating to
both partners.
Other reasons suggest: doubt of muscularity
and fear of impregnating the woman, which
prevents the men from sustaining an erection.
Sexual counseling to both partners may be
helpful to reduce stress in alleviating the
problem.
6. Persistent Sexual Arousal Syndrome
Excessive sexual arousal in the absence of
desire.
May be triggered by medications or
psychological
Assess herbal medications
Etiology:
● Urologic problem
●
●
●
●
Chronic conditions
○ Such as pulmonary disease
○ Peptic ulcer can also lead to sexual
dysfunction.
○ For example, pulmonary disease, if an
individual has chronic pulmonary
disease he/she has the tendency to
cannot perform, maybe the individual
will experience difficulty in breathing.
He/She will be deprived of air so the
individual cannot reach or an individual
has a sexual disorder.
○ Example: A diabetic individual has
decreased libido because of the
hormone and overweight individuals can
also be one of the etiology of sexual
dysfunction.
Hormonal imbalance
Alcohol and drugs
Nerve damage from operations
Psychological in origin
Signs and Symptoms:
● Lack of sexual desire
○ Lack of interest into coitus
● Difficulty in arousal
○ Problems like erectile dysfunction or
impotence
● Pain during intercourse
Management:
● Counseling, behavior modification
● Sildenafil (Viagra)
○ Problems of impotence (relaxant of the
smooth muscle, enabling blood flow to
the penis)
○ Prescribed to this individual to correct
some sexual dysfunction
● Mechanical aids
○ Such as vaginal vacuum, these are
mechanical aids in helping relieve pain
during sexual intercourse and maybe
penile implant
○ Dilators for women who experience
narrowing of the vagina, vibrators to
improve sexual enjoyment and climax
● Psychotherapy
Nursing Considerations:
● Educate on preventing sexual dysfunction.
○ How to prevent: We need to understand
the underlying cause then we can be
●
●
able to help them abstain or prevent
from having sexual dysfunction.
Diet modification
○ Obesity could be a cause in sexual
dysfunction. A diabetic individual can
also experience sexual dysfunction.
Control health if comorbidities are present.
○ Health
conditions
like
chronic
conditions. We need to inform them that
they need to see a doctor to have
maintenance medication so that they
may be able to do some of the activities
that they wanted to do, especially
activities for couples.
CANCER
A group of diseases involving abnormal cell growth with
the potential to invade or spread to other parts of the
body (malignant).
EARLY WARNING SIGNS FOR CANCER (CAUTION)
Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or scrotum
Indigestion or difficulty in swallowing
Obvious change in a mole or wart
Nagging cough or hoarseness
MALIGNANCY
ETIOLOGY
Cervical
HPV, DES, multiparity, smoking,
OCPs (oral contraceptives)
Endometrial
Obese, metabolic syndrome,
Tamoxifen, estrogen alone,
nulliparity, early menarche, late
menopause
Uterine
HFD (heredofamilial dxs),
endometriosis
Ovarian
Postmenopausal hormone, therapy,
obesity
Vaginal
Old age, HPV
Cervical Cancer
★ Cancer carcinoma of cervix
★ 2nd Most Prevalent Cancer in women
★ 5th Leading Cause of Cancer Deaths
Endometrial / Uterine Cancer
★ Major Risk Factor: Cumulative Exposure to
Estrogen
○ Occurs with the use of estrogen therapy
without the use of progestin
★ Other
risk
factors:
Infertility,
diabetes,
nusaftaxophin (treatment/prevention of breast
cancer; may cause proliferation of the
endometrial lining)
Vaginal Cancer
★ Rare
Signs and Symptoms:
● Vaginal bleeding
● Pelvic pain
Diagnosis:
Pelvic Exam
➢ Visual and physical examination of the
reproductive organ
➢ Inspects vagina, cervix, fallopian tube, vulva,
ovaries, uterus
Dilatation & Curettage
➢ Cervical canal is widened with a dilator, uterine
endometrium is scraped with a curette
➢ To secure endometrial/endocervical tissue for
cytologic examination (to control abnormal
bleeding & therapeutic measure for incomplete
abortion)
Pap Smear
➢ Cytologic Test for Cancer
➢ Cervical secretions are gently removed from the
cervix orifice, transferred to a glass slide, and
fixed immediately by spraying with a fixative or
immersed in a solution
➢ Atypical cells = liquid method allows for HPV
➢ Performed when patient is not menstruating,
blood interferes with the testing
HPV Testing
➢ Screening Test for Cervical Cancer
➢ Detects the presence of the virus that causes
cervical cancer
➢ Done concurrently with a Pap Smear
Colposcopy
➢ If Pap Smear result requires further evaluation
➢ Colposcope - a portable microscope that
visualizes the cervix and obtain a sample of
abnormal tissue for analysis
➢ After, examiner applies acetic acid to the cervix
➢ Subsequent Abnormal Findings: (-> Biopsy)
○ Leukoplakia: white plaque visible before
applying acetic acid
○ Acetowhite Tissue: white epithelium
after applying acetic acid
○ Punctation: Dilated capillaries occurring
on a dotted or stippled pattern
Biopsy
➢ If biopsy results show premalignancy cells,
patient must undergo cryotherapy, laser therapy,
or cone biopsy
○ Cryotherapy: freezing of cervical tissue
with nitrous oxide
■ Result to cramping, faintness
○ Laser treatment: outpatient setting
Transvaginal Ultrasound
➢ Abdominal - probe is placed on the abdomen;
vaginal - probe is placed on the vagina
➢ Less than 10 minutes
➢ No discomfort, full bladder is necessary
(abdominal)
PROSTATE CANCER
Most common cancer in men
Risk Factors:
● Increase in age
● HFD
● Obesity
Signs and Symptoms: (Early stages = no S/S)
● Dysuria
● Blood in semen
● Pelvic pain
● Erectile dysfunction
Diagnosis:
Digital Rectal Exam (DRE)
➢ Early cancer may be detected within the gland
(hardening of the posterior lobe of the prostate)
➢ Provides clinical information about the rectum,
sphincter, and quality of stool
Prostate Specific Antigen (PSA) Test
UTZ Guided Transrectal Ultrasound Scan (TRUS) with
Biopsy
➢ Diagnosis for Prostate Cancer is confirmed by a
histologic
examination of tissue removed
surgically by TURT (UTZ Guided Transrectal
Ultrasound
Rectal
Scan)
and
open
prostatectomy or UTZ Guided Transrectal
Needle Biopsy
Treatment:
● Surgery
○ Radical Prostatectomy - standard first
line treatment; used for px with tumors
confined to the prostate; complete
removal of the prostate, semilunar
vesicles, tip of vas deferens, surrounding
fat and blood vessels
● Radiation Therapy
○ Teletherapy (External Beam Radiation
Therapy) - 5 days per week, for 7-8
weeks; low-risk prostate cancer
○ Brachytherapy (Internal Beam Radiation
Therapy)
Internal
implants:
Implantation of interstitial radioactive
seeds under anesthesia; monotherapy
treatment for early and clinically organ
confined prostate cancer
● Hormone (Testosterone-Antagonist)
○ Androgen Deprivation Therapy (ADT) suppress the adregonic stimuli to the
prostate by decreasing the level of
circulating plasma testosterone or
interrupting the conversion of binding to
the dihydrotestosterone.
■ >
Prostatic
epithelium
atrophies/decrease
in size,
accomplished through surgical
castration (removal of testes)
■ Removal of testes decreases
the plasma testosterone levels >
testicular stimulus required for
continued prostatic growth is
removed > decreasing the size
of prostate
Offered implantation of a testicular
prosthesis during procedure
Chemotherapy - Used for germinal and
advanced metastatic disease
Radiation Therapy - Used if Chemotherapy is not
effective; for lymph nodes where surgery is not
recommended
Cisplatin - Used in combination with other
chemotherapeutic agents
○
●
●
●
PENILE CANCER
TESTICULAR CANCER
Rare type of cancer in men
Testicles contain several types of cell. Each of which
may develop a type of cancer.
Germinal Cancer: from the Germ cells
Non-Germinal Tumor: Develop in the supportive and
hormone-producing tissues (stroma)
Signs and Symptoms:
● Lump (painless) & feeling of heaviness
● Dull pain on abdomen & groin
● Back pain
● Weight loss, overall weakness
● Enlargement of testes without pain
Risk Factors:
● Cryptorchidism (Undescended testicles)
● 15-35 years old
● White race
Diagnosis:
TSE
UTZ
Treatment:
● Radical Inguinal Orchiectomy - Removal of
affected testes with a high ligation of the
spermatic cord
Risk Factors:
● Lack of circumcision (Trapped body fluids)
● Poor genital hygiene
● Phimosis (Foreskin of penis cannot be retracted
over the glans)
● Exposure to HPV, AIDS
● Smoking
● UV Light Treatment of Psoriasis of the Penis
● Increasing Age
Signs and Symptoms:
● Penile lesions
● Painless lump or discoloration
● Ulceration (Wart-like)
● Crusty bumps
● Smelly discharges
● Swelling
Diagnosis:
Physical Examination
Biopsy
➢ Determine cell type of the penile cancer
➢ Tissue is collected from the lesions
Treatment:
Goal for Invasive Penile Cancer: Complete excision with
adequate margins
● External Beam Radiation
● Surgical Removal - Used in all forms of the
disease
Therapeutic Options include: Simple
excision, wide local excision,
circumcision, surgical removal of the
part (partial penectomy) or penis (total
penectomy)
Chemotherapy
○
●
Nursing Management (Cancer):
● Lifestyle interventions for prevention
● Assistance in therapy
● Chemotherapy nursing management
● Reproductive counseling
●
INFECTIONS
organisms, usually bacteria normally
found in the vagina like lactobacilli, are
outnumbered by other bacteria such as
anaerobes . If anaerobic bacteria
become too numerous they accept the
balance causing bacterial vaginosis.
○ This type of vaginitis seems to be linked
to sexual intercourse especially if a
person has multiple sexual partners or a
new sex partner. It also occurs in
women who aren’t sexually active.
Trichomoniasis
○ Common sexually transmitted infection
is caused by a microscopic one celled
parasite called trichomonas vaginalis.
○
Vaginitis
○
●
An inflammation of the vagina that can result in
abnormal discharges, itching, irritation, burning and pain.
- The cause is usually a change in the normal balance of
the vaginal bacteria or an infection.
- Normal low pH: 3.5 - 4.5 (lactobacillus acidophilus)
- Reduced estrogen level after menopause and some
skin disorders can also cause vaginitis.
Etiology:
● Yeast infection
○ Occurs when there is overgrowth of
fungal organisms, usually caused by
candida albicans in the vagina.
○
○
●
Candida albicans also causes infection in
other moist areas of the body such as in the
mouth in the form of oral thrush, skin folds
and nail beds. The fungus can also cause
diaper rash.
Antibiotics, hormone therapy, diabetes
Bacterial Vaginosis - STI
○ Most common cause of symptoms
○ Results from a change of the normal
bacteria found in the vagina. The
overgrowth of one of the several
Trichomonas vaginalis
■ This organism spread through
sexual intercourse with some who
have the infection. In men, the
organism usually infects the urinary
tract that often causes no
symptoms.
In women, trichomoniasis usually infects the
vagina and might cause symptoms also
increases a woman’s risk of getting sexually
transmitted infection.
Atrophic Vaginitis - the thinning of tissues and
less moisture due to decreased estrogen (e.g.
menopause)
Signs and Symptoms:
● Discharges
○ Changes in the color, odor and amount
of discharges from the vagina.
● Redness, swelling, itching, pain during
intercourse
● Odor
● Dysuria (Painful urination) - involvement of
urethra
● Light vaginal bleeding or spotting
● Pain or bleeding upon sex
● Edema aggravated by urination or defecation
Nursing Considerations:
● Explain the importance of a complete course of
antibiotic therapy to prevent resistance to the
drug. (Usually 7 days)
● Avoid douching.
● Avoid irritants.
○
This includes scented
douching, scented soap.
tampons,
pads,
○
○
●
●
Rinse soap from the outer genital area after a
shower and dry the area well to prevent
irritation.
Do not use harsh soaps such as those with
deodorant and antibacterial action or bubble
bath.
Avoid tampons. Regularly change sanitary pads.
Practice protected sex.
○
○
○
○
The use of latex condoms. Both male and
female latex condoms may help you avoid
infections spread by sexual contact.
Treatment:
After identifying the causative organism, appropriate
treatment is prescribed right away. May be oral or
inserted into vagina through an applicator.
Pelvic Inflammatory Disease (PID)
- Infection of the female reproductive organ spreading
from the vagina to the uterus, fallopian tubes or ovaries.
- This is an ascending infection in the upper genital tract
caused by poly microbial organisms.
- Starts at the infection of the cervix > the rest follows i.e.
uterus > fallopian tubes > etc.
- This may include infection of any of the following
anatomical structures: endometrium, oviduct, ovary,
uterine wall, uterine serosa, broad ligaments and the
pelvic peritoneum.
Etiology:
● STDs (Gonorrhea and Chlamydia)
○ Many types of bacteria can cause PID
but gonorrhea and chlamydia are the
most common one.
○ These bacteria are usually acquired
during unprotected sex. Less commonly,
bacteria can enter the reproductive tract
anytime.
● Childbirth, miscarriage and abortion
The normal value created by the cervix
is disturbed.
This can happen during menstruation
and childbirth, or miscarriage or
abortion.
Rarely bacteria can also enter the
reproductive tract during the insertion of
IUD, a form of long term birth control or
any medical procedure that involves
inserting instruments to the uterus.
Risk Factors:
● Sexually active, more than one sexual partner
○ Women younger than 25 years old
having multiple sexual partners or being
in a sexual relationship with a person
who has more than one sexual partner.
● Unprotected sex
○ Sex without condom
● Douching regularly
○ Which upset the balance of good versus
harmful bacteria in the vagina.
● History of PID or STD
Signs and Symptoms:
● Pain in your lower abdomen and pelvis
● Heavy vaginal discharge with an unpleasant
odor
● Abnormal uterine bleeding, especially during or
after intercourse, or between menstrual cycles
● Pain or bleeding during intercourse
● Fever, sometimes with chills, N/V, malaise,
anorexia, headache
● Painful or difficult urination
● On Pelvic Examination: Intense tenderness
noted on palpation of uterus or movement of
cervix
● Symptoms may be acute and severe or
low-grade and subtle
Diagnosis:
Pap smear (Papanicolaou smear)
Culture & Sensitivity Testing - know
causative agent
UTZ (ultrasound)
Nursing Considerations:
● Encourage to practice safe sex and use of
contraception.
○
The use of condoms every time an individual
engage into sex and the limitation of numbers
○
○
○
●
of partner and ask about potential partner
sexual history.
The use of birth control pills does not protect
against the development of PID.
Using barrier methods such as condoms
helps to reduce the risk even if you are taking
birth control pills.
The use of condom every time an individual
engage into sex with a new partner protects
STI.
Avoid douching.
○ Douching upsets the balance of bacteria
in the vagina.
Treatment:
● Antibiotics (same with partner)
○ Ceftriaxone - if bacterial
● Temporary abstinence
Chlamydia
Causative agent: Chlamydia trachomatis.
- Women = no S/S but if present, a mucopurulent
(presence of mucus or pus with exudates) in the
endocervical canal
- Men = no S/S but if present burning sensation during
urination with penile discharges
Gonorrhea
SEXUALLY TRANSMITTED DISEASES
Signs and Symptoms:
● Sores or bumps on the genitals or in the oral or
rectal area
● Dysuria, dyspareunia
● Discharge from the penis
● Unusual or odd-smelling vaginal discharge
● Unusual vaginal bleeding
● Sore, swollen lymph nodes
● Lower abdominal pain
● Fever, Rashes
Etiology:
Bacteria
Parasites
Viruses
Diagnosis:
Culture &
Sensitivity
Testing
Pap Smear
Risk Factors:
Unprotected sex
Multiple partners
History of STI
Vertical transmission
Treatment:
● Antibiotics
● Antiviral drugs
Nursing Considerations:
● Promote prevention of STIs (Abstinence, stay
with one uninfected partner, vaccination,
protected sex)
● Pre Exposure prophylaxis (eg. Truvada Descovy)
● Genital hygiene
● Counseling
Causative agent: Neisseria gonorrhoeae
- Women: Purulent cervicitis (exudate in the cervical
canal); present with UTI or vaginitis
- Men: Burning sensation during urination, penile
secretions, painful and swollen testicles
Syphilis
Acute, chronic infection disease
Causative agent:Treponema pallidum.
Course of Syphilis
● Primary Syphilis
○ Occurs 2-3 weeks upon exposure of the
organism
○ Painless lesion: Chancre
■ Resolves on its own about 2
months
● Secondary Syphilis
○ Occurs when the spread of organism
from the original chancre leads to
generalized infection
Rashes about 2-8 weeks after
the chancre, involves trunks and
extremities
Tertiary Syphilis
○ Final stage: Presents a slowly,
progressive, inflammatory disease with
the potential to affect multiple organs
■ Aortitis, neurosyphilis
(evidenced by dementia)
psychosis, stroke, meningitis
■
●
Genital Herpes
HIV
Human Immunodeficiency Virus
Spread by contact with infected blood, or mother-to-child
through pregnancy, delivery, breastfeeding
- Weakens the immune system, chronic potentially life
threatening disease
Signs and Symptoms:
Acute Phase: Fever, headache, sore throat, painful mouth
sores, diarrhea, night sweats
Common. Caused by HPV.
- After initial infection, the virus lies dormant in the body
and can reactivate several times a year.
- Cause pain, itching, sores in the genital area.
- Some may have no S/S.
- Small red bumps, tiny white blisters may appear few
days to weeks after the infection
- Ulcers may form when blisters rupture and ooze out
blood
- Ulcers may cause pain when urinating and cause scabs
as ulcers heal
Genital Warts
Caused by HPV
- Affect the moist tissue of the genital area
(small flesh-colored bumps or cauliflower
appearance
- Itching, discomfort in the )genital area, bleeding
in intercourse
Prostatitis
- Inflammation or swelling of the prostate gland. It can
be very painful and distressing but will often get better
eventually. - Can come at any age but usually between
the age 30-50 years old. - Prostate is a small gland that
lies between the penis and the bladder. It produces fluid
that mixes with sperm to create semen.
Signs and Symptoms:
● Dysuria, nocturia, hematuria
○ Pain when peeing
○ There is frequency, urgency or the need to pee
particularly at night or stop-start peeing.
● Pain in the abdomen, groin or lower back
● Pain in the area between the scrotum and rectum
● Pain or discomfort of the penis or testicles
● Painful ejaculation
● Fever
Pain is also present in and around the penis, testicles,
anus, lower back or lower abdomen. There is also
enlargement or tenderness of the prostate on rectal
examination. Sexual problem could also be present such
as erectile dysfunction, pain when ejaculating or pelvic
pain after sex. And the typical sign of infection such as
fever. These symptoms can have a significant impact on
the quality of life but in most cases they gradually
improve every time and with treatment.
Epididymitis
- Where a tube or the epididymis at the back of the
testicle becomes swollen and painful.
- It is often caused by an infection and is usually treated
with antibiotics.
- If the testicles is also affected, if maybe called
epididymo-orchitis
- The inability to retract the foreskin from the glans of the
penis.
- Can occur naturally or be the result of scarring.
- Young boys may not need treatment, unless it makes
urination difficult or causes other symptoms.
- Tight foreskin is common in baby boys who are not
circumcised (usually stops by 3-years-old).
Balanitis
Signs and Symptoms:
● A swollen, red or warm scrotum
● Testicle pain and tenderness
● Dysuria
○ Pain upon urination
● Discharge from the penis
● Pain or discomfort in the lower abdomen or pelvis
● Blood in the semen
● Fever
○ Typical sign of infection
Etiology:
● Current UTI
○ Less common in men
● STI (chlamydia or gonorrhea)
○ More likely in younger men under 35-years-old
● Groin injury (epididymitis)
○ Undergone surgery to the groin, prostate and
bladder
- Inflammation of the phimotic foreskin (glans/head of
the penis).
- Due to infection or other causes.
- Can be uncomfortable and sometimes painful but is
not usually serious.
- Relieved with topical medication.
Nursing Considerations:
● Encourage proper hygiene.
● Instruct not to forcibly retract the skin.
○ Paraphimosis may occur.
○ A urologic emergency in which the retracted
foreskin of an uncircumcised male cannot be
returned back to its normal anatomical position;
recognizing the condition promptly, can lead to
gangrene and amputation of the glans penis.
Treatment:
● Steroid cream
● Circumcision (Left: Phimosis; Right: Normal Retracted
Foreskin)
Treatment:
● Antibiotic
Nursing Considerations:
● Lie down with elevated scrotum.
● Cold packs over scrotum (hypogastric area) to relieve
pain and discomfort.
● Avoid lifting heavy objects.
● Abstinence ● Avoid alcohol, caffeine, spicy and acidic
foods that irritate the bladder.
● Encourage increase in water intake.
INFANTS
Phimosis
Hypospadias
- Abnormal ventral placement of urethral opening on the
underside of the penis.
- Birth defect or congenital condition in which the
opening of the urethra is on the underside instead of at
the tip.
- Urethra: Tube through which urine drains from the
bladder and exits to the body.
- Common and does not cause difficulty caring for this
infant.
- Surgery usually restores the normal appearance of the
child’s penis.
Signs and Symptoms:
● Opening of the urethra other than the tip of the penis
● Chordee
○ Downwards curvature of the penis
● Hooded appearance of the penis (only the top half of
the penis is covered by foreskin)
● Normal (spraying?) during urination
Nursing Considerations:
● No circumcision
● Catheter care (in surgery)
● Urinary diversion
○ Position drainage bag at lower level to
facilitate continuous flow of urine.
● Avoid tub baths, straddle toys, sandboxes, swimming
and rough activities.
● Encourage quiet play after the first few weeks of
surgery. Avoid contact sports while the catheter is in
place.
Pharmacological Management:
● Anticholinergic (Oxybutynin)
○ Used to treat bladder spasm
- Failure of urethra to close; opening at the dorsal of the
penis.
- The urethra does not form properly.
- So all boys with bladder exstrophy also have
epispadias, but it can occur on its own.
Nursing Considerations:
● Clamp cord with soft umbilical tape or silk suture.
● Parental support
Treatment:
● Surgery
(How Bladder Exstrophy looks like with Epispadias: Male)
Cryptorchidism
Treatment:
● Surgical correction: 6-12 months of age
● Testosterone (pre-op)
○ To increase the size of the penis
● Goal: To improve the physical appearance, to be able
to void in a standing position and sexually adequate
organ.
Bladder Exstrophy
- Severe defect involving the musculoskeletal system
and urinary, reproductive and intestinal in some cases.
- Congenital abnormality that occurs whenever the skin
over the lower abdomen does not form properly—the
bladder is open and exposed on the outside of the
abdomen.
- “Exstrophy” = turned inside out
Epispadias
- Failure of one or both testes to design through the
inguinal canal into the scrotum.
- Undescended testicle. Usually one testicle is affected
but about 10% of the time, both testicles are
undescended. An undescended testicle is uncommon in
general but common among babies born prematurely.
The undescended testicle moves into proper position on
its own within the first few months of life. If your son has
undescended testes that don't correct themselves, then
surgery can relocate the testicle into the scrotum.
Signs & Symptoms
- Absence of testes in the scrotum. Testicles formed in
the abdomen during fetal development. During the last
couple of months of normal fetal development, the
testicle gradually descends from the abdomen through a
tube-like passageway in the groin or inguinal cavity into
the scrotum.
- Acquired undescended testes
- Retractile testes on warm baths
Treatment
- Spontaneous descend within 6 months of life
- Surgery 12-18 months of life
- Orchiopexy (a procedure to move testicle that has not
descended or moved down to its proper place in the
scrotum. Done 6-24 months of life)
Nursing Consideration
- Pain management
- Keep post-op site free from stool and urine. Take note
of the anatomical position of the site and the possibility
of contaminating urine
- Avoid rough sports and straddling
- Teach child TSE starting puberty
Treatment
Surgery - for communicating hydrocele, this is corrected
within 1 year
Nursing Consideration
- Swelling and discoloration are temporary
- Change dressing everyday and bathe after 3 days
- Avoid straddle toys for 2-4 weeks
ADOLESCENTS
Varicocele
Hydrocele
- Presence of peritoneal fluid in the scrotum between the
parietal and visceral layers of the tunica vaginalis. Most
common painless scrotal swelling in children.
- Swelling in scrotum that occurs when fluid collects in
the thin sheet surrounding the testicle.
- Common in newborns and usually disappear without
treatment by age 1. Other boys and adult men can
develop hydrocele due to inflammation or injury within
the scrotum.
- Is not usually painful or harmful and might not need any
treatment
2 types of Hydrocele
Communicating Hydrocele
- Open processus vaginalis
- Has an opening into the abdominal cavity. The opening
allows abdominal fluid to pass into the scrotum.
Noncommunicating
- Less serious
- Usually remains the same size or has a very slow
growth. No connection with peritoneum or due to
secondary trauma, infection, torsion.
If the communicating hydrocele does not go away on its
own, and is not treated, it can lead to an inguinal hernia.
- Elongation, dilation and tortuosity of the veins of the
spermatic cord or rather this is an enlargement of the
vein within the loose bag of skin that holds the testicle or
the scrotum.
- Similar to varicose vein that you may seen in the legs
- Common cause of low sperm production and decrease
sperm quality which can cause infertility
- Can cause testicle to fail to develop normally or shrink Most varicocele develop overtime or most varicocele is
easy to diagnose and may not need treatment
- If it causes symptoms is often can be repaired
surgically
Signs and Symptoms:
● Rarely it might cause pain (sharp to dull discomfort).
● There is increased pain when standing or physical
exertion over long periods. It worsened over the course
of the day and relieved when the person lay down on his
back. This causes impaired infertility.
● Physical Appearance:
○ Wormlike mass above the testes
○ Decrease testes
○ Decrease dihydrotestosterone
Treatment:
● Varicocelectomy
○ A surgery is performed to remove those
enlarged veins and it is done to restore proper
blood flow to the reproductive organ.
ADULT WOMEN
Breast Cancer
- Cancer that forms into the cells of the breast , after skin
cancer breast cancer is the most common diagnosis in
women.
- Occurs both in men and women, but far more common
in women.
- Survival rates have increased and the number of deaths
associated with this disease is steadily declining.
- Largely due to factors such as early detection, new
personalized approach to treatment and better
understanding of the disease.
Signs and Symptoms:
● A breast lump or thickening that feels different from
the surrounding tissue
● Changes in the size, shape or appearance of a breast
particularly during physical and breast examination
● Changes to the skin over the breast, such as dimpling
● A newly inverted nipple
● Peeling, scaling, crusting or flaking of the pigmented
area of the skin surrounding the nipple (areole) or breast
skin
● Redness or pitting of the skin over your breast like the
skin of an orange
Treatment:
● Lumpectomy
○ A surgery to remove cancer or other abnormal
tissue from the breast.
○ Also called breast conserving surgery or wide
location incision because only a portion of the
breast is removed.
○ During lumpectomy, a small amount of tissue
around the lump is taken to help ensure that all
cancer or other abnormal tissue is removed.
● Mastectomy
○ A surgery to remove all breast tissues from a
breast as a way to treat or prevent breast cancer.
○ With those early stages of cancer mastectomy,
maybe one treatment option.
● Chemotherapy
○ Drug treatment that uses powerful chemicals
to kill fast growing cells in the body.
○ Is most often used to treat cancer, since
cancer cells grow and multiply more quickly than
most cells in the body.
○ Many different chemotherapeutic drugs are
available, chemotherapy drugs can be used
alone or in combination to treat a wide variety of
cancer.
● Radiation Therapy
○ A type of cancer treatment that uses a beam
of intense energy to kill cancer cells.
○ Most often used x-rays but proton or other
types of energy can be used.
○ Most often refers to external beam radiation
therapy.
○ Damages cells by destroying genetic material
that controls how cells grow and divide. While
both health and cancerous cells are damaged by
radiation therapy.
○ The goal is to destroy as few normal cells,
healthy cells as possible. Normal cells can often
repair much of the damage caused by radiation.
Nursing Considerations:
● Chemotherapy support
○ Helps aid in the overall health and well-being
of an individual. So support from family, friends
and healthcare providers has value to participate
as to deal with the disease and treatment.
● Hydration
○ Providing adequate hydration can counter the
effect of dehydration for significant planned
visits to cancer clinics, proper hydration of the
patient.
● Address body image concerns.
○ The body image concerns in women have
been attributed to loss of breast from surgery,
this result scarring, physical changes resulting
from adjuvant treatment.
○ All of which have an impact on overall quality
of life, particularly body image perception.
Fibrocystic Breast
- Nodular or glandular breast tissue or these are
composed of tissues that feel lumpy or ropelike in
texture.
- More than half of women experienced fibrocystic
breast changes at some point of their life.
- In fact medical professionals have stopped using the
term fibrocystic breast disease and now simply refer to
fibrocystic breast. Fibrocystic breast changes because
having fibrocystic breast is not really a disease.
- Breast changes categorized as fibrocystic are
considered normal. Although many women with
fibrocystic breasts do not have symptoms, some women
experience breast pain, tenderness and lumpiness
especially in the upper outer area of the breast.
- Breast symptoms tend to be most bothersome just
before menstruation. Simple self-are measures can
relieve discomfort associated with fibrocystic breasts.
Etiology:
● Related to estrogen
Signs and Symptoms:
● Breast lumps with fluctuation size especially during or
nearing menstruation
● Generalized breast pain or tenderness
● Green or dark brown nonbloody nipple (secretion is
present)
● Monthly increase in breast pain or lumpiness from mid
cycle (ovulation) to menstruation
Diagnosis: (Detected through)
○ Clinical & self-breast exam
- the doctor checks the breast and lump
modules by the lower neck and underarm areas;
if normal breast changes = no need for
additional tests
○ Mammogram
- 45 yrs & above; to take annually. Focuses on a
specific area of concern in the breast.
○ Ultrasound
- uses soundwaves to produce image of the
breast and often performed with mammogram;
better use for younger women; can help the
doctor distinguish fluid filled cyst and solid
mass
Treatment
● Fine-needle aspiration
● Surgical incision
Fibroadenoma of the Breast
- Solid, non cancerous breast lumps that occur most
often in women between the ages of 15 and 35.
Hormonal in nature.
- Cause is unknown
- Occurs more often during the reproductive years
- Becomes bigger during pregnancy or hormone therapy
- May shrink after menopause
S/S:
● Firm, smooth, rubbery or hard and has a well-defined
shaped lump
● Painless, moveable
● Complex fibroadenomas - this contains changes such
as an overgrowth of cells or hyperplasia that can grow
rapidly; diagnosed after reviewing the tissue from a
biopsy
● Juvenile fibroadenomas - most common; found in
adolescent girls (10-18 y.o.). It can grow large but
shrinks overtime and some may disappear
● Giant fibroadenomas - can grow larger than 2 in. or 5
cm; might need to remove because they can press on or
replace other breast tissue
● Phyllodes tumor - usually benign; some can become
cancerous or malignant. Doctors recommend removing
the tumor.
Fine-needle aspiration
- Pain at the suprapubic area or lower abdomen during or
shortly after menstruation
Two Types
● Primary dysmenorrhea
- due to prostaglandin release.
- 8-48 hrs.
○ Occurs at menarche and continues throughout
life
○ Commonly first 3 to 5 years after menarche or
after ovulation is established
○ Usually life-long
○ Can cause frequent and severe menstrual
cramping for severe and abnormal uterine
contraction
● Secondary dysmenorrhea
- due to pathologic condition. Dull pain that
radiates to buttocks and thighs
○ Usually starts later in life which may be
because of another medical condition such as
PID and endometriosis
Risk Factors:
● Obese, Smoking
● Drinking alcohol during period tends to prolong
menstrual pain
● Early menarche (before the age of 11), nulliparity
- May collapse the cyst and resolve the discomfort
Treatment
● Monitoring to detect changes in the size (can shrink or
disappear on their own)
● Biopsy - to evaluate the lump
● Surgery - to remove the lump
○ Lumpectomy
○ Cryoablation
Nursing Considerations
● Instruct to wear firm support bra
● Avoid caffeine and fats
● Warm pack for discomfort
Dysmenorrhea
Nursing Considerations:
● Heating pad or hot baths
● Massage on lower back to relieve cramping
● Yoga, acupuncture, aromatherapy
● TENS or transcutaneous electrical nerve stimulation
● Diet modifications: low salt and sugar
● NSAIDS or Nonsteroidal Anti-Inflammatory Drugs
Imperforate Hymen
Most females are born with hymen. A hymen is a thin
membrane that stretches across the vagina. It generally
has a ring-like appearance with a small opening. There is
no real medical purpose for the hymen although some
think it may have evolved over time to help protect
vagina from infection.
Most girls have a small crescent or donut-shaped
opening in their hymen. This opening allows for access
to the vagina and approximately 1 in 1,000 girls are born
with what is called imperforate hymen.
Imperforate hymen is a hymen in which no opening to
the vagina is present. Many girls will not even be aware
that they have an imperforate hymen until they begin
their menstrual period and experience complications due
to blood pooling in the vagina.
Signs and Symptoms:
● Abdominal pain and swelling which often come and go
each month
● Back pain
● Lack of a menstrual cycle despite having other signs
of sexual maturity (developing breast and pubic hair)
● Dysuria and unable to void
Diagnosis:
● Gynecologic exam
● Vaginal or Pelvic Ultrasound
○ Rule out transverse vaginal septum or mass
■ Imperforate hymen diagnosed in girls
younger than 10 years old are often
found by chance.
■ In some cases, doctors may suspect
an imperforate hymen following a
routine newborn check. So if the doctor
suspects an imperforate hymen, they
can order a vaginal or pelvic ultrasound.
■ Can also be mistaken for other pelvic
conditions such as transverse vaginal
septum. This is a thick mass blocking
the vagina and ultrasound can help
confirm the diagnosis.
Different Types of Hymen:
● Normal
● Imperforate
● Microperforate
● Cribriform
● Septate
○ Surgically cut away part of the hymen using a
scalpel or laser
Nursing Considerations:
● NSAIDS, antibiotics as ordered
● Dilator-application
Premenstrual Syndrome
3 of every 4 menstruating women have experienced
premenstrual syndrome. Symptoms may occur in
predictable patterns but the physical and emotional
changes women experience with PMS may vary from
just slightly noticeable to all the way to intense.
We do not let this problem control our life. Treatment
and lifestyle adjustment can help reduce or manage the
signs and symptoms of premenstrual syndrome. Signs
and symptoms could be behavioral, physical, or
emotional.
Signs and Symptoms:
● Abdominal bloating
● Pelvic fullness
● Joint muscle pain
● Breast tenderness
● Weight gain due to fluid retention
● Premenstrual cravings or appetite changes
● Headache, fatigue
● Constipation, Diarrhea
● Alcohol Intolerance, Acne flares
● Depression, crying spells, irritability, panic attacks,
anger (mood swings)
● Insomnia, social withdrawal, change in libido, poor
concentration
○ Generally, these will disappear 4 days after the
start of the menstruation.
Premenstrual Dysphoric Disorder (PMDD)
- Significant physical and behavioral symptoms that
interfere with daily living.
Treatment:
● Hymenotomy
Signs and Symptoms:
● Irritability or anger that may affect other people
● Feeling of sadness or despair
● Thoughts of suicide, Feeling out of control
● Feeling of tension or anxiety, panic attacks, mood
swings or crying
● Often lack of interest in daily activities and
relationships
● Trouble thinking or focusing
● Tiredness or low energy
● Food craving or binge eating and insomnia
● Bloating, breast tenderness, headache and joint or
muscle pain
Causes:
Unknown, but there are some factors that may
contribute:
● Cyclic change in hormones or hormonal fluctuation
○ Disappears in pregnancy and menopause
● Chemical change in the brain
○ Neurotransmitters: serotonin. This is thought
to play a crucial role in mood state. With the
fluctuation of serotonin, this could trigger PMS
symptoms.
○ Insufficient amounts of serotonin may
contribute to premenstrual depression as well as
fatigue, food cravings and sleep problems.
● Depression
○ Some women with severe premenstrual
syndrome
have undiagnosed depression
although depression alone does not cause all
the symptoms.
Treatment:
● Advise women to have regular exercise and enough
sleep
● Avoid smoking, limit sugar, salt, alcohol and caffeine.
● Yoga, acupuncture, hypnosis, massage
● Stress reduction techniques
● NSAIDs
Menopausal Syndrome
- The stage of life after you have not had a period for 12
months or longer.
- This is the time that marks the end of the menstrual
cycle.
- It is diagnosed after 12 months without a menstrual
period.
- This can happen to women in their 40s or 50s, but the
average age is 51.
- A natural, biological process but the physical
symptoms such as hot flashes, emotional symptoms of
menopause may disrupt sleep, lower the energy, or
affect emotional health.
Etiology:
● Decline of hormones
● Hysterectomy
● Chemotherapy and radiation
● Primary ovarian insufficiency
○ Is said to be genetic
Signs and Symptoms:
● Irregular periods
● Vaginal dryness
● Hot flashes
● Chills
● Night sweats
● Sleep problems
● Mood changes
● Weight gain and slowed metabolism
● Thinning hair and dry skin
● Loss of breast fullness
Complications:
● Osteoporosis
○ Due to loss of estrogen in the body
○ Will lose up to 25% of our bone density
following menopause up to the age of 60
○ Makes a woman susceptible to bone fractures
particularly in the hips, spine, and wrists
● Cardiovascular diseases
● Obesity
○ Due to slowed metabolism
● Vaginal dryness
● Urinary incontinence
Treatment:
● Hormone therapy
○ Replacement of declined hormones
● Gabapentin
○ For hot flashes
○ Is said to be an anticonvulsant drug but it is
used to treat vasomotor symptoms in
premenstrual women with contraindications to
hormonal therapy
● Vitamin D and calcium supplements
○ Prevent osteoporosis
Nursing Considerations: (Key focus is more on a
symptomatic approach)
● Dress lightly
○ To counter the effects of hot flashes
● Increase cold fluids. Minimize hot beverages, spicy
foods, smoking, alcohol, stress, hot weather, and warm
room
● Use water-based vaginal lubricants
○ For vaginal dryness
● Sleep and exercise
● Kegel exercises
○ For the muscle tone in the lower pelvic area
The specific disturbance in adult men includes:
1. Benign Prostatic Hyperplasia (BPH)
- Also called prostate gland enlargement
- Common condition in men as they get older
- An enlarged prostate gland can cause uncomfortable
urinary symptoms such as blocking the flow of urine out
of the bladder. So with the blockage, it causes stasis,
urinary tract and kidney problems.
Risk Factors:
○ Aging
■ 60-years-old and above
○ Family history of BPH
○ Diabetes and heart diseases
■ Because of the use of beta blockers
○ Obesity
This slide will help us compare a normal and enlarged
prostate gland. Prostate gland is located beneath the
bladder. The tube that transports urine from the bladder
out of the penis and passes through the center of the
prostate, that tube is called the urethra. When the
prostate enlarges, it begins to block the urine flow. Most
men have continued prostate growth throughout life, and
with the enlarged prostate, this can cause urinary
symptoms or significant blocked urine.
The one with the yellow picture is the normal prostate,
and there is no obstruction in the urethra.
On the other hand, the enlarged prostate, it pushes
through the urethra causing blockage. There is little urine
passed through the urethra because of the increased
size of the prostate. The compressed urethra, a
possibility of stasis of urine in the bladder.
The severity of symptoms in people who have prostate
gland enlargement varies, but they tend to gradually
worsen over time.
Signs and Symptoms:
● Frequent or urgent need to urinate
● Increased frequency of urination at night (nocturia)
● Difficulty starting urination
● Weak urine stream or a stream that stops and starts
● Dribbling at the end of urination
● Inability to completely empty the bladder
The less common signs or symptoms are urinary tract
infections, inability to urinate, and blood in the urine.
The size of the prostate doesn’t necessarily determine
the severity of the symptoms. Some men with only
slightly enlarged prostate can have significant
symptoms, while other men with a very large prostate
can only have minor urinary symptoms. Symptoms
usually stabilize or might even improve over time.
Complications:
● Urinary retention
○ Sudden inability to urinate, the need to have a
catheter inserted into the bladder to drain the
urine.
○ In some men with larger prostates, they need
surgery to relieve the retention.
● UTI (Urinary Tract Infection)
○ The inability to fully empty the bladder can
increase the risk of infection in the urinary tract.
○ If UTI occurs frequently, the need for surgery
to remove part of the prostate.
● Bladder stones and damage
○ Generally caused by inability to empty the
bladder.
○ Bladder stones can cause infection, bladder
irritation, blood in the urine, and obstruction of
urine.
● Damaged bladder
○ Is also a complication of BPH.
○ A bladder that hasn’t emptied completely, can
stretch and weaken over time. As a result, the
muscular wall of the bladder no longer contracts
properly and makes it hard to fully empty the
bladder.
● Kidney damage
○ Pressure in the kidney from urinary retention
can directly damage the kidneys and allow
bladder infection to reach the kidney or
ascending infection.
Diagnosis:
● DRE (Direct Rectal Exam)
○ This is when the doctor inserts a finger into
the rectum to check the prostate for
enlargement.
● PSA Test (Prostate Specific Antigen)
○ Blood test
○ A substance produced in the prostate, an
increased level of which is seen in a large
prostate. However, elevated PSA levels can also
be due to recent procedure, infection, surgery,
and prostate cancer.
● UTZ, Bx (Ultrasound and Biopsy)
○ Transrectal ultrasound
○ An ultrasound probe is inserted in the rectum
to measure and evaluate the prostate.
○ Prostate biopsy, this is an examination
wherein a tissue sample is taken to help the
doctor diagnose and rule out prostate gland
cancer.
○ A transrectal ultrasound guides the needle and
takes tissue samples for biopsy.
● Cystoscopy
○ Wherein an instrument called a cystoscope is
inserted to the urethra, allowing the doctor to
see the inside of the urethra and the bladder.
○ A local anesthesia is given before the test
Treatment:
For the treatment of BPH, this could either be minimally
invasive therapy like drug therapy or surgery.
For medication or drug therapy, this is the most common
treatment for mild to moderate symptoms of prostate
enlargement. This drug includes alpha blockers and
5-alpha reductase inhibitor:
● Alpha-blockers (Tamsulosin, Alfuzosin, Doxazosin)
○ A medication that relaxes the bladder neck
muscle and muscle fiber in the prostate making
urination easier.
● 5-alpha reductase inhibitor (Finasteride, Dutasteride)
○ This medication shrinks the prostate by
preventing hormonal changes that cause
prostate growth.
● Transurethral Resection of the Prostate (TURP)
○ Surgical management
○ Done using a lighted scope inserted into the
urethra, then the surgeon removes all but the
outer part of the prostate.
○ Generally relieves the symptoms quickly and
most men have a strong urine flow soon after
the procedure. After TURP catheter is inserted
temporarily to drain the bladder
● Transurethral incision of the prostate (TUIP)
○ Same with TURP; a lighted scope into the
urethra and the surgeon makes one or two cuts
in the prostate gland, making it easier for urine
to pass through the urethra.
○ This surgery might be an option if the man has
a small to moderate enlarged prostate gland,
especially if the man has health problems that
make other surgeries too risky.
● Transurethral Microwave Thermotherapy (TUMT)
○ The doctor inserts special electrodes through
the urethra into the prostate area. The
microwave energy from the electrodes destroy
the inner portion of the enlarged prostate gland,
shrinking it and easing the urine flow. ○ Only
partly relieves symptoms and it might take some
time before a man notices the result.
Nursing Considerations:
● Instruct the patient to spread the fluid intake
throughout the day.
● Limit beverages at night, caffeine and alcohol.
○ To prevent nocturia
○ This increases the needs to urinate
● Bladder care
○ Take plenty of time to urinate and try to relax.
○ Read or think of other things while waiting.
○ For dribbling (?) problems, wash penis daily to
avoid skin irritation and infection.
● Healthy diet, minimize obesity
UNIT 8 (Week 10)
INTRODUCTION TO GENETICS AND NURSING OF CLIENTS WITH
GENETIC DISORDERS
Understanding Genetics and Related Physiology
• Genetics is the study of heredity, or the study of the way such
disorders occur.
• Heredity is a biological process where a parent passes certain
genes onto their children or offspring. Every child inherits
genes from both of their biological parents and these genes, in
turn, express specific traits.
Nature of Inheritance
• Deoxyribonucleic acid (DNA) is the cell’s hereditary material
and contains instructions for development, growth, and
reproduction of a human being. It is a molecule that encodes
an organism’s genetic blueprint. It contains all the information
required to build and maintain an organism’s body.
• Even before you were born, you already have DNA imprinted
in the cells of your body. If the DNA states that you have brown
skin or black hair, then you are born, you will have brown skin
and black hair.
•
•
•
•
DNA is located inside the chromosomes. They are thread-like
structures located inside the nucleus of animal and plant cells,
or in a human being.
•
They are thread-like structures of nucleic acids and proteins,
for example, there are DNAs inside and are tightly packed to
form a chromosome.
These chromosomes are found in the cells, specifically inside
the nucleus. In every cell, the center portion of it is the nucleus.
These chromosomes carry genetic information in the form of a
gene.
•
•
•
•
For example, it is written in the DNA that if you reach 50-yearsold, you will become bald.
Basically, a DNA is in form of letters encoded or imprinted.
In humans, each cell, with the exception of the sperm and
ovum, contains 46 chromosomes (44 autosomes and 2 sex
chromosomes). Basically, we have 23 pairs of chromosomes in
our body.
One chromosome comes from the mother and the other is
from the father (23 + 23 = 46). Why 1 until 22? These are
autosomes. These are chromosomes that are not related to
gender, because chromosome 23 (the encircled one sa picture
below) is called the sex chromosome.
Genes are the basic units of heredity that determine both the
physical and cognitive characteristics of people.
If you pull a thread from the chromosome, the DNA can be
seen, or the book of instructions. A set of DNAs is called a gene.
It has a starting point and an end point.
majjyap ‘21
UNIT 8 (Week 10)
• In the 23rd pair of chromosome, this is where we determine the
gender. If the 23rd pair of chromosome is XX, the gender is
female. If it is XY, then it is male.
•
•
•
•
Gametes of the organism’s reproductive cells are haploid cells,
and each cell carries only one copy of each chromosome.
o An example is the sperm cell and egg cell, these are
reproductive cells in our body. When these cells unite
and fertilize, it will form a zygote. Once the zygote is
formed, there are 23 pairs (22 chromosomes + 1 copy
of each chromosome from the mother and father) or
46 chromosomes. After fertilization, it will form into
an embryo. It includes the 22 autosomes and 1 sex
chromosome.
In a chromosome, there are certain areas where specific genes
are located for a specific characteristic or trait. It is called a
gene locus. It is a specific physical location of a gene or other
DNA sequence on a chromosome, like a genetic street address.
The plural of locus is loci.
o For example, the gene locus for eye colors. There are
many variations or colors for our eyes. These
variations are called alleles, or the alternative
variations of a certain trait. If the mother has brown
eyes, she has an allele of the color brown. If the father
has blue eyes, he has an allele of the color blue.
o Another example is the gene locus for hair types. The
alleles coming from the parents are either curly or
straight hair. DNA are made up of letters. Instead of
writing these variations as curly and straight, they are
written as H (represented as the dominant allele) and
h (represented as the recessive allele).
•
•
This is all the information that is found inside the individual’s
cells. It is everything that someone inherited from their
parents. It depends on the hereditary information.
o For example, there is a person who has brown hair but
his cells contain one brown hair and one blonde hair
allele. The genotype includes all of this information,
even though this person does not have blonde hair.
If the combination has two dominant alleles (both are capital
letters), the genotype is called homozygous (dominant). If the
combination has a dominant allele (capital letter) and a
recessive allele (small letter), it is a heterozygous. If the
combination has two recessive alleles (both are small letters),
the genotype is called homozygous (recessive).
Phenotype is the expression of the genotype that is visible to
other people and can be observed. Basically, it refers to one’s
outward appearance or the expression of genes. That is, for
example, the color of the person’s eyes. It can be influenced by
the environment. Another example, the phenotype only
includes information about brown hair because that is what we
observe when we look at a person.
o Phenotype is defined as all the observable
characteristics of an organism that result from the
interaction of its genotype (total genetic inheritance)
with the environment. Examples of observable
characteristics include behavior, biochemical
properties, color, shape, and size.
o Alleles are codes of the specific variations written in
the DNA. It cannot be seen. However, in phenotype,
it is the traits or characteristics one has when they are
born, or your outward appearance.
Punnett square is a graphical representation of the possible
genotypes of an offspring arising from a particular cross or
breeding event. It is a tool used by biologists to predict the
probability of possible genotypes of an offspring.
<– Father
Normally, we have 46 pairs of chromosomes. The normal cells
are called diploid cells. From the syllable di which means two,
it has two chromosomes.
Mother –>
•
100% chance
of brown eyes
Genotype refers to the genetic code of the individual, or the
particular combination of alleles for a particular gene or locus.
majjyap ‘21
UNIT 8 (Week 10)
Father
Mother
75% chance of
straight hair;
25% chance of
curly hair
Screening of Genetic Disorders and Genetic Counseling
A genetic assessment begins with careful study of the pattern of
inheritance in a family. A history, physical examination of family
members, and a laboratory analysis such as karyotyping or DNA analysis
are performed to define the extent of the problem and the chance of
inheritance.
History and Assessment / Family Genogram
• Genetic disorders are often difficult because the facts detailed
may evoke uncomfortable emotions such as sorrow, guilt, or
inadequacy in parents. However, we should try to obtain
information and document diseases in family members for a
minimum of three generations. Remember to include the halfbrothers and sisters, or anyone related in any way as family.
Document the mother’s age because some disorders increases
in incidence with age.
o Documenting the family’s ethnic background can
reveal risks for certain disorders that occur more
commonly in some ethnic groups than others. If the
couple seeking counseling is unfamiliar with their
family history, ask them to talk to their senior family
members about other relatives (grandparents, aunts,
and uncles) before an interview. Have them also ask
the family and relatives for instances of spontaneous
miscarriage or children in the family who died at birth.
In many instances, these children died of unknown
chromosomal disorders or were miscarried because
of one of the 70 or more known chromosomal
disorders. Basically, some reasons why miscarriage
happens is because of chromosomal disorders.
o Attempt to obtain more information by asking the
couple to describe the appearance or activities of the
•
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affected individual, or ask for permission to obtain
health records, if available. An extensive prenatal
history of an affected person should be obtained to
determine whether there are environmental
conditions that could account for the condition, just
the genetic or hereditary part of the disease.
After gathering data from the history taking, make a
genogram. It helps, not only to identify the possibility of a
chromosomal disorder occurring in a couple’s child/ren, but
also helps identify other family members who might benefit
from genetic counseling.
When a child is born dead, parents are advised to have
chromosomal analysis and autopsy performed on the infant.
If, at some future date, they wish genetic counseling, this
would allow their genetic counselor to have additional medical
information. This is one purpose of having a family genogram.
Physical Assessment
• Because genetic disorders often occur in varying degrees of
expression, a careful physical assessment of any family
member with a disorder, the child, siblings, and a couple taking
counseling is needed.
• During inspection, pay particular attention to certain body
areas:
o Space between the eyes
o Height
o Contour and shape of ears
o Number of fingers and toes
o Presence of webbing
Also known as syndactyly
It is a term used to describe webbing or
conjoined digits of the fingers or toes.
o Note abnormal fingerprints or palmar creases as they
are present in some genetic disorders.
o Abnormal hair whorls or hair color
• Careful inspection of newborns is often sufficient to identify a
child with a potential chromosomal disorder. Infants with
multiple congenital anomalies, those born at less than 35
weeks’ gestation, and those whose parents have had other
children with chromosomal disorders need extremely close
assessment.
Diagnostic Testing
• Many diagnostic tests are available to provide important clues
about possible disorders.
• Before pregnancy, karyotyping of both parents and an already
affected child provides a picture of the chromosome pattern
that can be used to predict occurrences in future children.
o It is the process of pairing and ordering all the
chromosomes of an organism, thus providing a
genome-wide snapshot of an individual’s
chromosomes.
o Karyotypes are prepared using standardized staining
procedures that reveal characteristic structural
features for each chromosome.
o A sample of peripheral venous blood or excreting of
cells from the buccal membrane is taken. Cells are
allowed to grow until they reach the metaphase.
Metaphase is the most easily observed phase. Cells
are then stained, placed under a microscope, and
photographed.
o Chromosomes are identified according to size, shape,
stain, cut from the photograph, and arrangement.
o Any additional locking or abnormal chromosomes can
be visualized by this method.
o A newer method of staining, Fluorescence in Situ
Hybridization (FISH), is a laboratory technique for
detecting and locating a specific DNA sequence on a
chromosome. It allows karyotyping to be done
immediately, rather than waiting for the cells to reach
the metaphase. This makes it possible for a report to
be obtained in only 1 day.
o Aside from the cells in the buccal membrane, the fetal
skin cells can also be used by obtaining through
amniocentesis. A few fetal cells circulate in the
maternal bloodstream. Most noticeably, those
trophoblasts, lymphocytes, and granulocytes. They
are present but in a few number during the first and
second trimester, but plentiful during the third or last
trimester. These cells can be cultured and used for
genetic testing for such disorders such as trisomies.
majjyap ‘21
UNIT 8 (Week 10)
•
Once a woman is pregnant, several other tests may be
performed to help in the prenatal diagnosis of a genetic
disorder. These include:
o Maternal serum alpha-fetoprotein (MSAFP)
Alpha-fetoprotein (AFP) is a glycoprotein
produced by the fetal liver that reaches peak
in maternal serum between the 13th and 32nd
week of pregnancy.
During a baby’s development, some AFP
passes through the placenta into the
mother’s blood.
An AFP test measures the level of alphafetoprotein in pregnant women during the
second trimester of pregnancy. Too much or
too little of this protein in the mother’s blood
may be a sign of a birth defect or other
conditions which includes a neural tube
defect, Down syndrome, multiple births,
miscalculation of due date because AFP
levels change during pregnancy. It is used to
check a developing fetus for risks of birth
defects and genetic disorders.
Blood is withdrawn from the vein of the
mother between the 16th to 18th week of
pregnancy.
o Chorionic villi sampling (CVS)
o
It is a prenatal test that is used to detect birth
defects, genetic diseases, and other
problems during pregnancy.
During the test, a small sample of cells called
the chorionic villi is taken from the placenta
where it attaches to the wall of the uterus. A
catheter is inserted through the vaginal
canal into the uterus to get a sample villi
from the placenta. These cells are then
submitted for analysis. The cells removed in
CVS are karyotyped, and then submitted for
DNA analysis to reveal whether the fetus has
a genetic disorder.
More fetal cells can be found earlier in
pregnancy. Although this procedure may be
done as early as week 5 of pregnancy, it is
more commonly done at 8 to 10 weeks.
Is highly accurate and yields no more false
positive results than the amniocentesis.
However, this test carries a small risk less
than 1% of causing excessive bleeding
leading to pregnancy loss.
After CVS, instruct the woman to report
chills or fever suggestive of infection, or
symptoms of threatened miscarriage such as
uterine contractions or vaginal bleeding.
Amniocentesis
It is the withdrawal of amniotic fluid through
the abdominal wall for analysis at the 14th to
16th week of pregnancy.
Because amniotic fluid has reached about
200 mL at this point, enough fluid can be
withdrawn for karyotyping of skin cells found
in the fluid as well as an analysis of the alphafetoprotein.
A packet of amniotic fluid is located through
an ultrasound. A needle is then inserted
transabdominally, and about 20 mL of fluid is
aspirated. Skin cells in the fluid are
karyotyped for chromosomal number and
structure. The level of the alpha-fetoprotein
is analyzed.
o
Has the advantage over the chorionic villi
sampling of carrying only 0.5% risk of
spontaneous miscarriage. Unfortunately, it is
usually not done until the 14th to 16th week
of pregnancy. At this time, this may prove to
be a difficult time because the woman is
beginning to accept her pregnancy and has
already bonded with the fetus. In addition,
the termination of pregnancy during the
second trimester is more difficult than
during the first trimester.
Support the woman while she waits for the
test results, and to make a decision about
the pregnancy.
After the procedure, all women needs to be
observed for about 30 minutes to be certain
that labor contractions are not beginning
and the fetal heart rate remains within
normal limit.
Percutaneous umbilical blood sampling (PUBS)
Also called as cordocentesis
The removal of blood from the fetal
umbilical cord at about 17 weeks using an
amniocentesis technique, or basically just
the aspiration of blood from the umbilical
vein for analysis.
After the umbilical cord is located through an
ultrasound, a thin needle is inserted by
amniocentesis technique into the uterus and
is guided by the ultrasound until it pierces
the umbilical vein.
A sample of blood is then removed for blood
studies such as a complete blood count,
direct Coombs test, blood gases, and
karyotyping.
The fetus is monitored by a nonstress test
before and after the procedure to be certain
that uterine contractions are not present,
and by ultrasound to see that no bleeding is
evident.
This procedure carries little additional risk to
the fetus and mother over amniocentesis
majjyap ‘21
UNIT 8 (Week 10)
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and can yield information not available by
any other means, especially about blood
dyscrasias.
Ultrasound
It is an imaging test that uses soundwaves to
create a picture (also known as sonogram) of
organs, tissues, and other structures inside
our body.
This diagnostic tool is used to assess a fetus
for general size, structural disorders of the
internal organs, spine, and lips. Some genetic
disorders are associated with physical
appearance. Usually, a congenital anomaly
scan is usually done around 5 to 6 months of
pregnancy because by that time, the body
parts of the baby is formed.
Fetoscopy
The insertion of fiberoptic fetoscope through
small incision in the mother’s abdomen into
the uterus and membranes to visually
inspect the fetus for gross abnormalities.
It can be used to confirm an ultrasound
finding to remove skin cells for DNA analysis
or to perform surgery for a congenital
disorder.
If a photograph is taken through the
fetoscope, it can document a problem or
reassure parents that their infant is perfectly
formed.
The procedure is used to confirm the
intactness of the spinal column and obtain
biopsy samples of fetal tissue and fetal blood
samples.
The earliest time in pregnancy that
fetoscope can be performed is about the 16th
or 17th week. For the procedure, the mother
is prepared and draped as for amniocentesis.
A local anesthesia is injected into the
abdominal skin. The fetoscope is then
inserted through a minor abdominal incision.
If the fetus is very active, meperidine
(Demerol) may be administered to the
o
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woman to help sedate the fetus to avoid
fetal injury by the scope and to allow better
observation.
Preimplantation diagnosis
It is only possible for in vitro fertilization
procedures.
It is the genetic profiling of embryo prior to
implantation.
It may be possible in the future for a
naturally fertilized ovum to be removed from
the uterus by lavage before implantation and
studied for DNA analysis this same way. The
ovum would then be reinserted or not,
depending on the findings and the parents’
wishes. This would provide genetic
information extremely early in a pregnancy.
Newborn Screening Test – after the delivery of the
child
Is already a mandated law in the Philippines
that every Filipino child should undergo.
It is a simple blood test that detects rare
genetic, hormone-related, and metabolic
conditions that can cause serious health
problems. It lets doctors diagnose babies
quickly and start treatment as soon as
possible.
A small blood sample taken by pricking the
baby's heel is tested. This happens before
the baby leaves the hospital, usually at 1 or 2
days of age. The blood sample should be
taken after the first 24 hours of life.
Often, parents will not hear about results if
screening tests were normal. They are
contacted if a test was positive for a
condition. A positive newborn screening test
does not mean a child definitely has the
medical condition. Doctors order more tests
to confirm or rule out the diagnosis.
If a diagnosis is confirmed, doctors might
refer the child to a specialist for more testing
and treatment. When treatment is needed,
it is important to start it as soon as possible.
Treatment may include special formula, diet
restrictions, supplements, medicines, and
close monitoring.
Genetic Counseling
• It is the process of advising individuals and families affected by
or at risk of genetic disorders to help them understand and
adapt to the medical, psychological, and familial implications
of genetic contributions to genetic diseases.
• Any individual concerned about the possibility of transmitting
a disease to their children should have access to genetic
counseling for advice on the inheritance of a disease.
• It can serve to:
o Provide concrete, accurate information about the
process of inheritance and inherited disorders.
o Reassure people who are concerned that their child
may inherit particular disorder that the disorder will
not occur.
majjyap ‘21
UNIT 8 (Week 10)
o Allow people who are affected by inherited disorders
to make informed choices about future reproduction.
o Offer support to people who are affected by genetic
disorders.
• Genetic counseling can result in making individuals feel “well”
or free of guilt for the first time in their lives if they discover a
disorder they were worried about is not an inherited one but
rather occurred by chance.
• In other instances, counseling can result in informing
individuals they are carriers of a trait responsible for a child’s
condition. Even when people understand they had no control
over this, knowledge about passing a genetic disorder to a child
can cause guilt and self-blame. Marriages and relationships can
end unless both partners receive adequate support.
• Couples who are most apt to benefit from a referral for genetic
testing or counseling include:
o A couple who has a child with a congenital disorder or
an inborn error of metabolism.
o A couple whose close relatives have a child with a
genetic disorder such as a chromosomal disorder or
an inborn error of metabolism.
o Any individual who is a known carrier of a
chromosomal disorder.
o Any individual who has inborn error of metabolism or
chromosomal disorder.
o A consanguineous (closely related) couple.
o Any woman older than 35 years of age and any man
older than 55 years of age.
o Couples of ethnic backgrounds in which specific
illnesses are known to occur.
For example, those with a Chinese ancestry
have a high incidence of glucose-6phosphate
dehydrogenase
(G6PD)
deficiency, a blood disorder where
destruction of red cells can occur.
Mediterranean people have a high incidence
of thalassemia, a blood disorder.
Nursing Responsibilities
• Nurses play important roles in assessing for signs and
symptoms of genetic disorders, in offering support to
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•
individuals who seek genetic counseling, and in helping with
reproductive genetic testing procedures.
By such actions as:
o Explaining to a couple what procedures they can
expect to undergo.
o Explaining how different genetic screening tests are
done and when they are usually offered.
o Supporting a couple during the wait for test results.
o Assisting couples in values clarification, planning, and
decision making based on test results.
A great deal of time may need to be spent offering support or
a grieving couple confronted with the reality of how tragically
the laws of inheritance have affected their lives. Genetic
counseling is a role for nurses only if they are adequately
prepared in the study of genetics, however, because without
this background, genetic counseling can be dangerous and
destructive.
Whether one is acting as the nurse member of a genetic
counseling team or as a genetic counselor, some common
principles apply.
o The individual or couple being counseled needs a
clear understanding of the information provided.
o It is never appropriate for a healthcare provider to
impose his or her own values or opinions on others.
Individuals with known inherited disease in their
family must face difficult decisions, such as how much
genetic testing to undergo or whether to terminate a
pregnancy that will result in a child with a specific
genetic disease. Be certain couples have been told all
the options available to them and then leave them to
think about the options and make their decision by
themselves. Help them to understand that no one is
judging their decision because they are the ones who
must live with the decision in the years to come.
Reproductive Alternatives and Future Possibilities
• Some couples are reluctant to seek genetic counseling because
they are afraid they will be told it would be unwise to have
children. Helping them to realize viable alternatives for having
a family exist can allow them to seek the help they need.
o Artificial Insemination by donor (AID)
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An option for couples if the genetic disorder
is one inherited by the male partner or is a
recessively inherited disorder carried by
both partners. AID is available in all major
communities and can permit the couple to
experience the satisfaction and enjoyment
of a usual pregnancy.
If the inherited problem is one arising from
the female partner, surrogate embryo
transfer is an assisted reproductive
technique that is a possibility. For this, an
oocyte is donated by a friend or relative or
provided by an anonymous donor, which is
then fertilized by the male partner’s sperm
in the laboratory and implanted into a
woman’s uterus. Like AID, donor embryo
transfer offers the couple a chance to
experience a usual pregnancy.
Use of a surrogate mother
A woman who agrees to be alternately
inseminated, typically by the male partner’s
sperm, and bear a child for the couple.
All of these procedures are expensive and,
depending on individual circumstances, may
have disappointing success rates.
Adoption
An alternative many couples can also find
rewarding. Choosing to remain child free
should not be discontinued as a viable
option. Many couples who have every
reason to think they will have healthy
children choose this alternative because
they believe their existence is full and
rewarding without the presence of children.
Stem cell
Is looking at the possibility immature cells
from a healthy embryo (stem cells) could be
implanted into an embryo with a known
abnormal genetic makeup, replacing the
abnormal cells or righting the affected child’s
genetic composition.
majjyap ‘21
UNIT 8 (Week 10)
•
Although presently possible, stem cell
research is costly ad produces some ethical
questions.
Help couples decide on a solution that is correct for them, not
one they sense you or a counselor feels would be best. They
need to consider the ethical philosophy or beliefs of other
family members when making their decision, although
ultimately, they must do what they believe is best for them as
a couple. A useful place to start counseling is with values
clarification, to be certain a couple understands what is most
important to them.
Legal and Ethical Aspects of Genetic Screening and Counseling
• Nurses can be instrumental in making sure couples who seek
genetic counseling receive results in a timely manner and with
compassion about what the results may mean to future
childbearing. Always keep in mind several legal responsibilities
of genetic testing, counseling, and therapy including:
o Participation by couples or individuals in genetic
screening must be elective.
o People desiring genetic screening must sign an
informed consent for the procedure.
o Results must be interpreted correctly yet provided to
the individuals as quickly as possible.
o The results must not be withheld from the individuals
and must be given only to those persons directly
involved.
o After genetic counseling, persons must not be
coerced to undergo procedures such as abortion or
sterilization. Any procedure must be a free and
individual selection.
• Failure to heed these guidelines could result in charges of
invasion of privacy, breach of confidentiality, or psychological
injury caused by “labeling” someone or imparting unwarranted
fear and worry about the significance of a disease or carrier
state. If couples are identified as being at risk for having a child
with a genetic disorder and are not informed of the risk and
offered an appropriate diagnostic procedure such as
amniocentesis during a pregnancy, they can bring a “wrongful
birth” lawsuit if their child is born with the unrevealed genetic
disorder.
Mechanisms of Genetic Mutation and Inheritance Patterns
Chromosomal Abnormalities (Cytogenic Disorders)
• Nondisjunction Abnormalities
o The failure of homologous chromosomes to separate
properly during meiosis.
•
Deletion Abnormalities
o It is a structural abnormality where a portion of the
chromosome is missing or deleted.
o Example: Cri cu Chat syndrome (Cat-cry syndrome)
•
Translocation Abnormalities
o It is a structural abnormality where a portion of one
chromosome is transferred to another chromosome.
•
Mosaicism
o An abnormal condition that is present when the
nondisjunction disorder occurs after fertilization of
the ovum, as the structure begins mitotic (daughtercell) division. If this occurs, there are different cells in
the body that will have different chromosome counts.
The extent of the disorder depends on the proportion
of tissue with normal chromosome structure or
constitution.
o Usually, a nondisjunction abnormality occurs during
the meiosis phase of cell division.
•
Isochromosomes
o If a chromosome accidentally divides not by a vertical
separation but by a horizontal one, a new
chromosome with mismatched long and short arms
can result. It has much the same effect as a
translocation abnormally when an entire extra
chromosome exists.
o Example: Turner syndrome (45XO)
majjyap ‘21
UNIT 8 (Week 10)
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Classification of Common Genetic Disorder (Wala gi discuss ni Miss)
• Autosomal Dominant Inheritance
• Autosomal Recessive Inheritance
• X-Linked Dominant Inheritance
• X-Linked Recessive Inheritance
• Multifactorial (Polygenic) Inheritance
• Mitochondrial Inheritance
• Imprinting
• Autosomal Trisomies
Selected Genetic Disorders and their Nursing Management
• Trisomy 21 or “Down” Syndrome
o A genetic condition caused by an extra chromosome.
Most babies inherit 23 chromosomes from each
parent, for a total of 46 chromosomes. Babies with
Down syndrome however, end up with three
chromosomes at position 21, instead of the usual pair.
o The most frequently occurring chromosomal
disorder, occurs in about 1 in 800 pregnancies. In
women who are older than 35 years of age, the
incidence is as high as 1 in 100 live births.
o The physical features of children with Down
Syndrome are so marked that fetal diagnosis is
possible by sonography in utero. The nose is broad
and flat. The eyelids have an extra fold of tissue at the
inner canthus (an epicanthal fold), and the palpebral
fissure (opening between the eyelids) tends to slant
laterally upward. The iris of the eye may have white
specks, called Brushfield spots. The tongue is apt to
protrude from the mouth because the oral cavity is
smaller than usual. The back of the head is flat, the
neck is short, and an extra pad of fat at the base of
the head causes the skin to be loose it can be lifted
easily and so thin it can be revealed on a fetal
sonogram.
The ears may be low set. Muscle tone is poor, giving
the newborn a rag doll appearance. This muscle tone
can be so lax that the child’s toe can be touched
against the nose (not possible in the average mature
newborn). The fingers of many children with Down
syndrome are short and thick, and the little finger is
often curved inward. There may be a wide space
between the first and second toes and between the
first and second fingers. The palm of the hand shows
a peculiar crease (a simian line) or a single horizontal
crease rather than the usual three creases in the
palm.
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Children with Down syndrome are usually cognitively
challenged to some degree. The challenge can range
from an IQ of 50 to 70 to a child who is profoundly
affected (IQ less than 20). The extent of the cognitive
challenge is not evident at birth, but the fact the brain
is not developing well is usually evidenced by a head
size smaller than the 10th or 20th percentile at wellchild healthcare visits.
Internally, congenital heart disease, especially an
atrioventricular defect, is common. Stenosis or atresia
of the duodenum, strabismus, and cataract disorders
may also be present. In addition, the child’s immune
function may be altered because as these children
grow, they are prone to upper respiratory tract
infections. Probably due to a second gene aberration,
they tend to develop acute lymphocytic leukemia
about 20 times more frequently than the general
population. Even if children are born without an
accompanying disorder such as heart disease or do
not develop leukemia, their life span usually is limited
to only 50 to 60 years because aging seems to occur
faster than usual.
majjyap ‘21
UNIT 8 (Week 10)
o It is important for children with Down syndrome to be
enrolled in early educational and play programs so
they can develop to their full capacity. Because they
are prone to infections, sensible precautions such as
using a good hand washing technique are important
when caring for them. The enlarged tongue may
interfere with swallowing and cause choking unless
the child is fed slowly. Because their neck may not be
fully stable, an x-ray to ensure stability is
recommended before they engage in strenuous
activities such as competitive sports or Special
Olympics. As with all newborns, these infants need a
physical examination at birth to enable the detection
of the genetic disorder and the initiation of parental
counseling, support, and future planning.
o Nursing Management:
Provide adequate nutrition
Frequent consultations are a must
Assess understanding of Down syndrome
Provide emotional support and motivation
• Trisomy 18 or “Edward’s” Syndrome
o A genetic condition in babies that causes severe
disability. It is caused by an extra copy of
chromosome 18 and babies born with the condition
usually do not survive for much longer than a week.
o Children with trisomy 18 syndrome (Edwards
syndrome) have three copies of chromosome 18. The
incidence is approximately 0.23 per 1,000 live births.
These children are severely cognitively challenged
and tend to be small for gestational age, have
markedly low-set ears, a small jaw, congenital heart
defects, and usually misshapen fingers and toes (the
index finger deviates or crosses over other fingers).
Also, the soles of their feet are often rounded instead
of flat (rocker-bottom feet). As in trisomy 13
syndrome, most of these children do not survive
beyond infancy.
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Nursing Management:
There is no cure for Edwards’ syndrome.
Treatment will focus on the symptoms of the
condition, such as heart conditions,
breathing difficulties, and infections.
Pediatric patients may also need to be fed
through a feeding tube, as they can often
have difficulty feeding.
Edwards’ syndrome has an impact on the
baby’s movements as they get older, and
they may benefit from supportive treatment
such as physiotherapy and occupational
therapy.
Depending on the baby’s specific symptoms,
they may need specialist care in hospital or a
hospice, or parents may be able to look after
them at home with the right support.
Trisomy 13 or “Patau’s” Syndrome
o A syndrome caused by a chromosomal abnormality,
in which some or all of the cells of the body contain
extra genetic material from chromosome 13. The
extra genetic maternal disrupts normal development,
causing multiple and complex organ defects.
o In trisomy 13 (Patau syndrome), the child has an extra
chromosome 13 and is severely cognitively
challenged. The incidence of the syndrome is low,
approximately 0.45 per 1,000 live births. Midline body
disorders such as cleft lip and palate, heart disorders
(particularly ventricular septal defects), and abnormal
genitalia are present. Other common findings include
microcephaly with disorders of the forebrain and
forehead, eyes that are smaller than usual
(microphthalmos) or absent, and low-set ears. Most
of these children do not survive beyond early
childhood.
o Defects that come with this syndrome:
Heart defects
Brain or spinal cord abnormality
Small or poorly developed eyes
Extra fingers or toes
Cleft lip or palate
Weak muscles
majjyap ‘21
UNIT 8 (Week 10)
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Nursing Management:
There is no cure for trisomy 13, and
treatments focus on the baby’s symptoms.
These can include surgery and therapy.
Although, depending on the severity of the
baby’s issues, some doctors may choose to
wait and consider any measures based on
the chances of the baby’s survival.
Trisomy 13 is not always fatal. But doctors
cannot predict how long a baby might live if
they do not have any immediate lifethreatening problems. However, babies born
with trisomy 13 rarely live into their teens.
Cri du Chat Syndrome
o Also known as 5p- (5p minus) syndrome
o The result of a missing portion of chromosome 5. In
addition to an abnormal cry, which sounds much
more like the sound of a cat than a human infant’s cry,
children with cri-du-chat syndrome tend to have a
small head, wide-set eyes, a downward slant to the
palpebral fissure of the eye, and a recessed mandible.
They are severely cognitively challenged.
Turner’s Syndrome
o A condition that affects only females, results when
one of the X chromosomes (sex chromosomes) is
missing or partially missing.
o The child with Turner syndrome (gonadal dysgenesis)
has only one functional X chromosome. The child is
short in stature and has only streak (small and
nonfunctional) ovaries. She is sterile and, with the
exception of pubic hair, secondary sex characteristics
do not develop at puberty. The hairline at the nape of
the neck is low set, and the neck may appear to be
webbed and short. A newborn may have appreciable
edema of the hands and feet and a number of
congenital anomalies, most frequently coarctation
(stricture) of the aorta as well as kidney disorders. The
incidence of the syndrome is approximately 1 per
10,000 live births. The disorder can be identified on a
sonogram during pregnancy (a nuchal translucency
scan) because of the extra skin at the sides of the
neck.
o Although children with Turner syndrome may be
severely cognitively challenged, difficulty in this area
is more commonly limited to learning disabilities.
Socioemotional
adjustment
problems
may
accompany the syndrome because of the lack of
fertility and if the nuchal folds are prominent.
o Human growth hormone administration can help
children with Turner syndrome achieve additional
height. If treatment with estrogen is begun at
approximately 13 years of age, secondary sex
characteristics will appear, and osteoporosis from a
o
lack of estrogen during growing years may be
prevented. If females continue taking estrogen for 3
out of every 4 weeks, this produces withdrawal
bleeding which results in a menstrual flow. This flow,
however, does not correct the basic problem of
sterility; ovarian tissue is scant and inadequate for
ovulation because of the basic chromosomal
aberration. A woman with Turner syndrome could,
however, have IVF with surrogate oocyte transfer in
order to become pregnant.
Clinical Features:
Grow more slowly than their peers during
childhood and adolescents
Have delayed puberty and lack of growth
spurts, resulting in an average adult height of
4 feet, 8 inches.
Does not experience breast development.
May not have menstrual periods.
Have small ovaries that may only function for
a few years or not at all.
Typically does not go through puberty,
unless they get hormone therapy in late
childhood and early teens.
Does not make enough sex hormones.
majjyap ‘21
UNIT 8 (Week 10)
o Nursing Management:
Hormone replacement therapy
They may also be given low doses of
androgen
• Klinefelter’s Syndrome
o Children with Klinefelter syndrome are males with an
extra X chromosome. Characteristics of the syndrome
may not be noticeable at birth. At puberty, secondary
sex characteristics do not develop; the child’s testes
remain small and produce ineffective sperm. Affected
individuals tend to develop gynecomastia (increased
breast size) and have an increased risk of male breast
cancer. The incidence of the syndrome is about 1 per
1,000 live births. Karyotyping can be used to reveal
the additional X chromosome.
o
o
Before puberty, boys with fragile X syndrome may
typically demonstrate maladaptive behaviors such as
hyperactivity, aggression, or autism. They may have
reduced intellectual functioning, with marked deficits
in speech and arithmetic. On physical exam, frequent
findings identified are a large head, a long face with a
high forehead, a prominent lower jaw, large
protruding ears, and obesity. Hyperextensive joints
and cardiac disorders may also be present. After
puberty, enlarged testicles may become evident.
Affected individuals are fertile and can reproduce.
Carrier females may show some evidence of the
physical and cognitive characteristics. Although
intellectual function from the syndrome cannot be
improved, a combination of stimulants, a agonists,
atypical antipsychotics, and serotonin reuptake
inhibitors may improve symptoms of poor
concentration and impulsivity.
o
o
A rare genetic disorder in which the body is not able
to break down complex sugars, which affects organs
and tissues, particularly muscles.
A genetically inherited condition caused by
insufficient functioning of an enzyme called
lysosomal acid a-1,4-glucosidase or just acid alphaglucosidase due to a mutation of the GAA gene. It can
cause buildup of glycogen, eventually damages
muscles and other cell types.
o
•
Nursing Management:
Provide education, resources, and support.
Counseling about infertility, marriage, and
relationships.
Ideally, patients should begin testosterone
treatment as they enter puberty. A regular
schedule of testosterone injections will
increase strength and muscle size and
promote the growth of facial and body hair.
Fragile X Syndrome
o The most common cause of cognitive challenge in
males. It is an X-linked disorder in which one long arm
of an X chromosome is defective which results in
inadequate protein synaptic responses. The incidence
of the syndrome is about 1 in 4,000 males.
o
o
•
Behavioral Features:
Hypersensitivity
Intolerance to change in routine
o Nursing Management:
Protein replacement and gene therapy
Referral to early intervention program
Prognosis: Expected to live normal life span
Pompe Disease
o
Glucose is used for energy by most cells of the body,
and it is stored inside the cells as a compact, branchshaped molecule called glycogen. When a cell needs
energy, it uses enzymes to remove glucose molecules
from the branches. One of the organelles within the
cell is the lysosome, which function a bit like a tiny
recycling plant. The lysosome contains enzymes that
break down cellular substances so that they can be
recycled.
Small amounts of glycogen ends up in the lysosomes,
where it is broken down by an enzyme called acid
alpha-glucosidase, to release glucose from the
glycogen chain.
majjyap ‘21
UNIT 8 (Week 10)
o In Pompe disease, a mutation of the GAA gene
prevents the production of enough functional acid
alpha-glucosidase, and lysosomes cannot break down
glycogen. This leads to a buildup of glycogen within
the cytoplasm and lysosomes, and that leads to
cellular damage and destruction.
o Normally, glycogen is found in the largest amounts in
the cytoplasm of liver cells and all three types of
muscle cell. In individuals with Pompe, glycogen
mostly accumulates in the lysosomes of those cells.
Skeletal muscles include various muscles of the body
as well as the diaphragm which is the primary
breathing muscle. Cardiac muscle makes up the
majority of a healthy heart, and smooth muscle is
found in the walls of blood vessels and many other
organs.
o
Nursing Management:
o
o
•
o
Clinical Features:
Tay-Sachs Disease
o A rare disorder passed from parents to child. It is
caused by the absence of an enzyme that helps break
down fatty substances. These fatty substances, called
gangliosides, build up to toxic levels in the child’s
brain and affect the function of the nerve cells. As the
disease progresses, the child loses muscle control.
Eventually, this leads to blindness, paralysis, and
death.
o A lysosomal storage disorder caused by a mutation in
a gene on chromosome 15, which codes for a
lysosomal enzyme called beta-hexosaminidase A, or
HEX-A for short. This enzyme normally breaks down a
lipid called GM2 ganglioside. GM2 is found mainly in
neurons, so without HEX-A, it accumulates inside
lysosomes.
o
o
This results in progressive symptoms of central
nervous system or CNS degeneration, like decreased
muscle tone, visual difficulties and seizures, which
usually begin by 3 to 6 months of age, proceeding to
death by age 4.
Depending on age of onset, TSD can be infantile, with
onset at 3 to 6 months; juvenile, with onset at 2-5
years; chronic, with onset in the first or second
decade of life; and late-onset, with the first indication
of symptoms in the second or third decade of life.
Common signs for the first three forms are signs of
CNS degeneration, like decreased muscle tone,
abnormally increased reflexes, seizures and visual
disturbances. For adult-onset, there may be motor
difficulties and some adults may manifest bipolar type
psychological symptoms.
Ophthalmologists may be the first to consider TSD by
finding a “cherry red spot” in the macula of the eye,
which results from GM2 buildup in the retinal cells
around the central macular area.
majjyap ‘21
UNIT 8 (Week 10)
amniocentesis and chorionic villus sampling
as well as artificial insemination, ovum
donation, and in-vitro fertilization to have
children who do not have Tay-Sachs disease
or related GM2 disorders.
•
o
o
Clinical Features:
Loss of learned skills
Loss of smile, crawl, grab
Blindness, deafness, paralysis
Dementia
Unable to swallow
Muscle atrophy
Nursing Management:
There is no cure for TSD or its variants.
Treatment for the infantile and juvenile form
involves supportive care to manage
symptoms. Usually this involves many
specialists including neurologists to manage
seizures, gastroenterologists, surgeons, and
nutritionists to manage feeding, as well as
occupational and physical therapists to assist
with the tasks of daily living and mobility.
Management of symptoms in later onset
forms is also primarily supportive, dealing
with the slower, but progressive nature of
the degeneration in these related
conditions. Enzyme replacement or gene
therapy continue to be areas of research, but
until they are in hand, genetic counselling for
individuals at high risk can help prevent
passing on the mutations associated with
TSD.
More specifically, couples at risk of having an
affected
child
have
options
like
Wilson Disease
o A rare inherited disorder that causes copper to
accumulate in your liver, brain, and other vital organs.
o A rare inherited disorder, when your body takes in
and absorbs too much copper. Normally, copper from
the diet is filtered out by the liver and released into
bile, which flows out of the body. People who have
Wilson disease cannot release copper from the liver.
When the copper storage capacity of the liver is
exceeded, copper is released into the bloodstream
and travels to other organs including the brain,
kidney, and eyes.
o Clinical Features:
Most people with Wilson's disease present
with one or more of these three different
systems: hepatic problems or liver problems
which occur in 40% of people, neurological
problems or problems with the brain which
occur in 50% of people, or psychiatric
problems which occur in 10% of people.
Copper deposition in the liver leads to
chronic hepatitis so, inflammation of those
liver cells that have excessive copper in them
and eventually this leads to liver cirrhosis.
Copper deposition in the nervous system
leads to neurological and psychiatric
problems. The neurological symptoms can
be subtle and range from concentration or
coordination difficulties to dysarthria
(speech difficulties) and dystonia (abnormal
muscle tone).
Copper deposits in the basal ganglia and the
brain
leads
to
something
called
Parkinsonism and this is where you get
tremors, bradykinesia (small movements),
and rigidity.
o
•
Psychiatric symptoms can vary for mild
depression to full-blown psychosis and the
underlying cause of Wilson's disease is often
missed and treatment is delayed.
Kizer flescher rings are found in the cornea
of the eye and they are deposits in decimates
corneal membrane. These are small circular
brown rings that present around the eye in
patients with Wilson's disease and these
brownish circles surrounding the iris can
usually be seen by the naked eye, but proper
assessment
requires
a
slit-lamp
examination.
There are a few other features. You get a
hemolytic anemia where the red blood cells
are being broken down too quickly, you can
get renal tubular damage which leads to
renal tubular acidosis, and you can get
osteopenia which is a loss of the bone
mineral density.
Nursing Management:
Heredity Hemochromatosis
o Caused by a mutation in a gene that controls the
amount of iron your body absorbs from the food you
eat. These mutations are passed from parents to
children. A gene called HFE is most often the cause of
heredity hemochromatosis. You inherit one HFE gene
from each parent.
o An iron storage disorder that results in excessive total
body iron and the deposition of iron in tissues.
o The human hemochromatosis protein which is
abbreviated to HFE is encoded by a gene that is
located on the chromosome 6, and the majority of
majjyap ‘21
UNIT 8 (Week 10)
cases of hemochromatosis relate to mutations in this
gene.
o The hemochromatosis genetic mutation is inherited
in an autosomal recessive way and the gene is
important in regulating iron metabolism in the body,
which is why it causes an iron storage disorder.
o Clinical Features:
Hemochromatosis usually takes a bit of time
before enough iron builds up in the body for
it to become symptomatic. It usually
presents after the age of 40.
Can present with chronic tiredness, joint
pain because of iron deposits in the joints
causing arthritis. They can present with
pigmentation or a bronze discoloration of
their skin because of the iron deposits in the
skin, hair loss, sexual problems such as an
erectile dysfunction or amenorrhea, and
cognitive problems like problems with
memory and mood disturbance.
o
Nursing Management:
Need to get rid of all of that excess iron in the
body, and we do this through venesection
which is a weekly protocol of removing blood
from the body and along with that blood
comes the extra iron.
Carefully monitor the serum ferritin.
Monitor and treat any complications of the
condition.
•
•
Alkaptonuria
o A rare inherited disorder. It occurs when your body
cannot produce enough of an enzyme called
homogentisic dioxygenase (HGD). This enzyme is
used to break down a toxic substance called
homogentisic acid, a product of tyrosine and
phenylalanine metabolism.
o When you do not produce enough HGD, homogentisic
acid builds up in your body. The buildup of
homogentisic acid causes your bones and cartilage to
become discolored and brittle.
o This typically leads to osteoarthritis, especially in your
spine and large joints. People with alkaptonuria also
have urine that turns dark brown or black when it is
exposed to air.
o Clinical Features:
Black spots in the eyes
Early onset osteoarthritis (especially in the
spine)
Kidney and prostate stones
Blue or grey tinge (or darkening) to the ears
Hardening of blood vessels in the heart
Black urine
properly. The condition gets its name from the
distinctive sweet odor of affected infants’ urine.
o
Clinical Features:
Sleepiness or irritability
Coma or brain damage
Symptoms may develop at a later stage
Vomiting
Poor feeding
Urine smells like maple syrup or burnt sugar
Psychomotor delay
Intellectual disability
Death
Maple Syrup Urine Disease
o An inherited disorder in which the body is unable to
process certain protein building blocks (amino acids)
majjyap ‘21
UNIT 8 (Week 10)
o
o
o
o
o
Nursing Management:
Diet – whole proteins restricted diet; special
metabolic formula
Regular blood testing
Small amounts of breast milk or standard
infant formula
Avoid foods high in protein
Dietitian will help determine diet routine
Your clinic will teach you how to track and
limit BCAA
Height and weight measurements
Review and make potential dietary
adjustments
Inborn Errors on Metabolism (detected by Conventional Newborn
Screening)
• Phenylketonuria
o An inborn error of metabolism that results in
decreased metabolism of the amino acid
phenylalanine. Untreated, PKU can lead to
intellectual disability, seizures, behavioral problems,
and mental disorders.
o An autosomal recessive genetic disorder that affects
function of the phenylalanine hydroxylase enzyme. It
is located on chromosome 12 and over 600 mutations
o
o
o
have been described. The degree of enzyme function
can vary.
When untreated, people with PKU develop symptoms
such as severe intellectual disability, psychiatric
disorders, and seizures.
A pregnant woman with PKU must pay special
attention to her phenylalanine levels to reduce the
risk of Maternal PKU Syndrome that can result in
heart defects, microcephaly, and developmental
disability in her baby.
Testing for PKU is typically done as part of routine
newborn screening approximately 24 hours after
birth.
First line therapy for PKU is the low phenylalanine
diet. This includes medical foods such as low or no
phenylalanine medical formulas that are a synthetic
form of protein and foods modified to be low in
protein.
All high protein foods such as meat, fish, eggs, and
dairy are eliminated from the diet. Measured
amounts of some grains, vegetables and fruit are
allowed depending upon the individual patient’s
tolerance of small amounts of phenylalanine.
Each patient will need to customize the amount of
phenylalanine dietary intake with medical
professionals according to their individual needs.
In addition to the low phenylalanine diet, two FDA
approved pharmaceutical treatments are now
available.
Kuvan is a cofactor for phenylalanine
hydroxylase which helps improve the PKU
patient’s innate PAH enzyme activity and
increase their phenylalanine tolerance. It
must be used in conjunction with the low
phenylalanine diet.
Palynziq can be used in adults with PKU. It is
an enzyme, injected under the skin every day
by the patient that circulates in the blood,
metabolizing phenylalanine, and substitutes
for the defective phenylalanine hydroxylase
enzyme. It works well for many adult PKU
patients, but can have serious side effects in
some patients.
•
Galactosemia
o Which means “galactose in the blood,” refers to a
group of inherited disorders that impair the body’s
ability to process and produce energy from a sugar
called galactose. When people with galactosemia
ingest foods or liquids containing galactose,
undigested sugars build up in the blood.
o
•
The treatment for Galactosemia is the removal of
galactose from your diet. All lactose products must be
totally avoided. Milk and milk products contain the
most amount of lactose; however, it is also present in
other foods such as legumes, organ meats, and
processed meats.
o Infants will need to be fed with food that is lactose
free such as soy formulas, meat-base formula, or
Nutramigen (a protein hydrolysate formula).
o There is no definite cure for Galactosemia, the
condition is life long and it can only be controlled.
Doctors advise a calcium supplement for patients
with Galactosemia as milk is an important source of
calcium for a growing child.
Congenital Adrenal Hyperplasia
o A collection of inherited conditions that affect the
body’s adrenal glands, which are the cone-shaped
organs that sit on top of the kidneys. In a person with
CAH, the adrenal glands are very large and are unable
to produce certain chemicals, including cortisol, a
majjyap ‘21
UNIT 8 (Week 10)
chemical that helps protect the body during stress or
illness and helps the body regulate the amount of
sugar in the blood.
•
o
•
Clinical Features:
Low blood salt and sugar levels
Change in the genitalia
Early puberty
Irregular periods
o Nursing Management:
Replace missing corticosteroids
Congenital Hypothyroidism
o Previously known as cretinism, is a severe deficiency
of thyroid hormone in newborns. It causes impaired
neurological function, stunted growth, and physical
deformities. The condition may occur because of a
problem with the baby’s thyroid gland, or a lack of
iodine in the mother’s body during pregnancy.
o Almost all cases identified through neonatal
screening.
o Clinical Features:
Constipation
Hypotonia (decreased muscle tone)
Hoarse cry
Macroglossia (unusual enlargement of the
tongue)
o Delayed treatment can lead to:
Learning disabilities
•
Cognitive deficits
Clumsiness
Diminished fine motor skills
o Treatment:
Levothyroxine is either in tablet or liquid
form. In tablet form, it can be crushed and
given with liquid formula to ensure safe
swallowing.
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency
o Occurs when a person is missing or does not have
enough of an enzyme called glucose-6-phosphate
dehydrogenase. This enzyme helps red blood cells
work properly.
o Too little G6PD leads to the destruction of red blood
cells. This process is called hemolysis. When this
process is actively occurring, it is called a hemolytic
episode. The episodes are most often brief. This is
because the body continues to produce new red
blood cells, which have normal activity.
o Symptoms:
Asymptomatic until exposed to an oxidative
stressor
Jaundice
Dark tea-colored urine
Back pain (kidney damage)
Anemia symptoms (fatigue, hypotension,
tachycardia, confusion, and others)
o Treatment:
Removal of triggering agent and avoiding
exposure
Supportive therapy (blood transfusion and
folic acid supplements)
Treatment of infection
Genetic counseling
Maple Syrup Urine Disease (gi discuss na ni Miss sa previous
slides)
Nursing Management…
Nursing Diagnoses
•
Delayed
growth
and
development related to
impaired
cognitive
functioning
•
Outcomes
Nursing Interventions
Interrupted
family
processes related to having
a child with cognitive
impairment
• Delayed
growth
and
development related to
impaired ability to achieve
developmental tasks
• Self-care deficit: bathing and
hygiene, dressing, feeding,
toileting related to cognitive
impairment
• Impaired
verbal
communication related to
impaired
receptive
or
expressive skills
• Potential for low selfesteem related to body not
developing secondary sex
characteristics as peers of
same age
• Disturbed
body
image
related to differences in
physical characteristics as
evidenced by webbed neck,
shield chest, and short
stature
Child will achieve optimum:
• Growth and development
potential
• Socialization
Family will:
• Receive
adequate
information and support
• Be prepared for long-term
care of the child
• Perform a physical and
developmental assessment
• Assist with and explain
diagnostic tests
majjyap ‘21
UNIT 8 (Week 10)
•
•
•
•
•
•
•
•
•
•
Care During Hospitalization
•
•
Educate child and family
o Managing stimulations
o Providing simple, onestep instructions
o Motivation and positive
reinforcement
o Early
intervention
program available in
area
Teach child self-care skills
Promote child’s optimal
development
Encourage play and exercise
Provide
means
of
communication
Establish discipline
Encourage socialization
o Inclusion
o Camps
o Special Olympics
Provide information on
sexuality
Help family adjust to future
care needs
o At home
o Daycare
o Long-term care
Teach prevention to families
or parents
o Reduce risk factors
(smoking,
drugs,
alcohol)
o Prenatal care
o Early screening
Mutual participation model:
working with parents to
share child’s care
Obtain
a
thorough
assessment
o Self-care abilities
o
•
•
•
Special devices needed
(braces,
equipment,
etc.)
o Routines,
unusual
behaviors
o Nutrition and eating,
elimination
o Play, special toys, and
activities
Explain procedures and
treatments
at
child’s
cognitive level
Work in partnership with
parents
Opportunity to learn and
grow in areas of self-care
and socialization
majjyap ‘21
UNIT 9 (Week 11)
OVERVIEW AND ASSESSMENT OF RESPIRATORY
FUNCTIONS AND PEDIATRIC VARIATIONS AND NURSING
CARE OF THE CHILD WITH A RESPIRATORY DISORDER
Slides 1 - 7 (Sophia)
●
●
Respiratory disorders are among the most common
causes of illness and hospitalizations in children.
Overall respiratory dysfunctions in children tend to be
more serious than in adults, because the lumens of a
child’s respiratory tract are smaller and therefore more
likely to become obstructed.
ANATOMY AND PHYSIOLOGY
RESPIRATORY SYSTEM
OVERVIEW
OF
THE
The upper respiratory tract is composed of:
● Nose - serves as the passageway of air
● Mouth - passageway of food and air
● Epiglottis - covers the larynx during swallowing
● Nasal cavity - filters, warms, and moistens the air
● Pharynx (Throat) - common passageway for air, food,
and liquid
● Larynx (Voice box) - production of sound
The lower respiratory tract is composed of:
● Pleural membranes - cover the lungs and line the chest
cavity
● Trachea (Windpipe) - main airway
● Lung - organ of gas exchange
● Bronchi - branching airways
● Intercostal muscle - moves ribs during respiration
● Alveoli - air sacs for gas exchange
● Rib
●
Diaphragm - skeletal muscle of respiration
●
Video Transcript:
Respiratory System
● To understand the process of breathing
● In humans, the main organs responsible for respiration
are present in the thoracic cavity
● In the thorax region, the rib cage and the dome-shaped
fibrous tissue known as the diaphragm are observed
● Present within the rib cage are the pleural membranes
which includes the lungs
● The right lungs is divided into three lobes, the right
superior, right middle and the right inferior lobe
● The left lung is smaller and has only two lobes the left
superior and the left inferior lobe
● Both the lungs are associated externally with small
tubular bronchi which unite and extend into the trachea
● The trachea has incomplete c-shaped rings of cartilage
which prevents the tracheal wall from collapsing
● The trachea leads into the pharynx which is connected
to the nostrils
● As we breathe an air the oxygen molecules enter the
nostrils and travel downwards through the pharynx and
trachea to finally reach the bronchi
● From each bronchus, oxygen travels into the lungs,
within the lungs the bronchus divides repeatedly to form
bronchioles.
● Oxygen travels through these bronchioles and reaches
the alveoli. Each of which is surrounded by a network of
capillaries.
● A section of one alveolus shows the presence of
numerous alveolar chambers with pores. Blood
containing RBCs is seen flowing through the capillaries
● The oxygen molecules from the alveolus diffuse into the
capillary and then get absorbed by bluish purple RBCs,
this causes oxygenation of the RBCs and the transition
of their color from bluish purple into red is observed.
● The blood moving into the alveolus contains RBCs and
carbon dioxide molecules. These molecules are
released into the alveolus, the CO2 collects from the
alveolar chamber and then from the alveolus it travels
through the bronchioles, then into the bronchus, which
finally reaches the trachea and it is breath out through
the nostrils
●
So the process of breathing in air rich in oxygen is called
inhalation, after the contraction of the muscular
diaphragm the lungs expand and the air rushes in
resulting in the inflammation of the alveoli. During
exhalation, the diaphragm moves up and the lungs
contract thus the alveoli deflate causing the air to be
forced out. This exhaled air is rich in CO2.
This process of inhalation and exhalation is known as
respiration, which occurs approximately 20 times per
minute.
DIFFERENCES BETWEEN THE RESPIRATORY SYSTEM
OF ADULTS AND CHILDREN
●
●
●
●
●
●
●
Because the respiratory tract continues to mature during
childhood, children have several important differences in
respiratory anatomy and physiology than adults
Nasopharynx - usually smaller and is easily occluded
during infections
Lymph tissue (tonsils, adenoids ) - grows rapidly in early
childhood, atrophies after age 12
○ Children 12 years old below - enlarged tonsils
and adenoids because of the lymph tissue that
is rapidly growing
Smaller nares - easily occluded
Small oral cavity and large tongue increases risk of
obstruction
Long, floppy epiglottis - vulnerable to swelling with
resulting obstruction
Larynx and glottis are higher in neck - increases risk of
aspiration
UNIT 9 (Week 11)
● Because thyroid, cricoid, and tracheal cartilages are
immature they may easily collapse when neck is flexed
● Because fewer muscles are functional in airway - less
able to compensate for edema, spasm, and trauma
● The large amounts of soft tissue and loosely anchored
mucous membranes lining the airway- increases risk of
edema and obstruction
RESPIRATORY TRACT DIFFERENCES IN CHILDREN
●
●
●
●
Changes until age 12 - child respiratory illness is risk
greater than adult
Upper airway more prone to obstruction - smaller airway
= greater resistance.
Children have less alveolar surface area - reduced area
for gas exchange compared to adults
More diaphragmatic breathing - flexible chest reduces air
intake
Chest or Respiratory System
●
Infants are considered Obligate nasal breathers (until 4
– 6 weeks) because they are dependent on the patency
of their nasal airway for ventilation
● Short neck
● Tongue is larger in proportion to the mouth
○ more likely to obstruct airway in unconscious
child
Smaller, shorter, narrower airways more susceptible to airway
obstruction and respiratory distress
ASSESSING RESPIRATORY ILLNESS IN CHILDREN
RESPIRATORY DEVELOPMENT
Newborn (pic sa babaw)= 4 mm ra ang lumen sa iya airway, that
is the normal. Then if mag swell, 2 mm nalang. Compared to
adults, dagko na ug lumen. Therefor, children are susceptible to
airway obstruction
●
●
●
Respiratory structures grow in size and distance from
each other - as the child matures in age the respiratory
structure still grows until they reach the age of 12
Immature infant respiratory and neurologic system offers
less efficient response to hypoxia and elevated PCO2
(partial CO2)
Chest will stiffen with age - less retraction with distress
Slides 8 - 14 (Mygel)
RESPIRATORY TRACT DIFFERENCES IN CHILDREN
Chest or Respiratory System
● Smaller lung capacity and underdeveloped intercostal
muscles, poor chest musculature
○ less pulmonary reserve, lung damage w/o
fracture
● Children rely on diaphragm breathing
○ high risk for resp. failure if the diaphragm unable
to contract
Diaphragm breathing is basically just using abdominal muscles
to assist in inhalation. Infant’s chest muscle man gud is not yet
fully developed until the age of 12, so they use their abdominal
muscles instead. The change to thoracic breathing begins at 2-3
years of age, and is complete at 7 years; therefore, children 2
years below, are obligate diaphragm breathers
For the position of trachea, the bifurcation (division of something
into two parts) of trachea in children is at T3 level, while in
adults, its at T6. The right mainstem bronchus in children, has a
steeper slope than the adults. In children, trachea is shorter and
the angle of the bronchus in the bifurcation is more acute than in
adults.
Changes in chest wall shape as the children matures (right side)
Assessment of respiratory illness in children includes an
interview, physical examination assessment, laboratory testing. If
the child is in acute distress, the interview and the health history
may only cover the most important details. That includes when
the child became ill, and what symptoms are present. It is
important to get the accurate picture as possible.
HISTORY
● Chief concern: Cough (characteristics, when it started),
rapid respirations, noisy breathing, rhinitis, reddened
sore throat, lethargy, cyanosis, difficulty, sucking, fever.
These are common chief concerns
PAST MEDICAL HISTORY
● Poor weight gain, difficulty with respirations at birth,
prematurity
PHYSICAL EXAMINATION
● We have to check for fever, auscultate abnormal breath
sounds, monitor respirations (rate, depth quality, note
any dyspnea), percussing for dullness which indicate
fluid. Inspect also if there is presence in color changes,
especially cyanosis. Observe for alertness and change
in mental status. Intercostal, suprasternal, sternal and
substernal retractions could indicate respiratory distress.
UNIT 9 (Week 11)
●
●
INSPECTION
Chest
○ Size, symmetry movement. Because with
chronic obstructive lunch disease, children may
be unable to exhale quickly, allowing air to be
chronically trapped in the lung.. This condition
produces an (innogated??) anterior-posterior
diameter of the chest. Sometimes termed as
pigeon breast. There is an accompanying
tympanic sound heard over the lungs.
○ Infancy shape is almost circular
○ < 6-7 years respiratory movement primarily
abdominal or diaphragmatic
Respirations
○ Rate, rhythm, depth, quality, effort
○ > 60 /min in small children = significant
respiratory distress; tachypnea- increased
respiratory rate. Often an indicator of first
obstruction in young children. When we assess
the respiratory rate in infants, try to count it
before waking them because crying distorts the
respiratory rates.
Slides 15 - 21 (Hannah)
❏ AUSCULTATION
● Listen comparing one areas to the other
- Equality of breath sounds
- Diminished
- Poor air exchange
● Abnormal breath sounds
> Also known as Fious sounds. They are caused by pathologic
conditions and can be heard on lung assessment on children
and respiratory disorders
- Fine crackles
- Wheezes
- Rhonchi (coarse crackles)
- Stridor
● Cough
○ One rule of coughing in children is NEVER TO
SUPPRESS IT AT FIRST. Don’t encourage
parents to use cough suppressants during the
early stage.
○ Coughing is a reflex. It is initiated by the
stimulation of nerves in the respiratory tract. If
there is presence of dust, chemicals, mucous or
inflammation, when detected by the nerves in
the respiratory tract (mucosa), the body will
cough.
○ Infants don’t know how to expectorate yet and
they are predispose to inflammation in the lower
respiratory tract infection like pneumonia
because there will be pooling of secretions in the
lower respiratory tract
○ Coughing is a useful procedure to clear excess
mucous in the respiratory tract.
○ Coughing only becomes harmful and needs
suppression when there is no mucous or debris
to be expelled already to the point the child is
already exhausted and the amount of coughing
is exhausting to the part of the patient or there is
already stomach or chest pain due to coughing,
that’s the time cough suppressants are
indicated.
LUNG SOUNDS / ADVENTITIOUS BREATH SOUNDS
❖ Crackles
- High pitched
- Heard during inspiration
- Not cleared by a cough
- It happens when the alveoli becomes fluid-filled
- Discontinuous
❖ Rhonchi
- Rumbling coarse sounds like that of a snore
- During inspiration or expiration
- May clear with coughing or suctioning
- Continuous
- If the obstruction is in the nose or pharynx. The
noise is produced like snoring sounds.
Obstructions like mucous
❖ Wheeze
- Musical noise
- During inspiration or expiration
- Usually louder during expiration
- Continuous
- Happens if there is an obstruction in the lower
trachea or bronchioles
- Most noticeable on expiration
❖ Stridor
- Happens if the obstruction is at the base of the
tongue or in the larynx.
- You can hear a harsh strident sound during
inspiration
- It is often most marked when the child is on a
supine position and less marked when a child
sits upright
UNIT 9 (Week 11)
❖ Diminished / absence of breath sounds
- can occur when the alveoli are so fluid-filled that
little or no air can enter that.
Types of retractions:
1. Supraclavicular
2. Suprasternal retractions
3. Intercostal retractions
4. Substernal retractions
5. Subcostal retractions
RESPIRATORY PATTERNS
❏ COLOR
- Mucous membranes
- Nailbeds (for presence of clubbing)
- Skin
- Cyanosis (bluish skin which indicates hypoxia or
decreased oxygen in the tissues)
❏ TEMPERATURE
● Febrile state increases oxygen consumption
- children with fever has increased respiratory
rate. Hyperthermia can occur in respiratory
infections
❏ RETRACTIONS
● A sign of respiratory distress
● when children must inspire more forceful than
normal to inflate their lungs because of an
airway obstruction or stiffness, an intrapleural
pressure is decreased to the point that no rigid
parts of the chest draw inwards creating
retractions
● these retractions occur more commonly in
newborn and infants than in older children
because the intercostal tissues are weaker and
less developed in younger children
● retractions of upper chest muscles specifically
the suprasternal and supraclavicular (higher
than suprasternal) suggest upper airway
obstruction.
● retractions of the intercostal and subcostal
muscles suggest lower airway obstruction
Examples of Respiratory Distress:
● Left side upper photo – with intercostal and sternal
retractions. The center part between the ribs has
indentions (retractions)
● Left side lower photo – intercostal retractions (in
between the ribs). The chest draw inward in between the
ribs
● Right side upper photo – sternal retractions with
indentions
➢ Normal Respiration – chest and abdomen rises together
with inspiration
➢ Retraction – chest wall retracts and abdomen rises with
inspirations. Chest draw inward while abdomen rises
called “Seesaw inspiration” or presence of retractions
in respiratory distress
Highlighted information:
● Infants <2 years old are diaphragmatic breather meaning
they use their abdomen rather than thoracic cavity upon
breathing. Their chest cavity is not yet fully mature. Their
chest is very flexible having small lung capacity that’s
why they cannot fully expand their chest
● Diaphragmatic breathing (see image for normal
respiration) when the child inhales, chest and abdomen
rises together. If there is deviation from normal or if
there’s a sign of airway obstruction if the chest will draw
inward or retract, there’s more force will be used to
inhale.
● In children and young infants, adventitious breath
sounds cannot be heard yet because their respiratory
structures are not mature yet.
● First thing to look if there is respiratory illness in an infant
is to check their respiratory rate. Tachypnea or
increased RR is the first symptom that is indicative of
airway obstruction.
● >60 RR regardless of having a cough or adventitious
breath sounds, that could already be an indicative of
airway obstruction. Airway obstruction like mucous or
secretions or foreign body that is ingested by patient.
Most common is secretions or pooling that can cause
airway obstruction
● Children and young infants shifts to thoracic breathing
(chest) when they reach >2 years old and their chest
cavity becomes mature at 7-12 years old
COMMON LABORATORY AND DIAGNOSTIC TESTS
❏
❏
❏
❏
❏
❏
Blood Gas Analysis
Allen Test
Pulse Oximetry
Sputum Analysis
Chest Radiography
Pulmonary Function Test
UNIT 9 (Week 11)
22-28
Respiratory Determinants of Acid-Base Imbalance & their
Normal Values
PaO2- shows adequacy of the gas exchange between alveoli
and the external environment (alveolar ventilation); CO2 cannot
escape when there is damage in the alveoli
Excess CO2 + Water = Carbonic Acid > Acidotic State
(Mahimong Bicarbonate- a buffer system; compensatory
mechanism of the body if there is an increase of CO2 in the
alveoli)
*23
Arterial
Blood
Gas
Normal
Values
-To determine acid-base imbalance, you need to know and
memorize these values to recognize what deviates from normal.
-The normal range for ABGs is used as a guide, and the
determination of disorders is often based on pH
*If the blood is basic the HCO3 level is considered because the
kidneys regulate bicarbonate ion levels.
*If the blood is acidic, The PaCO2 or partial pressure of CO2 in
arterial blood is assessed because the lungs regulate the
majority of acid.
PaCO2- it is increased if a child cannot expire adequately, since
there is trapping of Co2 in the alveoli. H= Hydrogen Ion, ion
concentration of the blood determines also acidity or alkalinity of
the body fluids.
pH - important in the results of the ABG
HCO3 - remember as “metabolic determinant” it is an alkaline
substance that comprises over half of the total buffer base in the
blood. deficit=indicates metabolic acidosis
excess= metabolic alkalosis
O2 - measured in percentage, basically the amount of O2 in the
blood that combines with hemoglobin.
Interpreting Arterial Blood Gas-used to detect Respiratory
Acidosis or Alkalosis / Metabolic Acidosis or Alkalosis
To determine the type of Arterial Blood gas, the key components
are checked, that’s why we have to memorize the values.
We have 3 GOALS OF ABG ANALYSIS
1.) Determine if values interpret Acidosis or Alkalosis by
looking at the pH value
2.) Determine if values define Metabolic or Respiratory
Acidosis through PaCO2 (respi) and HCO3 (meta)
3.) Determine the compensation:
Fully, Partially or Uncompensated
There are 8 steps to interpret the arterial blood gas
results using the “Tic-Tac Toe Method”:
1. Memorize the normal values
(Draw the arrow diagram to guide)
Remember:
<35 PaCO2= alkalosis
>45 PaCO2=acidosis
<22 HCO3=acidosis
>26 HCO3=alkalosis
(*pH same interpretation sa HCO3)
< pH value = acidosis
> pH value = alkalosis
2. Create your tic-tac-toe grid
-Based on their values, determine in which
column we will place the pH, PaCO2 and HCO3
3. Determine if pH is under normal, acidosis or
Alkalosis
1st example: 7.35 - 7.39- slightly acidosis >> pH
under normal but put an arrow leading to
acidosis
2nd example: 7.41 - 7.45- normal, arrow towards
alkalosis
3rd example: any blood pH below 7.35- Acidosis
4th example : any blood pH 7.45 aboveAlkalosis
UNIT 9 (Week 11)
7. Solve for Goal #2- Metabolic or Respiratory?
●
4. Determine if PaCO2 is under normal, acidosis or
alkalosis
1st example: above 45- acidosis
2nd example: 45-35- normal
3rd example: below 35-alkalosis
5. Determine if HCO3 is under normal, acidosis or
alkalosis
1st example: below 22 - acidosis
2nd example: 22-26 - normal
3rd example: above 26 - alkalosis
●
●
If pH is under the same column as
PaCO2= Respiratory
If pH is under the same column as
HCO3= Metabolic
If pH is under the normal value
determine where it is leaning to and
interpret accordingly
Solve for Goal #3- Type of Compensation?
Normal pH= Fully Compensated
All 3 values are abnormal= Partially
PaCO2 or HCO3 is normal and the other is
abnormal= Uncompensated
6. Solve for Goal #1- Acidosis or Alkalosis?
1- Leaning to acidosis = Acidosis
2-Leaning to alkalosis = Alkalosis
Slides 29 - 35 (Cloy)
UNIT 9 (Week 11)
-
pH = 7.26 which is ABNORMAL = ACIDOSIS
PaCO2 = 32 which is ABNORMAL = ALKALOSIS
HCO3 which is ABNORMAL = ACIDOSIS
✓ ACIDOSIS
✓ METABOLIC
✓ PARTIALLY COMPENSATED ABG
METABOLIC ACIDOSIS, PARTIALLY COMPENSATED
pH = 7.1 which is ABNORMAL = ACIDOSIS
PaCO3 = 40 which is NORMAL = NORMAL
HCO3 = 18 which is ABNORMAL = ACIDOSIS
✓ ACIDOSIS
✓ RESPIRATORY
✓ FULLY COMPENSATED ABG
METABOLIC ACIDOSIS, UNCOMPENSATED
Hyperventilation therefore the findings of our patients
are rapid deep breathing, confusion, and
unconsciousness. pH is increased and decreased
PaCO2
Metabolic Acidosis
Findings of patients usually altered level of
consciousness, disorientation, lack of appetite,
coma, and jaundice.
- Can be seen in patients with diabetic ketoacidosis,
chronic renal failure, dehydration (bec. Of electrolyte
imbalances).
Metabolic Alkalosis
- Findings of patients kay edema, disorientation and
patients with excessive vomiting (bec. The loss of
gastric secretions specifically the hydrochloric acid; kung
mawa si hydrogen ions class, if mo excrete na sya, kay
ang bicarbonate ions kay adto na sya mo shift sa
extracellular tissues sa body).
pH = 7.44 which is NORMAL -> ALKALOSIS = ALKALOSIS
PaCO3 = 30 which is ABNORMAL = ALKALOSIS
HCO3 = 21 which is ABNORMAL = ACIDOSIS
✓ ALKALOSIS
✓ RESPIRATORY
✓ FULLY COMPENSATED ABG
RESPIRATORY ALKALOSIS, FULLY COMPENSATED
Respiratory Acidosis
(Discussion)
- Managhan si PaCO2 kay di man ma excrete si carbon
dioxide.
- Basically, in respiratory acidosis, a hypoventilation
trapping carbon dioxide in the alveoli therefore ang pH is
decreased and increased ang PaCO2.
- Findings of patients usually kay shallow breathing,
inability
to
expire
freely,
confusion,
and
disorientation.
Respiratory Alkalosis
Slides 36 - 42 (Shannen)
2. ALLEN TEST
- used to assess collateral blood flow to the hands
UNIT 9 (Week 11)
- Because children cannot raise sputum with a cough sputum
collection is not feasible in children younger than school age.
(because they are not receptive to instructions, there is a specific
way to collect sputum)
- Instruct children to breathe in and out several times, cough
deeply and spit mucus into the sterile sputum cup. ( proper way
of collecting the specimen)
- also known as sputum culture (tan awon ang organism
present sa sputum. Ex. Mycobacterium tuberculosis – causative
org for TB)
-Before obtaining an ABG from the radial artery, it is important to
establish that the child has collateral circulation to the hand.
Otherwise, the needle puncture may block the artery and block
blood flow to the hand.
-To prove that there is collateral circulation, we need to perform
ALLEN TEST. By doing so, we have to compress both radial and
ulnar arteries on the inner side of the wrist and elevate the hand
until the color disappears (pallor)(muluspad). Release the
pressure over the ulnar artery first, and observe for a color
change in the hand. If the hand does not turn into pink which is a
proof that there is a blood flow, the radial artery on that wrist
should not be used for catheter insertion because that indicates
clotting in the radial artery (occluded).
3. PULSE OXIMETRY
- is a noninvasive and painless test that measures oxygen
saturation level, or the oxygen level in your blood. It can rapidly
detect even small changes in how efficiently oxygen is being
carried to the extremities furthest from the heart, including the
legs and the arms.
- For measurement, a sensor and a photodetector are placed
around a vascular bed, most often a finger in a child and a foot
in an infant. Infrared light is directed into the finger from the
sensor to the photodetector because hemoglobin absorbs
lightweights differently when it is bound to oxygen than not. So
the oximeter can detect the degree of oxygen saturation in the
hemoglobin.
- To those px with respiratory illness, automatic apil najud na ang
O2 Saturation, nig kuha vital signs.
4. SPUTUM ANALYSIS
- is a test that checks for bacteria or another type of organism
that may be causing an infection in your lungs or the airways
leading to the lungs
5. CHEST RADIOGRAPHY
- an imaging test that uses small amounts of radiation to produce
pictures of the organs, tissues, and bones of the body. When
focused on the chest, it can help spot abnormalities or diseases
of the airways, blood vessels, bones, heart, and lungs. Chest
x-rays can also determine if you have fluid in your lungs, or fluid
or air surrounding your lungs.
- Chest x-ray films will show areas of infiltration or consolidation
in the lungs. If a foreign body is present(?), a chest x-ray study
will show its exact location. With the help of a doctor, we can
identify asa nga part of specific lobes in the lungs ang affected
sa disorder.
-Chest x-ray films are more difficult to obtain in infants than in
older children, because infants cannot take a breath and hold it
when instructed. It is therefore difficult to picture the lungs in its
most expanded position. (px are encouraged to inhale aron mas
maklaro siya tan awon sa x ray)
6. PULMONARY FUNCTION TEST
- are non-invasive tests that show how well the lungs are
working. The tests measure lung volume, capacity, rates of flow,
and gas exchange.
- indicated to patients who already have respiratory illness,
specifically chronic respiratory illness. Because nanay
dysfunction sa ilang system nya e test na siya how well their
lungs are still working.
There are 2 types of disorders that cause problems with air
moving in and out of the lungs:
• Obstructive – this is when air has trouble flowing out of the
lungs due to airway resistance. This causes a decreased flow in
air.
Children with obstructive lung diseases such as asthma
and bronchiolitis have some difficulty moving air into the lungs
but they have even more difficulty moving air out of the lungs.
Even though they inspire the same amount of air as the average
child, they expire it over a longer period.
• Restrictive – This is when the lungs tissue and/or chest
muscle can’t expand enough. This creates problems with air
flow, mostly due to lower lung volumes.
Children with restrictive ventilatory disorders such as
neuromuscular disorders have equal difficulty with inspiration
and expiration.
6. PULMONARY FUNCTION TEST
2 Methods ( they can be used together and perform different
tests depending on the information that the doctor is looking for)
1.
Spirometry. A spirometer is a device with a mouthpiece
hooked up to a small electronic machine.
2.
Plethysmography. You sit or stand inside an air-tight
box that looks like a short, square telephone booth to do the
tests.
-Children younger than 4 years of age are unusually unable to
participate in pulmonary function tests, because this test requires
their cooperation. All children need preparation and teaching for
this test because they must breathe forcedly into the mouth on
the mouthpiece at cue (?). Some test require for the nose to be
closed with a clip/clump/ assistant hand, this can be frightening
feeling for children with respi disease. They may need some trial
runs to ensure themselves that they can breathe with the clump
in place. Without good orientation to the equipment, they may
become so anxious that they may develop tachypnea and they
may not be able to inhale or exhale with their full capacity. So the
test results are altered. The result pulmonary function studies
help determine nature and extent of the child’s respiratory
problem and the best method of achieving more effective
ventilation.
THERAPEUTIC TECHNIQUES USED IN THE TREATMENT
OF RESPIRATORY ILLNESS IN CHILDREN
Slides 43 - 49 (Brian)
EXPECTORANT THERAPY
• Liquefying agents
➔ Pharmacologic agents
(expectorants) – ex. Guaifenesin(Robitussin) is given orally
and designed to liquefy a mucus in the trachea and bronchi
UNIT 9 (Week 11)
➔ Instilling saline nose drops or using saline nasal sprays
can be effective in moistening and loosening dried
mucus in the nose.
• Nebulizers
- mechanical devices that provide a stream of moistened
air directly into the respiratory tract.
- Serve as an important means for the delivery of
respiratory tract medication, drugs such as antibiotics
are bronchodilators that can be combined with nebulized
mist and sprayed into the lungs.
- It is indicated to patients having acute asthma attack
- Some of these medications also can cause drying of
mucous membranes.
- Many children find nebulizer treatment uncomfortable
because the feeling of the mist in the upper respiratory
tract is irritating. Assure them that aerosol administration
is the most effective route.
• Coughing
- Encourage coughing rather than suppress it in children
because it is an effective method of raising mucus.
- Changing a child's position and suggesting mild exercise
or deep breathing are helpful techniques to initiate
coughing.
- Cough and child preparations are not recommended in
children less than 6 years of age because both the lack
of evidence of their effectiveness and their potential
harmful side effects
• Mucus - Clearing Devices
- A flutter device that can be used to aid in the removal of
mucus.
- This device looks like a small plastic pipe. A
stainless-steel ball inside the device moves when
children breathe out, causing vibration in the lungs.
- This vibration helps loosen mucus so that it can be
moved up the airway and expectorated.
- This device is used most frequently with children who
have cystic fibrosis or pneumonia to help remove mucus
from the lungs
• Chest Physiotherapy
- is an airway clearance technique (ACT) to drain the
lungs, and may include percussion involves striking a
cupped or curved palm against the chest to determine
the consistency of tissue beneath the surface area
(clapping), vibration is done by pressing a vibrating
hand against a child’s chest during exhalation. Like
percussion, it mechanically loosens and helps move
tenacious secretions upward, deep breathing, and
huffing or coughing.
Nursing Considerations:
- Before performing CPT we have to auscultate first the
lung fields of the patients so that we will know that lobe
or lung field is affected. With that, we can determine
what position to be done to the patient.
- Upon position of the child so that the lobe of the lungs
affected or to be brained in a superior position.
- After each position ask the child to cough
- Simply changing a child’s position helps mucus to move
so it initiates a cough reflex and is expelled, and to
prevent mucus from pooling certain lung areas.
- If a child has a localized mucus problem, lying
predominantly in one position can encourage drainage of
that lung segment.
- When the child is repositioned and the mucus drains into
new bronchi, this will often result in a cough from
irritation caused by this new drainage.
- Chest Physiotherapy is best scheduled before meals or
an hour after meal so that the subsequent coughing
does not cause vomiting
- Limit the chest physiotherapy for at least 30 minutes
because this technique is tiring.
THERAPY TO IMPROVE OXYGENATION
- Improving oxygenation almost automatically relieves
breathing distress
• Oxygen administration
- elevates the arterial oxygen saturation level by supplying
more oxygen to red blood cells through the respiratory
tract.
- Oxygen may be delivered to an infant by flooding an
incubator using a plastic hoods mask or a cannula.
- Plastic Oxygen hoods
- are tight fitting enclosures that can keep oxygen
concentration at nearly at a 100%.
- Always check that the hood fits snugly in the infant's
head making sure that it does not rub the infant's neck,
chin or shoulders.
- Nasal catheter or Nasal Prongs
- can be used in infants, but they usually reserve for
older children.
- Most children do not like nasal prongs or catheters
because they are intrusive.
- Assess their nostrils carefully when using these as the
pressure of prongs can cause areas of necrosis,
particularly on the nasal septum.
- Snug-fitting oxygen mask (non-rebreather mask)
- a method for supplying nearly 100% oxygen and is
frequently used in emergencies
- Masks, like prongs or catheters, are often not well
tolerated by children because they tend to slip and
obstruct their view, and if necessary let them hold the
mask.
- Oxygen must be administered warm and moistened, and
without proper humidification, oxygen dries mucous
membranes and thickens secretions, compounding
breathing difficulty.
Nursing Considerations:
- When caring for a child with any form of oxygen
equipment, follow safety rules. Because oxygen
supports combustion, keep open flames away from
oxygen and minimize the risk of sparks. Because oxygen
is humidified, the equipment is a good source of
microbial contaminants and so should be changed
according to your agency’s policy at least once a week
to keep bacterial counts within safe limits.
- Monitor and record child's oxygen saturation level via
pulse oximeter
- Also, the importance of monitoring the 02 saturation to
know whether effective ang oxygen administration. But,
initially we should take the baseline oxygen sat of the
patient para after administering oxygen administration
we check again the oxygen level or flow rate.
- Obtain ABG measurements with any changes of oxygen
or otherwise ordered by the physician.
• Metered - dose inhalers
- is a handheld device that provides a route for medication
administration directly to the respiratory tract. (ex. of
meds: bronchodilators, corticosteroids)
- Corticosteroids are first administered because the
mechanism of action of steroids is to reduce the
inflammation of the airway, then Bronchodilators are
administered which dilates the airway of the patient.
- The child inhales while depressing a trigger on the
apparatus.
UNIT 9 (Week 11)
- For successful use of MDI, children need to follow five
general rules: shake the canister, exhale deeply,
activate the inhaler and place it in their mouth as they
begin to inhale, take a long slow inhalation, and then
hold their breath for 5 to 10 seconds. They should only
take one puff at time, with a 1 minute wait between puffs.
But if it is two medications like bronchodilators and
corticosteroids they have to wait for 3-5 minutes in
between the puffs
- Coordinating inhalation with MDI use can be difficult;
therefore, use of an aerochamber (spacer) is generally
recommended to prevent deposition on the posterior
pharynx.
- Younger children can use an MDI attached to an
aerochamber with a mask.
- All children using inhaled corticosteroids need an
aerochamber to prevent deposition of the medication in
the mucous membranes of the mouth and pharynx,
which can contribute to the development of thrush.
• Incentive spirometry
- Devices that encourage children to inhale deeply to
aerate the lungs fully or move mucus.
- Common type consist of a hollow plastic tube containing
a brightly colored ball or dome-shaped disk that will rise
in the tube when a child inhales through the attached
mouthpiece and tubing.
- The deeper the inhalation, the higher the ball rises in the
tube.
- Children need instruction on how to use this type of
device because their first impression is that they should
blow out against the mouthpiece rather than inhale.
- Incentive spirometry can be very effective with children
because the device and procedure resemble a game
more than an actual treatment.
• Breathing Techniques
- blowing a piece of cotton or a plastic ball across a table,
blowing through a straw or blowing out with the lips
pursed are effective techniques for better emptying
alveoli.
- Can be used if there is no incentive spirometry
- For best results, make these activities a game or contest
rather than exercise.
• Tracheostomy
-
is an opening into the trachea to create an artificial
airway to relieve respiratory obstruction that has
occurred above that point.
- Tracheotomy = the procedure to create an
airway
- Tracheostomy = the resultant artificial airway
- It also may be used as a route for suctioning mucus when
accumulating mucus causes lower airway obstruction.
- Few medical emergencies are as frightening to a child or
parents as an acute obstruction of a child’s upper airway
requiring a tracheostomy or endotracheal intubation.
Indication:
The child suddenly becomes limp and breathless, with color
changing quickly to systemic cyanosis.
Procedure:
1. The cricoid cartilage of the trachea is swabbed with an
antiseptic.
2. If readily available, a local anesthetic may be injected
into the cartilage ring.
3. An incision is made just under the ring of cartilage.
4. A tracheostomy tube with its obturator in place is
inserted into the opening.
5. When the obturator is removed, the child can breathe
through the hollow tracheostomy tube.
6. Have suction equipment available for immediate use to
clear any blood caused by the incision and any
obstructing mucus from the trachea.
- The color change in children after tracheostomy is usually
dramatic. They inhale deeply several times through the tube, and
color returns to normal.
- A few sutures may be necessary at the tube insertion site to
halt the bleeding or to reduce the size of the incision so the tube
fits snugly.
- As the children begin to breathe normally and, if unconscious,
regain consciousness, they often thrash and push at people
around them, both from oxygen deficit and from fright. They call
for a parent but can make no sound, adding To their fright.
Nursing Management:
1. Assure children that everything is alright, even
though they cannot speak. A school-age child
can understand a simple explanation such as “
You can’t speak right now because of the tube in
your throat”.
2. As soon as children’s respirations are even and
they are no longer experiencing acute
respiratory distress, show them how, by placing
a finger over the tracheostomy tube opening, air
will again flow past the larynx and they can
speak.
3. If this causes a child to become short of breath,
supply a paper and pencil or chalkboard for
communication.
4. Be certain parents understand why the tube is in
place and how important it is that it remain
patent.
5. Assure parents that it is a temporary measure to
provide oxygen
➔ Suctioning technique
-Most tracheostomy tubes used with children today are
plastic. They do not include an inner cannula that would
require removal and regular cleaning.
-Most children, however, do require frequent suctioning
to keep their airway free of mucus.
-Use sterile technique to prevent introducing
microorganisms, and suction gently yet thoroughly.
Slides 50 - 56 (Mira)
●
Lung Transplantation
○ A possibility for children with a chronic
respiratory illness such as cystic fibrosis. The
transplant may involve a single lung, or it can be
done in conjunction with heart transplantation if
chronic respiratory disease has caused
ventricular hypertrophy of the heart.
○ As with any organ transplantation, children need
continued immunosuppression therapy with
drugs such as cyclosporine or azathioprine
(Imuran) following a lung transplant to decrease
cell-mediated immunity.
○ Although this level of immunosuppression is the
key to successful transplantation, it also makes
UNIT 9 (Week 11)
post-transplant children susceptible to fungal,
bacterial, and viral lung infections.
○ In addition, families experience a tremendous
psychosocial toll as they wait to see whether the
new transplant will be rejected.
○ Children may need to have chest physiotherapy
or use a portable spirometry device daily to help
mobilize secretions resulting from loss of nerve
innervation or a reaction to accumulating mucus
in the transplanted lung.
○
RESPIRATORY DISORDERS AND THEIR NURSING
MANAGEMENT
UPPER RESPIRATORY DISORDERS
The upper respiratory tract warms, humidifies, and filters the air
that enters the body. As such, the structures of the upper
respiratory tract constantly come into contact with a barrage of
foreign organisms, including pathogens, that can lead to airway
irritation and illness. Congenital malformations of respiratory
structures also cause some upper respiratory tract disorders.
1. Choanal Atresia
○ Nasal Passages are blocked or narrowed by soft
tissue or bone
○ A congenital obstruction of the posterior nares
by an obstructing membrane or bony growth,
preventing a newborn from drawing air through
the nose and down into the nasopharynx . It may
be either unilateral or bilateral. Newborns up to
approximately 3 months of age are naturally
nose-breathers. Infants with choanal atresia,
therefore develop signs of respiratory distress at
birth or immediately after they quiet for the first
time and attempt to breathe through their nose.
○ Choanal atresia can also be assessed by
holding the newborn’s mouth closed, then gently
compressing first one nostril, then the other. If
atresia is present, infants will struggle as they
experience air hunger when their mouth is
○
closed. Their color improves when they open
their mouth to cry.
Atresia is also suggested if infants struggle and
become cyanotic at feedings because they
cannot suck and breathe through the mouth
simultaneously.
■ Congenital Disorder
■ Unilateral Choanal Atresia
● Only one nasal passage
affected
■ Bilateral Choanal Atresia
● Both nasal passages affected
Symptoms:
Unilateral
Difficulty Breathing
Persistent Nasal Drainage
Recurrent Sinus infections
○
○
Bilateral
Difficulty Breathing
Respiratory Distress
Cyanosis
Diagnosis:
■ Medical
History
and
Physical
Examination
■ Test for nasal airflow
■ CT scan
Treatment:
■ Transnasal Endoscopic Surgery
● treatment for choanal atresia is
either local piercing of the
obstructing
membrane
or
surgical removal of the bony
growth.
● Because infants with choanal
atresia have such difficulty with
feeding, they may receive
intravenous fluid to maintain
their glucose and fluid level until
surgery can be performed.
Some infants may need an oral
airway inserted so they can
continue to breathe through
their mouths. Following surgery,
children have no further difficulty
or symptoms.
2. Acute Nasopharyngitis
○ Caused by one of several viruses, most
predominantly by rhinovirus, coxsackievirus,
RSV, adenovirus, and influenza viruses.
○ The common cold is the most frequent infectious
disease in children—in fact, toddlers have an
average of 10 to 12 colds a year. School-age
children and adolescents have as many as four
or five yearly. The incubation period is typically 2
to 3 days.
○ Children are exposed to colds at school or while
playing with other children. If they are in ill health
from some other cause, or if their immune
system is compromised, they are more
susceptible than others to the cold viruses.
○ Symptoms:
■ begin with nasal congestion, a watery
rhinitis, and a low-grade fever. The
mucous membrane of the nose
becomes edematous and inflamed,
constricting airway space and causing
difficulty breathing. Posterior rhinitis,
plus local irritation, leads to pharyngitis
(sore throat). Upper airway secretions
that drain into the trachea lead to a
cough. Cervical lymph nodes may be
swollen and palpable. The process lasts
about a week and then symptoms fade.
In some children, a thick, purulent nasal
discharge occurs because bacteria such
as streptococci invade the irritated nasal
mucous membrane and cause a
secondary purulent infection.
○ Management:
○ There is no specific treatment for a common
cold. Although many parents ask to have
UNIT 9 (Week 11)
antibiotics prescribed, because colds are caused
by a virus, antibiotics are not effective unless a
secondary bacterial invasion has occurred. If a
child has a fever, it can be controlled by an
antipyretic such as acetaminophen (Tylenol) or
children’s ibuprofen (Motrin). Help parents
understand that these drugs are effective only in
controlling fever symptoms; they do not reduce
congestion or “cure” the cold.
○ Therefore, they should not be given unless the
child has a fever. If infants have difficulty nursing
because of nasal congestion, saline nose drops
or nasal spray may be prescribed to liquefy
nasal secretions and help them drain. Removing
nasal mucus via a bulb syringe before feedings
also allows infants to breathe more freely and be
able to suck more efficiently.
○ Caution parents that if they use a bulb syringe,
they must compress the bulb first, then insert it
into the child’s nostril. If they insert the bulb
syringe first, then depress the bulb, they will
actually push secretions further back into the
nose, causing increased obstruction.
○ There is little proof that oral decongestants
relieve congestion to an appreciable degree with
the common cold. Cough suppressants are not
necessary either as coughing raises secretions,
preventing pooling of secretions and the danger
of consequent lower respiratory infection.
Guaifenesin is an example of a drug that
loosens secretions but does not suppress a
cough so is safe to use. Parents may use a cool
mist vaporizer to help loosen nasal secretions if
they wish.
■ Antipyretic for fever
■ Saline nasal drops or spray
■ Removal of nasal mucus via a bulb
syringe
■ Guaifenesin
■
● To loosen secretions
Cool mist vaporizer to help loosen nasal
secretions
3. Pharyngitis
○ Pharyngitis is infection and inflammation of the
throat. The peak incidence occurs between 4
and 7 years of age. It may be either bacterial or
viral in origin.
○ It may occur as a result of a chronic allergy in
which there is constant post nasal discharge that
results in secondary irritation. At least a slight
pharyngitis usually accompanies all common
upper respiratory infections.
4. Viral Pharyngitis
○ The causative agent of pharyngitis is usually an
adenovirus.
○ Symptoms:
■ Generally mild: a sore throat, fever, and
general
malaise.
On
physical
assessment, regional lymph nodes may
be noticeably enlarged. Erythema will be
present in the back of the pharynx and
the palatine arch. Laboratory studies will
indicate an increased white blood cell
count.
○ Therapeutic Management:
■ If the inflammation is mild, children
rarely need more than an oral analgesic
such as acetaminophen or ibuprofen for
comfort.
■ Warm heat applied to the external neck
area using a warm towel or heating pad
also can be soothing. By school age,
children are capable of gargling with a
solution such as warm water to help
reduce the pain. Before this age,
children tend to swallow the solution
unless the procedure is well explained
and demonstrated to them.
■
Because children’s throats feel so sore,
they often prefer liquids to solid food.
Infants, especially, must be observed
closely until the inflammation and
tenderness diminish to be certain that
they take in sufficient fluid to prevent
dehydration.
5. Streptococcal Pharyngitis
○ Group A beta-hemolytic streptococcus is the
organism most frequently involved in bacterial
pharyngitis in children. All streptococcal
infections must be taken seriously because they
can lead to cardiac and kidney damage from the
accompanying autoimmune process.
○ Symptoms:
■ Streptococcal infections are generally
more severe than viral infections. The
fact that symptoms are mild, however,
does not rule out streptococcal infection.
■ With a streptococcal pharyngitis, the
back of the throat and palatine tonsils
are usually markedly erythematous
(bright red); the tonsils are enlarged and
there may be a white exudate in the
tonsillar crypts. Petechiae may be
present on the palate.
■ A child typically appears ill with a high
fever, an extremely sore throat, difficulty
swallowing,
and overall lethargy.
Temperature is usually elevated to as
high as 104° F (40° C). The child often
has a headache. Swollen abdominal
lymph nodes may cause abdominal
pain. A throat culture, often completed
as a quick office procedure, confirms the
presence of the Streptococcus bacteria.
○ Therapeutic Management:
■ Treatment consists of a full 10- day
course of an oral antibiotic such as
UNIT 9 (Week 11)
■
■
penicillin
G
or
clindamycin.
Cephalosporins
or
broad-spectrum
macrolides such as erythromycin may
be prescribed if resistant organisms are
known to be in the community. Help
parents understand the importance of
completing the full prescribed days of
therapy.
The recommended treatment days are
necessary to ensure the streptococci
are eradicated completely. If they are
not, the child may develop a
hypersensitivity or autoimmune reaction
to group A streptococci that can result in
rheumatic fever (although the chance of
rheumatic fever occurring is probably as
low as 1%) or glomerulonephritis.
In addition, instruct them about
measures for rest, relief of throat pain,
and maintaining hydration, the same
actions as for a common cold. Because
it is impossible for parents to
discriminate between a pharyngitis
caused by a virus (and needing no
therapy other than comfort measures)
and a streptococcal pharyngitis (needing
definite
therapy
to
prevent
life-threatening illnesses), a child with
pharyngitis always should be examined
by health care personnel.
Viral
Causative Agent:
● Adenovirus
Symptoms:
● Mild sore, throat, fever
and general malaise
Management:
Bacterial
Causative Agent:
● Group A beta-hemolytic
streptococcus
Symptoms:
● Back of the throat and
palatine
tonsils
are
erythematous, tonsils are
●
●
●
Oral analgesics such as
acetaminophen
or
ibuprofen
Warm heat applied to
external neck area
Gargling with warm water
to reduce pain
enlarged, petechiae on
the palate, high fever,
extremely sore throat,
dysphagia and lethargy.
Management:
● Penicillin,
G
or
Clindamycin for bacterial
infection
● Measures for rest
● Maintaining hydration
Slides 57 - 63 (Joash)
4. Tonsillitis
○ refers to infection and inflammation of the
palatine tonsils.
○ Tonsillar tissue is lymphoid tissue that filters
pathogenic organisms from the head and neck
area. The palatine tonsils are located on both
sides of the pharynx; the adenoids are in the
nasopharynx.
○ Infection of the palatine tonsils presents with all
of the symptoms of severe pharyngitis. Children
drool because their throat is too sore for them to
swallow saliva.
○ They may describe swallowing as so painful it
feels as if they are swallowing bits of metal or
glass.
○
In addition, they usually have a high fever and
are lethargic.
○ Tonsillar tissue appears bright red and may be
so enlarged the two areas of palatine tonsillar
tissue meet in the midline.
○ Pus can be detected on or expelled from the
crypts of the tonsils (whitish exudates).
○ Tonsillitis occurs most commonly in school-age
children. The responsible organism is identified
by a throat culture. In children younger than 3
years of age, the cause is often viral. In
○
school-age children, the organism is generally a
group A beta hemolytic streptococcus
Management:
■ Antipyretic - for fever
■ Analgesics - for pain
■ Antibiotics (penicillin or amoxicillin;
10-day course) - If the cause is viral, no
therapy other than comfort or fever
reduction strategies is necessary.
Although the pain of the infection will
subside a day or two after the antibiotic
administration is begun, remind parents
that children need the full 10-day course
of antibiotic to eradicate streptococci
completely from the back of the throat.
■ Tonsillectomy - removal of the palatine
tonsils. In the past, tonsillectomy was a
common procedure following an episode
of tonsillitis, but today it is not
recommended
unless
all
other
measures to prevent frequent infections
prove ineffective. Tonsillar tissue is
removed by ligating the tonsil or by laser
surgery. Because sutures are not
placed, the chance for hemorrhage after
this type of surgery is higher than after
surgery involving a closed incision. The
danger of aspiration of blood at the time
of surgery and the danger of a general
anesthetic compound the risk. After
surgery we usually put children or any
other patient, place them in a prone
position to prevent aspiration and
secretions. In younger children we place
a pillow under their chest to help
secretions flow out of the mouth.
■ Chronic tonsillitis is about the only
reason for removal of palatine tonsils.
UNIT 9 (Week 11)
Tonsillectomy is indicated for chronic
tonsillitis.
■ Tonsillectomy or adenoidectomy is
never done while the organs are
infected, because an operation at such
a time might spread pathogenic
organisms into the bloodstream, causing
septicemia. Parents often ask why an
operation to remove tonsils must be
delayed until the child is well again.
They think that as long as the tonsils are
sore, they should be immediately
removed.
■ Help them understand why it is safer to
schedule surgery for a later date. Most
parents report an improvement in their
child’s general health and performance
after tonsillectomy surgery, as this ends
the chronic infections.
5. Epistaxis (Nosebleed)
○ Extremely common in children and usually
occurs from trauma, such as picking at the nose,
from falling, or from being hit on the nose by
another child.
○
In homes that lack humidification, the hot dry
environment
causes
children’s
mucous
membranes to dry, feel uncomfortable, and be
susceptible to cracking and bleeding.
○ In all children, epistaxis tends to occur during
respiratory illnesses. It also may occur after
strenuous exercise, and it is associated with
several systemic diseases, such as rheumatic
fever, scarlet fever, measles, or varicella
infection (chickenpox).
○ It can occur with nasal polyps, sinusitis, or
allergic rhinitis. Some families show a familial
predisposition.
○ Nosebleeds are always frightening because of
the visible bleeding and a choking sensation if
blood should run down the back of the
nasopharynx.
○ Management:
■ Keep children with nosebleeds in an
upright position with their head tilted
slightly forward to minimize the
amount of blood pressure in nasal
vessels and to keep blood moving
forward, not back into the nasopharynx.
■ Apply pressure to the sides of the
nose with your fingers. Make every
effort to quiet the child and to help stop
crying, because crying increases
pressure in the blood vessels of the
head and prolongs bleeding.
■ If these simple measures do not control
the bleeding, epinephrine (1:1000) may
be applied to the bleeding site to
constrict blood vessels. A nasal pack
may be necessary to provide continued
pressure.
○ Every child has an occasional nosebleed.
Chronic nasal bleeding, however, should be
investigated to rule out a systemic disease or
blood disorder.
6. Sinusitis - infection and inflammation of the sinus
cavities
○ It is rare in children younger than 6 years of age
because the frontal sinuses do not develop fully
until age 6. It can occur as a primary infection or
a secondary one in older children when
streptococcal, staphylococcal, or H. influenzae
organisms spread from the nasal cavity
○ Children develop a fever, a purulent nasal
discharge, headache, and tenderness over the
affected sinus. A nose and throat culture will
identify the infectious organism.
○ Treatment for acute sinusitis consists of an
antipyretic for fever, an analgesic for pain, and
an antibiotic for the specific organism involved.
Hot shower is also encouraged to relieve pain,
promote drainage and open up the sinus cavity.
Encourage: drink a lot of fluids, saltwater nasal
irrigation, steam humidifier. Warm compresses
to the sinus area may also encourage drainage
and relieve pain.
○ Oxymetazoline hydrochloride (Afrin), supplied
as nose drops or a nasal spray, shrinks the
edematous mucous membranes and allows
infected material to drain from the sinuses and
relieve pain. To avoid a rebound effect, this type
of nasal spray should be used for only 3 days at
a time; otherwise, it actually causes more nasal
congestion than was present originally.
○ Sinusitis is considered by many adults to be a
minor illness. It needs to be treated, however,
because it can have serious complications if the
infection spreads from the sinuses to invade the
facial bone (osteomyelitis) or the middle ear
(otitis media). Chronic sinusitis can also interfere
with school and social interactions because of
the constant pain.
7. Laryngitis - inflammation of the larynx.
○ Symptoms include sore throat, loss of voice,
voice change.
○ It results in brassy, hoarse voice sounds or
inability to make audible voice sounds. It may
occur as a complication of pharyngitis or from
excessive use of the voice, as in shouting or
loud cheering. Laryngitis is as annoying for
children as it is for adults.
○ Treatments include:
■ Sips of fluid (either warm or cold,
whichever feels best) offer relief from
the annoying tickling sensation often
present.
■ The most effective measure, however, is
for the child to rest the voice for at least
24 hours, until inflammation subsides.
■ Use of humidifier
■ Gargling salt water
■ Encouraging oral fluids
8. Allergic Rhinitis
○ Results from a local defense mechanism in the
nasal airways that attempts to prevent irritants
and allergens from entering the lungs.
UNIT 9 (Week 11)
○ In children, it is often caused by sensitization to
animal dander, house dust, pollens and molds.
○ It is often associated with different symptoms in
the upper respiratory tract that includes:
■ Runny nose
■ Sneeze
■ Stuffy nose
■ Itchy eyes
■ Headache
■ Sinus pain (upon percussing)
○ Management:
■ Antihistamine & Cetirizine (not advisable
to be always used. The body tends to be
dependent on this.)
■ Steroids - most common medication
given
■ Avoidance of allergens or environmental
controls.
■ For severe cases: Allergen-specific
immunotherapy (sublingual or allergy
shot)
○ Immune system hypersensitivity is the cause for
this allergic reaction, no pathogens involved. It is
just that patients with allergic rhinitis are
hypersensitive to these allergens.
9. Congenital Laryngomalacia/Tracheomalacia
○ means that an infant’s laryngeal structure is
weaker than normal and collapses more than
usual on inspiration
○ This produces laryngeal stridor (a high-pitched
crowing sound on inspiration) present from birth,
possibly intensified when the infant is in a supine
position or when sucking
○ Symptoms include noisy breathing in inspiration,
stridor may be louder in exertion, crying or
feeding.
○ The infant’s sternum and intercostal spaces may
retract on inspiration because of the increased
effort needed to pull air into the trachea past the
collapsed cartilage rings. Many infants with this
condition must stop sucking frequently during a
feeding to maintain adequate ventilation and to
rest from their respiratory effort, which is
exhausting.
○
Most children with congenital laryngomalacia
need no routine therapy other than to have
parents feed them slowly, providing rest periods
as needed. The condition improves as infants
mature and cartilage in the larynx becomes
stronger at about 1 year of age.
○ Be certain parents know the importance of
bringing the child for early care if signs of an
upper respiratory tract infection develop. If not,
laryngeal collapse will be even more intense
during these times, and complete obstruction of
the trachea could occur. If stridor becomes more
intense, advise parents to have the infant seen
by their primary care provider, because
generally this indicates beginning obstruction
and probably the beginning of an upper
respiratory tract infection.
10. Croup (Laryngotracheobronchitis) - inflammation of
the larynx, trachea, and major bronchi
○
one of the most frightening diseases of early
childhood for both parents and children. In
children between 6 months and 3 years of age,
the cause of croup is usually a viral infection
such as parainfluenza virus. In previous years,
the most common cause was H. influenzae.
○ However, since immunization against this
organism has been included in a routine
immunization series, the incidence of croup from
this cause has declined by 90%
○ Assessment:
■ Children typically have only a mild upper
respiratory tract infection at bedtime.
Temperature is normal or only mildly
elevated. During the night, they develop
a barking cough (croupy cough),
inspiratory
stridor,
and
marked
retractions. They wake in extreme
respiratory distress.
■ The larynx, trachea, and major bronchi
are all inflamed. These severe
symptoms typically last several hours
and then, except for a rattling cough,
subside by morning.
■ Symptoms may recur the following
night.
○
Management:
■ One emergency method of relieving
croup symptoms is for a parent to run
the shower or hot water tap in a
bathroom until the room fills with steam,
then keep the child in this warm, moist
environment.
■
If this does not relieve symptoms,
parents should bring the child to an
emergency department for further
evaluation and care.
■ When a child is seen at an emergency
room, cool moist air with a corticosteroid
such as dexamethasone, or racemic
epinephrine, given by nebulizer,
reduces inflammation and produces
effective bronchodilation to open the
airway.
■ Other
managements
include
antipyretic, fluid intake, decreasing
anxiety, and vital signs monitoring
Slides 64 - 70 (Mary)
11. Epiglottitis
○ Inflammation and swelling of the epiglottis,
which is the flap of cartilage that covers the
opening to the larynx to keep out food and fluid
during swallowing. Although it is rare,
inflammation of the epiglottis is an emergency
because the swollen epiglottis cannot rise and
allow the airway to open. It occurs most
frequently in children from 2 to about 8 years of
age.
○ Epiglottitis can be either bacterial or viral in
origin. Haemophilus influenzae type B has
been replaced as the most common bacterial
cause of the disorder followed by pneumococci,
streptococci, or staphylococci. Echovirus and
RSV also can cause the disorder. The incidence
of epiglottitis has greatly decreased with the
introduction of the H. influenzae type B vaccine.
○ Assessment:
■ Symptoms begin as those of a mild
upper respiratory tract infection. After 1
UNIT 9 (Week 11)
○
or 2 days, as inflammation spreads to
the epiglottis, the child suddenly
develops severe inspiratory stridor, a
high fever, hoarseness, and a very sore
throat. Children may have such difficulty
swallowing that they drool saliva. They
may protrude their tongue to increase
free movement in the pharynx.
■ If a child’s gag reflex is stimulated with a
tongue blade, the swollen and inflamed
epiglottis can be seen to rise in the back
of the throat as a cherry-red structure. It
can be so edematous, however, that the
gagging procedure causes complete
obstruction of the glottis and shuts off
the ability of the child to inhale.
Therefore, in children with symptoms of
epiglottitis (e.g. dysphagia, inspiratory
stridor, cough, fever, and hoarseness),
never attempt to visualize the epiglottis
directly with a tongue blade or obtain a
throat culture unless a means of
providing an artificial airway, such as
tracheostomy
or
endotracheal
intubation, is immediately available. This
is especially important for the nurse who
functions in an expanded role and
performs physical assessments and
routinely elicits gag reflexes.
Clinical Presentation:
■ Drooling
■ Holding neck in hyperextended position
■ Tripod position
■ Stridor is a late finding!
■ Not usually associated with cough
12. Aspiration
○ Inhalation of a foreign object into the airway,
occurs most frequently in infants and toddlers.
When a child aspirates a foreign object such as
a coin or a peanut, the immediate reaction is
choking and hard, forceful coughing. Usually,
this dislodges the object. However, if the airway
becomes so obstructed and no coughing or
speech is possible, intervention is essential. A
series of back blows or subdiaphragmatic
abdominal thrusts may be used with children.
○ Symptoms:
■ Choking, coughing, or gagging while
eating
■ Weak sucking
■ Fast or stopped breathing while feeding
■ Hoarse voice or cry
■ Noisy breathing or wheezing
■ Chest discomfort or complaints of food
coming back up or feeling stuck
■ Apnea, bradycardia, or cyanosis
■ Excessive salivation
○ Management:
13. Bronchial Obstruction
○ The right main bronchus is straighter and has a
larger lumen than the left bronchus in children
older than 2 years of age. For this reason, an
aspirated foreign object that is not large enough
to obstruct the trachea may lodge in the right
bronchus, obstructing a portion or all of the right
lung. The alveoli distal to the obstruction will
collapse as the air remaining in them becomes
absorbed (atelectasis), or hyperinflation and
pneumothorax may occur if the foreign body
serves as a ball valve, allowing air to enter but
not leave the alveoli.
○ Assessment:
■ After aspirating a small foreign body, the
child generally coughs violently and may
become dyspneic. If the article is not
expelled, hemoptysis, fever, purulent
sputum, and leukocytosis will generally
result as infection develops. Localized
wheezing (a high whistling sound on
expiration made by air passing through
the narrowed lumen) may occur.
Because this is localized, it is different
from the generalized wheezing of a child
with asthma.
■ A chest x-ray will reveal the presence of
an object if it is radiopaque. Objects
most frequently aspirated include
buttons, bones, popcorn, nuts, and
coins. Because objects such as those
made of plastic, nuts, or popcorn cannot
be visualized well on x-ray film, an x-ray
UNIT 9 (Week 11)
study may be inconclusive. Foreign
bodies may also lodge in the esophagus
and cause respiratory distress because
of compression on the trachea. Care
must be taken when feeding young
children to avoid potential choking or
aspiration hazards. Popcorn, grapes,
nuts,
etc.
can
pose
hazards.
Additionally, children may aspirate on
nonfood items such as toys, coins, and
etc.
○ Symptoms:
■ Coughs violently
■ Dyspnea
■ Hemoptysis, fever, purulent sputum and
leukocytosis may develop as a result of
infection
■ Localized wheezing
○ Management:
■ A bronchoscopy may be necessary to
remove the foreign body in the operating
room. After a bronchoscopy, assess the
child closely for signs of bronchial
edema and airway obstruction that
occur
from
mucus
accumulation
because of the bronchus manipulation.
Obtain frequent vital signs (increasing
pulse and respiratory rates suggest
increased edema and obstruction).
■ Keep a child nothing by mouth (NPO)
for at least an hour. Once a gag reflex is
present, offer the first fluid cautiously to
prevent additional aspiration. Cool fluid
may feel more soothing than warm fluid
and also can help reduce the soreness
in the throat. Breathing cool, moist air or
having an ice collar applied may further
reduce edema.
14. Infectious Mononucleosis
○ Mono, or infectious mononucleosis, refers to a
group of symptoms usually caused by the
Epstein-Barr virus (EBV). It typically occurs in
teenagers, but you can get it at any age. The
virus is spread through saliva, which is why
some people refer to it as “the kissing
disease.”
○ Many people develop EBV infections as children
after age 1. In very young children, symptoms
are usually nonexistent or so mild that they
aren’t recognized as mono.
○ Once you have an EBV infection, you aren’t
likely to get another one. Any child who gets
EBV will probably be immune to mono for the
rest of their life.
○ Symptoms:
■ High fever
■ Swollen lymph glands in the neck and
armpits
■ Sore throat
■ Headache
■ Fatigue
■ Muscle weakness
■ A rash consisting of flat pink or purple
spots on skin or mouth
■ Swollen tonsils
■ Night sweats
○ Management:
■ Getting plenty of rest
■ Drinking lots of fluids
■ Antipyretic for fever
■ Analgesics for headache
■ In some cases, corticosteroids, a type of
steroid medication, can reduce swelling
of the throat and tonsils.
15. Influenza
○ Or flu, is a very contagious viral infection that
affects the air passages of the lungs
○ Caused by influenza virus
○ A flu virus is often passed from child to child
through sneezing or coughing.
○ A flu virus is often passed from child to child
through sneezing or coughing. The virus can
also live for a short time on surfaces. This
includes doorknobs, toys, pens or pencils,
keyboards,
phones
and
tablets,
and
countertops. It can also be passed through
shared eating utensils and drinking. Your child
can get a flu virus by touching something that
○
○
was touched by an infected person, and then
touching his or her mouth, nose, or eyes.
People are most contagious with the flu 24
hours before symptoms start, continuing while
symptoms are most active.
Symptoms:
■ Sore throat
■ Dry cough
■ Rhinitis
■ Fever
■ Chills
■ Headache
■ In some cases, your child may also
have symptoms such as nausea,
vomiting, and diarrhea.
■ Most children recover from the flu within
a week. But they may still feel very tired
for as long as 3 to 4 weeks.
■ It is important to note that a cold and the
flu have different symptoms:
Cold Symptoms
Flu Symptoms
Low or no fever
High fever
Sometimes a headache
Headache in most cases
Stuffy, runny nose
Clear nose, or stuffy nose in
some cases
Sneezing
Sneezing in some cases
Mild, hacking cough
Cough, often turning severe
Mild body aches
Severe body aches
Mild tiredness
Extreme tiredness that can
last weeks
Sore throat
Sore throat in some cases
○
Management:
■ Treatment will depend on your child’s
symptoms, age, and general health. It
will also depend on how severe the
UNIT 9 (Week 11)
■
■
■
■
■
■
■
condition is. The goal of treatment is to
help prevent or ease symptoms.
Acetaminophen. This is to help lessen
body aches and fever. Do not give
aspirin to a child with a fever.
Cough medicine. This may be
prescribed by your child’s healthcare
provider.
Antiviral medicine. This may help to
ease symptoms, and shorten the length
of illness. This medicine does not cure
the flu. The medicine must be started
within 2 days after symptoms begin.
Antibiotics are not effective against viral
infections, so they are not prescribed.
Instead, treatment focuses on helping
ease your child’s symptoms until the
illness passes.
Get lots of rest in bed
Drink plenty of fluids
Prevention: Emphasize the importance
of yearly flu vaccine to the parents.
16. Otitis Media
○ An infection of recent onset, and is associated
with a build-up of fluid in the middle ear.
○ Middle ear infections can be caused by viruses
or bacteria.
○ Most children who develop a middle ear
infection have a viral infection (such as a cold),
which causes inflammation and swelling in the
nasal passages and eustachian tube.
○ Symptoms: Ear Pain
■ Irritability and crying in young children
who are unable to tell you that they have
a sore ear
■ Tiredness
■ Disrupted sleep
■ Fever
■ Reduced appetite
■ Vomiting
○ Management:
■ Pain relievers
■ Self-care measures
● Rest
●
Applying a warm compress to
the ear to relieve pain
● Applying a cool compress to the
forehead to relieve fever
● Keeping up their fluid intake to
avoid dehydration
■ Antibiotics
● Patients younger than 6 months
of age
● They are unwell
● Who have been treated with
pain relievers and self-care
measures and are getting worse
or not improving after 2 days.
17. Acute Otitis Externa
○ Also known as “swimmer’s ear,” is a common
disease of children. It is defined by diffuse
inflammation of the external ear canal. It can be
caused by many different types of bacteria or
fungi.
○ Symptoms:
■ Ear pain
■ Itching
■ Hearing loss
■ The outer ear may look red or swollen.
■ Lymph nodes around the ear can get
enlarged and tender.
■ Discharge from the ear canal–this might
be clear at first and then turn cloudy,
yellowish, and pus-like.
○ Management:
■ Analgesia
■ Topical antibiotic or steroid drops
■ If the canal is very swollen and
installation of drops is not possible,
consider referral to ENT for wick
insertion.
RESPIRATORY DISORDERS AND THEIR NURSING
MANAGEMENT (LOWER RESPIRATORY DISEASES)
Slides 1 - 4 (Mygel)
The structures of the lower respiratory tract are subject to
infection basing pathogens that attack the upper respiratory tract.
Inflammation and infection of the lungs or bronchi is particularly
troublesome. It occurs in various forms and is caused by several
organisms.
1.
Bronchitis
● Inflammation of the major bronchi and trachea
● One of the more common illnesses affecting pre-school
and school-age children.
● Characterized by fever and cough and usually a
conjunction with nasal congestion.
● Usually viral (influenza virus, adenovirus
● May develop after a cold or other viral infection in the
nose, mouth, throat, or upper respiratory tract. Such
illness can spread easily from direct contact by the
person who is sick.
Symptoms:
● Starts with mild upper respiratory tract infections for 1-2
days. May begin as rhinitis or nasal congestion
● Fever
● Productive cough (may be purulent) with increased
mucus. May contain pus.
● These symptoms may last for a week with full recovery
sometimes taking as long as 2 weeks
● Upon auscultation bronchi and (coarse/horse??? haha)
crackles can be heard
● Chest radiograph would reveal diffuse alveolar
hyperinflation and some marking in the lungs
Management:
● Therapy is aimed at relieving symptoms, reducing fever
and maintaining adequate hydration
● Increase fluids
● Assess VS, secretions, respiratory effort
● Antipyretics for fever
● Quiet activities for diversion
●
Expectorant may be given if mucus is viscid to help
child raise sputum.
● It is important that children with bronchitis to cough to
raise the accumulating sputum
2.
Bronchiolitis
●
Inflammation of the fine bronchioles and small bronchi
that can eventually congest the smaller airways.
● This time, smaller airways are affected which are the fine
bronchioles and smaller bronchi. Unlike bronchitis, which
only affects the major bronchi.
UNIT 9 (Week 11)
● Most common lower respiratory illness in children
younger than 2 years. Peak incidence at 6 months of
age.
● Many children who develop asthma later in life have
numerous instances of bronchiolitis during the first year
of life.
● Viruses such as adenovirus, influenza virus, RSV in
particular appear to be the common pathogen
SYMPTOMS:
● Starts with mild upper respiratory tract infections
for 1-2 days
● It starts with a nasal congestion then suddenly
begins to demonstrate nasal flaring.
● Intercostal and subcostal retractions on
inspiration and there will be an increased
respiratory rate.
● Fever because of infection.
● Leukocytosis and increased erythrocytes rate
indicating the amount of bronchial inflammation
present. Both accumulating and mucous and
inflammation block the small bronchioles. Air
can no longer enter or leave the alveoli freely.
●
Hyperinflation of the lungs on X-ray because air
enters more easily than it leaves the inflamed
narrow bronchioles.
● This increases the expiratory phase of
respiration and can create Wheezing. After initial
hyperinflation areas (inaudible..) in alveoli may
occur. So, nay parts na mag lung collapse or
alveoli collapse because air cannot be expired
but instead it is absorbed.
● Tachycardia and cyanosis develop from hypoxia.
Infants soon become more exhausted from rapid
respirations. A chest radiograph may also show
pulmonary infiltrates caused by a secondary
infection or collapse of alveoli.
● Pulse oximeter shows low oxygen saturation
MANAGEMENT:
● If mild, treated at home
○ Antipyretics, hydration
● Maintaining a watchful eye for progression to
more serious illness is necessary.
● Hospitalization is waranteed?? For children in
severe distress such as when an infant is
●
●
●
●
●
●
●
tachypnic already and has mark retractions, has
history of poor fluid intake
If symptoms is sever, children need Humidified
O2 to counteract hypoxemia and adequate
hydration to keep respiratory membranes moist.
Nebulize bronchodilators
Some children need ventilatory assistance to
achieve adequate ventilation (severe)
All infants with bronchiolitis needs to be carefully
observed because if RSV is the cause or
pathogenic agent, apnea may occur or periodic
cessation of breathing.
Feeding is also a problem because infants tire
easily and therefor cannot finish a feeding. Thus
intravenous fluids may be given for the first 1 or
2 days of illness to eliminate the need for oral
feeding.
HOB elevated
Antibiotic not given unless secondary bacterial
infection
●
●
inflammation of bronchial mucosa / mucosal edema
increased bronchial secretions / increased mucous
secretions
all 3 processes act to reduce the size of the airway lumen
leading to acute respiratory distress
-
Bronchial constriction occurs because of the stimulation
of the parasympathetic nervous system which initiates
the smooth muscle constriction
Inflammation in the mucous production can occur
because of mast cell activation to release leukotrienes,
prostaglandin and histamine
In patients with asthma, the bronchi and bronchioles are
chronically inflamed and can become so inflamed that it
leads to an asthma attack (wheezing, chest tightness,
shortness of breath, coughing), which is usually due to a
trigger of some type.
Slides 5 - 8 (Hannah)
ASTHMA
- A chronic inflammatory lung disease that causes airway
hyperresponsiveness. It is an immediate hypersensitivity
response to a triggering factor. There is no pathogen causing the
disorder, instead the immune system of the patient is
hypersensitive to a triggering factor.
- It is the most common chronic illness in children accounting
from a large number of days of absenteeism in school and many
hospitalization admissions each year, very common in pediatric
ward
-
It tends to occur initially before 5 years of age
- Tends to occur in children with atopy or those who tend to be
hypersensitive to allergens
- It primarily affects the small airways and involves 3 separate
processes (triad of inflammation):
●
Bronchospasm
With an asthma attack:(see image)
●
there will be tightened muscles because of the
constriction (triad of inflammation), that is how our
immune system works if there are triggering factors
UNIT 9 (Week 11)
especially to patients with hypersensitive immune
system
● There will be excess mucous, pooling of exudates in that
certain area because of inflammation
● There will be hyperinflation of the alveoli, because of the
trapping of the air since air cannot be expired because of
the constriction due to the inflammation
Increased immune system sensitivity causes the lungs and
airway to swell, and produce mucous when exposed to certain
triggers. Triggers vary from child to child and can include:
Triggering factors:
-
Pet dander
Exercise (physical activity)
Pollen
Insects in the home
Chemical fumes
Cold air (weather changes)
Smoke (air pollutants)
Pollution
Stress
Viral infection
Allergies to dust mites
Mold
❏ Because bronchioles are normally larger in lumen on
inspiration than expiration even with bronchoconstriction
children may inhale normally or have little difficulty.
❏ However in asthma, they develop increasing difficulty in
exhaling. However, as it becomes more and more
difficult to force air through the narrowed lumen of the
inflamed bronchioles filed with mucous, this causes
atypical dyspnea and wheezing (the sound caused by air
being pushed forcibly tasked obstructed bronchioles
typically associated with asthma)
❏ Wheezing is heard primarily on expiration. Lumen of
bronchioles is bigger upon inspiration so there will be no
problem. However, when it is very severe, it maybe
heard on inspiration as well. Hearing it during inspiration,
means a child is having extreme breathing difficulty. If a
child coughs up mucous, it is generally copious and may
contain white cast bearing a shape of the bronchi from
which it was dislodged.
●
●
Symptoms:
Coughing
Chest tightness
Wheezing
Shortness of breath (dyspnea)
Increased mucous production
Typically after exposure to certain allergen, an episode
begins with a dry cough often at night as
bronchoconstriction begins.
●
●
●
Assessment:
When an individual is exposed to these triggers, an immediate
inflammatory response with bronchospasm happens. This
inflammatory process leads to recurrent episodes of asthmatic
symptoms
❏
Prevention:
●
Positive family history
- Asthma is a hereditary disease, and can be
possibly acquired by any member of the family
who has asthma within their clan.
Environmental factors
- Seasonal changes, high pollen counts, mold, pet
dander, climate changes, and air pollution are
primarily associated with asthma.
- After the attack or if the attack subsides, we
should ask the parent or the child to describe
their home environment including their pets, the
child’s bedroom, outdoor pace based?, the
classroom environment and the eating to see
whether there are more environmental control to
reduce occurrences of the attack
Hx of child’s symptoms
- Assessment should include a thorough history of
the development of a child’s symptoms. For
example what the child was doing during the
attack and what actions were taken by the
parents or child to decrease or stop the
symptoms.
Allergens
- Allergens, either seasonal or perennial, can be
prevented through avoiding contact with them
whenever possible.
Knowledge
- Knowledge is the key to quality asthma care. We
should encourage, instruct and educate the
parents about the disease especially in
identifying the allergens of the patient to
minimize recurrence of the attack
Evaluation
- Evaluation of impairment and risk are key in the
control. Since asthma is recurring, it has to be
manages well. The child should have a check up
regularly to check the progress of the disease or
how their body receives or react to the
medications. The doctor will evaluate if there is a
need to change or reduce or increase the dose
of medicine depending on the clients condition
There is no cure for asthma but it can only be prevented and
managed the relief of symptoms through pharmacological
therapy or agents:
Pharmacologic therapy:
●
●
Corticosteroids. – mild persistent asthma
❏ Fluticasone
(Flovent)
–
inhaled
anti-inflammatory corticosteroid
Bronchodilators – moderate persistent asthma,
children are prescribed a long acting bronchodilator at
bedtime in addition to the inhaled anti-inflammatory daily
corticosteroids
• Anticholinergics
o Ipratropium (common)
•
Short-acting
agonists.
beta2
–
adrenergic
o Albuterol, terbutaline, salbutamol
UNIT 9 (Week 11)
● Mast cell stabilizers
•
Cromolyn sodium – given by a nebulizer
or a meter dose inhaler. This can prevent
bronchoconstriction
and
thereby prevent
symptoms of asthma. It is not effective once
symptoms have begin.
●
Leukotriene modifiers.
•
Montelukast – this medication is used
for prophylaxis and chronic treatment of asthma
in children over 6 years of age. They are not
effective in an acute attack.
Symptoms:
-
Short, shallow breaths
Wheezing
Coughing
Difficulty breathing
Heavy sweating
Trouble speaking
Fatigue and weakness
Abdominal, back or neck muscle pain
Panic or confusion
Blue-tinted lips or skin
Loss of consciousness (due to deprivation of O2 in the
brain)
-
Wheezing or stridor
Cyanosis
Clubbing of fingers
Easy fatigability
Physical growth may be restricted
Enlarged chest
Management:
●
●
●
●
Mucolytic agent
Bronchodilators
Chest Physiotherapy
Antibiotic if infection is present
Management:
➢ Cough suppressants are contraindicated with asthma
because as a rule again, as long as a child can continue
to cough up mucous they are not in serious danger.
Coughing up mucous take plugs form that may lead to
pneumonia, atelectasis and further acidosis.
➢ Steroids – it decreases the swelling and the
inflammation of the bronchus specifically in asthma
➢ Bronchodilators – acts to dilate the airway
➢ Children who have severe persistent asthma symptoms
take a high dose of both an oral and an inhaled
corticosteroids daily as well as long acting
bronchodilators at bedtime
Slides 9 - 12 (Cybelle)
STATUS ASTHMATICUS
-it refers to an asthma attack that doesn’t improve with traditional
treatments. These attacks can last for several minutes or even
hours. This is an extreme emergency because if the attack
cannot be relieved, a child may die because of heart failure due
to the combination of exhaustion, atelectasis and respiratory
acidosis from bronchial clogging.
●
Higher doses of inhaled bronchodilators
-such as Albuterol or Levalbuterol to open up your
airways
●
Oral, Injected, or inhaled corticosteroids
PNEUMONIA
-
Affects the lower respiratory system and is due to an
infection caused by either bacteria, virus, or fungi that
causes inflammation of the alveoli sacs
-The lung parenchyma are affected which are the alveolar ducts,
bronchioles, and alveoli.
-to reduce inflammation
●
Ipratropium Bromide
-another type of bronchodilator different than albuterol
●
●
●
An epinephrine shot
Temporary ventilation support
Oxygen administration via face mask
BRONCHIECTASIS
-
a condition where the bronchial tubes of the lungs are
permanently damaged, widened and thickened
is a chronic dilatation and plugging of bronchi. It may
follow pneumonia, aspiration of foreign body, pertussis
or asthma
Symptoms:
-
Chronic cough with mucopurulent sputum
Slides 13 - 16 (Joash)
Symptoms
●
Fever (Infection)
●
Fast and difficult
Signs
●
●
●
Tachypnea
Chest Retraction
Grunting and stridor
UNIT 9 (Week 11)
breathing
●
●
●
●
Cough
●
Chest pain
●
Abdominal pain
●
Poor feeding
●
Irritability
●
Nasal flaring
Cyanosis
Dullness on
percussion
Diminished breath
sounds, wheeze,
crackles on
auscultation
IMPORTANT POINT TO ASSESS
WHO respiratory rate thresholds for identifying children
with pneumonia:
●
●
●
Children younger than 2 months >= 60 breaths/min
Children aged 2-11 months >= 50 breaths/min
Children aged 12-59 months >= 40 breaths/min
*Wheezing and crackles are almost never heard in infants that’s
why it is important to note the respiratory rate*
CLASSIFICATION
Community
Acquired
(CAP)
Ventilator-Associat
ed (VAP)
Hospital-Acquired
(HAP)
- Pneumonia that
develops outside
the hospital
- Pneumonia that
develops 48-72 hrs
after endo tracheal
intubation
- This type is
harder to treat than
- Pneumonia that
develops 48 hours
after admission
- This type of
pneumonia
causes
CAP
CHLAMYDIAL
PNEUMONIA
CLASSIFICATION - according to their specific causative
agent
1. Pneumococcal Pneumonia
● Caused by bacteria called streptococcus
pneumoniae
● Localized in a single lobe
● In infants, pneumonia tends to remain
bronchopneumonia with poor consolidation
(infiltration of exudate into the alveoli).
●
In older children, pneumonia may localize in a
single lobe, and consolidation may occur.
● With this, children may have blood-tinged
sputum as exudative serum and red blood cells
invade the alveoli.
● After 24 to 48 hours, the alveoli are no longer
filled with red blood cells and serum but fibrin,
leukocytes, and pneumococci.
●
At this point, the child’s cough no longer raises
bloodtinged sputum but thick purulent material.
● The fever with pneumococcal pneumonia may
rise so high and fast a child has a febrile seizure
● Children with pneumococcal pneumonia appear
acutely ill. Tachypnea and tachycardia
develop. Because the lung space is filled with
exudate, respiratory function will be diminished.
Breath sounds become bronchial (sound
transmitted from the trachea) because air no
longer or only poorly enters fluid-filled
alveoli. Crackles (rales) may be present as a
result of the fluid. Dullness on percussion
over a lobe indicates that total consolidation
has occurred. Chest radiographs will usually
show this type of lung consolidation in older
children but only patchy diffusion in young
children. Laboratory studies will indicate
leukocytosis.
● Management
○ Antibiotics
1. Ampicillin
2. Third generation cephalosporin
○
○
○
○
○
3. Amoxicillin-clavulanate
(Augmentin) may be
prescribed for penicillin-resistant
organisms
Reposition child frequently - to avoid
pooling of secretions
Intravenous therapy - to supply fluids
especially in infants, because infants tire
so readily with sucking they may not be
able to achieve a good oral intake.
Antipyretic
Humidified oxygen - to alleviate
labored
breathing
and
prevent
hypoxemia
Chest physiotherapy - encourages the
movement of mucus and prevents
obstruction. Older children may need to
be encouraged to cough so that
secretions do not pool and become
further infected.
Slides 17 - 20 (Mira)
CHLAMYDIAL PNEUMONIA
● Caused by bacteria called Chlamydia trachomatis
● Can be contacted from the mother’s vagina duri
■ Elevated level of IgG and IgM antibodies
and specific antibody of C.trachomatis
Management:
■ Macrolide- erythromycin
VIRAL PNEUMONIA
● Caused by viruses called Respiratory Syncytial Virus
(RSV), myxovirus or adenovirus
UNIT 9 (Week 11)
● Viral pneumonia is generally caused by the viruses of
upper respiratory tract infection: the RSVs, myxoviruses,
or adenoviruses. Symptoms begin as an upper
respiratory tract infection. After a day or two, additional
symptoms such as a low grade fever, nonproductive
cough, and tachypnea begin. There may be diminished
breath sounds and fine rales on chest auscultation. RSV
may cause apnea. Chest radiographs will show diffuse
infiltrated areas.
● Because this is a viral infection, antibiotic therapy usually
is not effective. The child needs rest and, possibly, an
antipyretic for the fever; intravenous fluid may be
necessary if a child becomes exhausted or is dehydrated
and refusing fluids.
● After recovery from the acute phase of illness, a child will
have a week or two of lethargy or lack of energy, the
same as occurs with bacterial pneumonia. Parents may
be confused because their child is not receiving an
antibiotic, despite the diagnosis of pneumonia. Explain
the difference between viral and bacterial infections so
they can better understand their child’s therapy and plan
of care
○ Symptoms:
■ Begin as an upper respiratory tract
infection
■ Low grade fever
■ Non productive cough
■ Tachypnea
■ Diminished breath sounds
■ Fine crackles
■ RSV may cause apnea
○ Management::
■ Adequate rest
■ Antipyretic
■ Intravenous fluid
LIPID PNEUMONIA
● Caused by the aspiration of an oily or lipid substance
such as oily foreign bodies (peanuts or popcorn).
●
An inflammatory response occurs when lung lipases act
on the aspirated oil.
● Lipid pneumonia is caused by the aspiration of an oily or
lipid substance. It is much less common than it once was
because children are not given oil-based tonics, such as
castor oil or cod liver oil anymore, as they were in the
past. Today it is most often caused by aspirated oily
foreign bodies such as peanuts or popcorn.
● A proliferative inflammatory response occurs when lung
lipases act on the aspirated oil. This is then followed by
diffuse fibrosis of the bronchi or alveoli. The area then
becomes secondarily infected. A child may have an
initial coughing spell at the time of aspiration. A period
follows during which the child is symptomless; then a
chronic cough, dyspnea, and general respiratory distress
occur.
● A chest radiograph shows densities at the affected site.
Antibiotic therapy is ineffective unless a secondary
bacterial infection has occurred. Surgical resection of a
lung portion may be necessary to remove a lung
segment if the pneumonitis does not heal by itself.
○ SYMPTOMS:
■ Initially coughing spell Chronic cough
Dyspnea General respiratory distress
Chest xray reveal densities on the
affected area
○ MANAGEMENT:
■ Antibiotic therapy is ineffective unless a
secondary infection is noted Surgical
resection of a lung portion
HYDROCARBON PNEUMONIA
● Several common household products such as furniture
polish, cleaning fluids, kerosene, gasoline, lighter fluid
and insects sprays have hydrocarbon.
● These products are a common cause of childhood
poisoning and result to hydrocarbon pneumonia
○ ASSESSMENT
■ Children who swallow a
hydrocarbon-based product usually
○
○
exhibit gastrointestinal symptoms such
as nausea and vomiting. Next, they
become drowsy and develop a cough
from inhalation as vapors from the
stomach rise and are inhaled. As
bronchial edema occurs from irritation
and inflammation, respirations become
increased and dyspneic.
■ Physical assessment shows an
increased percussion sound caused by
the presence of air trapped in the alveoli
beyond the point of inflammation. Rales
may be heard as air passes through
collecting mucus. Because air cannot
reach and inflate the alveoli fully, breath
sounds may be diminished.
SYMPTOMS:
■ Nausea & vomiting
■ Drowsy
■ Cough
■ Increased RR and dyspnea
■ Rales
MANAGEMENT:
■ Irritation from fumes of hydrocarbon
ingestion may occur when children
initially swallow the fluid. If they are
given an emetic to induce vomiting, it
can cause them to aspirate vomitus or
cause additional irritation.
■ In the emergency room, gastric lavage
may be done by health care personnel
with great care to remove the substance
from the stomach and help prevent
inhalation. The child is usually admitted
to a hospital observation unit for a short
time. Obtain vital signs and observe the
child’s general appearance carefully for
evidence of increased respiratory tract
obstruction or increasing drowsiness or
UNIT 9 (Week 11)
■
■
other symptoms of CNS involvement
from CNS intoxication.
Cool, moist air administered by a
nebulizer with supplemental oxygen
may be prescribed to decrease lung
inflammation. If febrile, a child needs an
antipyretic. Frequent changes of
position will prevent pooling of
secretions, which could lead to a
secondary infection. Chest
physiotherapy will help to move
secretions and reduce areas of stasis.
Do not induce vomiting Gastric lavage
Obtain V/S Monitor sx of CNS
involvement Cool, moist air through
nebulizer Supplemental O2
7. Atelectasis
● Atelectasis is the collapse of lung alveoli. It may occur in
children as a primary or secondary condition. It must be
considered as a possibility in all children with respiratory
distress.
PRIMARY ATELECTASIS
●
●
●
This is seen most commonly in immature infants or in
infants with CNS damage. It may occur if infants have
mucus or meconium plugs in the trachea. When
atelectasis occurs, the newborn’s respirations become
irregular, with nasal flaring and apnea. After a few
minutes, a respiratory grunt and cyanosis may occur.
The sound of a respiratory grunt is caused by the
newborn’s glottis closing on expiration. At first, this is a
helpful action because it increases pressure in the
respiratory tract, keeps alveoli from collapsing, and
allows for better alveoli exchange surfaces. This action
is also tiring, however, and as the infant tires, hypoxemia
will increase, and the infant will become hypotonic and
flaccid.
The Apgar score will invariably be low. As infants cry or
are administered oxygen, more alveoli become aerated
and cyanosis may decrease. The cause of the
atelectasis must be established, however, so that
therapy directed to the specific cause can be initiated.
SECONDARY ATELECTASIS
●
Secondary atelectasis occurs in children when they have
a respiratory tract obstruction that prevents air from
entering a portion of the alveoli. As the residual air in the
alveoli is absorbed, the alveoli collapse.
● The causes of obstruction in children include mucus
plugs that may occur with chronic respiratory disease or
aspiration of foreign objects. In some children,
atelectasis occurs because of pressure on lung tissue
from outside forces, such as compression from a
diaphragmatic hernia, scoliosis, or enlarged thoracic
lymph nodes.
● The signs of secondary atelectasis depend on the
degree of collapse. Asymmetry of the chest may be
noticed. Breath sounds on the affected side are
decreased. If the process is extensive, tachypnea and
cyanosis will be present. A chest radiograph will show
the collapsed alveoli (a “whiteout”). Children with
atelectasis are prone to secondary infection because
mucus, which provides a good medium for bacteria,
becomes stagnant without air exchange.
SUMMARY
PRIMARY ATELECTASIS
●
Occurs on newborns
who do not breathe
with enough
respiratory strength at
birth to inflate lung
tissue or whose
alveoli are so
immature or lacking
in surfactant that
alveoli cannot
expand.
○ Symptoms:
SECONDARY ATELECTASIS
●
●
Occurs in children
when they have a
respiratory tract
obstruction
In some children, it
occurs because of
pressure on lung
tissue from outside
forces such as
diaphragmatic hernia,
scoliosis or enlarged
thoracic lymph nodes.
-newborns respiration is
irregular, with nasal flaring
and apnea. Cyanosis and
respiratory grunt may occur.
○ Symptoms:
-asymmetry of chest,
decreased breath sounds,
tachypnea, cyanosis
Slides 21 - 23 (Sophia)
21st slide
7. Atelactasis
- is the collapse of lung alveoli
- If caused by a mucus plug, will be resolved when the
plug dissolves, or is moved or expectorated
Management:
○
Children may need oxygen and assisted
ventilation to maintain adequate respiratory
function until this time
○ Make certain also that the chest of the child with
atelactasis is kept free from pressure so that the
lung expansion is as full as possible, to allow as
much breathing space as possible
○ Check the clothing to be certain if it is loose and
non binding
○ Make certain also that the child’s arms are not
positioned across the chest where their weight
could interfere with deep inspiration
○ Position px on semi fowlers to generally allow for
the best lung expansion because it lowers
abdominal contents and increases chest space
○ Increase the humidity of the child’s environment
to prevent further bronchial plugging
○ Suction and chest physiotherapy may be
necessary to keep the respiratory tract clear and
free of mucus
○ Observe closely for increase respirations or
cyanosis as this indicates filling oxygenation
8. Pneumothorax
- Is the presence of atmospheric air in the pleural space;
its presence cause the alveoli to collapse ( basically
naay tear sa pleural space)
UNIT 9 (Week 11)
- Pneumothorax in children usually occurs when air exit
from ruptured alveoli and collects in the pleural cavity
- They can also occur with external puncture wound that
allows air to enter the chest such as pneumo trauma or
sharp objects that can penetrate the chest cavity can
also cause pneumothorax
- Occurs in approx. 1% of newborns because of the
rupture of alveoli from the extreme intrathoracic pressure
needed to initiate first inspiration
Symptoms:
○ Tachypnea
○ Grunting respiration
○ Nasal flaring
○ Cyanosis
○ Auscultation reveals absent or decreased breath
sounds
○ The chest film will show the darkened area of
the air filled pleural space
Management:
○ Oxygen therapy - to relieve respiratory distress
○ Thoracotomy catheter or needle - may be placed
in the pleural space and atmospheric air
aspirated or low pressure suction with water
sealed drainage applied to remove aspirated air.
In most children with pneumothorax symptoms
are relieved after suction has begun
○ If the air in the pleural space is from a puncture
wound such as stab wound - cover the chest
wound immediately with impervious material (
e.g., petroleum gauze) to prevent further air
from entering and help decrease the possibility
of atelactasis.
○ In emergency cases, an impervious object can
be your gloved hand ( as much as possible
tabunan with pressure para way air mo sud)
○ Pneumothorax is always a potential serious
respiratory problem, the extent of the symptoms
and the outcome will depend on the cause of
inhaled air in the pleural space whether it can be
moved
9. Bronchopulmonary Dysplasia ( BPD)
- is a chronic pulmonary involvement that occurs in 10%
to 40% of infants who are treated for acute respiratory
distress in the first days of life
-
-
-
the condition most often occurs in infants who received
mechanical ventilation for respiratory distress syndrome
at birth
The condition is thought to occur from a combination of
surfactant deficiency, barotrauma, lung damage from
ventilator pressure, oxygen toxicity from high levels
needed to counteract the original respiratory distress
and continuing inflammation
It occurs more often in infants born weighing less than
1,000 grams, basically pre-mature infants. They can’t
produce enough surfactants pa man sa ila body also
mao nang ig gawas nila naay assistive ventilators upon
birth
Oxygen toxicity- not allowed to give high rates of oxygen
to pediatric clients because their alveoli is not receptive
to oxygen which will possibly collapse
Symptoms:
○ Tachypnea
○ Retractions
○ Nasal flaring
○ Tachycardia
○ Oxygen dependence - since premature infants
pa man but in a low rate
○ Abnormal radiograph findings that show areas of
overinflation, inflammation and atelactasis
○ As inflamed surfaces heal they are left with
fibrotic scarring
○ Upon auscultation there will be decreased air
movement that can be detected
○ Infants who already have respiratory system
defects are more at risk for BPD
Management:
○ Administration of corticosteroid to reduce
inflammation
○ Bronchodilator by nebulizer greatly improves
respiratory function
○ Infants need to be monitored carefully for
nutrition and fluid intake especially if ventilator
dependent
○ Emphasize long hospitalization until the child is
independently breathing and doesn’t need
supplemental oxygen, so that’s the time na they
are allowed to wean from ventilation machine
Slides 24 - 26 (Brian)
10. Tuberculosis
● Highly contagious pulmonary disease that affects the
lungs
● Causative agents: Mycobacterium tuberculosis
● Mode of transmission: inhalation of infected droplets
● Tb spreads from person to person by airborne
transmission an infected person releases a droplet
nuclei of the bacteria through talking, coughing,
laughing, singing or sneezing.
● Larger droplets can settle however smaller droplet
remains suspended in the air and are inhaled by the
susceptible person.
Risk factors:
➔ Close contact with someone who has active TB
➔ Children who are homeless or severely impoverished
➔ Any person without adequate health care
➔ Immunocompromised status
➔ Who have chronic illnesses
➔ Pre Existing Medical conditions or special treatment
➔ Living in overcrowded, substandard housing (High risk)
ASSESSMENT/ DIAGNOSTIC TESTS
● All children should have a tuberculosis test as a part of
basic preventive healthcare screening at 9 to 12 months
of age and yearly thereafter.
●
Mantoux test - or tuberculin test (purified protein
derivative (PPD) test)
➔ It determines if a person has been infected or exposed
with TB
UNIT 9 (Week 11)
➔ A standard procedure should only be performed by a
trained by the organization
➔ 5 units of protein derivative vaccine is Injected
intradermally at left lower arm, then 0.1 ml of protein
derivatives is injected creating an elevation in the skin
and a wheeler of a blood is formed
➔ A healthcare professional inspects the area 72 hours
after administration is necessary to evaluate the level of
reaction
➔ After 3 days reaction on the site is noted
➔ Positive reaction – 5-15mm of reddened induration
(hardening, nagtuyok nga gahi) , indicates the child has
been exposed to tuberculosis or has developed
antibodies to the foreign products of the tuberculosis
organism
➔ Children with positive reactions need a follow up chest
radiograph to ascertain the reaction.
Note:
- Skin testing should not be done on children who
have a history of tuberculosis diagnosis because
of the risk of intense reaction at the testing site.
- Tuberculosis screening test should not be done
immediately after administration of the measles,
mumps, and rubella (MMR) vaccine because of
the possibility of a false-negative result
● X Ray will show cloudiness in the inflamed area, and it
may
not
be
evident on chest
radiography.
As
local inflammation
occurs,
calcification and
cloudiness in the
flamed area will
be noticeable
●
Sputum analysis (Sputum Culture) - for confirmatory dx,
SYMPTOMS:
When mycobacterium tuberculosis invades a child’s lungs there
is primary inflammation, the child develops a
➔ slight cough
➔ Fatigue
As disease progresses there will be:
➔ Weight loss
Hemoptysis also may occur
Anorexia
Night sweats
Low grade fever
Finger clubbing, a late sign of poor oxygenation, may
occur
➔ The inflamed parenchyma may cause pleuritic chest
pain
Severe cases:
➔ Dyspnea
➔
➔
➔
➔
➔
MANAGEMENT:
➔ Pulmonary TB is treated primarily with anti-tuberculosis
agents for 6 to 12 months.
For prevention:
➔ BCG vaccine is given at birth to prevent it
Slides 27 - 29 (Shannen)
10. Tuberculosis
The World health Organization has a recommended strategy
through TB DOTS Project which means Directly Observed
Treatment, Short-Course for those px that has tuberculosis. This
management includes first line drugs or anti tubercular drugs
given to the patient. So with DOTS, nay partner habang ga take
sa medication because usually 6-12 months ang treatment (long
term) and dapat everyday imnon to prevent multidrug resistance.
Good thing nga ma detect nimo early para ma prevent ang
transmission since highly contagious kayo.
Antitubercular drugs include:
FIRST LINE DRUGS
Isoniazid (H)
Rifampicin (R )
Pyrazinamide (Z)
Ethambutol ( E)
Streptomycin (S)
Naa lang juy factor nga dili kayo mu comply ang patient sa
tambal because of the series of adverse effects :
Health teaching, tell patient nga normal ni siya nga effect sa
tambal, pero dili nimo e reason nila nga to stop, sultii kung unsay
further complication if ila e stop
OTHER MGT STRATEGIES​
·
Nutritional therapy​
well balanced diet
·
Lifestyle modification​
Esp. if smoker ang patient, we need to educate
to stop smoking kay it can further complicate the
condition
·
Cough hygiene​
TB is Highly contagious, teach client about
proper cough etiquette
·
Regular follow-up​
Even if patient is treated with tuberculosis, we
have to encourage this because possible nga mu
reccur ang disease.
·
Prevention of complications​
11. Cystic Fibrosis
- Autosomal recessive disorder​that has a defect on the long arm
of chromosome 7. Two genes are needed one gene from each
parent is needed to manifest the disease. (so if one gene, carrier
lang ang patient, if ang two parents are carriers then the child will
have 100 percent acquisition of the disease)
- This disorder s characterized by abnormalities affecting certain
gland of the body especially those that produce certain mucus,
particularly a dysfunction of the exocrine glands. Exocrine gland
UNIT 9 (Week 11)
excretes substances through ducts either internally (glands in the
lungs) or externally ( though the sweat glands)
- What happen in cystic fibrosis, mucus secretions in the body
particularly in the pancreas and in the lungs are so tenacious
that they have difficulty flowing through the gland ducts causing
obstruction caused by the thick viscous mucus and leads to
irreversible lung damage. It can cause complex disorders also
that affects multiple organ systems especially the respiratory and
GI.
- The body produces thick sticky mucus in the lungs that could
clog the lungs, it can obstruct the pancreas therefore producing
malabsorption and malnutrition.
- What happen with cystic fibrosis, if nay dysfunction sa
pancreas (we all know pancreas secretes enzymes that are
responsible for digesting fat , protein and some sugars). Without
those pancreatic enzymes , children cannot digest those,
therefore there will be malabsorption and malnutrition
·
Dysfunction of exocrine glands ​
·
Obstruction caused by thick,
viscous mucous ​
·
Leads to irreversible lung damage ​
·
Complex disorder: affects multiple
organ systems, especially respiratory & GI​
· Clogs the lungs- stagnant mucus​
· Obstruct the pancreas – malabsorption
and malnutrition​
SYMPTOMS:​
1.Meconium ileus – seen at birth ​
- Meconium ileus = bowel obstruction that occurs when the
meconium in the child’s intestine is even thicker and stickier than
the normal meconium creating a blockage in the part of small
intestine, so it can be usually seen at birth. And with this, there
will be abdominal distension in newborn.
2.Salty-tasting skin -when newborn is kissed ​
- this is the first symptom nga manotice sa parents. Because of
the dysfunction of sweat gland nga ang concentration sa chloride
kay daghan (2-5 times than normal)
3.Steatorrhea • Greasy, large, bulky and foul smelling ​
- fat in the stool
-when the intestinal flora increase because of the undigested
food in the patient’s stomach, when combined with fat in the
stool gives the stool an extremely foul odor compared to that of a
cat’s stool.
4.Poor growth/weight gain in spite of good appetite ​
- because of the malabsorption that is happening sa
gastrointestinal tract sa patient
5.Chronic coughing, at times with phlegm ​
- because of the viscous mucus pulling in the airway
6.Frequent lung infections​
- because of the high rate of sodium absorption and low rate of
chloride secretion reduces salt and water content in mucus
depleting the periciliary liquid in the airway. The mucus adheres
to airway surfaces leads to decreased mucus clearing. With
mucus nga naa ra sa airway can predispose for the patient to
acquire secondary infection ( specifically bacterial infection)
Slides 30 - 32 (Cloy)
11. Cystic Fibrosis
○
○
Diagnostic:
■ Chromosome
Analysis
or
Karyotyping - to detect the defected
genes, specifically, the chromosome 7
■ Sweat testing - time-honored method
to detect the abnormal concentration in
sweat in children
■ Duodenal Analysis - analysis of the
duodenal secretions for detection of
pancreatic enzymes. It reveals the
extent of pancreatic involvements
■ Stool Analysis - maybe collected and
analyzed for fat content and lack of
trypsin.
■ Pulmonary Testing - part of the
pulmonary function test, a chest
radiograph, generally confirms the
extent of the pulmonary involvement.
May be done to determine atelectasis
and emphysema are present.
Management:
■ Therapy for children with CF consist of
measures to reduce involvement of the
pancreas, lungs, and sweat glands.
■ Humidified oxygen - oxygen is
supplied to children by masks,
ventilators or nebulizers. Mist can be
supplied by an ultrasonic compressor
and delivered through a nebulizer mask
which makes the droplet size so small
that the mist reaches the smallest
bronchioles spaces.
■ Aerosol Therapy - 3 or 4 times a day,
children may be given aerosol therapy
by means of embolization to provide
antibiotics or bronchodilators. Antibiotics
are given specifically if there is
secondary bacterial infection.
■ Mucolytic - can be given specifically
acetylcysteine mucomyst can be added
to the mist to aid in diluting and liquifying
secretion.
Children’s
coughs will
become loose and productive after
using aerosol therapy.
UNIT 9 (Week 11)
■
■
■
■
Chest physiotherapy - because the
bronchioles secretions with CF are so
tenacious even with liquefaction by mist
are aerosol therapy, children may be
unable to raise them. To aid drainage
and secretions, children need this
therapy approx. 3-4 times a day.
Encourage exercise. To keep mucus
from moving. Children with CF need to
maintain their usual activity as much as
possible. When in bed, they need
frequent position changes so that at
various times of the day, all lobes of
their lungs will be encouraged to drain
by being in a superior position. Be
certain they sit a part of each day to
drain the upper lobes.
Respiratory hygiene. The sputum that
a child coughs may have a disagreeable
taste or odor do offer frequent mouth
care, toothbrushing and a good
mouthwash
to
make
a
child’s
mouthfresh.
Lung Transplantation - As children
with CF reach adolescents, they are
now candidates for lung transplant.
Some of these are done as lower lobe
transplants from a living donor. People
who donate a single lobe in this manner,
report that they feel a little lost lung
capacity afterward. A lung transplant is
advantageous for children with CF
because the new lung does not possess
the defective gene that causes mucus to
be so thick therefore lifespan can be
greatly improved.
to go and swells up in the affected lung. When this
occurs over the period of 4-5 weeks, the long expands
and its functions appear to be improved. So this type of
blockage can be achieved through a temporarily
blocking the fetal windpipe or trachea with a balloon over
a period of time. So this is done by performing operative
fetoscopy.
➔ Fetal surveillance and delivery planning - There is a high
possibility that a baby with cdh will get worse before the
anticipated due date. part of a comprehensive treatment
plan will involve close fetal and maternal monitoring to
avoid severe fetal deterioration .
The presence of these abdominal organs in the chest
limits the space of the lungs and can result in respiratory
complications because CDH forces the lungs to grow in a
compressed state, several aspects of their function may not
develop normally until after the birth of the baby. So before birth,
the placenta takes over all the functions of the lungs so that a
fetus can grow in a womb without suffering low oxygen levels or
hypoxemia. However, after birth, the baby depends on the
function of the lungs and if their development is severe, artificial
ventilation techniques may be necessary.
SYMPTOMS:
➔ difficulty breathing.
➔ fast breathing.
➔ fast heart rate.
➔ cyanosis (blue color of the skin)
➔ abnormal chest development, with one side being larger
than the other.
➔ abdomen that appears caved in.
MANAGEMENT
Following a delivery, a baby with CDH may undergo:
➔ Surgery - to close the defect. However, surgery after
delivery does not address the lung damage since it has
already occurred. For this reason, fetal therapeutic
procedures are recommended in some pregnancies
which may help decrease the amount of lung damage
that can occur during pregnancy. The goal of fetal
treatment is to reverse some of the lung damage that
results from the compression of the lungs.
➔ Fetoscopic tracheal occlusion (FETO) - The fetal lungs
produce fluid that leaves the body through the babies
mouth. If this outflow of fluid is blocked, It has nowhere
Most people infected with covid-19 virus will experience
mild respiratory illness and recover without special treatment.
Older people and those with underlying medical problem like
cardiovascular disease, diabetes, chronic respiratory disease
and cancer are more likely to develop serious illness.
MODE OF TRANSMISSION
● Virus is spread through DROPLETS when an infected person
speaks, coughs, or sneezes, and these can land on:
○ mouths or noses of people up to one (1) meter away
○ surfaces up to one (1) meter away, and survives for at
least three (3) days.
● AIRBORNE transmission may be possible in may be possible
in healthcare settings, during aerosol-generating procedures,
fand areas with poor ventilation
UNIT 9 (Week 11)
younger, 35 or older, those with
pre-existing conditions) show
symptoms, but they are infected
and can transmit the virus.
Slides 33 - 35 (Mary)
13. Corona Virus Disease of 2019 (COVID-19)
○ Symptoms of Intubation:
■ Symptoms can take up to 14 days from
infection to show.
■ The most common symptoms are:
● Fever (not necessarily high
fever)
● Dry cough
● Tiredness or fatigue
● Shortness of breath or difficulty
breathing
● Patients may experience aches
and pains, nasal congestion,
and sore throat
● Some
would
say
they
experience body or muscle pain,
severe fatigue, diarrhea, loss of
smell and taste (mostly in mild
cases).
■ Severe symptoms include:
● Difficulty
breathing
or
breathlessness while speaking
● Constant pain or pressure in the
chest
● Paleness
● Confusion, or changes in mental
state because of deprivation of
oxygen.
■ Some people are asymptomatic—they
do not show symptoms, but they are
infected and can transmit the virus.
○ People At Risk (Vulnerable Groups):
■ People of all ages can catch COVID-19
■ People at risk of severe illness if they
catch the virus:
● The elderly
● Persons
with
pre-existing
medical conditions (heart or
lung disease, diabetes, asthma,
etc.)
● Persons who smoke
● Women
with
high-risk
pregnancies (aged 17 or
○
○
Prevention:
■ Avoid crowded places and limit time in
enclosed spaces
■ Maintain at least 1 meter distance from
others
■ When possible, open windows and
doors for ventilation
■ Keep hands clean and cover coughs
and sneezes
■ Wear a mask
Management:
■ Tocilizumab belongs to a class of drugs
known as Interleukin-6 (IL-6) blockers.
It works by blocking IL-6, a substance
made by the body that causes swelling
(inflammation).
■ Antiviral medication
● Remdesivir
Slides 64 - 70 (Mary)
UNIT 10 (Week 12)
OVERVIEW AND ASSESSMENT OF CARDIOVASCULAR FUNCTION
AND PEDIATRIC VARIATIONS AND NURSING OF THE CHILD WITH A
CARDIOVASCULAR DISORDER
Fetal Circulation
Video Transcript (Basic Cardiac Anatomy and Physiology):
Normal Cardiac Anatomy
The right side of the heart receives venous blood from the body
through the superior and inferior vena cava, which enter the right
atrium. Blood flows through the tricuspid valve into the right ventricle.
Blood leaves the right ventricle through the pulmonary valve into the
main pulmonary artery. The pulmonary artery divides into right and
left pulmonary arteries to transport deoxygenated blood from the right
side of the heart to the right and left lungs. The pulmonary arteries
branch further into the pulmonary capillary bed where oxygen and
carbon dioxide exchange occurs. The four pulmonary veins, two from
the right lung and two from the left lung, carry oxygenated blood from
the lungs to the left side of the heart. The oxygenated blood flows
from the left atrium through the mitral valve (bicuspid valve) and into
the left ventricle and out through the aortic valve and into the aorta
and to the body.
Cardiac Valves
The heart valve openings are protected by flaps of tissue called leaflets
or cusps that are attached to the papillary muscles by the chordae
tendineae. The papillary muscles are extensions of the heart muscle
that pull the cusps together and downward at the onset of ventricular
contraction. As the pressure increases in the ventricles, the valves
close, and the papillary muscles prevent the valves from opening.
Coronary Arteries
The branch of circulation that supplies oxygen and other nutrients to
the cells of the heart is called the coronary circulation. The major
coronary arteries are the right coronary artery and the left coronary
artery. The left coronary artery originates from a single opening behind
the left cusp of the aortic valve and divides into the left anterior
descending artery and the circumflex artery. The right coronary artery
originates from an opening behind the right cusp of the aortic valve
and divides into three major branches: the conus, the marginal–the
right marginal branch, and the posterior descending branch.
Coronary Veins
After flowing through an extensive network of capillaries, blood from
the coronary arteries drain into the cardiac veins. The veins follow into
the great cardiac vein and coronary sinus. Blood empties from the
coronary sinus into the right atrium.
Cardiac Conduction System
Electrical impulses originate in the sinoatrial node located at the
junction of the right atrium and superior vena cava. Each electrical
impulse generated from the SA node travels through the right and left
atrium, causing the atria to contract. The impulse then travels to the
atrioventricular node, AV node, then to the bundle of His, and finally
through the right and left bundle branches of the ventricles, causing
the ventricles to contract.
●
●
Closure of shunts: Minimum of 3 to 10 days and maximum of
3 months
Lungs have greater resistance because it is fluid filled so there
is little blood passing through there. When the baby is born,
the resistance decreases which allows blood to pass through.
Cardiac Assessment in Children
The assessment in heart disease in children begins with:
● Health History
o Should indicate a thorough pregnancy history of the
mother to determine whether an intrauterine
problem could have led to poor fetal formation.
Cardiac anomalies can occur as a result of
intrauterine infections such as toxoplasmosis (can
Electrocardiogram
sometimes cause miscarriage) and cytomegalovirus
The P-wave of electrocardiogram represents atrial contraction. The PR
or rubella (can cause congenital disorders to the
interval is a measure of time from the onset of atrial contraction to the
baby). Ask whether the mother took any medications
onset of ventricular contraction. The QRS complex represents the
during pregnancy, whether nutrition was adequate,
complete depolarization of the ventricles. The ST segment represents
or whether she was exposed to any radiation (this
the complete repolarization of the ventricles. Elevation or depression
may also contribute to congenital heart disorders).
of this segment may indicate heart muscle ischemia. The QT interval
o Child’s activity. A mark of older children with heart
represents the complete depolarization and repolarization of the
disease is that they become easily fatigued. Ask how
ventricles. A prolonged QT interval is a risk factor for ventricular
much activities it takes before a child becomes tired
arrhythmias and sudden death.
(e.g. an hour of strenuous play, a short walk). Be sure
that parents are not confusing sedentary activities
Intracardiac Pressures
(e.g. sit and read) with activities that result in fatigue
Pressures on the left side of the heart are usually three times greater
(e.g. coming home from school and falling asleep day
than the right side of the heart. A normal right atrial pressure is usually
after day).
around 3, with a range of 2 to 8. And left atrial pressure is usually 8,
o Ask about the child’s usual position when resting.
with a range of 6 to 12 millimeters of mercury (mmHg).
Some infants with congenital heart disease prefer a
knee-chest position whereas older children often
Remember:
voluntarily squat. These positions are unusual in
● Left side of the heart has greater pressure because it pumps
children but drop blood in the lower extremities
blood throughout the entire body (systemic circulation). The
because of the sharp bend at the knee, allowing the
right side of the heart only pumps blood to the lungs so it
child to oxygenate blood remaining in the upper
does not need that much pressure (pulmonary circulation).
body more fully and easily.
● Veins carry blood towards the heart.
o Ask about frequency of infections because children
● Arteries carry blood away from the heart.
with heart disease have higher incidence of lower
● Right side of the heart: Bicuspid
respiratory tract infections, probably due to less than
● Left side of the heart: Tricuspid
usual pulmonary circulation.
● Decreasing prostaglandin stimulates the closure of ductus
o Ask if the infant is wetting diapers or if an older child
arteriosus.
is voiding normally. Urine is produced only when
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
cardiac function is adequate to perfused kidneys. Ask
how many times the infant voided or how many
times did the mother change the infant’s diapers in a
day. Edema from retained fluids is a late sign of
heart disease in children because there is a decrease
in urine output with edema.
o Ask the history of nosebleeds and headaches.
Children with coarctation of the aorta and high
blood pressure in the head and upper extremities
have a history of nosebleeds and headaches.
Because of corresponding low blood pressure in the
lower extremities, such children may have pain in the
legs when running; reported as growing pain.
● General Assessment
o Take a look at the overall appearance of the patient.
What is the color of their skin? How alert are they?
What is their nutritional status? Do the parents
report that the child is taking a normal amount of PO
intake?
●
Physical Examination
o It is best if the child is relaxed and not crying. Provide
age-appropriate toys that can distract a child readily.
A bottle of formula or breast milk, or asking the
mother to breastfeed, can help comfort the infant.
Play with both children and infants, if possible,
before an examination so that they are acquainted
and are not afraid of you.
o
o
Inspection:
▪ Look for any signs and symptoms of
diminished cardiac output or poor cardiac
function. You will be able to tell by color,
perfusion, and general overall appearance.
The color of your patient should be pink and
well-perfused. If the child looks incredibly
pale, this could indicate a number of things
from anemia to poor cardiac output or
narrowing of your patient’s blood vessels
and response to shock.
▪ See if the patient has the presence of
clubbing which is the expansion of the
patient’s fingernails or fingertips. This is
often caused by prolonged and long-term
hypoxemia or low oxygen levels in the
blood, and is typically seen in children with
congenital heart defects.
▪ Look for edema or swelling. Edema can
either be in a generalized capacity or overall
body of the patient (meaning the patient as
a whole looks puffy) and fluid overload.
Perhaps it is more localized to certain
regions such as their lower extremities.
Lower extremity edema is often associated
with congestive heart failure. It is also
important to note whether the edema is
pitting in which, if you pushed on the
edema, you would see an indention and
may remain for some time. It is graded from
0 (no pitting) to +4 (severe pitting).
▪ Look for any visible (distention) pulsations.
The most important one to look for is in the
neck. You look for a jugular vein distention.
In some babies, this is normal but to some
patients who are laying at a 30 to 45 degree
angle, you should see no extra pulsations in
their neck. If you see this, this could be an
indicative of some sort of a blockage or
obstruction for a certain heart problem.
Palpation:
▪
▪
▪
▪
Assess the central pulses. In infants, the best
place to assess the central pulse is the
brachial artery (upper or medial part of the
arm). You can also palpate for femoral pulse
which is located in the groin. In older
children, feel for a carotid pulse that is in
the neck. It is imperative to note that the
absence of a central pulse indicates the
need for an immediate CPR and call for an
emergency response.
Feel for the child’s peripheral pulses. It can
be palpated on the radial artery which is
found on the wrist; compare both sides. You
can feel in their feet, the dorsalis pedis and
posterior tibial pulses. Note whether these
pulses are strong, normal, weak, or
threading. They are graded from 0 to +4
basis. It is important to note because a
bounding pulse (+3 to +4) can be an
indicative of a hyperdynamic state of the
patient, which would be indicative for warm
shock.
Feel the overall temperature of the patient.
Do they feel hot, cold, or warm? Warm and
dry is usually normal. If they are cold and
clammy, this may be indicative that
something is going on with their vasculature
and warrants for their investigation.
Test the patient’s capillary refill time. This
can be judged by pressing on either a finger
or toe until it turns white or blanched.
Watch for spontaneous return of the color.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
o
Normal time for the color to return is less
than 2 seconds. If it reaches 3 to 4 seconds,
this is described as a delayed capillary refill.
Anything more than 5 seconds is indicative
for a serious problem; requires immediate
intervention.
Auscultation:
▪ Normally, anyone will be able to hear the S1
and S2 or “lub-dub.”
- S1 indicates the closing of the AV
valve
- S2 is the closing of the semilunar
valve.
- They are the two normal heart
sounds and we have to be sure that
we hear these noises.
▪ However, as we move forward, you might
hear an S3 and S4.
- S3 can be normal but should be
reported to the physician. It is
sometimes heard in small children.
This is usually heard at the apex of
the heart and it can also be
identified as a gallop. This may be
normal but report to a physician if
this is a new finding.
- S4 is a concerning finding and it is
usually identified at the atrial
contraction portion of the heart
pumping cycle. It is a low frequency
sound that can often indicate
severe hypertension and potential
cardiomyopathy.
▪ Some other abnormal heart sounds that we
want to be aware of is the pericardial
friction rub.
- This may sound sort of like when
you pull out a piece of hair and rub
it between your fingers.
- This is concerning as well as it
could indicate that there is
▪
pericardial effusion. It could
develop after a pericardiotomy.
The first thing you want to be aware of is a
murmur.
- This often indicates there is some
sort of an opening or (abnormal)
connection
between
heart
chambers, indicating abnormal
valve function. It should be brought
to the attention of the physician in
order to best diagnose and treat
the problem.
*Check urine and cardiac output sad. Note lack of central pulse which
indicates immediate need for CPR and chest compressions.
●
●
●
●
Tachycardia: One of the first indicators that the child is more
ill; Fast HR
Decreased perfusion: Poor color, pallor, mottling or poor
white spots in the body
No cardiac output = blood flow to kidneys decrease =
decrease urine output
Flaccidity: Low muscle tone
Common Diagnostic and Therapeutic Procedures
1. Chest X-ray
o Can show an accurate picture of the heart size, the
contour or anatomic changes, and even the size of
the heart chambers. It can also reveal fluid collecting
in the lungs or pulmonary artery from cardiac failure.
o Used to confirm the placement of pacemaker leads.
o
2.
It cannot tell us how severe or the extent of the
damage of the heart.
Laboratory Testing
o
Children with heart disease usually undergo a
number of blood tests to support the diagnosis of
heart disease or to rule out anemia.
o Check for hematocrit or hemoglobin.
- It is usually obtained to assess the rate of
erythrocytes or the RBCs production, which
may increase in an attempt to produce more
oxygen carrying red blood cells.
- If the increase in the number of RBC is
extreme (polycythemia), there will be an
increase in the blood volume.
- Newborns
are
normally
slightly
polycythemic, having a hemoglobin level
over 25 grams per 100 mL or a hematocrit
level over 70%.
- In an older child, they have a hemoglobin
level over 16 grams per 100 mL or
hematocrit level over 55%.
o Elevated erythrocyte sedimentation rate is taken if it
denotes inflammation. It is useful in documenting
that an inflammatory process such as rheumatic
fever, Kawasaki disease, or myocarditis occurs or is
present.
o Blood gas levels are also determined.
- To test for this, a child is given 100% oxygen
for about 15 minutes.
- If the child’s PO2 is less than 150 mmHg
after this time, a shunt directing
deoxygenated blood into oxygenated blood
is suspected.
o
Before cardiac catheterization or surgery, blood
clotting must be assessed. Expect prothrombin,
partial thromboplastin, and platelet count studies to
be completed before the procedure. Some children
with polycythemia from heart disease, have an
associated
reduced
platelet
count
or
thrombocytopenia. Because platelet formation is
necessary for blood coagulation, the platelet count
must be corrected before cardiac surgery.
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UNIT 10 (Week 12)
o In children with heart failure, serum sodium may be
obtained to ensure that an increased sodium level is
not causing edema.
o All children receiving diuretics, such as furosemide,
should have serum potassium levels determined
periodically because diuretics tend to deplete the
body potassium. Low serum potassium levels
potentiate or increase the effect of cardiac glycosides
such as digoxin. For this reason, serum potassium
levels are usually obtained in children receiving these
medications. Hypokalemia increases risk for digoxin
toxicity.
3. Electrocardiogram
o Written record of the electrical voltages generated by
the contracting heart. It provides information on
heart rate, rhythm, state of the myocardium,
presence or absence of hypertrophy (thickening of
the heart), ischemia (necrosis due to inadequate
cardiac circulation), and abnormal conduction of the
heart.
o P wave: Atrial contraction
o T wave: Recovery or relaxation
o Abnormal Results:
▪ Longer P wave: Suggests atrial hypertrophy
and is taking longer than usual for the
electrical conduction to spread over the
atrium
▪ Lengthened PR interval: Difficulty in
coordination between the SA and AV nodes
▪ Heightened
R
wave:
Ventricular
hypertrophy
▪ Decreased R wave height: Ventricles cannot
fully contract as it happens when they are
surrounded by fluid
▪ Elongated T wave: Hyperkalemia
▪ Depressed Y wave: Anoxia
▪ Depressed ST segment: Abnormal calcium
levels
4. Holter or Event Monitor
o Continuous ambulatory ECG
o Gives us a diagnostic information over a period of
time
5.
6.
Records patient ECG tracing non-stop for 24 hours or
longer
o Not invasive
o The child’s regular activities will not be altered.
o Purpose: Detects arrhythmias and checks other signs
and symptoms that may be heart-related such as
fatigue, shortness of breath, dizziness, or fainting
o Event monitor does not record until the patient feels
symptoms. The patient must trigger the monitor to
record the ECG tracing at the time the symptoms
occur
Echocardiogram
o Or ultrasound cardiography
o Primary diagnostic test for heart disease
o Uses high frequency sound waves to make detailed
pictures of the heart
o Used to locate and study the movement and
dimensions of the cardiac structures such as the size
of chambers, thickness of walls, relationship of major
vessels to chambers, and the thickness, motion, and
pressure gradients of the box
o Can be done in Transthoracic echo (TTE) wherein a
hand-held wand called the transducer is used across
the chest over the area where the heart is, then the
transducer sends and receives sound waves that are
changed into images.
o Types:
▪ Two-dimensional: Reveals chambers and
vessel size
▪ Doppler: Reveals velocity of the blood
o Can reveal heart anomalies as early as 18 weeks into
a pregnancy. This can alert the staff to be prepared
with immediate resuscitation or other needed
equipment for the baby’s birth.
o Remind the parents that this does not use x-ray so it
can be repeated at frequent intervals without
exposing children to possible risks of radiation.
Computed Tomography or Magnetic Resonance Imaging
o Both are non-invasive and used to capture images
within the body.
o The biggest difference is that MRIs use radio waves
and CT scans use x-rays.
o
o
o
7.
8.
MRI: complementary role to ECG
Purpose:
▪ Evaluate the structure of the heart and
surrounding blood vessels
▪ Assess causes of arrhythmia (abnormal
heart rhythm)
▪ Evaluate infections
▪ Assess blood flow to the heart muscle
▪ Evaluate findings following cardiovascular
surgery
Exercise Stress Testing
o uses treadmill walking
o Can give information about how the heart responds
to the extra demands of activity.
o The test is done on children who are able to walk and
run on a treadmill and are mature enough to
understand what is being asked of them, usually ages
5 and up.
o Patient’s ECG and blood pressure will be taken while
they exercise on a treadmill. The patient will be
continuously monitored. Make sure there are no
problems as the exercise level increases. Although
the exercise is not harmful, it checks the child’s heart
as it works to its highest level so some shortness of
breathing and fatigue is expected. However with
children who have heart defects that obstruct the
blood flow to the lungs (such as those with
pulmonary stenosis), exercise is not possible because
it can cause extreme exertion of dyspnea to the
patient.
o This test is difficult to perform successfully with
young children because this requires their
cooperation.
Cardiac Catheterization
o gold standard for cardiac imaging
o Invasive outpatient procedure
o A procedure in which a small radiopaque catheter is
passed through a major vein in the arm, leg, and
neck into the heart to secure blood samples or inject
dye which helps to evaluate cardiac function
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
o allows for direct measurements of pressure as well as
visualization of the heart and all blood vessels with
the aid of a contrast medium/dye
o Can be diagnostic cardiac catheterization (used to
help diagnose specific heart disorders and
anticipation of surgery) or interventional cardiac
catheterization (used to correct an abnormality).
Both types can evaluate the pressure of blood flow in
all heart chambers and total cardiac output.
o many corrective procedures can also be performed in
the catheterization lab, such as atrial and ve
o Ambulatory or one day surgery with conscious
sedation
o Before the procedure:
▪ Children must have a recent radiograph,
ECG, electrolyte levels, and blood must be
typed and crossmatched.
▪ Take baseline pedal pulses.
▪ Measure height and weight for catheter size
and amount of sedation.
▪ Do not draw blood specimens from the
projected catheterization entry site.
▪ NPO for 2 to 4 hours to reduce the danger
of vomiting and expiration during the
procedure.
○ Risks:
▪ Arrhythmias as catheter or dye is passed
through; may be transient
▪ Inadvertent perforation of the heart
▪ Bleeding
▪ Thrombophlebitis
Congenital Heart Disorders
● These are problems in the heart’s structure that are present at
birth.
● Approximately 1 in every 100 newborns have congenital heart
defects which can range from mild to severe.
● It happens because of incomplete or abnormal development of
the fetus’ heart during the early weeks of pregnancy
● Some are associated with genetic disorders, but the cause of most
congenital heart defects is unknown.
●
Four classifications: This classification has been established to
address the hemodynamic and blood flow patterns of the
disorders rather than the effect allowing a more uniform and
predictable signs and symptoms.
Disorders With Increased Pulmonary Blood Flow
● Increase in pulmonary flow occurs as blood shunts from left
to right at either the atrial level or a ventricular level through
a hole in the septum and recirculated back to the lungs. This
shunting of the blood causes the volume overload on the
heart and the lungs. The pressures on the right side are lower
from the pressures of the left side of the heart.
● In defects, which causes opening between the chambers in
the heart, blood will flow between the openings from the left
side of the heart to the right side. Blood will flow the path of
the least resistance going from the area with the highest
pressure (left side), to an area of lower pressure (right side).
These are problems in the heart’s structure that are present at birth.
The four classifications are:
1. Ventricular Septal Defect
● The most common type of congenital heart disease.
It occurs about 25% of all congenital heart disease
(about 2 in 1000 live births).
● Occurs when there is an opening in the ventricular
septum, the wall between the two lower chambers
of the heart known as the right and left ventricles.
● A VSD allows the oxygen rich red blood that is
coming from the lungs to pass from the left ventricle
to the septum and get mixed with oxygen poor blue
blood in the right ventricle.
● The blood flows from the left side of the heart thru
the abnormal opening the right side of the heart.
Because the pressure on the left side is higher than
the right.
● VSD occurs during fetal development when the
separating process that forms the septum is not
completed.
● Impairs the effort of the heart because the blood
that should go into the aorta and out of the blood is
shunted back into the pulmonary circulation
●
●
●
●
●
●
●
●
●
resulting in right ventricular hypertrophy, an
increased pressure in the pulmonary artery.
There will be an extra blood nga mu congest sa right
ventricles. Supposedly kaning blood coming from the
lugs nga muenter sa left side of the heart should
normally pass through the aorta, to be distributed
throughout our body. However, with a hole in the
septum, nay mga extra blood na oxygenated na unta
will get mixed sa non-oxygenated blood because of
the hole that is present. Eventually it can cause
pulmonary infection/pulmonary problems.
Since the right ventricle is pumping too much extra
blood to the lungs, sometimes the lungs cannot
handle it, specifically the arteries connecting the
lungs will become damaged and narrow. Narrowing
of arteries in the lungs can cause pulmonary
hypertension and can cause several breathing
problems in the infants.
With that pulmonary hypertension, since arteries are
already narrow in the lungs, the right ventricles have
to exert a lot of effort/pressure to pump those extra
blood nga nag congest sa right side of the heart.
Left ventricle normally has higher pressure because it
has to pump the blood throughout the body, while
the right ventricle only has to pump the
non-oxygenated blood only to the lungs.
With extra congested blood in the right side of the
heart, eventually it's going to have hypertrophy
because of the exertion of a lot of pressure
It is found approximately 25% of all CHD.
The size of the defect can be small or large.
Cause is unknown
Risk Factors:
○ VSD appears to run in families and
sometimes occurs with other genetic
problems, such as Down syndrome
○ Having the following conditions during
pregnancy can also increase the risk of
having heart defect:
■ Rubella infection- that’s why during
history taking we ask the mother if
she had measles during pregnancy
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UNIT 10 (Week 12)
■
■
●
●
Poorly controlled diabetes
Drug or alcohol use or exposure to
certain substances
● Signs and Symptoms: “HOLE”
○ The size of the ventricular opening will
affect the type of symptoms noted.
○ Heart Failure and pulmonary hypertension:
Dyspnea, fatigue, swelling extremities,
crackles, sweating, clammy with activity
○ Often experiences lung infection: With the
narrowed arteries, it can cause possible
secondary bacterial infection.
○ Low growth rate and loss of weight: It ties
back to the heart and breathing problems
burning a lot of energy to maintain the life
of the patient. The heart has to pump
harder.
○ Extra heart sounds: Murmurs heard at the
left sternal border, at the 3rdor
4thinterspace. Typically one of the major
signs of ventricular septal defect (Murmurs).
Happens because of the turbulent radiant
blood crossing over the septum during
systole. A small defect will cause a large
amount of resistance to blood flow and
result in a loud murmur.
Diagnostic Tests:
○ Echocardiogram
○ MRI reveals right ventricular hypertrophy in possibly
pulmonary artery dilatation from the increased blood
flow.
○ ECG reveals right ventricular hypertrophy.
Management:
○ In small VSD usually no medical management is
required because up to 85% of VSD are so small that
they close spontaneously.
○ Surgical repair may be indicated in some cases.
○ Especially in large VSD (over 3 mm) requires open
heart surgery. Scheduled before 2 years of age to
prevent pulmonary artery hypertension. Closure is
important because if left open, cardiac failure from
the artery hypertension can result. Heart can
●
●
●
●
2.
become infected or cause endocarditis because of
recirculating blood flow.
○ Small-closed with a stitch
○ Larger-Dacron or Silastic patch is applied
Post-Op interventions: Alert for arrhythmias (because edema
in the septum can interfere with ventricular contraction),
prophylactic antibiotic given to prevent bacterial endocarditis
for 6 months afterwards.
Adequate nutrition- prevent failure to thrive
Infection control- prevent lung and heart infection
Medications:
○ Digoxin makes contraction of the heart strong but at
the same time at slow rate para di ma-stress
○ Furosemide: To get the excess fluid that are
congesting
○ ACE inhibitors increase blood pressure, especially the
left ventricle.
Atrial Septal Defect
o An abnormal communication between the two atria,
allowing blood to shift from the left to the right
atrium.
o A “hole” in the wall that separates the top two
chambers (atria) of the heart.
o This defect allows oxygen-rich blood to leak into the
oxygen-poor blood chambers in the heart.
o This defect allows oxygen-rich blood to leak into the
oxygen-poor blood chambers in the heart.
o Female predominance (more common in girls than
boys)
o Occurs 5-10% of all children born with congenital
heart disease.
o This causes an increase in volume in the right side of
the heart and generally results in ventricular
hypertrophy and increased pulmonary artery blood
flow, the same as with a VSD (ventricular septal
defect).
o Two Types:
▪ Ostium primum (ASD 1): Where the
opening is at the lower end of the septum.
▪ Ostium secundum (ASD 2): Where the
opening is near the center of the septum.
ASD2 defects may be asymptomatic and not
o
o
o
o
discovered until infection from circulating
blood occurs.
Signs and Symptoms:
▪ Shortness of breath, especially when
exercising
▪ Fatigue
▪ Swelling or edema of legs, feet, or abdomen
▪ Heart palpitations or skipped beats
▪ Frequent lung infection
▪ Stroke
▪ Heart murmur: Heard over the 2nd or 3rd
interspace (pulmonic area)
A harsh systolic murmur is heard over the second or
third interspace (the pulmonic area) because of the
extra amount of shunted blood that crosses the
pulmonic valve. As the volume of the blood crossing
it causes the pulmonic valve to close consistently
later than the aortic valve, the second heart sound
will be auscultated as split (fixed splitting). Such a
sound is almost always diagnostic of ASD.
Diagnostic Tests:
▪ Echocardiogram with color flow Doppler will
generally reveal the enlarged right side of
the heart and increased pulmonary
circulation.
▪ Cardiac Catheterization: Although rarely
needed for diagnosis. Would reveal the
separation in the atrial septum and the
increased oxygen saturation in the right
atrium.
▪ ECG
Management:
▪ Surgery to close the defect is done electively
at 1 to 3 years of age. Closure is important
because without it, a child is at risk for
infectious endocarditis and eventual heart
failure or hypertension.
▪ It is particularly important that ASD be
repaired in girls, because they can cause
emboli during pregnancy.
▪ Surgery in which the edges of the opening in
the septum are approximated and sutured
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
3.
may
be
completed
with
cardiac
catheterization technique if only the defect
is small.
▪ Large defects may still require open heart
surgery and cardiopulmonary bypass.
▪ As with VSDs, if the defect is very large, a
Silastic or Dacron patch may be sutured into
place to occlude the space.
▪ Postoperatively, carefully observe the child
for arrhythmias because edema of the right
atrium could interfere with SA node
function. With uncomplicated surgery,
children can expect a normal quality and
length of life.
Atrioventricular Canal Defect
o Also called endocardial cushion defect
o Caused by a poorly formed central area of the heart.
Typically there is a large hole in the upper chamber
of the heart(atria) and an additional hole in the
lower chambers of the heart (ventricles).
o Instead of having 2 separate valves (tricuspid and
mitral valve) there is one large common valve which
is quite malformed
o There is low ASD continuous with VSD and distortion
of the mitral valve and tricuspid valve.
o Blood may flow between all four heart chambers.
o Commonly seen in trisomy 21 (although rare in the
general population, as many as 50% of children with
trisomy 21 (Down syndrome) who have heart disease
have this type of congenital heart defect.
o Signs and Symptoms:
▪ The same symptoms of ASDs
▪ Right ventricular hypertrophy
▪ Increased pulmonary blood flow
▪ Fixed S2 splitting (fixed second heart sound
splitting)
▪ Caused by closure of
the aortic and
pulmonary valve are not synchronized
during inspiration.
o Diagnostic Tests:
▪ ECG: Reveal first degree heart block. An ECG
often will reveal first degree heart block as
4.
impulse conduction is halted before the AV
node. In the first degree heart block, there
is no electrical blocking rather there is a
slowing or delay of the electrical activity of
the heart.
▪ Echocardiography: Confirm the diagnosis
o Management:
▪ Pulmonary artery banding: This increases
pressure in the pulmonary artery and right
side of the heart, reducing the amount of
shunting.
▪ Surgery: Necessary for final repair because
these defects are too large to close
spontaneously. Because surgery may involve
a valve repair as well as a septal repair,
mitral and tricuspid insufficiency from poor
valve function may occur at a later date.
▪ Post-Op: Observe for jaundice, Prophylactic
anticoagulant, Antibiotic therapy
▪ Postoperatively, closely observe children for
jaundice resulting from red blood cell
destruction as red cells are destroyed by
the newly constructed valves. Both
prophylactic anticoagulation and the
antibiotic therapy may be necessary
postoperatively, but with these drugs, the
artificial valve should help ensure the child
can lead an active life.
Patent Ductus Arteriosus
o It is a persistent vascular connection between the
pulmonary artery and the aorta that persist after
birth.
o Normally closes between birth and first 2 weeks of
life as the vessel is filled with fibrin.
o Functionally the closure of the ductus arteriosus
occurs soon after birth.
o Delayed closure is common in premature infants. It
accounts about 12 percent of congenital heart
diseases and it is more common in females.
o When ductus arteriosus remains patent and open
after pulmonary artery due to higher pressure in the
aorta.
o
o
o
PDA is common in preterm infants.
It is a more common type in female babies.
A small PDA may cause no symptoms, but a large one
may cause poor eating, failure to thrive or
breathlessness.
o Ductus arteriosus is a vessel that connects the aorta
and the pulmonary artery in the fetus. It carries
blood from the right side of the heart to the rest of
the body bypassing the nonfunctional lungs. After
birth it should close because it is no longer needed.
o Patent: Wala ni close
o In this defect there will be an increase in pulmonary
blood flow in the lungs. How? Normally, the
oxygenated blood coming from the lungs enters into
the left ventricle then to the aorta then to be
pumped out to the rest of the body. But because of
the increase pressure in the aorta because ductus
arteriosus did not close, some oxygenated blood will
enter into the ductus arteriosus then will go to the
pulmonary artery going back to the lungs, therefore
there will be an increase blood flow to the lungs, this
results to right ventricular hypertrophy and
ineffective heart function.
o IMPORTANT TO NOTE: Full closure may not occur
until 3 months of age.
o Signs & Symptoms: CALL
▪ Cardiac
● Continuous “machine-like” murmur:
Hallmark sign; The heart sound that
is unique. Continuous meaning
you're gonna hear in both diastole
and systole and you are gonna hear
it in the left upper sternal border.
Murmurs can be heard because of
the strong pressure or turbulence of
the blood flow that is happening in
the affected area.
● Risk for endocarditis: If there is
increased pulmonary blood flow,
there will be a hypertrophy of the
right ventricle since the RV has to
put a lot of force and exertion to
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UNIT 10 (Week 12)
▪
▪
▪
pump the extra blood to the lungs
because of the resistance. Over time
there will be a damage in the heart’s
lining that will occur and eventually
predispose any infection.
● Increased heart rate: Due to the
right ventricle that is pumping so
hard so the heart rate will increase
and also because of the narrowed
arteries that the RV is pumping so
hard.
● Wide pulse pressure: This is where
you take the systolic BP and you can
subtract it to the diastolic and you
get the number that would
represent the force that is needed
for the heart to contract; high due to
the blood flow to the ductus
● Heart Failure: Crackles and dyspnea
is not normal for a baby to have a
heart failure; because of the
pulmonary infiltrates.
Activity Intolerance
● Fatigues easily due to the
happenings of the lungs and heart.
Any kind of activity can cause them
to fatigue
● Sweating or diaphoresis
Lungs
● Pulmonary hypertension happens
when there is too much flow
towards the lungs. Over time, the
arteries feeding the lungs will
narrow
causing
increased
hypertension in the lungs and
predisposing the risk of infection.
● Risk for infection
Loss of weight
● Generally because of the problem of
feeding. These infants are burning a
lot of calories in order to breathe so
●
o
Management:
o Indomethacin 0.1 to 0.25mg/kg/IV over 30
mins very slowly is administered every 12 to
24 hours for 3 doses. (Since 1 reason that
the ductus arteriosus remains open in fetal
life is because of the stimulation of
prostaglandin from the placenta and low
oxygen level of fetal blood; medication is
given if ductus arteriosus does not close)
o Supportive care is provided with rest,
adequate intake of calorie for weight gain
and promotion of growth and development.
o Surgery-Transaction or ligation of patent
ductus arteriosus is performed via lateral
thoracotomy, a closed heart intervention. If
surgery is not done, the child is at risk for
heart failure.
Disorders With Obstruction to Blood Flow
● Because vessel or valve narrows
● Prohibit enough blood from reaching intended site
● Threaten to overwhelm the heart due to the pressure
1.
■
oftentimes they do not have energy
anymore to feed.
Infants cannot feed simultaneously
while they are experiencing air
hunger.
2.
Pulmonary Stenosis
○ It is a narrowing of the pulmonary valve or
pulmonary artery just distal to the valve.
○ pulmonary valve does not open properly
○ Inability of the right ventricle to evacuate blood by
way of the pulmonary artery because of the
obstruction leads to right ventricular hypertrophy
○ If mild, pulmonary stenosis may never require any
treatment.
○ Signs and Symptoms
■ Mild: asymptomatic (Infants with PS may be
asymptomatic or have signs of mild right
sided heart failure
Severe: cyanosis (if narrowing is severe;
because of the inability of adequate blood
to reach the lungs for oxygenation or right
to left shunting across the foramen ovale
because of the increased right sided heart
pressure)
■ systolic ejection murmur (grade 5,
crescendo decrescendo murmur) heard at
upper left sternal border (because of the
turbulence of the blood flow), S2 splitting
(because of the late closure of the
pulmonary valve)
○ Diagnostic Test
■ ECG will reveal right ventricular hypertrophy
■ Cardiac catheterization: Rarely necessary for
diagnosis but is used for interventional
enlargement of the stenosis valve
○ Management
■ Balloon angiography is a catheter with an
un-inflated balloon at its tip inserted and
passed through the heart into the stenosed
valve. As the balloon is inflated, it breaks
valve adhesions and releases the stenosis.
Following the procedure, although children
may have residual heart murmur, you can
expect a normal life span.
Aortic Stenosis
○ Stenosis or stricture of the aortic valve prevents
blood from passing freely from the left ventricle of
the heart into the aorta
○ Because the heart must work harder to pass blood
through the narrowed area, increased pressure and
hypertrophy occur in the left. If this pressure
becomes severe, pressure in the left atrium will
increase, resulting in back pressure through the
pulmonary veins to the lungs, possibly causing
pulmonary edema.
○ There will be increased pressure and hypertrophy of
the left ventricle
■ Back-pressure in pulmonary veins
■ Pulmonary edema
○ Signs and Symptoms:
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■
○
○
Most children with aortic stenosis are
asymptotic, a physical assessment generally
reveals a typical murmur, a rough systolic
sound heard loudest in second and third
beat in the interspace or aortic space.
Murmur may be transmitted to the right
shoulder, clavicle and up to the vessels and
even at the apex of the heart.
■ In severe cases, there will be decreased
cardiac output as evidenced by:
● Faint pulses
● Hypotension
● Tachycardia
Inability to suck for long periods
■ When the child is active there will be chest
pain similar to angina because the coronary
arteries receive inadequate blood.
■ Sudden death can occur when the amount
of oxygen needed by the heart muscle on
excoriation far exceeds what is available
■ An ECG or echocardiogram will reveal left
ventricular hypertrophy.
Management:
■ Stabilization of beta-blocker or calcium
channel blocker may be necessary to reduce
cardiac hypertrophy before the defect is
corrected.
■ Balloon valvuloplasty is a surgical treatment
of choice. It is a surgery that involves
dividing the stenotic valve or dilating
constrictive aortic ring for severe defects.
Such repair may lead to aortic valve
insufficiency in later life at which time
further surgery may be needed.
■ Artificial valve replacement
● Some children will need artificial
valve replacement for correction as
well. If there is a prosthetic valve
used, children generally continue
anticoagulation or antiplatelet
therapy.
●
●
3.
An antibiotic prophylaxis is given
to fight or prevent endocarditis.
In addition, children need exercise
testing before participating in
competitive sports if an artificial
valve is in place.
Coarctation of the Aorta
○ The narrowing of a portion of lumen of the aorta due
to a constricting band and it often seriously
decreases blood flow from the heart out to the
upper portion of the body.
○ It occurs more frequently in boys and in girls and it is
the leading cause of congestive heart failure in the
first few months of life.
○ There are two locations in which this commonly
occurs:
■ Preductal: The constriction occurs between
the subclavian artery and the ductus
arteriosus.
■ Postductal: The constriction is distal to the
ductus arteriosus.
○ Signs and Symptoms:
■ Because it is difficult for blood to pass
through the narrowed lumen of the aorta,
blood pressure increases proximal to the
coarctation and decreases distal to it. So this
results in an increased blood pressure in the
heart and upper portion of the body as
pressure in the subclavian artery increases.
Elevated upper body blood pressure
produces:
● Headache
● Vertigo
● Because a child under 3 years of
age has difficulty describing these
sensations, exceptional irritability
may be the main clue that these
symptoms are present.
● Epistaxis or nose bleeding can
occur.
● Cerebrovascular accident (CVA): In
an event not generally associated
○
○
○
○
○
with children can occur from this
dangerously
elevated
blood
pressure.
Decreased blood pressure in the lower parts of the
body, there will be:
■ Absence or decreased femoral pulses
■ Cool extremities
■ Lower BP in lower extremities
As children with coarctation of aorta grow older they
may experience leg pain on exertion because of the
diminished blood supply to the lower extremities,
because collateral circulation is necessary to allow
blood to flow around the constriction.
Collateral arteries are enlarged and may be seen
under ribs as obvious nodules such as the child grows
older.
Diagnostic Tests:
■ History and physical assessment
■ Upon examination, the BP in the arms will
be at least 20 mmHg higher than in the legs,
a reversal of the normal pattern.
■ ECG,
Echocardiogram,
MRI,
X-ray
examinations of older children will reveal
the left sided heart enlargement from back
pressure and also notching the ribs for the
large collateral vessels.
Management:
■ Interventional
angioplasty
(balloon
catheter): With this procedure, a catheter
with an inflated balloon at its tip is inserted
and passed through the heart and into the
aorta. As the balloon is inflated it breaks the
adhesions and reveals the stenosis.
■ The narrowed portion of the aorta is
removed and the new ends of the aorta are
anastomosed, a graft of transplanted
subclavian artery may be necessary if the
narrowed section is so expensive and an
anastomosis is not accomplished readily.
■ Many infants with coarctation of aorta
require therapy of digoxin and diuretics in
the time before surgery can be performed.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■
■
■
■
This drug aims to reduce the severity of
congestive heart failure.
Surgical repair is usually scheduled by 2
years of age, if the surgery is successful the
child can expect to live a normal life. After
surgery the abdominal vessels receive more
blood than they did previously, this may
result in abdominal pain or generalized
abdominal discomfort, but this is just a
short term problem.
Some children continue to have elevated
upper body hypertension after the repair,
they need continued treatment with
antihypertensive agents.
Some children also require repeated balloon
angioplasty if adolescent to enlarge the
aortic lumen and help reduce the upper
body hypertension.
○
○
○
○
○
○
Pulmonary artery arises at the left ventricle
however in this condition, it arises at the
right ventricle.
ASD and AVD occur in connection with this
transposition.
ASD, VSD, and PDA permit mixing of two circulations.
Fetus survive in utero
Once they are born, present signs and symptoms.
Structures or shunts needs to be open until surgery
to have oxygenated blood to be circulating in the
system
have some type of other congenital defects which
allows a little bit of mixing of the blood
Angiography: Imaging and diagnostic tests
Angioplasty: Repair
Disorders With Mixed Blood Flow
Are cardiac anomalies that involve mixing of blood from the pulmonary
artery and systemic circulation in the heart chambers. This mixing
results in a relative deoxygenation of systemic blood flow. Although
cyanosis is not always visible, mix defects include:
1. Transposition of the Great Arteries
○ The great arteries such as the aorta and pulmonary
artery are switched (transposed; swapped position in
the heart).
○ Normal heart: left side deals with systemic
circulation; aorta arise in left ventricle; right side
deals with pulmonary circulation)
○ Each side of the heart has its own circulation without
communication.
■ Pulmonary Circulation (left side of the
heart)
■ Systemic Circulation (right side of the heart)
■ Aorta arises on the right ventricle.
2.
○
○
Diagnostic Tests:
■ Echocardiogram: Reveals enlarged heart
■ ECG - may not reveal heart changes
■ Cardiac Catheterization
- reveal low oxygen
saturation
Signs and Symptoms: “SWAP”
■ Severe Cyanosis
● Will not resolve without treatment
● Degree vary if CHD is present (worst as
structures close normally)
● Low oxygen: Increased HR & RR (body’s way
of trying to compensate to pump more
oxygen but it does not happen because
there is no connection between right and
left side of heart)
● Poor feeding lead to decreased growth rate
● Cool extremities
■ Watch heart rate, rhythm, and O2 saturation levels
● Give O2
● Prepares for intervention
■ Alprostadil (Prostaglandin E): Keep connection
between aorta and pulmonary artery (PDA); Keep
ductus arteriosus open; Buys us some time until
surgery
■ Procedures to correct
● Balloon atrial septal pull-through
○ Enlarged Septal Opening
○ Temporary
○ first few days of infants
○ done by cardiac catheterization
wherein balloon is passed from
foramen ovale through right atrium
○ creates artificial ASD
● Arterial Switch Procedure
○ Permanent
○ Done to 1 week to 3 months of age
○ major vessels are switched in
position
○ Survival heart of 95%
Total Anomalous Pulmonary Venous Return
○ A birth defect of the heart in a baby with TAPVR,
oxygen-rich blood does not return from the lungs to
the left atrium or to a vein flowing to the right atrium
or SVC . Instead, the oxygen-rich blood returns to the
right side of the heart via the superior vena caviar
the right atrium. Thus, oxygen-rich blood mixes with
oxygen-poor blood.
○ For the infant to live, an atrial septal defect (ASD) or
patent foramen ovale (the passage between the left
and right atria) must exist to allow oxygenated blood
to flow to the left side of the heart and the rest of
the body.
○ pressure build ups in the pathway and pulmonary
veins
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
○ Signs and Symptoms:
■ Tire easily
■ Trouble breathing
■ Mildly cyanotic
■ If the ductus arteriosus closes or the septal
defect is small, cyanosis increases.
■ Right sided heart failure develops as
complication
○ Management:
■ Continuous infusion of prostaglandin to help
keep the ductus arteriosus open
■ Balloon atrial septal pull-through procedure
to enlarge a small foramen ovale
■ Continuous IV infusion with prostaglandin to
help keep ductus arteriosus open
■ Surgery: Reimplanting the pulmonary veins
into the left atrium (permanent correction)
3. Truncus Arteriosus
○ A rare type of heart disease in which a single blood
vessel (trunk) comes out of the right & left ventricles,
instead of the normal 2 vessels (pulmonary artery &
aorta).
○ There are holes in the ventricles associated with this
defect.
○ There is usually an accompanying VSD
○ There will be mixing of oxygenated and
deoxygenated blood.
○ Complications include pulmonary hypertension and
heart failure.
○ single artery comes out of the two ventricles which
allows oxygenated and deoxygenated blood mixes
○ causes extra fluid to build up
● Signs & Symptoms:
○ Cyanotic: Decreased O2 blood in the system
○ Increased RR: Compensatory mechanism of
the lungs
○ Extreme fatigue
○ Poor feeding
○ Decreased
cardiac
output-activity
intolerance, cold, clammy skin
○ May have a typical VSD murmur: Usually
heard at the upper sternal border
●
4.
Management:
○ Repair involves restructuring the common
trunk to create 2 separate vessel
■ Some children need a 2nd surgical
procedure during school age as the
graft inserted to separate the aorta
& pulmonary artery may be large
(permanent correction)
■ Done for the first 2 weeks
■ Digoxin,
diuretics
and
ACE
inhibitors decrease pressure in the
pulmonary arteries: Given before
surgery; Goal is to decrease the
stress of the heart while increasing
the contraction.
Hypoplastic Left Heart Syndrome
○ It is a severe congenital heart defect in w/c the left
side of the heart is underdeveloped.
○ Left ventricles not functioning or is too small
○ Absence of mitral and aortic valve.
○ Aorta(main artery leaving the heart) smaller than
normal
○ The left side of the heart can’t effectively pump
blood to the body. Instead, the right side of the heart
must pump blood to the lungs and to the rest of the
body.
○ Signs and Symptoms:
○ Blue or purple tint to lips, skin and nails (cyanosis)
○ Difficulty breathing
○ Difficulty feeding
○ Lethargy (sleepy or unresponsive)
○ Management:
■ Prostaglandin therapy: To maintain PDA
■ Inhaled nitrogen combined with oxygen: To
decrease PO2
■ Surgery (restructuring of the heart)
● Limited success in this syndrome
● Norwood procedure
■ Heart transplantation: Ultimate answer for
prolonging the child’s life; donor hearts for
newborns is limited.
Disorders With Decreased Pulmonary Blood Flow
As the category implies, the disorders will decrease pulmonary blood
flow, involves some type of obstruction to blood flow in the pulmonary
artery because of the obstruction, pressure increase sin the right side
of the heart and if an ASD or VSD is present, the oxygenated blood
shunts from right to left. This results in deoxygenated blood invading
the systemic circulation. Common disorders include:
1. Tricuspid Atresia
○
○
○
○
○
○
Blood normally flows from the right atrium to the
right ventricle through the tricuspid valve. In
tricuspid atresia the valve is replaced by a plate or
membrane that does not open.
An extremely serious disorder because the tricuspid
valve is completely closed.
No blood flow from the right atrium to the right
ventricle.
Instead, blood crosses through the patent foramen
ovale into the left atrium bypassing the lungs and the
step of oxygenation. It reaches the lungs for
oxygenation by being shunted back through a Patent
ductus arteriosus.
Signs and Symptoms:
■ As long as the foramen ovale and DA remain
open, the child can obtain adequate
oxygenation.
■ As foramen ovale and ductus arteriosus
close, extreme cyanosis, tachycardia and
tachypnea will develop.
Management:
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■
2.
IV infusion of prostaglandin to ensure that
ductus arteriosus remains open.
■ Surgery: Restricting the right side of the
heart
■ Fontan Procedure: Construction of a vena
cava to pulmonary atresia which deflects
more blood to the lungs. It restructures the
RS of heart.
Tetralogy of Fallot
○
○
○
○
○
○
○
○
A rare condition caused by a combination of 4 heart
defects present at birth, these defects which affect
the structure of the cause oxygen poor blood to flow
out of the heart and to the rest of the body. Infants
and children with this condition usually have blue
tinged skin because their blood does not carry
enough oxygen.
Occurs during fetal growth.
termed as “Blue Baby” due to severe cyanosis
Most common complex congenital heart defect.
Occurs when the baby is developing in the womb.
Factors the increases the risk of this condition:
■ Poor maternal nutrition
■ Viral illness
■ Genetic condition
In most cases, the cause of tetralogy of fallot is
unknown.
Four anomalies are present: “RAPS”
■ Right Ventricular Hypertrophy
■
Aorta Displacement
● Aorta is the main artery leading out
to the body branches out to the left
ventricle. In the tetralogy of fallot,
the aorta is shifted slightly to the
right and lies directly above to the
ventricular septal defect. In this
position, the aorta both receives
blood from the right and left
ventricles which normally the aorta
should only receive oxygenated
blood from the left ventricle to be
pumped through the body. In this
condition, the aorta both received
the
oxygenated
and
non-oxygenated blood. The right
ventricular hypertrophy, when the
heart's
pumping
action
is
overworked, it causes the muscular
wall of the right ventricle to thicken
overtime this may cause the heart
to stiffen, become weak and
eventually fail. Like in pulmonary
valve stenosis, there is narrowing.
If there is a consistent resistance,
overtime it can hypertrophied the
ventricle. There will be a right
ventricular
hypertrophy
with
tetralogy of fallot.
■
■
Pulmonary Stenosis
● Pulmonary valve is a valve that
separates the lower right chamber
of the heart from the main blood
vessel leading to the lungs which is
the pulmonary artery.
● Stenosis is the narrowing of the
pulmonary valve. The constriction
reduces the blood flow to the lungs
affecting the muscles beneath the
pulmonary valve. In some severe
cases the pulmonary valve does
not form properly when there is
pulmonary atresia and causes
reduced blood flow to the lungs. As
we all know the blood coming from
the right ventricle will be pumped
through the pulmonary valve to the
pulmonary artery to be oxygenated
in the lungs. However, with
stenosis or narrowing, there is a
resistance only little blood will
enter the lungs.
Septal Defect (Ventricle)
● A hole that separates the two
lower chambers of the heart (right
and left ventricle). The hole allows
the oxygenated blood in the right
ventricle to mix with the
oxygenated blood on the left
ventricle. The blood that has
circulated to the body and is
returning to the lungs to replenish
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
○
oxygen supply will be mixed to flow
to the left ventricle and mix with
the oxygenated blood fresh from
the lungs.
Signs and Symptoms: “AFFLICT”
■ Because there will be decreased pulmonary
blood flow, there will be less oxygenation of
the systemic circulation. The signs and
symptoms of this condition will be due to
poor oxygenation.
■ Activity. Like crying, feeding or playing could
put a lot of stress and demand on the heart.
With all those structural changes, it does
not for the heart to work correctly and
properly so it cannot replenish the blood
with oxygen. Any activity that could stress
the heart out could lead to Tet Spell. In
remembering the tetralogy of fallot, you
have to remember Tet Spell and the need of
knee chest position or squatting.
■ “Tet Spell”
● Cyanosis
● SOB (shortness of breath)
● Increased RR
■ Fingernail Changes: Clubbing. Chronic low
oxygen in the blood causes those nails to
have an abnormal appearance. You may
notice this around 6 months of age.
■ Chronic Hypoxia
● Fatigue or faints easily: Related to
the chronic low oxygen in the
blood especially during Tet Spell,
the patient can faint easily leading
to activity intolerance.
● Lift knee to chest or squats:
Anytime the patient is having a Tet
Spell, you need to put the patient
in a knee chest position or
squatting for older children, give
oxygen and calm the patient.
Squatting increases the systemic
vascular resistance, it decreases
■
the right to left shunting which is
going to improve the blood flow
and help increase the oxygen level.
● Inability to grow: Children will be
usually smaller for their age.
● Cardiac sound-systolic murmur: A
harsh systolic murmur will be heard
in the left of the sternal border in
the second intercostal space
because it is where the pulmonary
valve is located. Definitely if there
is stenosis, you can hear a systolic
murmur.
● Trouble feeding and thriving: There
will be delay in meeting their
developmental
milestones
compared to their peers because of
the chronic poor oxygen in the
body.
Management:
● Surgery: Correct the heart defects.
Usually done at 1 to 2 years of age.
Parents need to try to keep
hypercyanotic episodes (tet spell)
to have a minimum during this
waiting time.
● During hypoxic episode:
○ Administer oxygen
○ Place baby in knee-chest
position can help trap the
blood in the lower
extremities keeping the
heart
from
being
overwhelmed
○ Propranolol (Inderal): A
beta-blocker to aid in
pulmonary artery dilation
● Temporary palliative surgical repair
○ Blalock Taussig procedure
can create a shunt
between the aorta and
the pulmonary artery
●
creating ductus arteriosus
to allow blood to leave
the aorta and enter the
Pulmonary
artery,
oxygenate the lungs and
return to the left side of
the heart, the aorta and
body.
Because
the
subclavian artery is used
in the blalock taussig
procedure, the child will
not have a palpable pulse
in the right arm after this
procedure.
For
this
reason, blood pressure
and venipuncture should
be avoided in the affected
arm.
Full-repair
○ Brock procedure relieves
the pulmonary stenosis,
TSD and overriding if aorta
is scheduled.
○ Postoperatively: Observe
for arrhythmias which may
result in any ventricular
septal repair, edema,
conduction interference.
Acquired Heart Disease
A. Congestive Heart Failure
o It is a common pediatric emergency.
o It indicates inadequate cardiac output.
o Heart failure (HF) results from structural or
functional cardiac disorders that impair the ability of
the ventricle(s) to fill with and/or eject blood.
o Clinical condition in which the heart fails to meet the
metabolic and circulatory demands of the body.
o Pulmonary and/or systemic congestion may develop
as a consequence of heart failure, resulting in
Congestive Heart Failure (CHF).
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
o Congestive Heart Failure (CHF) usually occurs as a
result of a congenital heart disorder or a disease such
as rheumatic fever, Kawasaki disease, or infectious
endocarditis. This occurs when the myocardium of
the heart cannot pump and circulate enough blood
to supply oxygen and nutrients to body cells.
o Blood pools in the heart (excessive preload) or in the
pulmonary or venous systems. This may result from a
congenital disorder that lessens the effectiveness of
the heart’s pumping action, or it may occur after
cardiac surgery or rheumatic fever, when the
myocardium is weakened.
o CHF is most apt to occur in children under 1 year of
age.
o The heart can compensate in several ways to move
blood forward and attempt to increase cardiac
output. The muscle fibers can lengthen, causing the
ventricles to enlarge in an attempt to handle more
blood with each heart stroke (ventricular
hypertrophy). The heart can also increase the
number of beats per minute. As long as these
mechanisms allow for adequate cardiac output, the
signs of heart failure are not apparent. However, the
heart’s capacity for compensation is limited,
particularly in infants, an age group in which
hypertrophy is restricted. Eventually, in children of all
ages, the heart can no longer compensate and
becomes overwhelmed by the amount of blood
present, which cannot be pushed forward effectively.
o Causes:
▪ Various forms of congenital heart disease
such as ventricular septal defect (VSD),
patent ductus arteriosus (PDA) or common
AV canal
▪ Heart valve disease caused by Rheumatic
fever or other infections
▪ Infections of the heart valves and/or heart
muscle (endocarditis)
▪ Cardiac arrhythmias (irregular heartbeats)
▪ Cardiomyopathy or another primary disease
of the heart muscle
▪ Coronary artery disease
o
o
o
o
o
o
o
o
▪ Inflammation of heart muscle (myocarditis)
Signs and Symptoms:
▪ Tachycardia: Early sign
▪ Tachypnea
▪ Right heart failure: Increased venous
pressure, Hepatomegaly, Irritability, Restless
from abdominal pain caused by liver
distention, Lower extremity edema-late sign
▪ Left heart failure: Dyspnea, Orthopnea,
Rales, Bloody sputum on coughing, Cyanosis
▪ In infants: Breathless, Tires easily, Difficulty
feeding, Diaphoresis, Generalized edema
One of the first signs of CHF is tachycardia as the
heart attempts to beat faster to move blood forward
more effectively; this is quickly followed by
tachypnea or rapid breathing.
When a child has primary right heart failure,
increased venous pressure and hepatomegaly
(enlarged liver) occur from back-pressure in the
portal circulation.
The child may feel irritable and restless from the
abdominal pain caused by the liver distention. Lower
extremity edema, usually a primary sign in adults, is
often a late sign of heart failure in children.
With left-sided heart failure, back-pressure causes
blood to accumulate in the pulmonary system.
Dyspnea is usually the dominant symptom, especially
when a child lies flat (this is orthopnea or difficulty
breathing except in an upright position; it occurs due
to increased pulmonary congestion).
A child may have rales and may produce bloody
sputum on coughing (from lung capillaries broken
under increased pulmonary blood pressure).
A child may appear cyanotic from interference with
gas exchange in the alveoli, which begin to fill with
fluid (pulmonary edema).
Left-sided heart failure can ultimately lead to
right-sided heart failure as extensive pressure in the
pulmonary system prevents blood from leaving the
right ventricle. In an infant, heart failure is often
difficult to detect because it presents with very
subtle signs.
o
o
o
○
The infant becomes breathless from rapid
respirations, tires easily, and has difficulty feeding
because of the exhaustion and dyspnea present.
Often an infant becomes diaphoretic from the effort
of feeding.
If edema is present, it is generalized rather than
dependent and often is first noticed as periorbital
edema. An abrupt gain in weight may be the most
obvious indication that extra fluid is accumulating.
Diagnostic Tests:
■ Detail history of illness
■ Physical Examination
● Palpation of weak peripheral pulse
with cold extremities
● Auscultation of heart sound
● Auscultation of lungs
■ Chest X-ray
■ ECG
■ ECHO
■ Cardiac catheterization
■ On physical examination, an infant will have
an enlarged liver (a liver palpable more than
2 cm below the right costal margin) and may
have ascites or fluid in the peritoneal space.
The apical heartbeat is displaced laterally
and downward.
■ As a rule, if the width of the heart is more
than half the width of the chest (in a child
over 1 year of age), the heart is enlarged.
■ In addition, a galloping heart rhythm or an
accentuated third heart sound may be
heard because of the sudden distention of
the ventricle during the rapid filling phase.
■ Heart failure may be confirmed by
echocardiography, which reveals the
enlarged heart. Ventricular hypertrophy can
be confirmed by ECG.
Management:
■ Pharmacologic treatment:
● Diuretics: Furosemide
● Inotropic Agent: Digoxin
● Vasodilator: Hydralazine
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
●
●
■
■
■
■
■
■
ACE Inhibitor: Captopril
Calcium
Channel
Blocker:
Nifedipine
Therapy for heart failure consists of
reducing the workload of the heart by
measures such as evacuating the
accumulated fluid (reduces preload) with
diuretics, slowing the heart rate and
strengthening cardiac function (increases
contractility) by administering an inotropic
(heart-strengthening) drug, and reducing
afterload with a vasodilator.
Commonly
used
diuretics
include
furosemide (Lasix) and spironolactone
(Aldactone). The most common drug used
to increase contractility and slow
tachycardia is digoxin.
Drugs that decrease afterload include
hydralazine,
an
arterial vasodilator;
nifedipine, a calcium channel blocker;
nitroprusside, a direct-acting vasodilator;
and captopril, an angiotensin converting
enzyme (ACE) inhibitor.
Provide for rest periods.
Put the patient in a semi-fowler's position.
Sedation with morphine
● Rest, a major aspect of care for a
child with heart failure, reduces the
metabolic
rate,
decreasing
myocardial and body oxygen
demand.
● Most children with heart failure
feel more comfortable in a
semi-Fowler’s position than in a
supine position.
● This chest-elevated position lowers
the abdominal contents, enlarging
the thoracic cavity and allowing for
easier, more comfortable lung
expansion.
●
■
■
■
Babies are most comfortable in an
infant seat, which supports them in
a semi-Fowler’s position.
● Sedation with morphine may be
necessary to encourage bedrest in
some children. Most children with
heart
failure,
however,
automatically limit their activity, so
the need for sedation must be
considered on an individual basis
Provide oxygen as necessary
● If a child has dyspnea, hypoxemia,
or cyanosis, supplemental oxygen
by way of hood, mask, or nasal
prongs is usually necessary.
● Assess the nostrils of the child
receiving oxygen with nasal prongs
every 4 hours to prevent pressure
and subsequent irritation and
breakdown of the interior nostrils
(this is a major problem in
newborns).
● For a child with heart failure, it is a
strain to be submitted to strange,
frightening equipment. Orient a
child to oxygen equipment before it
is brought to the bedside. Children
generally experience such relief
from dyspnea when they are
receiving oxygen that their
apprehension quickly disappears.
Maintaining proper nutrition
● Small frequent feeding (6 to 8 small
meals daily = less tiring).
● Infants need to drink smaller
amounts of liquid frequently to
have adequate daily intake or
receive a higher calorie formula.
Diet should be planned with low salt for
sodium restriction and to be given in small
amounts frequently.
■
B.
Continuous monitoring of child’s condition
Maintenance of intake output and other
records.
■ Emotional support and health education
with necessary instruction should dietary
and activity restriction, drug intake,
prevention of complication, daily hygiene
care and measures of prevention of
infection.
Persistent Pulmonary Hypertension
○ Results when the pulmonary vascular resistance
present at birth because of unopened alveoli fails to
normal.
○ In fetal circulation, when there is an increase of
vascular resistance in the lungs since it is filled with
fluid and not functioning in the utero.
○ Four blood flow that cannot enter to the lungs:
■ When the baby is born, this pressure
normally subside or down as the lungs starts
to function, however with this condition,
the hypopulmonary (?) resistance still
persists does the name of this condition.
● Occurs most often in full-term
infants who have experienced
perinatal asphyxia from conditions
such as post term birth where
there is a decrease of oxygenation
while the baby is still in the uterus.
● PPH occurs because of hypoxia and
acidosis from respir
○ Signs and Symptoms: Infant develops tachypnea and
pulse oximetry shows low PO2 from inability of blood
to perfuse the lungs because of the pulmonary artery
constriction.
○ Management:
■ Supportive therapy:
● Oxygen administration
● Assistive ventilation
● IV Glucose: Provides calories
● Antibiotics: Combats infection
● Medication to reduce pulmonary
resistance such as low dose of
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
C.
dopamine to elevate systemic
blood pressure
● Sildenafil citrate: Vasodilation and
reduced resistance
● Sodium
bicarbonate:
Relieve
acidosis
and
help
reverse
pulmonary vasoconstriction
● Inhaled nitric oxide: Promote
pulmonary vasodilation
● ECMO: For infants who does not
respond
Rheumatic Fever and Endocarditis
Rheumatic Fever
● It is an inflammatory disease that can develop as a
complication of inadequately treated streptococcus
infection. The disease often follows an attack of
pharyngitis, tonsillitis, scarlet fever, impetigo because
the organism common to this infection is a group A
beta hemolytic streptococcus.
● It is a diffuse inflammatory disease of connective
tissue primarily involving heart, blood vessels, joints,
subcutaneous tissue, and CNS.
● The heart damage and joint lesions of rheumatic
fever are not infectious in the sense that these
tissues are not invaded and directly damaged by the
destructive organism, rather they present a
sensitivity phenomenon or a reaction occurring in
response to hemolytic streptococci.
● Common in children 6 to 15 years of age with a peak
incidence at 8 years. It is most seen in a poor
crowded urban area because children do not develop
immunity to streptococcal infections referring to
rheumatic fever.
● Children appear well again in 1 to 3 weeks however if
the child is not treated with an appropriate antibiotic
for the original infection the rheumatic fever’s
symptoms can begin.
● As nurses, we have to advise the parents to seek
healthcare and advise them to adhere to medicine
administration especially with antibiotics.
● Since rheumatic fever is an autoimmune disease
where it occurs after streptococcal infection basically
●
●
●
it occurs in a late reaction of its response to
infection.
Researchers believe that this is a cross reactivity
caused by antibodies binding to sites such as heart,
brain, and especially the joints.
The name takes after “Rheumatism”
Signs and Symptoms:
○ Fever
○ Sydenham’s Chorea
■ In 20-30% of cases, damage can
happen to the basal ganglia of the
brain, causing spastic movements
of the head, face, and limbs.
■ This is known as chorea or St. Vitus’
dance.
■ Most cases resolve in 2 to 6
months, but extreme cases usually
need physical therapy.
○ Chest pain
○ Erythema marginatum: A subcutaneous rash
that does not itch and forms rings that
spread out overtime.
○ Carditis: In 50% of cases, the infection can
spread to the heart and form bacterial
vegetations. These usually target the valves
and can cause life-long heart issues.
○ Bacterial vegetations on tricuspid valve
○ Wrist inflammation
○ Rheumatism. Inflammation occurs in the
joints making it painful to move. The joints
of the legs are usually affected first with the
inflammation migrating to upper joints.
●
Management:
○ Encourage bedrest and decrease oxygen
demands by allowing the patient to rest.
○ Monitor vital signs during the acute phase.
In obtaining apical pulse for a full minute is
preferred, it may be ordered if the child is
asleep as well as the child is awake to
measure the effect of activity on the pulse
rate)
○ Penicillin therapy: Benzathine penicillin is
used to eliminate group A beta-hemolytic
streptococci.
○ Oral Ibuprofen: Reduce inflammation and
joint pain
○ Corticosteroid: Reduce inflammation on
children who are not responding to
ibuprofen therapy
○ Phenobarbital and Diazepam: Reducing the
purpose less movement of the chorea
○ Digoxin and Diuretics: Reduce heart failure
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
Endocarditis
● Inflammation and infection of the endocardium or
valves of the heart. It may occur to children without
heart disease but more commonly occur as a
complication of a congenital heart disease such as
ventricular septal effect.
● It is caused by streptococci of the viridans type. The
streptococcal infection tends to invade the body
during oral surgery such as dental extractions, it also
can enter from a urinary tract infection or a skin
infection such as impetigo.
● As the disease progresses, vegetation composed of
bacteria, fibrin and blood appears on the
endocardium of the valves and heart chambers. This
tends to occur more commonly on the left side of the
heart although if a heart defect is present the
erosions begin at the site of the defect. Over a period
of time, the invading process destroys the
endocardial lining of the heart so underline muscle
and also with valve.
● Management:
○ Should have a prophylactic antibiotic
administration before ear, nose, throat,
tonsil, or mouth surgery to prevent
infectious endocarditis.
○ If it does occur, these preventive measures
therapy is directed toward the underlying
infection and also include supportive
measures to reduce heart failure.
○ Maintain patient on bed rest if acute heart
failure is noted. Again, it is to decrease
oxygen demand
○ Antibiotics
■ Penicillin:
Nafcillin
(Unipen)
prescribed and given IV through
essential venous access devices.
○ Long term follow-up care to be certain that
the invading organism is eliminated and
disease process has stopped.
○ Prognosis is good and less embolus from the
vegetation
on
the
valve
causes
complications such as renal occlusion or
cerebrovascular accident or stroke.
●
●
D. Kawasaki Disease
● Also known as mucocutaneous lymph node
syndrome
● It is an acute systemic vasculitis, or the inflammation
of the blood vessels, of unknown origin which occurs
usually in children less than 5 years of age.
● It is a febrile, multisystem disorder that occurs
almost exclusively in children before the age of
puberty. It has replaced rheumatic fever as the most
likely cause of acquired heart disease in children. The
peak incidence is in boys under 4 years of age.
● Vasculitis (inflammation of blood vessels) is the
principal (and life-threatening) finding because it can
lead to formation of aneurysm and myocardial
infarction.
● The cause of Kawasaki disease is unknown, but it
apparently develops in genetically predisposed
individuals after exposure to an as-yet-unidentified
infectious agent. After the infection (perhaps an
upper respiratory infection), altered immune
function occurs. An increase in antibody production
creates circulating immune (antibody–antigen)
complexes that bind to the vascular endothelium and
cause inflammation.
The inflammation of blood vessels leads to
aneurysms, platelet accumulation, and the formation
of thrombi or obstruction in the heart and blood
vessels.
Signs and Symptoms:
○ Acute Phase (Stage I)
■ High fever (102° to 104° F [39.0° to
40.0° C]) that does not respond to
antipyretics.
■ Child acts lethargic or irritable and
may have reddened and swollen
hands and feet.
■ Conjunctivitis: Soon the bulbar
mucous membranes of the eyes
become inflamed and the child
develops a “strawberry” tongue
and red, cracked lips.
■ A variety of rashes occur, often
confined to the diaper area.
■ Cervical lymph nodes become
enlarged. As internal lymph nodes
swell, children may develop
abdominal pain, anorexia, and
diarrhea.
■ Joints may swell and redden,
simulating an arthritic process.
○ Subacute Phase (10 days after the onset)
■ The skin desquamates, particularly
on the palms and soles.
■ The platelet count rises; this
increases the possibility of clotting,
which could result in necrosis of
distant body cells, particularly the
fingertips, if they no longer receive
adequate blood.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■
●
●
Aneurysms may form in coronary
arteries,
compromising
heart
activity.
■ Sudden death from accumulating
thrombi or rupture of an aneurysm
may occur, making this the most
dangerous phase.
Criteria for Diagnosis of Kawasaki Disease:
○ Fever of 5 or more days’ duration
○ Bilateral congestion of ocular conjunctivae
○ Changes of the mucous membrane of the
upper respiratory tract, such as reddened
pharynx; red, dry, fissured lips; or
protuberance
of
tongue
papillae
(“strawberry” tongue)
○ Changes of the peripheral extremities, such
as peripheral edema, peripheral erythema,
desquamation of palms and soles
○ Rash, primarily truncal and polymorphous
○ Cervical lymph node swelling
○ To be diagnosed with Kawasaki disease, a
child must manifest fever and four of the
typical symptoms shown above, plus
echocardiographic confirmation of artery
disease.
○ Children are followed by sequential
echocardiograms
to
monitor
for
development of aneurysms.
Management:
○ Acetylsalicylic acid (aspirin) or ibuprofen
decreases inflammation and blocks platelet
aggregation.
○ Abciximab: A platelet receptor inhibitor
specific for Kawasaki disease.
○ IV immune globulin (IVIG): To reduce the
immune response
■ Caution: patients should not
receive routine immunizations
while
taking
IVIG or the
immunization will be ineffective.
○ Steroids, which may increase aneurysm
formation, are contraindicated.
○
Coronary artery bypass surgery: If the child
is left with coronary artery disease from
stenosis of the coronary arteries.
different tests that may be used to diagnose
arrhythmias, including:
● Electrocardiogram (EKG or ECG)
● Stress test
● Exercise EKG
● Holter or event monitor
● Continuous recording
Management:
■ Atropine: To counteract the vagal
stimulation
■ Digoxin: Decreases and strengthens heart
rate
■ Pacemaker: To maintain a steady heart
rhythm
Dysrhythmias
● Can be used interchangeably with arrhythmias.
● Are disturbances in the normal cardiac rhythm of the heart
○
which occurs as a result of alterations within the conduction
of electrical impulses.
● The heart beats in response to electrical signals that are
generated by the sino-atrial node. You can think of the Sino
atrial node as the heart’s pacemaker, found in the upper right
part of the heart. These electrical impulses pass through the
right chamber of the heart or the atria then to the
atrioventricular node. The specialized fibers allow the
electrical impulse to travel from the AV node to the lower
chambers of the heart or the ventricles. When any part of this
electrical signaling sequence is disrupted through the changes
in the heart tissue.
● Children have fewer cardiac dysrhythmias than adults.
● Sinus arrhythmia is commonly found in children.
● Ventricular tachycardia and atrial fibrillation are syndromes
that occur because of multiple or abnormal initiation of the
heartbeat and can occur following surgery for congenital
heart disease.
● Ventricular Tachycardia is a fast abnormal heart rate and it
starts in the ventricles.
● Atrial Fibrillation is an irregular and often rapid heart rate
that occurs when the two upper chambers of the heart
experience chaotic electrical signals = fast irregular heart
rhythm.
● Signs and Symptoms:
○ Some children with an arrhythmia have no
symptoms. When they do, symptoms can include:
■ Fatigue
■ Rapid Breathing
■ Palpitations
■ Dizziness
■ Fainting
○ Diagnosis:
■ In addition to a complete medical history
and physical examination, there are several
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
OVERVIEW AND ASSESSMENT OF DIGESTIVE FUNCTION AND
PEDIATRIC VARIATIONS AND NURSING CARE OF THE CHILD WITH A
GASTROINTESTINAL DISORDER
Pediatric Variations of the GI Tract
Gastrointestinal System
● At birth, the resistance of the newborn’s intestinal tract to
bacterial and viral infection is incompletely developed. That is why
they are very prone to different infections in the GI system.
● As children grow, they have higher nutritional, metabolic, and
energy needs.
● Children with nausea and vomiting dehydrate more quickly than
do adults with those symptoms.
● The infant’s stomach is small and empties rapidly.
● Newborns produce little saliva until 3 months of age.
● Swallowing is a reflex for the first 3 months.
● Hepatic efficiency in the newborn is immature, sometimes causing
jaundice.
● The infant’s fat absorption is poor because of a decreased pool of
bile acid.
Diagnostic and Therapeutic Techniques
Several typical procedures are used in the diagnosis and GI disorders.
Common diagnostic procedures include fiberoptic endoscopy,
colonoscopy, barium enema, and fluid, Electrolyte, and Acid-Base
Imbalance. Children need good preparations for these procedures
because they are potentially frightening. Therapy may include
alternative methods of feeding such as enteral, nasogastric tube
feeding, or nutritional sources such as TPN (Total Parenteral Nutrition)
and intravenous therapy through… A colostomy may be created to
further rest the GI tract.
A. Fiberoptic endoscopy
● A test used to see if a child has dysphagia (difficulty
swallowing). When a person has dysphagia, it can lead to
serious problems such as trouble with feeding and breathing.
Sometimes, it can lead to respiratory infections such as
bronchiolitis or pneumonia.
● During the test, a thin, flexible tool called an endoscope is put
into the nose and down the back of the throat. Parts of the
throat are viewed as the child swallows.
●
B.
During the test, the child will be seated and awake. ENT
specialists will put the endoscope through the nose, and
down to the throat or pharynx.
● Child may feel mild discomfort with the scope in place. The
endoscope allows the doctor to see parts of the voice box or
larynx, pharynx, and trachea on a video screen.
● The doctor will also look at the video screen to see how the
child swallows. They can see if the child is aspirating and the
doctor can also see how well the saliva is swallowed.
● They will also be able to see if there are problems in the
shape or the anatomic changes in the child’s throat.
● The child may swallow small amounts of food or liquid during
the test. These may be dyed, so they can be seen on the
screen.
● At the end of the test, the endoscope will be removed from
the throat and nose.
Colonoscopy
● A procedure that allows visualization of the lower part of the
child’s digestive system. This includes the rectum and large
intestine (the colon).
● During a colonoscopy, a thin flexible tube with a camera on
the end is inserted through the anus and up into the rectum
and large intestine. The doctor will look for changes in how
the bowel (the inside of the intestine) looks, such as bleeding,
inflammation, or polyps. They will also collect small samples
of tissue (called biopsies) for testing.
●
Special consideration before the procedure, the child must
follow strict eating and drinking rules before the procedure.
Child’s stomach must be empty before a general anesthesia.
● Once the child is in the hospital for colonoscopy, he or she will
take a second dose of bowel prep medication. At this point
the child must walk around and move as much as possible. He
or she must also drink plenty of fluid until 3 hours before the
colonoscopy. The child’s bowel is clear once they pass several
watery stools that are clear or yellow.
● If the bowel prep medication has not cleared the stools, the
child may need to receive an enema.
C. Barium Enema
● A type of fluoroscopy procedure that allows us to see images
of the child’s colon.
● It is done by using an x-ray machine and a contrasting agent
that is administered through the rectum.
● In most cases, barium enema is performed to help us
diagnose why a child is having difficulty with bowel
movements.
● Fluoroscopy procedure is an imaging technique that uses x-ray
to create real time or moving images of the body. It helps us
to see how an organ or bowel system functions.
● In most of these types of exams, the child will lie on the table
while the x-ray machine called a fluoro tower is brought
overhead. The fluoro tower has a curtain in it, it is like being
in a tent or a small car wash, so the doctor and the child will
be able to see the images on the television or the monitor in
the room.
D. Fluid, Electrolyte, and Acid-Base Imbalance
The GI system plays a major role in maintaining fluid, electrolyte,
and acid-base imbalance. It is the main route by which substances
are taken into the body and can be a major source of loss in
vomiting or diarrhea.
Please keep in mind that retaining fluid is a greater importance in
the body chemistry of infants and children than adults. This is
because fluid constitutes a greater fraction of the infants total
weight.
● Fluid Balance
● Fluid Imbalance
● Isotonic Dehydration
● Hypertonic Dehydration
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
● Hypotonic Dehydration
● Overhydration
● Acid-Base Imbalance
● Metabolic Acidosis
● Metabolic Alkalosis
Acid- Base Imbalance
●
●
●
●
●
These imbalances (metabolic acidosis and metabolic alkalosis)
occur with severe diarrhea and vomiting.
Recall in arterial blood gas interpretation wherein we can get
metabolic acidosis when there is a decrease in pH below 35 and a
decrease of bicarbonate below 22. Remember, when there is too
much acid in the body, the bicarbonate as a metabolic buffer
system will drop. Causes of this condition develop when there is
too much acid produced in the body. It happens in diabetic
ketoacidosis wherein substances called ketone bodies which are
very acidic builds up in the body during uncontrolled diabetes.
Metabolic acidosis can also occur when the kidneys cannot
remove enough acid from the body such as renal failure. Inability
of the kidney to excrete those waste (specifically the acid).
Another cause, it can happen also when there is loss of too much
bicarbonate in the body (it happens in severe diarrhea). In
diarrhea, those fluids have a lot of bicarbonate in them and losing
that in diarrhea kay like those alkaline fluids kay ma loss na siya sa
body leaving the body in acidotic condition.
For the signs and symptoms, let us go back to the laboratory
values. Whenever you have a metabolic acidosis, the respiratory
system tries to compensate. When there is a lot of carbon dioxide
in the lungs which is an acid, the lungs will breathe a lot more
rapidly or hyperventilate to expel this CO2. So lungs can, hopefully,
excrete that blood pH back to normal and increase the
bicarbonate level. Therefore, there will be Kussmaul breathing or
respiration, this is deep rapid breaths (compensatory
hyperventilation). Hyperkalemia can also happen when the body
detects acidosis, the potassium moves from cells intracellular to
extracellular fluid in the blood plasma in exchange for those
hydrogen ions. There will be muscle twitching, decreased muscle
tone, decreased reflexes, warm flushed skin, headache, decreased
blood pressure, nausea, and vomiting.
Nursing Responsibilities for Metabolic Acidosis:
○ Watch out for signs of respiratory distress because of
increased respiration, probably the patient will need assistive
or mechanical ventilation.
○ Watch out for laboratory values, especially the potassium,
BUN, creatinine which are signs for kidney failure.
○ Strict input and output (how much a patient drinks or pilay
napagawas nga fluids, we have to take note of that).
○ Some patients will undergo dialysis especially those nga nay
DKA, wherein and excess nga acids kay ipagawas na siya
through dialysis.
○ Metabolic Alkalosis occurs when the blood becomes overly
alkaline wherein there is an increase in bicarbonate in the
blood. This condition occurs when the body has experienced
excessive loss of hydrogen ions of acids, which in turn
increases all the bicarbonate in the body in cases with the use
of diuretics wherein a patient starts urinating a lot and they
are wasting all those hydrogen ions like chloride. Another
cause of loss of fluids, in conditions like vomiting and
nasogastric suctioning, the fluids gikan ani are very rich in
hydrogen ions, when there is a decrease in hydrogen ions, the
bicarbonate will increase. Another cause, it occurs when the
body has too many alkaline producing bicarbonate ions, in
cases like sodium bicarbonate administration. Physicians
order this to correct acidosis, however if super kadaghan ang
mahatag sa body then it will cause the body to be alkalotic.
○ The body will compensate, starting with the lungs, the body
will hypoventilate, because the lungs think that keeping these
carbon dioxide which is an acid will help balance the alkalotic
state. So, it slows down the ventilation or what we call
compensatory hypoventilation (decrease of respiratory rate
of 12). Going back to the laboratory, the patient will become
alkalotic, pH is greater than 7.45 and bicarbonate will be
greater than 26. There will also be signs and symptoms of
hypokalemia (reverse nga action sa acidosis; there will be
shifting of ions intracellularly). Symptoms like tremors, muscle
cramps, tingling of fingers and toes, there will be cardiac
arrhythmias or dysrhythmias, the patient will become
lethargic or restless, confusion, decrease level of
consciousness, irritability and nausea and vomiting can occur.
Common GI Symptoms of Illness in Children
A. Vomiting
● Vomiting results from sudden contractions of diaphragm and
muscles of the stomach.
● Many children with vomiting are suffering from a mild
gastroenteritis (infection) caused by viral or bacterial
organisms.
● Persistent vomiting requires investigation because it results in
dehydration and electrolyte imbalance specifically metabolic
alkalosis.
○ Continuous loss of hydrochloric acid and sodium chloride
from the stomach can cause alkalosis. These are hydrogen
ions that are very abundant in the GI tract so with
vomiting, il ana ipagawas, increase loss of those, there will
be an increase in bicarbonate causing alkalotic state of the
body.
○ Can result in death if left untreated.
● Multiple causes of vomiting
○ Improper feeding technique
○ Systemic illness such as increased intracranial pressure or
infection (swell of the tissues in the brain)
○ Child at risk for aspiration pneumonia
● In describing the symptoms of vomiting, be certain to
differentiate the various terms that are used. It is important
that vomiting is described correctly because different
conditions are marked by different forms of vomiting and
correct description of the child’s action can aid greatly in the
child’s diagnosis.
● Nursing Management:
○ Withhold feeding (NPO may it be fluid or food). Take note
that other parents feed the baby dayun after vomiting
because they do not want nga ma dehydrate. But this only
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
prolongs the vomiting and intensifies electrolyte
imbalance, mag alkalosis na nuon si baby. It can also tire
the baby.
○ Place the infant on their side after feeding to prevent
aspiration, if vomiting occurs (let them also burp after
feeding).
○ When an older child vomits, turn head to one side and
offer an emesis basin.
○ IV fluids may be ordered to replenish lost fluids.
○ Slowly introduce foods to allow the stomach to rest.
● Documentation:
○ Time, amount, color, consistency, force (projectile or not),
frequency, and whether vomiting was preceded by nausea
and feedings (especially the infants, kay pwede na sila
musuka kay busog pa ang baby).
○ Administration of antiemetic agents should also be
documented, including time given and if when vomiting
subsided (withhold feeding for 2 hours; if 2 to 3 or more
hours na siya since last nisuka then we can resume
feeding).
B. Diarrhea
● Diarrhea in infants is a sudden increase in stools from the
infant’s normal pattern, with a fluid consistency and a color
that is green or contains mucus or blood.
● Normal frequency of stool is 1 to 3 times a day.
● Diarrheal stool can be unlimited frequency.
● Normal color of stool is yellowish.
● Indicative of other conditions: green, mucus, blood.
○ Acute sudden diarrhea is most often caused by
inflammation, infection, or a response to medications,
food or poisoning.
○ Chronic diarrhea lasts more than 2 weeks and may
indicate malabsorption problem, long-term inflammatory
diseases, or allergic responses.
○ Infectious diarrhea caused by viral, bacterial, or parasitic
infection usually involves gastroenteritis.
1. Mild Diarrhea
● Signs and Symptoms:
○ Fever of 38.4 to 39℃ (101 to 102℉)
○ Anorexia
○ Irritability
○
●
●
●
Episodes: 2 to 10 loose, watery bowel movements
per day
○ Dry mucous membrane
○ Warm skin, no change in skin turgor
○ Rapid pulse
○ Urine output normal
Management:
○ Can be managed at home
○ Resting the GI tract
○ After an hour, start giving an oral rehydration
solution or Pedialyte.
○ Antipyretic
○ Zinc supplement
○ Probiotics
Assessment:
○ If diarrhea is mild, fever of 101 to 102℉ (38.4 to
39.0℃) may be present. Children are usually
anorectic and irritable and appear unwell.
○ The mucous membrane of the mouth appears dry
and the skin feels warm although skin turgor will noy
yet be decreased. The pulse will be rapid and out of
proportion to the low-grade fever. Urine output is
usually normal.
Therapeutic Management:
○ Diarrhea is not yet serious, and children can be cared
for at home. As with vomiting, treatment for diarrhea
must involve resting of the GI tract, but this is
necessary for only a short time. At the end of
approximately 1 hour, parents can begin to offer an
oral rehydration solution such as Pedialyte in small
amounts on a regimen similar to that for vomiting.
○ For breastfed infants, breastfeeding should continue.
Again, it may be difficult for parents to restrict fluid
for a short time if they think they should overfeed
children to make up for the fluid loss. Children also
need measures to reduce the elevated temperature.
In developing countries, where children may be zinc
deficient, zinc may be administered. Probiotics
(dietary
supplements
containing
potentially
beneficial bacteria or yeasts) to change bacterial
flora of the intestine may be administered. For mild
2.
diarrhea dili na mudritso og give ang doctor og
antibiotic, because and cause could be viral.
Severe Diarrhea
● Signs and Symptoms:
○ Fever of 39.5 to 40℃ (103 to 104℉)
○ Pulse and respirations are weak and rapid
○ Cool, pale skin
○ Lethargic and listless
○ Depressed fontanelles
○ Sunken eyes
○ Poor skin turgor
○ BM of every few minutes
○ Stool in liquid green, may have mucus or blood
○ Concentrated and scanty urine output
○ Weight loss of 5-15% of body weight
● Management:
○ IV rehydration therapy of normal saline
○ 125 ml/kg of body weight to replace fluid
○ Rapid administration for 3-6 hours
○ Resting the GI tract
○ Identifying causative agents through stool culture
○ ORS
○ Antipyretic
● Assessment:
○ Severe diarrhea may result from progressive mild
diarrhea, or it may begin in severe form. Infants with
severe diarrhea are obviously ill. Rectal temperature
is often as high as 103 to 104℉ (39.5 to 40℃). Both
pulse and respirations are weak and rapid. The skin is
pale and cool. Infants may appear apprehensive,
listless, and lethargic. They have obvious signs of
dehydration such as depressed fontanelle, sunken
eyes, and poor skin turgor. The episodes of diarrhea
usually consist of bowel movement every few
minutes. The stool is liquid green, perhaps mixed
with mucus and blood, and it may be passed with
explosive force. Urine output will be scanty and
concentrated.
○ Mild dehydration occurs with a loss of 2.5 to 5% of
body weight.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
○ In contrast, severe diarrhea quickly causes a 5 to 15%
loss. Any infant who has lost 10% or more of body
weight requires immediate treatment.
● Therapeutic Management:
○ Treatment focuses on regulating electrolyte and fluid
balance by oral or IV rehydration therapy, initiating
rest for the GI tract, and discovering the organism
responsible for diarrhea.
○ All children with severe diarrhea or diarrhea that
persists longer than 24 hours should have a stool
culture taken so definite antibiotic therapy can b e
prescribed. Stool cultures may be taken from the
rectum or stool culture in a diaper or a bedpan.
○ If a child can drink, the most effective way to replace
fluid is by offering oral rehydration therapy or
Pedialyte (ORS – Oral Rehydration Solution). For a
child who will not drink, an IV solution such as
normal saline or 5% glucose in normal saline is
begun. The solution will provide replacement of
fluid, sodium and calories. Although infants usually
have potassium depletion, potassium cannot be
given until established that they are not in renal
failure. Giving IV potassium when the body has no
outlet for excessive potassium can lead to excessively
high potassium levels and heart block. Be sure that
the infant has voided. This is proof that kidneys are
functioning.
○ Fluid must be given to replace the deficit that has
occurred, for maintenance therapy, and to replace
the continuing loss until diarrhea improves.
○ If infants have lost less than 5% of total body weight,
their fluid deficit is approximately 50 mL/kg of body
weight.
○ If infants have lost 10% of body weight, they need
approximately 100 mL/kg of body weight to replace
their fluid deficit.
○ If the weight loss suggests a 12 to 15% loss of body
fluids, they require 125 mL/kg of body weight to
replace the fluid lost. This fluid will be given rapidly
in the first 3 to 6 hours, then it will be slowed to a
maintenance rate.
○ Antipyretic can also be given to px with high fever.
C.
Bacterial Infectious Diseases that Cause Diarrhea and Vomiting in
Children
1. Salmonella
● Causative Agent: Salmonella bacteria
● Period of Communicability: As long as organisms are being
excreted (may be as long as 3 months)
● Mode of Transmission: ingestion of contaminated food,
especially chicken and raw eggs
● Confirmatory Test: Stool culture
● Signs and Symptoms:
○ Diarrhea
○ Abdominal pain
○ Vomiting
○ High fever
○ Headache
● Treatment:
○ Fluid and electrolyte replacement
○ Ampicillin for systemic infection like high grade fever
or a 3rd generation of cephalosporin to be given
● Incubation Period: 6 to 72 hours for intraluminal type; 7 to
14 days for extraluminal type
● Salmonella is the most common type of food poisoning in
the United States and a major cause of diarrhea in
children. The diagnosis of the infection can be made from
stool culture. Children develop diarrhea, abdominal pain,
vomiting, high temperature, and headache. They are
listless and drowsy. The diarrhea is severe and may contain
blood and mucus. Salmonella infection may remain in the
bowel as intraluminal disease. When it does, it is treated
like severe diarrhea, with fluid and electrolyte
replacement. Antibiotics are rarely prescribed as they may
actually prolong the length of the infection. If the infection
becomes systemic (extraluminal disease), it is treated with
the addition of antibiotics such as ampicillin or a third
generation cephalosporin.
● Complications such as meningitis, bronchitis, and
osteomyelitis may occur. Because the source of Salmonella
generally iz infected food (contaminated chicken and eggs
are common sources), caution parents to wash utensils
used to prepare raw chicken such as cutting boards well
and to cook eggs thoroughly.
2. Shigellosis (Dysentery)
●
●
●
3.
Causative Agent: Organism of the genus Shigella
Period of Communicability: 1 to 4 weeks
Mode of Transmission: Contaminated food, water, or milk
products
● Confirmatory Test: Stool culture
● Signs and Symptoms: Severe diarrhea with blood and
mucus
● Incubation Period: 1 to 7 days
● Treatment:
○ Intense fluid and electrolyte replacement
○ Cephalosporin
○ Shigella organisms, like the Salmonella group, cause
extremely severe diarrhea that contains blood and
mucus. As the organism becomes more resistant,
ampicillin or trimethoprim-sulfamethoxazole, typical
drugs used for therapy in the past, are being replaced
by cephalosporins. The child needs intense fluid and
electrolyte replacement. Shigella infection can be
prevented by safe food handling and cautioning
families to drink only from the safe water sources.
Staphylococcal Food Poisoning
● Causative Agent: Staphylococcus aureus
● Period of Communicability: Carriers may contaminate food
as long as they harbour the organism.
● Mode of Transmission: Ingestion of contaminate food such
as poultry, creamed foods (e.g., potato salad), and
inadequate cooking
● Confirmatory Test: Stool culture
● Signs and Symptoms:
○ Severe vomiting and diarrhea
○ Abdominal cramping
○ Excessive salivation and nausea within 2-6 hours of
eating
● Treatment:
○ Intense fluid and electrolyte replacement
○ Cefotaxime
○ The child needs intensive supportive therapy with
fluid and electrolyte replacement, and perhaps
administration of Cefotaxime. Food poisoning from
the source could be prevented by proper
refrigeration of the foods.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
Disorders of the Mouth and Esophagus
A. Ankyloglossia (Tongue-Tie)
●
●
●
●
●
●
It is a condition present at birth in which it restricts the
tongue’s range of motion.
With tongue-tie, an unusually short, thick or tight band of
tissue (lingual frenulum) tethers or is tied to the bottom of the
tongue's tip to the floor of the mouth, so it may interfere with
breast-feeding.
Someone who has tongue-tie might have difficulty sticking out
his or her tongue.
Tongue-tie can also affect the way a child eats, speaks and
swallows.
Signs and Symptoms:
○ Difficulty lifting the tongue to the upper teeth or moving
the tongue from side to side
○ Trouble sticking out the tongue past the lower front teeth
○ A tongue that appears notched or heart shaped when
stuck out
Management:
○ Tongue-tie’s management is controversial because some
doctors and lactation consultants recommend correcting it
right away even before the newborn is discharged from
the hospital. Other is to wait because the lingual frenulum
may loosen overtime in solving the condition
○ Frenotomy
■ A simple surgical procedure that can be done without
anesthesia
■ Uses sterile scissors to snip the frenulum free
■ After procedure the baby can breastfeed immediately
■ Possible Complications: Bleeding, Infection, damage
the tongue or salivary glands
○
B.
Frenuloplasty
■ More expensive and is done for if additional repair is
needed or lingual frenulum is too thick.
■ Done under general anesthesia with surgical tools
■ Surgical alteration of a frenulum when its presence
restricts range of motion between interconnected
tissues.
■ Possible Complications: Bleeding; Infection; Damage
to the tongue or salivary glands; Scarring is possible
due to the more intensive nature of the procedure as
a reaction to the anesthesia.
■ After the procedure, tongue exercises are
recommended to enhance tongue movement and
reduce potential for tongue scarring.
Thyroglossal Cyst
● It is a congenital disorder where the thyroglossal duct, which
is a tiny canal connecting the thyroid gland with the tongue
during fetal development, grows in size and fills up with
mucus, which forms a cyst. It is a pocket in the front part of
the neck that is filled with fluid.
● It is formed from leftover tissue from the development of the
thyroid gland with an embryo forming. The thyroid gland is
located in front of the neck.
● although the cyst is present at birth, it is usually not found
until a child is at least age 2. Often, a healthcare provider finds
a thyroglossal cyst when a child gets an upper respiratory
infection. What causes this condition, it forms during the early
stages of the development of an embryo. It begins at the base
of the tongue and moves down the neck through a channel or
tube called the thyroglossal duct. This duct normally goes
away once the thyroid reaches its final position in the neck.
Sometimes part of the duct remains, this leaves a pocket
called a cyst.
●
●
C.
Signs and Symptoms:
○ A small, soft, round lump in the center front of the neck
○ Tenderness, redness, and swelling of the lump, if infected
○ Difficulty swallowing or breathing
Management:
○ Antibiotic – If there is an inflammation or infection
○ Incision and drainage – Cutting into or draining of the cyst
especially if the antibiotic medicine does not get rid of
the infection.
○ Cutting out the cyst and some nearby tissue (surgical
excision)
Cleft Lip and Palate
● Openings or splits in the upper lip, the roof of the mouth
(palate) or both.
● Cleft lip and cleft palate result when facial structures that are
developing in an unborn baby do not close completely. These
are among the most common birth defects. They most
commonly occur as isolated birth defects but also associated
with many inherited genetic conditions or syndromes.
● Causes:
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
● When tissue in the baby’s face and mouth do not fuse
properly. Normally, the tissues that make up the lip and palate
fused together in the 2nd and 3rd months of pregnancy. In
baby’s with this condition, fusion never occurs, only part way
leaving an opening also known as cleft.
● Researchers believe that most cases of this condition is
caused by an interaction of genetic and environmental
factors. In many babies, a definite cause is not discovered yet.
●
●
●
●
●
Most cases of this condition are noticed right away at birth
and do not require a special test for diagnosis. Increasingly,
cleft lip and cleft palate are seen in the ultrasound before the
baby is born specifically congenital anomalies.
Usually a split in the lip or palate is immediately identifiable.
Signs and Symptoms:
○ A split in the lip and roof of the mouth (palate) that
affects one or both sides of the face.
○ A split in the lip that appears as only a small notch in the
lip or extends from the lip through the upper gum and
palates into the bottom of the nose.
○ A split in the roof of the mouth that does not affect the
appearance of the face.
Management: This is a permanent repair. The goals of this
treatment are to improve the child’s ability to eat, speak and
hear normally and achieve normal facial appearance.
Treatment:
○ Surgery – To repair the defect; To correct cleft lip and
palate is base on the child’s particular situation
○ Therapies – To improve any related conditions
●
Types of Surgeries:
○ Cleft lip repair – Within the first 3 to 6 months of age. It
closes the separation. The surgeon makes an incision of
both sides of the cleft and creates flaps of tissue and
these flaps are stitched together including the lip
muscles. The repair should create a more normal
appearance, structure and function. Initial nasal repair if
needed is usually done at the same time.
○ Cleft palate repair – By the age of 12 months, or earlier if
possible. Various procedures may be used to close the
separation and rebuild the roof of the mouth. Depending
on the child’s situation, the surgeon makes an incision on
both sides of the cleft and repositions the tissue and
muscles. Then the repair is stitched and closed.
○ Follow-up surgeries – For surgery to reconstruct
appearance, additional surgeries may be needed to
improve appearance of the mouth, lip and nose. Usually
follow-up surgeries are done between age 2 and late teen
years. To improve speech and improve the appearance of
the nose and lip.
●
●
●
happens, liquid gets into your baby’s lungs. This can cause
pneumonia and other problems.
It is caused by a failure of the tissues of the GI tract to separate
properly in prenatal life.
TE fistula often happens with another birth defect called
esophageal atresia which means that the baby’s esophagus
does not develop properly during pregnancy. It forms in two
parts instead of one. One part connects to the throat and the
other part connects to the stomach but the two parts do not
connect to each other since the esophagus is in two parts,
liquid that the baby swallows does not pass as it should
through the esophagus and reach the stomach. This means
that the baby cannot digest milk and other fluids.
Three Common Types of TEF:
1. (A) The upper esophagus ending in a blind pouch and the
lower esophagus ending in the trachea.
2. (B) The upper esophagus and the lower esophagus ending
in a blind pouch (fetal swallowing is prevented, and the
mother will develop polyhydramnios during pregnancy).
3. (C) Both the upper and lower esophagus end in the
trachea. In TEF, the newborn will have excessive mucous
secretions (drooling) and may choke or vomit if fed.
D. Tracheoesophageal Atresia and Fistula
● Fistula – Abnormal connection
● Atresia – Abnormal development
● This condition happens because of a connection between the
esophagus and the trachea. Esophagus is a tube that connects
the throat to the stomach. Trachea is the tube that connects
the throat to the windpipe and the lungs.
● Normally, esophagus and trachea are 2 tubes that are not
connected. This problem is also called TE fistula or TEF. It can
happen in one or more places.
● TE fistula is a birth defect. This means it is a problem that the
baby is born with. It happens when the baby is still forming
during pregnancy.
● Signs and Symptoms:
● When a baby with TE fistula swallows, liquid can pass through
○ Frothy, white bubbles in the mouth
the connection between the esophagus and trachea. When this
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
○ Coughing or choking when feeding
○ Vomiting
○ Blue color of the skin, especially when the baby is feeding
○ Trouble breathing
○ Very round, full stomach
● Nursing Management:
○ Prevent pneumonia, choking and apnea in the newborn
○ Assessment of the newborn during the first feeding for
signs and symptoms of TEF is essential
○ Feeding, usually, is with clear water or colostrum to
minimize seriousness of aspiration.
○ Surgical repair is essential for survival. This surgery is
almost done soon after birth. Both defects can often be
repaired at the same time. The surgery may take place
when general anesthesia is given and the patient then a
surgeon will make a cut between the ribs. The fistula
between the esophagus and windpipe where the trachea
is closed. The upper and lower portion of the esophagus
are sewn together if possible
Disorders of the Stomach and Duodenum
A. Achalasia
● Rare disorder that makes it difficult for food and liquid to pass
from the esophagus down to the stomach.
● This occurs when nerves in the esophagus become damaged.
As a result, the esophagus becomes para;yzed and dilated over
time and eventually loses the ability to squeeze food down into
the stomach.
● Food then collects in the esophagus, sometimes, fermenting
and washing back up into the mouth which can taste bitter.
Some people mistake this for gastroesophageal reflux disease
or GERD. However in achalasia, the food is coming from the
esophagus whereas in GERD, the materials come from the
stomach.
○
B.
●
●
●
●
No cure for achalasia. Once esophagus is paralyzed, the muscle
cannot work properly again but symptoms can usually be
managed with endoscopy, minimally invasive therapy or
surgery.
The exact cause for this condition is poorly understood.
Researchers suspect it may be caused by a loss of nerve cells in
the esophagus. Rarely, achalasia may be caused by genetic
disorder or infection.
Signs and Symptoms:
○ Dysphagia (inability to swallow) – Which may feel like the
food or drink is stuck in the throat
○ Regurgitating food or saliva – Due to reflux
○ Heartburn
○ Pneumonia (from aspiration of food into the lungs)
○ Weight loss
○ Vomiting
Management:
○ It focuses on relaxing or stretching upon the lower
esophageal sphincter so that food and liquid can move
through easily into the digestive tract.
○ First line of therapy: Doctors can either dilate the sphincter
or alter it.
○ Pneumatic dilation – Inserting a balloon into your
esophagus and inflating it. This stretches out the sphincter
and helps the esophagus function better. However,
sometimes, dilation tears the sphincter. If this happens,
there’s a need for additional surgery to repair it.
Esophagomyotomy – Uses a large or small incision to
access the sphincter and carefully alter it to allow better
flow into the stomach. However, some people have
problems afterward gastroesophageal reflux disease. If you
have GERD, the stomach acid backs up into the esophagus
and can cause heartburn.
○ Nitrates or calcium channel blockers – To relax the
sphincter
Pyloric Stenosis
● Obstruction of the lower end of the stomach caused by the
overgrowth of the circular muscles of the pylorus or spasms of
the sphincter. If hypertrophy or hyperplasia of the muscles
surrounding the sphincter occurs, it is difficult for the stomach
to empty.
● Commonly classified as a congenital anomaly
● Symptoms usually do not appear until the infant is 2 or 3 weeks
old.
● Most common surgical condition of GI tract in infancy.
●
Signs and Symptoms:
○ With this condition, at 4 to 6 weeks of age, infants begin to
vomit almost immediately after each feeding. The
vomiting grows increasingly forceful until its projectile.
Possibly projecting as much as 3 to 4 feet. The vomitus
contains mucus and ingested milk. Vomitus smells sour
because it has reached the stomach and has been in
contact with stomach enzymes. However, there is never
bile in vomiting pyloric stenosis because the feeding has
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
not reached the duodenum to become mixed with the
bile.
○ Projectile vomiting is outstanding symptom from force or
pressure being exerted on the pylorus
■ Vomitus contains mucus and ingested milk.
■ Infant is constantly hungry and will eat again
immediately after vomiting.
○ Dehydration – From vomiting when they are first seen.
S&S includes lack of tears, dry mucous membrane of the
mouth, sunken fontanelles, fever, decreased urine output,
poor skin turgor and weight loss.
○ Olive-shaped mass may be felt in the upper right quadrant
of the abdomen. Definitive diagnosis is made by watching
the infant drink and palpate the right upper quadrant of
the abdomen of pyloric mass prior to drinking. If one is
present, it feels round and firm and approx. the size of
olive. As the infant drinks, observe for gastric peristaltic
waves passing from left to right across the abdomen. The
olive-sized lump becomes more prominent. The infant
vomits with projectile emesis.
●
Management:
○ Surgery: Pyloromyotomy (It is performed before
electrolyte imbalance from the vomiting or hypoglycemia
from the lack of food occurs.
■ Preoperative Nursing Care
● IV fluids to treat or prevent dehydration
● Thickened feedings may be given by a teaspoon
or through a nipple with a large hole.
●
C.
Burped before and during feedings to remove any
gas accumulated in the stomach.
● Place on the right side (preferably Fowler’s
position) after feeding to facilitate stomach
drainage into the intestines. If an infant vomits,
the nurse is instructed to refer to the infant.
■ Postoperative Nursing Care
● Monitor IV fluids, provide feedings as prescribed
by the surgeon, document intake and output,
monitor surgical site. (For surgical correction, the
muscle of the pylorus is split down to the mucosa
allowing for larger lumen. Although the
procedure sounds simple, it is technically difficult
to perform and there is a high risk for infection
afterwards because the abdominal incision is near
the diaper area. Prognosis for infants with PS is
excellent if the condition is discovered before the
electrolyte imbalance occurs.
Hiatal Hernia
● The intermittent protrusion of the stomach up through the
esophageal opening in the diaphragm.
● The volume of the stomach is suddenly restricted, leading to
periodic vomiting. Normally, a portion of the esophagus and all
the stomach are situated on the abdominal cavity. However, in
this condition, part of the stomach moves up into the chest
cavity through the weakened area of the diaphragm.
●
This occurs when weakened muscle tissue allows the stomach
to bulge up to the diaphragm. It’s not always clear when this
happens but a hiatal hernia might be caused by age-related
changes in the diaphragm, injury to the area, being born with
an unusually large hiatus, persistent and intense pressure in
●
●
●
the surrounding muscles such as coughing, vomiting, straining
during a bowel movement, exercising or lifting heavy objects.
Signs and Symptoms:
○ Heartburn – Because of the acid reflux
○ Regurgitation of food or liquids into the mouth
○ Backflow of stomach acid into the esophagus (acid reflux)
○ Difficulty swallowing
○ Chest or abdominal pain
○ Feeling full soon after eating
○ Shortness of breath – It can occur by the compression of
the ling space by the stomach.
○ Vomiting of blood or passing of black stools, which may
indicate gastrointestinal bleeding.
○ Pain usually accompanies the vomiting
Diagnostic Tests:
○ History
○ UTZ
○ Barium swallow
Management:
○ Keeping the baby in an upright position prevents the
condition from recurring.
○ Antacids that neutralize stomach acid – Medications can
be given especially those that reduce acid secretions.
○ H-2-receptor blockers – These are medications that reduce
acid production. Examples include:
■ Cimetidine (Tagamet HB)
■ Famotidine (Pepcid AC)
■ Nizatidine (Acid AR)
○ Proton pump inhibitors – Medications that block acid
production and heal the esophagus, these are stronger
acid blockers then H-2 receptor blockers and allows time
for damaged esophageal tissue to heal. This includes:
■ Lansoprazole (Prevacid)
■ Omeprazole (Prilosec)
○ Laparoscopic surgery – If the condition has not corrected
itself by the time the infant is 6 months old even with
maintaining an upright position most of the day,
laparoscopic surgery may be performed. To reduce the
stomach's ability to protrude into the diaphragm. What
happens in the surgery, it involves pulling the stomach
down into the abdomen and making the opening in the
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
diaphragm smaller or reconstructing the esophageal
sphincter.
○ Some cases of hiatal hernia, surgery is combined with
weight loss surgery such as sleeve gastrectomy but it is not
usually applicable in pediatric clients.
D. Esophageal Varices
● These are abnormal, enlarged veins in the esophagus.
● These develop when normal blood flow to the liver is blocked
by a clot or scar tissue in the liver. To go around the blockages,
blood flows into smaller blood vessels that aren’t designed to
carry large volumes of blood. The vessels can leak blood or
even rupture, causing life-threatening bleeding.
●
●
●
This forms when blood flow to your liver is blocked, most often
by scar tissue in the liver caused by a liver disease. The blood
flow begins to back up increasing pressure within the large vein
or specifically the portal vein that carries blood to the liver. This
increased pressure portal pressure forces the blood to seek
other pathways through smaller veins such as those in the
lowest part of the esophagus. These thin-walled veins balloons
with the added blood and sometimes the veins ruptures and
bleed.
Common causes of varices include severe liver scarring or
cirrhosis in those patients with hepatitis infection. Also, a blood
clot can be a cause, specifically blood clot in the portal vein or
a vein that feeds into the splenic vein or that can cause
esophageal varices. Also, a parasitic infection can be one of the
causes, specifically the schistosomiasis.
Signs and Symptoms:
○ Usually esophageal varices do not cause any symptoms
unless they bleed
○ Vomiting large amounts of blood
○ Black,tarry or bloody stools
○ Lightheadedness
○
○
●
●
Loss of consciousness in severe cases
Signs of liver disease, including:
■ Yellow coloration of your skin and eyes (jaundice)
■ Easy bleeding or bruising
■ Fluid buildup in your abdomen (ascites)
Management:
○ Primary aim in treating esophageal varices is to prevent
bleeding.
○ Bleeding esophageal varices is life threatening so if it
occurs treatments are available to try to prevent bleeding.
Treatment:
○ Lowering the blood pressure in the portal vein, also may
reduce the risk of bleeding the esophageal varices,
medications to reduce pressure in the portal vein is given.
Type of blood pressure called a beta blocker may help
reduce blood pressure in the portal vein. Decreasing the
likelihood of bleeding these medications include
propranolol and nadolol.
○ Endoscopic Band Ligation – Using elastic bands to tie off
bleeding veins. If the esophageal varices appear to have a
high risk of bleeding and also if the patient had episodes
of bleeding before, the doctor might recommend a
procedure called endoscopic band ligation. Using an
endoscope the doctor uses suction to pull the varices into
a chamber at the end of the scope and wraps them with
an elastic band which essentially strangles the veins so
they can’t bleed.
○ Treatment During Bleeding:
■ An immediate treatment is essential to reverse the
bleeding
■ Octreotide (Sandostatin) and vasopressin (Vasostrict)
– Medications to slow blood flow into the portal vein
can be given. This drug is usually continued for up to 5
days after a bleeding episode.
■ Diverting blood away from the portal vein is essential
if medication or endoscopy treatment do not stop
bleeding the doctor might recommend a procedure
called Transjugular Intrahepatic Portosystemic Shunt
(TIPS) – This shunt is an opening created between the
portal vein and the hepatic vein, which carries blood
from the liver to heart. The shunt reduces pressure in
E.
the portal vein and often stops bleeding from
esophageal varices.
■ Balloon Tamponade – Applying pressure at the
esophageal varices, one way to stop bleeding is by
inflating a balloon to put pressure in the varices for up
to 24 hours.
■ Restoring blood volume – The patient might be given
a transfusion to replace the lost blood and a clotting
factor to stop bleeding.
■ Preventing infection – There is an increased risk of
infection with bleeding, patients might be given
antibiotics to prevent infection.
Hepatic Disorders
Hepatitis is an inflammation and an infection of the liver that is
caused by the invasion of hepatitis A, B, C, D, E viruses.
● Hepatitis A
○ Mode of Transmission: Fecal-oral route
○ In children ingestion of fecally contaminated water or
shellfish, it can spread from the contaminated changing
tables.
○ Symptoms:
■ Loss of appetite
■ Diarrhea
■ Fever
■ Nausea (sickness)
■ Malaise (general discomfort)
■ Jaundice (yellow skin)
■ An acute infection, these symptoms will last for
approximately a week and symptoms fade with full
recovery.
● Hepatitis B
○ Unlike with hepatitis B, the symptoms of hepatitis B
especially the acute one are more marked, children can
have generalized aching or right upper quadrant pain
where liver is located and headache, they may also have
low grade fever. Also, there will be jaundice for hepatitis B
with acute onset.
○ Mode of Transmission:
■ Sexual contact
■ Contaminated needles
■ Also spread via infected tear/saliva
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
■ Transfusion of contaminated blood and plasma, or
semen, inoculation by contaminated syringe or needle
through IV drug use
■ May be spread to fetus, if mother has infection in the
third trimester of pregnancy
○ It could possibly lead to cirrhosis of the liver and liver
cancer
○ Vaccines are already available for prevention
○ Although hep. A and hep.B are the viruses that most
frequently cause hepatitis, hep. C, D, and E may also be
involved.
● Hepatitis C
○ A single stranded RNA virus
○ Mode of transmission:
■ Blood-to-blood transmission
■ IV drug use
■ Sexual contact
○ The virus produces mild symptoms of disease but there is
a higher incidence of chronic infection with the virus.
Usually asymptomatic but if there are symptoms it will be
flu-like symptoms.
● Hepatitis D
○ Similar to hepatitis B in mode of transmission
○ Although it apparently requires a coexisting hepatitis B
infection to be activated
○ Disease symptoms are mild but there is a high incidence of
fulminant hepatitis after the first infection
○ Resides inside hepatitis B so there is also greater risk of
liver failure and progression to liver cirrhosis
● Hepatitis E
○ Mode of Transmission: Fecal-oral route
○ Disease symptoms from the E virus are usually mild except
in pregnant women. Pregnant women tend to have severe
symptoms.
○ 2 to 8 weeks duration
○ Signs and Symptoms:
■ Jaundice
■ Nausea
■ Fatigue
○ Chronic Stage: Weak immune system especially in
pregnant women that’s why they are at greater risk for
fulminant liver failure and cirrhosis.
○
○
○
○
No matter which virus is involved, hepatitis is a generalized
body infection with specific intense liver effects.
Type A occurs in children of all ages and accounts for
approximately 30% of… di masabtan
Hepatitis B tends to occur in newborns from placental-fetal
transfer. In adolescence, after intimate contact or the use
of contaminated syringe or drug injections.
Management:
○ Since it is a virus it is self limiting which means it
does not have a definite cure
○ Vaccines – Healthcare providers should receive
prophylaxis against hepatitis with the hepatitis
vaccines.
○ Infants should also receive routine immunization
against hepatitis B.
○ All women should be screened during pregnancy for
hepatitis surface antigen (HbsAg).
○ Infants born to hepatitis positive mothers should
receive both Hepatitis B immune globulin (HBIG)
and active immunization at birth to prevent them
from contracting the disease.
○ Hepatitis A vaccine is available for healthcare
providers and included in routine immunization
programs for infants beginning 1 year of age.
○ Strict hand washing and infection control
precautions are mandatory when caring with
children with hepatitis. Feces must be disposed
carefully because the type A virus can be cultured
from feces. Syringes and needles must be disposed of
with caution because the type B virus can be
transmitted by blood. Contact should receive
immune globulin for hep.A and hep. B immune
globulin as appropriate
○ For hepatitis A – Increased rest and maintains a good
calorie intake. A low fat diet is prescribed once it's
recommended, it is not required and in any event it
is difficult to enforce especially in children. Children
are generally hungrier at breakfast than later in the
day, encouraging them to eat a healthy breakfast.
○ For Hepatitis B – Lamivudine is an antiviral agent,
which may be effective in reducing viral replication
with hep. B infection. Of those with type B, 90% will
recover completely but 10% will develop chronic
hepatitis and become hepatitis carriers. Hep. B is
always potentially serious because newborns
contract the disease at birth and have an increased
risk for liver carcinoma later in life.
Intestinal Disorders
A. Diaphragmatic Hernia
● A diaphragmatic hernia occurs when one or more of the
abdominal organs move upward into the chest through a
defect (opening) in the diaphragm.
● This kind of defect can be present at birth or acquired later in
life.
● Congenital diaphragmatic hernia can be diagnosed through
fetal ultrasound.
●
●
Signs and Symptoms:
○ Difficulty breathing
○ Tachypnea
○ Cyanosis
○ Tachycardia
○ Diminished or absent breath sounds
○ Bowel sounds in the chest area Less full abdomen
Management:
○ Surgery
■ With a CDH, surgeons may perform surgery as early
as 48 to 72 hours after the baby is delivered.
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UNIT 11 (Week 13)
■ The first step is to stabilize the baby and increase its
oxygen levels.
■ With an ADH, the patient typically needs to be
stabilized before surgery. Because most cases of ADH
are due to injury, there might be other complications
such as internal bleeding. Therefore, the surgery
should happen as soon as possible.
B. Intussusception
● A slipping of one part of the intestine into another part just
below it
○ Often seen at the ileocecal valve
○ The mesentery, a double fan-shaped fold of peritoneum
that covers most of intestine and is filled with blood
vessels and nerves, is also pulled along.
● Edema occurs
● At first, intestinal obstruction occurs, but then strangulation of
the bowel occurs as peristalsis occurs
● Affected portion may burst, leading to peritonitis
● Generally occurs in boys between 3 months and 6 years
● A “lead point” on the intestine likely cues the invagination such
as Mickel’s diverticulum, hypertrophy of the Peyer's Patches,
and bowel tumors.
●
●
Intussusception, the invagination of one portion of the
intestine into another, usually occurs in the second half of the
first year of life. In infants younger than 1 year, intussusception
generally occurs for idiopathic reasons.
In infants older than 1 year, a “lead point” on the intestine
likely cues the invagination. Such a point might be a Meckel’s
diverticulum, a polyp, hypertrophy of Peyer’s patches
(lymphatic tissue of the bowel that increases in size with viral
●
diseases), or bowel tumors. The point of the invagination is
generally at the juncture of the distal ileum and proximal colon.
Signs and Symptoms:
○ Onset is usually sudden
■ May have a fever as high as 106° F (41.1° C)
■ As it progresses, child may show signs of shock,
sweating, weak pulse, shallow, grunting respirations;
abdomen is rigid
○ In infants, severe pain in abdomen, loud cries, straining
efforts, and kicking and drawing of legs toward abdomen.
○ Child vomits green or greenish- yellow fluid (bilious).
○ Bowel movements diminish, little flatus is passed.
○ Blood and mucus with no feces are common about 12
hours after onset of obstruction, called currant jelly stools.
○ Children with this disorder suddenly draw up their legs and
cry as if they are in severe pain; they may vomit. After the
peristaltic wave that caused the discomfort passes, they
are symptom-free and play happily. In approximately 15
minutes, the same phenomenon of intense abdominal
pain strikes again. Vomitus will begin to contain bile
because the obstruction is invariably below the ampulla of
Vater, the point in the intestine where bile empties into
the duodenum.
○ After approximately 12 hours, blood appears in the stool
and possibly in vomitus, described as a “currant jelly”
appearance. The abdomen becomes distended as the
bowel above the intussusception distends. If necrosis
occurs, children generally have an elevated temperature,
peritoneal irritation (their abdomen feels tender; they may
“guard” it by tightening their abdominal muscles), an
increased white blood cell count, and often a rapid pulse.
Diagnosis is suggested by history.
○ Any time a parent is describing a child who is crying, be
certain to ask enough questions to recognize the
possibility of intussusception:
■ What is the duration of the pain? It lasts a short time,
with intervals of no crying in between.
■ What is the intensity? Severe
■ What is the frequency? Approximately every 15 to 20
minutes
■ What is the description? The child pulls up legs while
crying.
■
○
○
C.
Is the child ill in any other way? Yes. Vomits; refuses
food; states stomach feels “full.”
The presence of the intussusception is confirmed by
ultrasound or a CT scan
Management:
■ Diagnosis is determined by history and physical
findings.
■ May feel a sausage-shaped mass in the right upper
abdomen Barium enema is treatment of choice, with
surgery if reduction does not occur.
■ The condition is a surgical emergency. Reduction of
the intussusception must be done promptly by either
instillation of a water-soluble solution, barium enema,
or air (pneumatic insufflation) into the bowel or
surgery to reduce the invagination before necrosis of
the affected portion of the bowel occurs.
■ If there is no lead point, just the pressure of these
nonsurgical
techniques
may
reduce
the
intussusception. After this type of reduction, children
are observed for 24 hours because some children will
have a recurrence of the intussusception within this
time. If this occurs, children will be scheduled for an
additional reduction or surgery.
Volvulus
● Refers to abnormal twisting of a part of the large or small
intestine.
● Leads to bowel obstruction
● Occurs due to malrotation of small intestines during fetal
development.
● It is a medical emergency that needs surgical treatment.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
■
●
●
●
●
●
●
The twist leads to obstruction of the passage of feces and
compromise of the blood supply to the loop of intestine
involved. This occurs most often because, in fetal life, a portion
of the intestine first protrudes into the base of the umbilical
cord at approximately 6 weeks of intrauterine life.
At approximately 10 weeks of intrauterine life, it returns to the
abdominal cavity. As the intestine returns to the abdominal
cavity, it rotates to its permanent position. After the rotation,
the mesentery becomes fixed in this position. In volvulus, this
action is incomplete and the mesentery does not attach in a
normal position.
The bowel is left free to move and twist. Usually, the symptoms
are those of intestinal obstruction and occur during the first 6
months of life.
Signs and Symptoms:
○ Intense crying and pain
○ Pulling up the legs
○ Abdominal distention
○ Vomiting
Diagnosis:
○ History
○ Abdominal examination – Abdominal mass
○ Ultrasound or barium enema reveals obstruction
Management:
○ Surgery
●
This must be done promptly before necrosis of the
intestine occurs from a lack of blood supply to the
involved loop of bowel.
■ Preoperative and postoperative care will be the same
as for infants with intussusception.
○ Relieve the volvulus and re-attach the bowel
○ Must be done promptly
○ Stoma may be needed if necrosis of parts of the intestine
is noted.
D. Necrotizing Enterocolitis (NEC)
● The bowel develops necrotic patches, interfering with digestion
and may possibly lead to paralytic ileus.
● Necrosis results from ischemia of blood vessels in sections of
bowel.
● The entire bowel may be involved or it may be localized.
● Incidences are higher in immature infants.
E.
●
●
Necrotizing enterocolitis (NEC) is a condition that develops in
approximately 5% of all infants in intensive care nurseries. The
bowel develops necrotic patches, interfering with digestion and
possibly leading to a paralytic ileus. Perforation and peritonitis
may follow. The necrosis appears to result from ischemia or
poor perfusion of blood vessels in sections of the bowel.
The ischemic process may occur when, owing to shock or
hypoxia, there is vasoconstriction of blood vessels to organs
such as the bowel. The entire bowel may be involved, or it may
be a localized phenomenon.
The incidence of NEC is highest in immature infants, those who
have suffered anoxia or shock, and those fed by enteral
feedings. Infants with infections may develop it as a further
complication of their already stressed state.
● There is a lower incidence of the condition in infants who are
fed breast milk than in those who are fed formula because
intestinal organisms grow more profusely with cow’s milk than
breast milk (cow’s milk lacks antibodies). A response to the
foreign protein in cow’s milk may also be a mechanism that
starts the necrotic process. Therefore, encouraging
breastfeeding may help prevent this disorder.
● Signs and Symptoms:
○ Abdominal distension
○ Stomach does not fully empty by the next feeding time
○ Occult blood in the stool
○ Periods of Apnea
○ Signs of blood loss
● Management:
○ IV or total parenteral nutrition
○ Enteral Probiotics
○ Antibiotic Therapy
○ Restrict Abdominal palpation
○ Surgery to remove necrotic bowel
○ Peritoneal drainage or laparotomy in cases of bowel
perforation
○ Temporary colostomy
Appendicitis
● Inflammation of the appendix
● Most common reason for emergency abdominal surgery
● Appendix may become obstructed with fecal matter or with
lymphoid tissue after a viral illness or with parasites
● Stasis, increased swelling, edema, and growth of organisms
● Initial pain usually in periumbilical and increases within a 4
hour period
● When inflammation spreads to peritoneum, pain localizes in
RLQ of abdomen
● Appendix may become gangrenous or rupture
● Can lead to peritonitis and septicemia
● Signs and Symptoms:
○ Anorexia
○ Nausea and Vomiting
○ Tenderness in RLQ, known as McBurney’s point
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UNIT 11 (Week 13)
○ Guarding
○ Decreased Bowel sounds
○ Leukocytosis
○ Fever
● Diagnosis:
○ Blood tests
○ Abdominal X-ray
○ CT Scan
○ Ultrasound
● Management:
○ Surgical Intervention (typically required)
○ Nursing care is the same as with most other abdominal
surgery patients
F. Meckel’s Diverticulum
● During fetal life the intestine is attached to the yolk sac by the
vitelline duct. A small blind pouch may form if this duct fails to
disappear completely.
● With this structure there may be some misplaced gastric
mucosa that can irritate the bowel
● This disorder is the most common congenital malformation of
the GI tract.
●
Signs and Symptoms:
○ Painless bleeding from the rectum (most common sign)
○ Bright red or dark red blood is more usual than tarry stools
○ Abdominal pain may or may not be present
● Diagnosis:
○ Barium Enema and radionuclide scintigraphy
○ x-ray films are not helpful because the pouch is so small
that it may not appear on the screen
●
Management:
○ Surgery-removal of the diverticulum
○ Nursing care is the same as for the patient undergoing
exploration of the abdomen.
○ Because this condition appears suddenly and bleeding
causes parental anxiety, emotional support is of particular
importance
G. Celiac Disease
● Also known as gluten enteropathy and sprue
● Sensitivity or abnormal immunologic response to protein found
in grains, wheat, rye, oats, and barley
● Leading malabsorption problem in children
● Repeated exposure to gluten damages the villi of intestines
resulting in malabsorption especially fat
● Deficiency in fat-soluble vitamins (Vit. A,D,E,K)
● Signs and Symptoms:
○ Steatorrhea
○ Malnutrition
○ Distended abdomen
○ Anorexia
○ Appears skinny, spindly extremities
○ Irritable
○ Infant presents with failure to thrive
○ Atrophy of buttocks
● Management:
○ Lifelong diet restricted in wheat, rye, barley, & oats.
○ Detailed parent teaching is essential.
■ A professional nutritionist or dietitian can aid in
identifying foods that are gluten-free.
Disorders of the Lower Bowel
A. Constipation
● Difficult or infrequent defecation with the passage of hard, dry
fecal matter
● Because passing a hardened stool is painful, a child represses
the next urge to defecate.
● Returns gradually distended.
● May have episodes of encopresis (involuntary release of stool)
when rectum can hold no more.
● Management:
○ Ask caregiver to define constipation
○
B.
Evaluate dietary and bowel habits – Some infants develop
constipation due to high iron content in formula
○ Note frequency, color, and consistency of stool
○ Document any medications child is taking
○ Dietary modifications include increasing roughage in diet
■ Foods high in fiber include whole-grain breads and
cereals, raw vegetables and fruits, bran, and popcorn
for older children.
○ Stool softener may be prescribed.
Inguinal Hernia
● A protrusion of a section of the bowel into the inguinal ring.
● It usually occurs in boys (9:1) because, as the testes descend
from the abdominal cavity into the scrotum late in fetal life, a
fold of parietal peritoneum also descends, forming a tube from
the abdomen to the scrotum.
● In most infants, this tube closes completely. If it fails to close,
intestinal descent into it (hernia) may occur at any time when
there is an increase in intra-abdominal pressure.
● In girls, the round ligament extends from the uterus into the
inguinal canal to its attachment on the abdominal wall. In girls,
an inguinal hernia may occur because of a weakness of the
muscle surrounding the round ligament.
●
Signs and Symptoms:
○ A hernia appears as a lump in the left or right groin. In
some instances, the hernia is apparent only in crying
(when abdominal pressure increases) and not when
children are less active. Inguinal hernias are painless. Pain
at the site implies that the bowel has become incarcerated
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UNIT 11 (Week 13)
in the sac, which is an emergency that requires immediate
action to prevent bowel obstruction and ischemia.
○ The diagnosis is established by a history and physical
appearance. When taking a history of a well child, be
certain to ask parents whether they have ever noticed any
lumps in the child’s groin area. The hernia may not be
noticeable at the time of a healthcare visit, so, unless
asked specifically, parents may not mention it. If present,
the herniated intestine can be palpated in the inguinal ring
on physical examination.
C.
●
Management:
○ Herniorrhaphy
○ Treatment of inguinal hernia is laparoscopic surgery. The
bowel is returned to the abdominal cavity and retained
there by sealing the inguinal ring. Pneumoperitoneum
(instillation of carbon dioxide into the perineal cavity)
during surgery may be performed to reveal the presence
of an enlarged inguinal ring on the opposite side. If this is
present, both sides may be repaired, and the child will
return from surgery with dressings on both groins.
○ Formerly, surgery for inguinal hernia was delayed until the
child was 3 or 4 years of age. Today, to prevent the
complication of bowel strangulation—a surgical
emergency—infants with inguinal hernia may have surgery
before 1 year of age. If surgery is proposed as a
prophylactic measure, setting outcomes may be difficult
for parents as they weigh the value of surgical repair
against the risk of anesthesia and surgery.
○ After surgery, keep the suture line dry and free of urine or
feces to prevent infection. Most indications in this area are
closed by a tissue adhesive, which is waterproof and seals
the incision from urine and feces. Even so, the infant will
need frequent diaper changes and good diaper-area care.
Assess circulation in the leg on the side of the surgical
repair to be certain that edema of the groin is not
compressing blood vessels and obstructing blood flow to
the leg.
Meconium Plug Syndrome
● Refers to a functional colonic obstruction in a newborn due to
an obstructing meconium plug.
● It is usually transient and affects the left colon with meconium
plugging the bowel distal to this segment.
● Delayed passage (more than 24 to 48 hours) of meconium and
intestinal dilatation
●
Signs and Symptoms:
○ Infants present in the first few days of life with failure to
pass stools, abdominal distention, and vomiting.
○ Thick, inspissated, rubbery meconium forms a cast on the
colon, resulting in complete obstruction.
● Management: Radiographic Contrast Edema — The
water-soluble contrast enema can be therapeutic by separating
the plug from the intestinal wall and expelling it. Occasionally,
repeated enemas are required.
D. Meconium Ileus
● Obstruction of the intestinal lumen by hardened meconium
● A specific phenomenon that occurs most exclusively in infants
with cystic fibrosis, resulting from the abnormal pancreatic
enzyme function seen with cystic fibrosis and reflects extreme
meconium plugging.
● The usual symptoms of bowel obstruction occur: no meconium
passage, abdominal distention, and vomiting of bile-stained
fluid.
● Meconium ileus is the only bowel obstruction that can present
with abdominal distention at birth. Unlike simple meconium
plugging, the obstruction point may be too high in the intestine
for enemas to reduce it; instead, the bowel must be incised
and the hardened meconium removed by laparotomy.
● Meconium ileus is so strongly associated with cystic fibrosis,
the infant needs close follow-up by an interprofessional cystic
fibrosis team in the following months.
E. Hirschsprung's Disease (Aganglionic Megacolon)
● An absence of ganglionic innervation to the muscle of a section
of the bowel—in most instances, the lower portion of the
sigmoid colon just above the anus. The absence of nerve cells
means there are no peristaltic waves (lack of normal
peristalsis) in this section to move fecal material through the
segment of intestine. This results in chronic constipation or
ribbonlike stools (stools passing through such a small, narrow
segment look like ribbons). The portion of the bowel proximal
to the obstruction dilates, thus distending the abdomen.
● The incidence of aganglionic disease is higher in the siblings of
a child with the disorder than in other children. It also occurs
more often in males than in females. It is caused by an
abnormal gene on chromosome 10. The incidence is
approximately 1 in 5,000 live births.
○ Seen more often in children with Down syndrome.
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UNIT 11 (Week 13)
○
●
●
Signs and Symptoms:
○ Occasionally, infants are born with such an extensive
section of bowel involved that even meconium cannot
pass. Because newborn stools are normally soft, however,
symptoms of aganglionic megacolon generally do not
become apparent until 6 to 12 months of age. By this time,
children appear thin and undernourished (sometimes
deceptively so because their abdomen is large and
distended) and have a history of not having a bowel
movement more than once a week of ribbonlike or watery
stools.
○ Newborns — Failure to pass meconium stools within 24 to
48 hours may be a symptom
○ Infants — Constipation, ribbon-like stools, abdominal
distention, anorexia, vomiting, and failure to thrive
Diagnostics:
○ The diagnosis is suggested by a rectal exam; if a gloved
finger is inserted into the rectum of a child with true
constipation, the examining finger will touch hard, caked
stool. With aganglionic colon disease, the rectum is empty
because fecal material cannot pass into the rectum
through the obstructed portion.
F.
A barium enema or ultrasound with contrast medium is
generally prescribed to substantiate the diagnosis. The
contrast mediums will outline the narrow, nerveless
portion and the large proximal distended portion of the
bowel. Enemas must be used cautiously, however,
because children cannot expel this afterward any more
effectively than they can stool.
○ A definitive diagnosis is by a (rectal) biopsy of the affected
segment to show the lack of innervation or by anorectal
manometry, a technique that tests the strength or
innervation of the internal rectal sphincter by inserting a
balloon catheter into the rectum and measuring the
pressure exerted against it.
● Management:
○ Repair of aganglionic megacolon involves dissection and
removal of the affected section, with anastomosis of the
intestine (termed a pull-through operation). Because this is
a technically difficult operation to perform in a small
abdomen, the condition is generally treated in infants by
two-stage surgery:
■ First, a temporary colostomy is established, followed
by bowel repair at 12 to 18 months of age.
■ After the final surgery, children should have a
functioning, normal bowel.
■ In the few instances in which the anus is deprived of
nerve endings, a permanent colostomy will need to be
established.
○ Nursing Care:
■ In newborns, detection is high-priority.
■ As the child grows, careful attention to a history of
constipation and diarrhea is important.
■ Signs of undernutrition, abdominal distention, and
poor feedings
Inflammatory Bowel Diseases
Two conditions are categorized as inflammatory bowel disease
(IBD). These disorders have some separate as well as some
overlapping characteristics. Both involve the development of
inflammation in the intestine. About 25% of IBD cases are
diagnosed in children younger than 20 years of age. The incidence
in the United States has been increasing. The cause of IBD is
unknown but thought to be multifactorial and due to an abnormal
response by the immune system to an environmental trigger in a
genetically susceptible individual.
Psychological factors have not been supported as a primary
contributory factor to IBD, but psychological problems often occur
secondary to the disease, possibly intensifying symptoms.
● Ulcerative Colitis
○ Affects only the mucosal lining of the colon.
○ Children with UC develop crampy abdominal pain, urgency,
tenesmus, and frequent bloody stools. Anemia and
hypoalbuminemia due to losses in the stool may be
present. It is treated with oral and sometimes IV
medications such as infliximab (Remicade). If it does not
respond to medical therapy, surgery to remove the colon is
performed, which is curative for UC. There is an
association between UC and colon carcinoma if the
disease persists over 10 years. Yearly colonoscopy should
be performed once the patient has reached 8 to 10 years
from the date of diagnosis.
● Crohn Disease
○ Can affect any part of the GI tract from the mouth to the
anus. The area most commonly involved is the last part of
the small intestine known as the terminal ileum. The
inflammation in CD can extend through the wall of the
intestine and cause abscesses and fistulae.
○ Smoking has been shown to be a precipitating factor.
○ The symptoms of CD depend on the severity and location
of the inflammation. Abdominal pain, diarrhea with or
without blood, and weight loss may be present. The
inflamed area may become narrowed causing a stricture of
the bowel, and a bowel obstruction may develop if this
goes untreated. Fistulae, small tunnels that run either
from the bowel to the skin or to another organ, can
develop. These most commonly involve the perianal area.
CD is also treated with oral and IV medications depending
on the severity of the disease. Remission has also been
achieved with exclusive enteral feeding. Surgery may be
necessary to remove strictures or repair fistulae, but the
disease can redevelop in other areas or the bowel. There
are periods of exacerbations and remissions in both
disorders. As inflammation becomes acute, children
develop abdominal pain. Because the inflamed areas do
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UNIT 11 (Week 13)
not absorb nutrients or fluid well, diarrhea and
malnutrition develop. To reduce abdominal pain, which is
most acute after eating, when the bowel becomes active,
children begin to skip meals. This can cause them to
become malnourished and develop a vitamin or iron
deficiency.
Assessment: (for both ulcerative colitis and crohn disease)
● In both disorders, diarrhea and steatorrhea develop from the
irritation and the unabsorbed fluid. If inflamed portions ulcerate,
there will be blood in the stool. Weight loss occurs; in prepubertal
children, growth failure can occur. a recurring fever may be
present.
●
Comparison Factor
Crohn Disease
Ulcerative Colitis
Part of bowel
affected
Ileum
Colon and rectum
Nature of lesions
Intermittent
Continuous
Diarrhea
Moderate
Severe and bloody
Anorexia
Severe
Mild
Weight loss
Severe
Mild
Growth retardation
Marked
Mild
Anal and perianal
lesions
Common
None
Association with
carcinoma
Rare
Common
Diagnosis is established by endoscopy and colonoscopy. Small
biopsies with very low risk of bleeding are taken from multiple
areas in the upper and lower GI tract. Inflammation, friability, and
bleeding may be seen. The histology report shows chronic
inflammation and sometimes granulomas in CD. A radiology study
such as an MRI is usually obtained to examine the parts of the
small bowel that cannot be reached with an endoscope.
Management: (for both ulcerative colitis and crohn disease sad)
● In mild to moderate cases, oral medications are usually sufficient
to control the symptoms. Vitamin and mineral deficiencies should
be corrected. In more severe cases, bowel rest may be indicated to
allow the bowel to heal. Enteral or total parenteral nutrition,
therefore, is usually provided for nutrition during the resting
period. A child can remain home during this period as long as
parents have thorough education about the child’s nutritional
needs.
● When food is reintroduced after the resting period, a high-protein,
high-carbohydrate, and high-vitamin diet is prescribed to replace
nutrients. Children may eat cautiously at first to avoid
reintroducing diarrhea, so assess intake and output carefully. The
treatment regimen depends on the child’s condition. In more
severe cases, remission is usually achieved with corticosteroids or
infliximab (Remicade), an antibody to the inflammatory cytokine
tumor necrosis factor alpha. Maintenance therapy may be with
infliximab or mercaptopurine (immunomodulator) or mesalamine
alone or a combination of medications. If surgery for UC becomes
necessary, the procedure is performed in two stages. During the
first stage, total colectomy is performed and an ileostomy created.
Several months later, an ileoanal pouch is created and the
ileostomy is taken down. This allows the child to be continent of
stool.
● Bowel surgery is always a serious step, but because it reduces the
possibility of the child developing colon cancer in association with
UC, it may be necessary in children whose disease is running a
long-term, debilitating course that does not improve. Caution
parents, although they want their children to be independent with
regard to bathroom use, to always report if change in the color or
consistency of bowel movements does occur so a relapse can be
detected.
G. Irritable Bowel Syndrome (Chronic Nonspecific Diarrhea)
● A functional bowel disorder that typically causes symptoms of
abdominal pain and altered bowel habits with no underlying
organic cause. It should not be confused with IBD. It may be
either constipation or diarrhea predominant or there may be a
mixed picture. Diagnosis is based on the Rome III Criteria. It is a
common disorder in adolescents and adults and thought to
affect 15% of the population with a 2:1 female to male
predominance. The symptoms can adversely affect quality of
life and cause children to miss school.
●
The cause is unknown. The onset of loose stools can follow an
infection and may be due to an alteration in the intestinal flora.
Other studies have looked at intestinal bacterial overgrowth,
food sensitivities, visceral hyperalgesia (heightened sensitivity
to bowel distention), and psychosocial factors.
● Antidepressants, anticholinergics, and antibiotics that work to
reduce bacteria in the gut such as rifaximin may be prescribed
to treat the symptoms of IBS.
H. Imperforate Anus
● The lower GI tract and the anus arise from two different
tissues.
● Early in fetal life, the two tissues meet and join; the tissue
separating them then perforates, allowing a passageway
between the lower GI tract and the anus.
● When this perforation does not take place, the lower end of
the GI tract and the anus end in blind pouches. This is called
imperforate anus.
● Basically, there is no opening in the rectum.
●
Signs and Symptoms:
○ No anal opening — Part of the routine newborn
assessment is to determine the patency of the anus. It is
important upon birth. Often, the first temperature of the
newborn is taken rectally through a certain patency (mao
ni atong buhatonon, almost always gyud sa DR after birth).
○ Distended abdomen — Because of failure to pass stool
○ Failure to pass meconium in the first 24 hours must be
reported.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
○ Infants should not be discharged to the home before a
meconium stool is passed because there are a lot of
conditions that need to be ruled out, especially if there is
failure to pass meconium.
● Diagnosis and Management:
○ Once a diagnosis of imperforate anus is established, the
infant is given nothing by mouth and is prepared for
surgery.
○ Diagnosis is confirmed by x-ray study or magnetic
resonance imaging (MRI).
○ The initial surgical procedure may be a colostomy.
■ The type of corrective surgery will depend on the
specific effects of the patient, or how far the baby’s
rectum descends, or how it affects the nearby
muscles, or whether fistulas are involved.
■ There will be a repair in the perineum to close any
fistulas that are present in the rectum.
■ A pull-through operation is done by allowing the
physician to pull the rectum down and connect it to
the new anus.
■ To prevent the anus from narrowing, it may be
necessary to stretch the anus periodically. This is
called anal dilation. The patient’s significant other
may need to repeat this periodically for a few months.
The physician can teach the significant other to
perform this at home.
○ Subsequent surgery can reestablish the patency of the anal
canal.
Disorders Caused By Food, Vitamin, and Mineral Deficiencies
There are many underfed and malnourished children in every part of
the world. Although extreme diseases of food or vitamin deprivation
are rare in the United States, they do exist. Such children need early
identification so they can receive better nutrition before permanent
damage occurs.
The average child does not develop a deficient intake of essential
nutrients because, even if the child is occasionally a fussy eater, over
the space of a week, a child does ingest foods containing the necessary
nutrients. Carefully assess any child who has an interference in
nutrition such as a GI illness or a child is receiving enteric feedings or
total parenteral nutrition to make sure that nutrient deficiencies do
not exist. Assess abused or neglected children closely for nutritional
deficiencies, because they may not have been given adequate food.
A. Kwashiorkor
● Caused by protein deficiency, occurs most frequently in
children ages 1 to 3 years, because this age group requires a
high protein intake.
● It tends to occur after weaning, when children change from
breast milk to a diet consisting mainly of carbohydrates.
● “...caused by inadequate amounts of proteins in the body. This
disease is usually found in countries where good food is not
readily available.”
● Signs and Symptoms:
○ Growth failure is a major symptom. Because edema is
also a symptom, however, children may not appear light
in weight until the edema is relieved.
○ Muscle wasting — There is a severe wasting of muscles,
but, again, this is masked by the edema.
○ Edema results from hypoproteinemia, which causes a
shift of body fluid from the intravascular compartments
to the interstitial space, causing ascites. This is the same
phenomenon that causes extensive edema in children
with nephrosis. The edema tends to be dependent, so it
is first noted in the lower extremities.
○ Irritable — Children are generally irritable and
uninterested in their surroundings. They fall behind other
children of the same age in motor development.
○ Failure to thrive
● Management: Diet rich in protein — Without treatment,
Kwashiorkor is fatal. For therapy, a diet rich in protein is
essential. Even so, there is evidence to suggest that protein
malnutrition early in life, even if corrected later, may result in
failure of children to reach their full potential of intellectual
and psychological development.
B. Nutritional Marasmus
● Caused by a deficiency of all food groups, basically a form of
starvation.
● These children are most commonly younger than 1 year of
age.
● They have many of the same symptoms as children with
kwashiorkor. But children with kwashiorkor are anorectic (loss
of appetite), children with nutritional marasmus are invariably
●
●
●
C.
hungry (starving) and will suck at any object offered to them,
such as a finger or their clothing.
Signs and Symptoms:
○ Growth failure
○ Muscle wasting
○ Irritability
○ Iron-deficiency anemia
○ Diarrhea
Treatment: A diet rich in all nutrients.
Two Types of Malnutrition:
Vitamin and Mineral Deficiencies
Both vitamin and mineral deficiencies occur at a low rate in
children of the United States because so many foods are enriched
(restoration of ingredients removed by processing) or fortified
(additional vitamins and minerals not normally present have been
added). Milk, for example, is fortified with vitamins D and A.
Orange juice is fortified with calcium. White bread is enriched with
B vitamins. Vitamin deficiency diseases are summarized in Table
below.
Vitamin
Cause of Deficiency
Vitamin A
Lack of yellow vegetables in
diet
Signs and Symptoms
●
●
Tender
tongue;
cracks at corners of
mouth
Night blindness
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
●
●
Vitamin B1
Most common in children
who eat polished rice as
dietary staple, because B1 is
contained in hull of rice
●
●
●
●
Niacin
Common in children who
eat corn as dietary staple,
because corn is low in niacin
Vitamin C
Lack of fresh fruits in diet
Vitamin D
Lack of sunlight
●
●
●
Xerophthalmia (dry
and
lusterless
conjunctivae)
Keratomalacia
(necrosis
of
the
cornea
with
perforation, loss of
ocular fluid, and
blindness)
Beriberi (tingling and
numbness
of
extremities;
heart
palpitations;
exhaustion)
Diarrhea
and
vomiting
Aphonia (cry without
sound)
Anesthesia of feet
●
●
Bowed legs
Tetany
spasms)
(muscle
D. Iodine Deficiency
● Because iodine is not supplemented in food except as iodized
salt, a diet deficient in iodine may lead to either
hypothyroidism or overgrowth (goiter) of the thyroid gland as
the gland struggles to produce thyroxine in the face of
deficient iodine.
● Goiter tends to occur most commonly in girls at puberty and
during pregnancy. It is potentially dangerous as an enlarged
thyroid gland may lead to difficulty breathing
● Supplemental iodine or synthetic thyroxine (Synthroid) is
needed to correct the deficiency. Children must also be
maintained on a diet adequate in iodine, found most
abundantly in seafoods.
Pellagra (dermatitis;
resembles a sunburn)
Diarrhea
Mental
confusion
(dementia)
Scurvy
(muscle
tenderness; petechiae)
●
●
●
●
Poor muscle tone;
delayed
tooth
formation
Rickets (poor bone
formation)
Craniotabes
(softening of the
skull)
Swelling at joints,
particularly of wrists
and cartilage of ribs
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
NURSING CARE MANAGEMENT 109
NURSING CARE OF A CHILD W GI DISORDER
Clinical Instructor: Isabella R. Dobluis, RN
VIDEO 1
OVERVIEW & ASSESSMENT:
DIGESTIVE FUNCTIONS & PEDIATRIC VARIATIONS;
NURSING CARE OF THE CHILD WITH GI DISORDER
ANATOMY-PHYSIOLOGY REVIEW
Overview of the Gastrointestinal System - Pediatric Variations
A. FUNCTIONS
●
●
●
●
●
Takes in food, breaks down food, absorbs nutrients,
and eliminates wastes.
The digestive tract breaks down ingested food by
mechanical and chemical processes, prepares it for
absorption, and eliminates water and waste products.
From the throat to the anus, a smooth muscle tube
moves food by peristaltic action, which is controlled
by the autonomic nervous system and action of the
hormones.
In the mouth, food is broken down by the teeth =
mechanical breakdown
○ And mixed with a moisturizing saliva
containing the digestive enzyme = amylase
(This starts the digestion of carbohydrates,
such as starch to glucose).
The bolus of food moves down the esophagus and into
the stomach through the cardiac sphincter, where the
mechanical breakdown by the three layers of muscles
turns the food bolus.
○ The food bolus is turned by the mechanical
action in the stomach and then it becomes
chyme eventually.
○ Bolus is food that has been mixed with saliva.
Chyme is food that has been mixed with
gastric juice. Bolus is chewed and then
swallowed to reach the stomach. Chyme
enters the small intestine after passing
through the stomach.
digestion. These enzymes include trypsin and chymotrypsin
to digest proteins, amylase for the digestion of carbohydrates,
and lipase to break down fats. The food then passes into the
next sections of the small intestines, the jejunum and the
ileum.
● The ileum is where the absorption of nutrients takes
place. The small capillaries of the blood system
transport them into the hepatic portal system and
hence, to the liver for distribution to the body tissues,
waste products, such as fiber and excess bile, are
then moved into the cecum to the large intestine,
called the colon.
● Here, water is reabsorbed into the blood system
together with vitamins K and B complex, which
have been manufactured by bacteria living in that
part of the gut. The waste is retained in the lower
part of this section, the rectum, until stretch
receptors initiate defecation.
C. STRUCTURES
1) PRIMITIVE GUT
● Foregut - from distal esophagus down to proximal half
of 2nd part of duodenum
○ Gives rise to the pharynx, lower respiratory
system, esophagus, stomach, first and
sections of the duodenum, liver, pancreas,
and biliary apparatus
● Midgut - from distal half of 2nd part of duodenum down
to proximal ⅔ of transverse colon
○ Gives rise to the duodenum through the
transverse colon
● Hindgut - from distal ⅓ of transverse colon to rectum
○ Develops into the rest of the large intestine to
the anus
●
●
●
B. SUBSTANCES
The anatomical combinations that eventually result
in the digestive system explain on how some infants
are born with strange anomalies, such as the
esophagus and trachea joined together, abdominal
contents which have grown outside the skin
covering of the abdomen rather than inside it, and
an imperforate anus.
In the embryo, the primitive digestive tract is a tube
evolving from 3 separate parts (foregut, midgut, &
hindgut), which develop separately from the yolk
sac.
Due to the herniation of the midgut into the
umbilical sac at week 6-10 of fetal life, the
mesentery, which is the skin keeping all the gut in
position, is fixed at the top in the left upper quadrant
of the abdominal cavity by the ligament of traits? and
at the bottom in the right iliac fossa.
1) STOMACH
● Water - makes the content more fluid
● Mucus - protects the stomach lining
● Hydrochloric acid - helps to kill ingested bacteria and
activate other digestive processes
● Intrinsic factor - allows absorption of iron
● Pepsin (*and renin) - commences the chemical
digestion of proteins
2) INTESTINES
● Chyme - moves into the duodenum, which is the first
part of the small intestine through the pyloric sphincter
● Bile - a waste product of the liver
● Pancreatic enzymes
Bile and pancreatic enzymes continue the chemical
digestion of carbohydrates, fats, and proteins. The pancreas
contains exocrine glands that produce enzymes important to
HISTOLOGY OF THE DIGESTIVE TRACT
The digestive system consists of a digestive tract and its
associated accessory organs. The digestive tract consists of
the oral cavity, pharynx, esophagus, stomach, small intestine,
large intestine, and anus.
Accessory organs, such as the salivary glands, liver,
gallbladder, and pancreas, are located along the digestive tract.
The digestive tract is composed of 4 tunics - mucosa,
submucosa, muscularis, and serosa or adventitia.
● Mucosa - consists of a mucus epithelium, a lamina
propria, and muscularis mucosae
● Submucosa - a connective tissue layer containing the
submucosal plexus or part of the enteric plexus, the
blood vessels, and small glands
● Muscularis - an inner layer of circular, smooth muscle
and an outer layer of longitudinal smooth muscle. The
myenteric plexus is between the two muscle layers.
● Serosa or Adventitia - forms the outermost layer of
the digestive tract
For the enteric nervous system, this consists of nerve
plexuses within the wall of the digestive tract. Nervous
regulation involves local reflexes in the ENS and CNS reflexes.
2) PERITONEUM & MESENTERIES
● The peritoneum is a serous membrane that lines the
abdominopelvic cavity and organs. These membranes
are very smooth and secrete a serous fluid, which
provides a lubricating film between the layers of the
membranes. These membranes and fluid reduce
friction as organs move within the abdominopelvic
cavity.
○ The visceral peritoneum covers organs and
is continuous with the parietal peritoneum,
which covers the interior surface of the body
wall.
● Mesenteries are peritoneum that extends from the
body wall to many of the abdominopelvic organs.
These are connective tissue sheets holding many of
the organs and placed within the abdominopelvic.
They provide a route by which vessels and nerves can
pass from the abdominal walls to the organs.
○ Lesser omentum - the mesentery
connecting the lesser curvature of the
stomach to the liver and diaphragm.
○ Greater omentum - the mesentery extending
as the fold from the greater curvature and
then into the transverse colon (see b picture).
● Retroperitoneal organs are located behind the
peritoneum.
3) ORAL CAVITY
● The oral cavity consists of vestibule and oral cavity
proper.
● Lips and cheeks - for facial expression, mastication,
and speech
● Palate & palatine tonsils - The roof of the oral cavity
is divided into hard and soft palates.
○ The palatine tonsils are located in the lateral
wall of the foces??
● Tongue - speech, taste, mastication, and swallowing
● Teeth
● These salivary glands produce serous and mucus
secretions.
○ The 3 pairs of large salivary glands are the
parotid gland, submandibular gland, and the
sublingual gland.
4) TEETH
● There are 20 deciduous teeth, which are eventually
replaced by 32 permanent teeth.
● Types of teeth are incisors, canines, premolars, and
molars.
● A tooth consists of a crown, a neck, and a root.
○ The root is composed of dentin. Within the
dentin of the root is the pulp cavity, which is
filled with pulp, blood vessels, and nerves.
○ The crown is dentin covered by enamel.
● Periodontal ligaments hold the teeth in the alveoli.
● Some pediatric variations:
○ Teeth may be present in the newborn (natal)
but generally may start to erupt at about 6-8
months.
○ The lower 2 central incisors are usually first.
○ Some infants do not commence teething until
12 months.
○ Teething leads to an increase of salivation,
and babies may have loose stools, diaper
rash, a raised temperature, and cough BUT
there is controversy in this point.
○ There’s also a controversy in symptoms
experienced by babies as some have no
problems at this time and others are unhappy
for days.
○
●
The complete set of deciduous teeth numbers
20, and is achieved by 30 months. They
should be carefully guarded.
○ Toothpaste also contains fluoride, and
should be used in moderation.
■ Mottling of teeth can be observed if
too much is absorbed but this does
not increase problems with caries.
○ Toothbrushing should begin at 6 months to
remove the plaque that deposits there.
■ Bacteria change sugars to acid,
which eat away at the tooth enamel.
○ The young child has no molar teeth so they
cannot chew thoroughly and the deciduous
teeth are rather blunt.
○ At 6-8 years, the deciduous teeth will begin to
be lost in the same order that they were
grown but the full set of adult teeth may not
arrive until adolescence.
Mastication → breaking large food particles into
-
However, many children will gag or spit out
clumps for some months over their first year.
smaller ones
REFLEXES OF THE MOUTH & THROAT
1) MOUTH - Pediatric Variations
● Fx: takes in food and water and prepares them for
chemical digestion and absorption as they pass
through the gut.
● Lips, teeth, tongue, hard palate, 3 pairs of salivary
glands, and muscles of the face all help in this process.
● Any malformation of the anatomy will make ingestion
of the food problematic.
● When a baby is born, it suddenly separates from its
source of nutrients in the maternal circulation.
Therefore, the neonate may lose 5-10% of its body
weight due to this shock at birth.
● At birth, the baby’s lips are well-adapted to closing
around a nipple to feed. They are usually parted at rest
and show sucking blisters or pars velosa? These
keep the seal when the baby sucks.
● At rest, the back of the mouth is firmly closed with the
tongue against the palate if not swallowing.
● When feeding, the baby draws the nipple far back into
the mouth then squeezes milk by elevating the dorsum
of the tongue from the front to the back against the
hard palate.
● The gums then open, the tongue slides forward, and
the system refills with milk.
● This stripping and swallowing cycle then repeats.
There is a rhythm of one breath to one or two swallows.
The efficiency of this system increases at birth from
week 40 of gestation.
● Very premature infants do not have this sucking ability
and may have to be fed by tube until they are mature
enough, and all young babies with blocked noses will
have this rhythm broken and may not feed adequately.
The pharyngeal esophageal swallow is a primitive
function, but the child’s mouth quickly learns
discriminative and motor skills.
● In the first few months, the suck and swallow will
progress to the manipulation of more solid food without
gagging.
● All infants have taste and smell present at birth, and
they can also learn to enjoy sweet tastes distinguished
by the taste buds at the tip of the tongue, soft palate,
and inside of the cheek.
● Breast Milk is sweeter than artificial feeds. Therefore,
breastfed infants appear to enjoy fruits as their first
foods.
● The ability to suck semi-solid food, bite, and chew
appears at 5-6 months, and lumpy food can be
tolerated at 6-7 months.
A sensitive period of this motor ability
2) PHARYNX
● Consists of the nasopharynx, oropharynx, and
laryngopharynx
3) ESOPHAGUS
● Connects the pharynx to the stomach
● The upper and lower esophageal sphincters regulate
movement
● Mucus glands create a lubricating mucus.
THE ACT OF SWALLOWING
During the voluntary phase of swallowing, a bolus of food is
moved by the tongue from the oral cavity to the pharynx.
The pharyngeal phase is a reflex caused by the stimulation
of the stretch receptors in the pharynx. The soft palate closes
the nasopharynx, and the epiglottis' vestibular folds and vocal
folds close the opening into the larynx. Pharyngeal muscles
move the bolus to the esophagus.
The esophageal phase is a reflex initiated by the stimulation
of the stretch receptors in the esophagus. A wave of
contraction or peristalsis moves the food to the stomach.
gas as the child continues to feed orally so gas is
taken in.
4) STOMACH
The best position to burp an infant: to hold its sitting
support at the back and neck to allow the gas to bubble up
straight to the esophagus. Windy? babies are more
comfortable propped up for an hour, carried upright looking
over the carrier’s shoulder or placed over the abdomen over
the carrier’s lap after the feed so that the wind can be
expelled. Therefore, being put to sleep flat on their backs.
●
The
openings
of
the stomach
are the
gastroesophageal opening and the pyloric orifice.
○ Gastroesophageal opening is to the
esophagus.
○ Pyloric orifice is to the duodenum.
The wall of the stomach consists of the externa serosa,
a muscle layer (which is lunged? Into the circular and
oblique), a submucosa, and simple columnar
epithelium surface mucous cells.
Rugae are folds in the stomach when it is empty.
Gastric pits are the openings to the gastric glands.
●
●
●
●
●
●
●
●
●
●
●
SECRETIONS OF THE STOMACH
Gastric juice - this is stomach secretions.
Chyme is ingested food mixed with gastric juice.
Mucus protects the stomach lining.
Pepsinogen is converted to pepsin, which digests
proteins.
Hydrochloric acid promotes pepsin activity and
kills microorganisms.
Intrinsic factors are necessary for vitamin B12
absorption.
Gastrin and histamine regulate stomach
secretions.
Hydrogen-potassium exchange pump - proton
pump which moves the hydrogen out of parietal
cells.
3 PHASES OF STOMACH SECRETIONS
The sight, smell, taste, or thought of food initiate the cephalic
phase. Nerve impulses from the medulla stimulate
hydrochloric acid, pepsinogen, gastrin, and histamine
secretion. Distention of the stomach, which stimulates gastrin
secretion and activates CNS and local reflexes that promote
secretion, initiates the gastric phase. Acidic chyme, which
enters the duodenum and stimulates neural reflexes and the
secretion of the hormones, such as secretin and
cholecystokinin that inhibit gastric secretions, initiates the
intestinal phase.
MOVEMENTS OF THE STOMACH
Mixing waves makes the stomach contents with stomach
secretions to form chyme. Peristaltic waves move the chyme
into the duodenum.
● The stomach normally holds food for 4-6 hours, and
has many important functions in digestion.
○ Its capacity increases as the child grows.
● Prior to birth, the GI tract is filled with fluid, and the
remnants of the developing bowel lumen acid grows
and sheds the lining.
● By 5 months, the fetus is swallowing small amounts
of amniotic fluid, dead hair, and skin cells and bile
excreted from the liver. Together, they form the
meconium, which is eventually passed through the
rectum as stomach’s first stool and proof of anal
function.
● At the first few breaths after birth, the infant
swallows air. After 3 hours, the whole gut contains
PEDIATRIC VARIATIONS
The position and shape of the infant’s stomach is high in the
abdomen and is oriented transversely rather than vertically
as in the older child. So, the older child we are referring to is
the 7-to-10-year-old child. The capacity of the stomach
changes with age (Table 7.1).
●
●
●
●
●
●
●
●
●
●
Emptying time of the stomach of a newborn is 2 and
a half to 3 hours.
5 YO - 3-6 hours.
At birth, the abdomen and thorax have equal
circumference, as all muscles of the body are poorly
developed initially.
The abdomen will appear prominent in early
childhood.
Muscle development also affects the digestive tract
and lowers esophageal tone.
○ An important barrier to preventing the
reflux of stomach contents.
The functional immaturity of the lower esophagus
sphincter also leads to inappropriate relaxation,
and the short intra-abdominal length of this
contributes to the child being able to readily bring
back their meals.
Hydrochloric acid in the stomach is present at birth
but falls too low to facilitate much digestion of
protein by the stomach enzyme pepsin or
destruction of ingested bacteria.
The bottle-fed neonate will be vulnerable to orallytransmitted gut infections from poor sterilization
techniques.
The stomach’s role at this time, however, is more
important for the coagulation of the casein of milk
and controlling its passage to the small intestine.
Curd or casein may stain the stomach and can be
gradually broken down over 24 hours, whereas the
fluid way will move through the duodenum within an
hour.
4) SMALL INTESTINE
● Divided into the duodenum, jejunum, and ileum
● Circular folds, villi, and microvilli greatly increase
the surface area of the intestinal lining.
● Absorptive goblet, granular, and endocrine cells
are in the intestinal glands.
● Duodenal glands produce mucus.
●
●
●
●
●
●
●
SECRETIONS OF THE S. INTESTINE
Mucus protects against digestive enzymes and
gastric acids.
Digestive enzymes such as disaccharides and
peptidases are bound to the intestinal wall.
Chemical or tactile irritation, vagal stimulation, and
secretin stimulate intestinal secretion.
MOVEMENT OF THE S. INTESTINE
Segmental contractions mix intestinal contents.
Peristaltic contractions move materials distally.
Distention of the intestinal wall, local reflexes, and
the parasympathetic nervous system stimulate
contractions.
Distention of the cecum initiates a reflex and
stimulates the contraction of the ileocecal sphincter.
PEDIATRIC VARIATIONS OF THE S. INTESTINE
Enzymes
Weaning
Mature for
milk diet
Recommen
ded from 6
months
Lactase
enzyme
activity
Amylase
First
3
months:
pancreatic
juice = little
lipase
Rice
is
recommend
ed at a first
cereal
FTT
Calorie
Needs
Too little
High
Metabolic
rate
Failure to
utilize
nutrients
Too much
out
BMR
Multifactoria
l
Choking still
a danger
Cow’s milk
protein
Most biochemical and physiological functions are present at
birth. Secretory cells are functional, but mature in efficiency
with age. The pancreatic secretions are sufficiently mature
for a milk diet, and lactose can be digested from 40 weeks of
gestation. This lactase enzyme activity is high in the small
intestine at birth but declines during infancy and is lost in adult
life for many individuals. Amylase, a pancreatic enzyme
secreted in the duodenum that breaks down carbohydrates
and enterokinase, which is secreted from the ileum mucosa
to activate trypsin for the breakdown of proteins to peptides,
are also present in the neonate gut. In the first 3 months,
pancreatic juice contains only a little lipase, which limits the
baby’s capacity to convert fat into fatty acids and glycerol.
Specific long-chain polyunsaturated fatty acids are
present in breast milk to feed the large developing brain, thus,
nature has matched the milk supply to the young human’s
physiology. First foods of brown rice and fruits are more easily
digested as starch and fructose are simple to digest.
Weaning programs are recommended from 6 months. They
incorporate the need to increase the consistency and texture
of solid foods at this age. Rice is recommended as a first
cereal because of the possibility that an allergy to gluten may
occur to some children. Wheats, oats, rye, and barley contain
gluten, but rice and corn do not. Choking on large lumps is
still a danger at this age. After 6 months, a mix of foods is
necessary to provide sufficient energy and trace elements
especially iron and vitamins. Cow’s milk protein is also
difficult for the child under 1 year to digest, and if given as the
main food is thought to be the one of the common causes of
iron deficiency anemia at this age. Salty foods should be
restricted in childhood, because sodium intake is indicated
in the onset of hypertension and cardiovascular damage in
adulthood.
Food that is dense in calories offered at routine meal times
is preferred so that snacking habits during the day are not
encouraged, especially under 5 YO. Children who fail to
thrive from feeding problems can be classified under too little
in, failure to utilize nutrients, and too much out. Too little food
intake can be due to physical feeding difficulties, such as cleft
palate or sore mouth, excess vomiting (which itself can be a
symptom of a multitude of conditions), anorexia (child refuses
to eat for psychological reasons), ignorance to feeding
requirements (such as parents with learning difficulties or
poor education), and economic poverty (where there is not
enough understanding or money to buy and generate healthy
meals for the family). Failure to utilize nutrients include
genetic conditions, such as cystic fibrosis, congenital
diseases (such as gluten allergies) or severe infestations
(such as intestinal worms) Too much out includes infections
(such as E. coli and Campylobacter) toddler diarrhea (which
is common when the child moves from baby diet to a more
mixed, lumpy diet of adult foods, and their digestion
processes are immature), and chronic conditions (such as
diabetes).
Children need to eat to fuel their high metabolic rate and
to support their energy expenditure for growth. Increases
in height and changes brought about by developmental
milestones lead to changes in shape and basal metabolic
rate. As surface area reduces to body mass and as size
increases, so do the calorie needs per kilogram reduce over
childhood. BMR and the use of fuel when the individual is at
rest is where the energy released from foods meets the needs
of the heart, lungs, nervous system, and kidneys, and excess
is lost as heat through the skin.
● The energy required to raise the temperature of 1
kilogram of water by 1 degree Celsius is 1
kilocalorie or 1,000 calories.
● The calorie needs of the preschool child from 15 YO, however, are not as high as that of the infant
but small children still need frequent and varied
meals with snacks consisting of foods high in
nutritional value.
● For the average child who is growing normally and
has a normal activity level, counting calories is
usually not necessary. Being familiar with calorie
requirements can also be helpful to evaluate a child
with failure to thrive, who is gaining weight well and
for a child who is overweight. In addition to age, for
older children, calorie requirements are also
identified by their gender, with boys, in general,
requiring more calories than girls. Other factors
include the child’s size, body composition, and
activity level.
5) LIVER & GALLBLADDER
● The liver has 4 external lobes - right, left, caudate,
and quadrate.
● Internally, the liver is divided into 8 segments.
○ Structural and functional units of liver =
hepatic lobules
○ Liver segments are divided into lobules.
● The hepatic cords are composed of columns of
hepatocytes separated by the bile canaliculi.
● The sinusoids are enlarged spaces filled with blood
and lined with endothelium and hepatic phagocytic
cells.
● Fx: The liver produces bile, which contains bile salts
that emulsify fats. The liver stores and processes
nutrients, produces new molecules, and detoxifies
molecules.
○ Hepatic phagocytic cells phagocytize RBCs,
bacteria, and other debris.
○ The liver produces blood components as well.
(2) The hepatic portal vein carries nutrient-rich,
deoxygenated blood from the intestines through the
porta of the liver. Hepatic portal vein branches become
part of the portal triads. Blood from the hepatic portal
vein branches enters the hepatic sinusoids and
supplies hepatocytes in the hepatic cords with
nutrients.
(3) Blood in the hepatic sinusoids that comes from the
hepatic artery and hepatic portal vein picks up plasma
proteins, processed molecules, and waste products
produced by the hepatocytes of the hepatic cords. The
hepatic sinusoids empty into central veins. The central
veins connect to hepatic veins, which connect to the
inferior vena cava.
(4) Bile produced by hepatocytes in the hepatic cords
enters bile canaliculi, which connect to hepatic duct
branches that are part of the portal triads.
(5) The hepatic duct branches converge to form the left
and right hepatic ducts, which carry bile out the porta
of the liver.
Portal triad = portal vein + hepatic artery + bile duct
Hepatic artery = oxygen rich & nutrient poor
Portal vein = oxygen poor & nutrient rich
BLOOD FLOW THROUGH THE LIVER
Branches of the hepatic artery and hepatic portal vein in the
portal triads empty in hepatic sinusoids. Hepatic sinusoids
empty into central veins, which join to form the hepatic veins,
which then leave the liver.
BILE TRANSPORT
●
●
●
●
●
Bile canaliculi collect bile from hepatocytes and join
the small hepatic ducts in the portal triads
Small hepatic ducts converge to form the right and left
hepatic ducts which exits the liver
The left and right hepatic ducts join to form the
common hepatic duct
The cystic duct from the gallbladder joins the common
hepatic duct to form the common bile duct
The common bile duct and pancreatic duct join the
hepatopancreatic ampulla which opens into the
duodenum at the major duodenal papilla
GALLBLADDER AND BILE STORAGE
●
The gallbladder is a small sac on the inferior surface
of the liver, it stores and concentrates bile.
Regulation of Bile Secretion And Release
BLOOD AND BILE FLOW THROUGH THE LIVER
(Figure 21.19)
(1) The hepatic artery carries oxygenated blood from the
aorta through the porta of the liver. Hepatic artery
branches become part of the portal triads. Blood from
the hepatic artery branches enters the hepatic
sinusoids and supplies hepatocytes in the hepatic
cords with oxygen.
Words in Process Figure 21.21 (image above)
1) Secretin, produced by the duodenum (purple
arrows) and carried through the circulation to the
liver, stimulates bicarbonate secretion into bile
(green arrows inside the liver)
2) Cholecystokinin, produced by the duodenum (pink
arrows) and carried through the circulation to the
gallbladder, stimulates the gallbladder to
3)
4)
●
●
contract and sphincters to relax, thereby
releasing bile into the duodenum (green arrows
outside the liver)
Vagus nerve stimulation (red arrows) causes the
gallbladder to contract, thereby releasing bile into
the duodenum
Bile salts stimulate bile secretion. 90% of bile salts
are reabsorbed in the ileum and returned to the liver
(blue arrows), where they stimulate additional
secretion of bile salts.
Secretin increases bile secretion
Cholecystokinin stimulates gallbladder contraction
and relaxation of the sphincters of the bile duct and
hepatopancreatic ampulla
Expounding on the liver’s vital functions:
● Several of its abilities are linked closely to digestion of
food.
○ The liver receives all the circulating blood and
filters out substances such as alcohol and
drugs
○ It breaks down worn-out red blood cells,
which it secretes as bile into the duodenum to
help digest fats
○ It redirects absorbed nutrients received via
the hepatic portal vascular system to all
organs and tissues
○ Stores vitamin A and other fat-soluble
vitamins and makes plasma proteins
■ Three main plasma proteins:
● Globulins: protect the
body from infection
● Albumin: maintains blood
viscosity
● Fibrinogen: involved in the
clotting cascade response
to injury
● One important action of the liver is to maintain blood
glucose levels so that the brain can continue to
function regardless of food ingestion. It does this by
responding to pancreas enzymes:
○ Insulin facilitates glucose entry to body cells
in the fed state
○ Glucagon which facilitates liver glycogen
stores to be released into the blood as
glucose in the starved state
Physiological Jaundice
● The neonatal liver is functionally immature. It has
low levels of the enzyme required for production of
bilirubin formed from the breakdown of the heme of
hemoglobin found in the red blood cells. This
enzyme system takes two weeks after birth to
develop into a normal functioning level, thus
physiological jaundice frequently occurs at this time.
● Jaundice occurs when there’s a rise of bilirubin in
the blood.
○ Normal levels are below 1.5 mg/ml
○ Jaundice is detected if the levels rise
above 3 mg/ml
● Physiological jaundice is made more severe if the
infant becomes dehydrated due to inadequate
feeding because the lack of circulating fluid allows
the concentration of bilirubin to rise and the
child becomes sleepy as the brain becomes
toxic. The risk of becoming dehydrated then
increases.
PANCREAS
ANATOMY AND HISTOLOGY
The pancreas is an endocrine and exocrine gland. Its exocrine
function is the production of digestive enzymes.
● The pancreas is divided into lobules that contain
acini. The acini connects to a duct system that
eventually forms the pancreatic duct.
● The pancreatic duct joins the hepatopancreatic
ampulla.
● The accessory pancreatic duct empties into the
duodenum at the minor duodenal papilla.
●
●
PANCREATIC SECRETIONS
The aqueous component of pancreatic juice is
produced by the small pancreatic ducts and
contain bicarbonate ions.
The enzymatic component of pancreatic juice is
produced by the acini and contains enzymes that
digest carbohydrates, lipids, and proteins.
LARGE INTESTINES
ANATOMY AND HISTOLOGY
●
●
●
●
●
●
●
●
●
●
The cecum forms a blind sac at the junction of the
small and large intestines.
The vermiform appendix is a blind tube of the cecum.
The ascending colon extends from the cecum
superiorly to the right colic flexure.
The transverse colon extends from the right to the left
colic flexure.
The descending colon extends inferiorly to join the
sigmoid colon.
The sigmoid colon is an S-shaped tube that ends at
the rectum.
Longitudinal smooth muscles of the large intestine wall
are arranged into bands called Teniae Coli.
Haustra are pouches
The mucosal lining of the large intestine is simple
columnar epithelium with mucus-producing crypts.
The rectum is a straight tube that ends at the anus.
●
An internal anal sphincter (smooth muscle) and an
external anal sphincter (skeletal muscle) are in the
wall of the anal canal.
●
●
●
●
●
SECRETIONS OF THE LARGE INTESTINES
Mucus protects the intestinal lining. Microorganisms
are responsible for vitamin K production, gas
production and much of the bulk of feces.
MOVEMENT IN THE LARGE INTESTINES
Haustra formation mixes the colon’s contents and
moves them slowly towards the anus
Mass movements are strong,
peristaltic
contractions that occur 3 or 4 times a day
Defecation is the elimination of feces. Reflex
activity moves feces through the internal anal
sphincter
Voluntary activity regulates movement through the
external anal sphincter
STOOLS
●
●
●
●
●
●
CONSTI
PATION
●
●
●
Stools of a newborn, called meconium,
are odorless, dark-green, have a
smooth paste-like appearance and are
passed within the first 24 hrs in about
85% of infants, and within about 48 hrs
in about 99% of infants.
This (meconium) is not influenced by
whether the infant is breastfed or bottlefed. After this, the method of feeding will
have an impact on stool frequency,
color, and consistency of the stool.
Breastfed
babies
have
softer,
uniformly yellow stools up to 5 times per
day or may occasionally pass no stool
for up to 3 days.
Bottle-fed babies appear more regular
and have fewer bowel actions normally
compared to their breastfed peers.
Stool frequency then reduces with age
with 96% of preschool children having
a normal average range of 3 motions
per day to every other day.
Stools in the first 2 days of life are
composed of digestive juices,
desquamated cells, and amniotic
fluid. The transitional stools are
slightly porridge-like. Water, casein, fat,
fatty acids, mineral salts, and dead and
live bacteria are present in these feces.
●
●
Water can move in either direction across the wall of
the small intestines depending on the osmotic gradient
across the epithelium.
Epithelial cells actively transport sodium, potassium,
calcium and magnesium from the intestines. Chloride
ions move passively through the wall of the duodenum
and jejunum but are actively transported from the
ileum.
SYSTEM INTERACTIONS
Effects of the digestive system on other systems.
Effects of other systems on the digestive system.
Is usually defined as a stool frequency
of less than 3 times per week. Where
the child experiences hard, painful
defecation and may subsequently
voluntarily withhold and experience an
overflow of fecal fluid.
First choice laxatives for children should
be stool softeners such as Lactulose,
which pulls water into the gut to swell
the stool and increase stimulus on the
smooth muscle to increase peristalsis
The irritant laxatives may cause the
child to have a painful tummy ache if
used without discretion
WATER AND IONS
CHILD HEALTH ASSESSMENT
ABDOMEN
The abdomen is divided anatomically into 4 quadrants. These
are the four quadrants and the organs that lie within them:
●
●
●
In adults: body water counts for approximately 60% of
total weight
In infants: it accounts as much as 75% to 80% of total
weight
In children: it averages approximately 65% to 70% of
total weight
Fluid is distributed in three body compartments:
● Intracellular: means within cells
○
35%-40% of body weight
● Interstitial: surrounding cells and blood stream
○ 20% of BW (body weight)
● Intravascular or blood plasma
○ 5% of BW
1)
2)
3)
To assess an abdomen, first inspect the surface for
symmetry and contour.
● It will be slightly protuberant in infants and
scaphoid in older children.
● Note any skin lesions or scarring
Next, auscultate the abdomen for bowel sounds
before palpating because palpating may alter bowel
movement or peristalsis and therefore disturb bowel
sounds.
● You can auscultate bowel sounds in all four
quadrants of the abdomen; these are actually
high pinging sounds that occur normally at
intervals of approximately 5-10 secs.
● They may be best heard with the bell of the
stethoscope because they are high pitched
sounds
Palpate the abdomen next in a systematic manner to
include all four quadrants
● First palpate lightly and then deeply. Then
ascertain whether any areas were tender by
watching the child’s face while palpating
Some considerations when it comes to pediatric age groups:
● For newborns and infants:
○ Kidneys may be located by deep
abdominal palpation and the right kidneys
slightly lower than the left, so it's easier to
locate
○ The optimal time to palpate the kidneys of
a newborn is during the first few hours of
life, before the bowel begins to fill with air
and obscure palpation
● For the preschool and school age children:
○ Children’s abdomens at this age are often
ticklish and these children tense or guard
their abdominal muscles when they are
touched, that would mean it would be
difficult to palpate.
○ You can try to distract the child by asking
questions about home or school or let the
child place their hand under your hand to
help them relax
ANATOMY-PHYSIOLOGY REVIEW
FLUID-ELECTROLYTE
BALANCE
AND
ACID-BASE
BALANCE
The GI system plays a major role in maintaining fluid,
electrolyte, and acid base balance. It is the main root by which
substances are taken into the body and can be a major source
of loss if vomiting or diarrhea occurs.
FLUID BALANCE
Retaining fluid is of greater importance in the body chemistry
of infants than that of adults because fluids constitute a greater
fraction of the infant's total weight.
The interstitial and intravascular fluid are often referred to as
the extracellular fluid (EFC) totalling 25% of the BW.
● In infants: the extracellular portion is much greater
totalling up to 45% of total BW
● In young children: that amount is 30%
● In adolescents: it’s 25% of BW
Distribution of Body Compartments
This is a more visual representation of distribution of body
compartment in adults vs infants
Key Points
Fluid Obtained:
● Fluid is normally obtained by:
○ The body through oral ingestion of fluid
○ Water formed in the metabolic breakdown
of food
Fluid Lost:
● Primarily, fluid is lost by:
○ Urine
○ Feces
● Minor Losses (aka Insensible Losses):
○ Evaporation from skin and lungs
○ Saliva
■ These are of little importance
except
for
children
with
tracheostomies or those requiring
nasal-pharyngeal suction
Pediatric Variations:
● Infants do not concentrate urine as well as adults due
to:
○ Kidneys are immature
■ They have a proportionally greater
loss of fluid in their urine.
○ Relatively greater surface area to body
mass
■ Also causes greater insensible loss
of fluid
● Fluid Intake is altered if child is nauseated and unable
to ingest fluid or is actively vomiting and losing fluid that
is ingested
● When diarrhea occurs or if child becomes diaphoretic
because of fever, the fluid output can also be markedly
increased
● Dehydration occurs when there is an excessive loss
of body water
Fluids
To help understand fluids, fluid loss and fluid exchange.
For example, an adult weighing 70 kg:
● ECF (Extracellular Fluid Volume) = 14,000 mL
● Ingests = 2000 mL of fluid every day
● Excretes = 2000 mL as urine every day
● Meaning, 14% of the adult’s total ECF (2000 mL of
14,000 mL) is exchanged each day.
However, in contrast, to an infant weighing 7 kg:
● ECF volume = 1750 mL
● Ingests = 700 mL daily
● Excretes = 700 mL daily
● Meaning, exchange is 40% of their volume daily
(there’s an increased exchange rate leading to fluid
balance being more critically affected when they are
ill).
○ Adults, even when they don’t eat for a day
because of a GI upset or some other
condition and whose kidneys would continue
to excrete at a normal rate, would only have
14% less fluid in the extracellular space by
the end of the day.
○ Meanwhile, infants who do not eat for a day,
providing that their kidney function remains
constant, will be 40% short of ECF by the end
of the day. Obviously, there is a more
important loss of fluid in an infant.
This implies:
● That dehydration is always a more serious problem
in infants than in older children and adults.
Method to Calculate Fluid Requirement
for Infants and Children
Body Weight
Fluid Requirement per 24 hrs
Up to 10 kg
100 mL/kg
11-20 kg
1000 ml + 50 ml/kg for each additional
kg over 10 kg
More than 20 kg
1500 ml +20 ml/kg for each additional
kg over 20 kg
2) HYPERTONIC DEHYDRATION
● Water is apt to be lost in a greater proportion than
electrolytes when fluid intake decreases in conjunction
with fluid loss increase.
● This may occur in a child with nausea because they will
be prevented from taking in fluid or with fever because
there is an increase of fluid loss through perspiration.
● Perfused diarrhea also where there is a greater loss of
fluid than salt or in renal diseases associated with
polyuria such as nephrosis with diaphoresis so in this
instances, fluid loss is out of proportion to the loss of
electrolytes and with such an increase of fluid than the
electrolytes become concentrated in the blood.
● Because of that fluid shifts from the interstitial and
intracellular spaces into the bloodstream, so areas
from less osmotic pressure to areas of greater
pressure.
● Dehydration occurs at the interstitial and intracellular
compartments. Meaning, this will lead to an
increased/elevated red blood cell count and hematocrit
because the blood is more concentrated than usual.
● So levels of electrolytes such as sodium, chloride, and
bicarbonate will also be likely increased.
3) HYPOTONIC DEHYDRATION
● With this type of dehydration there is a
disproportionately high loss of electrolytes relative to
the actual fluid that is lost.
● So the plasma concentration of sodium and chloride
will be low, this can result from excessive loss of
electrolytes from vomiting or from low intake of salt
associated with extreme losses through diuresis.
● Also occurs when there's extreme loss of electrolytes
in disease such as adrenocortical insufficiency or
diabetic acidosis.
● When low levels of electrolytes occur, the osmotic
pressure in extracellular spaces decreases. The
kidneys would begin to excrete more fluid to decrease
ECF volume and bring the proportion of electrolytes
fluid back into line. This may lead to a secondary
extracellular dehydration.
Signs and Symptoms of Dehydration
FLUID IMBALANCES
●
●
●
Under most circumstances, water and salt are lost in
proportion to each other. This is called isotonic
dehydration.
Occasionally, water is lost at a proportion to salt or
water depletion. This is called hypertonic
dehydration.
At other times electrolytes are lost at a proportion to
water, called hypotonic dehydration.
1) ISOTONIC DEHYDRATION
● When a child’s body loses more water than it absorbs,
for example, if they undergo diarrhea, or if they absorb
less fluid than they excrete, such as nausea and
vomiting, the first result is a decrease in volume of
blood plasma.
● The body compensates for this rapidly by shifting
interstitial fluid into the blood vessels.
● The composition of fluid in these two spaces is similar
so the replacement by this fluid does not change
plasma composition.
● However, this replacement phenomenon can proceed
only until the interstitial fluid reserve is depleted.
● That is a danger point for a child since it's difficult for
the body to replace interstitial fluid from the intracellular
fluid.
● If an infant continues to lose fluid after this point, the
volume of plasma will continue to fall rapidly, this will
ultimately result in cardiovascular collapse.
Isotonic
Hypotonic
Hypertonic
Thirst
Mild
Moderate
Extreme
Skin Turgor
Poor
Very Poor
Moderate
Skin
Consistency
Dry
Clammy
Moderate
Skin
Temperature
Cool
Cool
Warm
Urine Output
Decreased
Decreased
Decreased
Activity
Irritable
Lethargic
Very
Lethargic
Serum
Sodium Level
Normal
Reduced
Increased
ACID-BASE IMBALANCE
The GI system often is involved with two severe acid-base
imbalances, namely, metabolic acidosis and metabolic
alkalosis. These imbalances occur with severe diarrhea or
vomiting.
When dealing with acid-base balance a key component is pH.
This denotes whether a solution is acidic or alkaline, determined
by the proportion of hydrogen ions in relation to hydroxide ions.
● Happens due to severe diarrhea and vomiting
● A solution is acidic if it contains more hydrogen ions
than hydroxide ions.
○ Acid solution = pH below 7.0
● It is alkaline if the proportion of hydroxide ions
exceeds that of hydrogen ions
○ Alkaline solution = pH above 7.0
● Whether body serum is becoming acidotic is
determined by analyzing a sample of arterial blood
for blood gasses.
● Normal values:
○ Normal Blood pH: 7.35 to 7.45
○ Normal PCO2: 35 to 45 mm Hg
○ Normal HCO3: 22 to 26 mEq/L
●
1) METABOLIC ACIDOSIS
● May result from diarrhea.
● When diarrhea occurs a great deal of sodium is lost
with stool. This excessive loss of sodium causes the
body to conserve hydrogen ions in an attempt to keep
the total number of positive and negative ions in the
serum balanced.
○ As a result, a child becomes acidotic if the
number of hydrogen ions in the blood
increases proportionately over the number of
hydroxide ions present
● With metabolic acidosis, arterial blood gas analysis will
reveal a decreased pH (under 7.35) and a low
bicarbonate (HCO3) value (near or below 22
mEq/L).
○ The lower the bicarbonate value is,
presumably the more sodium ions that have
been lost, or the more extensive the diarrhea
has been
● To correct the problem, the body uses both its kidney
(slow) and respiratory (fast) buffering system because
a pH that's too low is actually incompatible with
life.
●
BUFFERING SYSTEMS
1) Respiratory buffering system
● This attempts to correct the imbalance quickly.
Hydrogen ions combine with bicarbonate ions to
form carbonic acid.
● In turn it is broken down to CO2 and water, which is
then eliminated by the lungs during expiration.
● This process works immediately
● As it continues for a time, the bicarbonate level in
the serum falls lower and lower as the body uses up
its bicarbonate store.
2) Kidney buffering system
● In the kidneys, hydrogen ions are excreted directly
or they combine with other substances such as
phosphate and ammonia to form a weak acid which
is then excreted.
● Unfortunately this process is quite slow and it takes
up 24hrs
● The child breathes rapidly (hyperpnea) to blow off
the carbon dioxide to prevent it from combining with
water and reforming bicarbonate
● Urine then becomes more acidic as ammonia
formation is increased
2) METABOLIC ALKALOSIS
● With vomiting a great deal of hydrochloric acid is lost.
● When chloride ions are lost, this way, the body has
to decrease the number of hydrogen ions present so
the number of positive and negative charges remains
balanced.
●
●
●
●
This causes the child to become alkalotic as the
number of hydrogen ions becomes proportionally
lower than the number of hydroxide ions present
To further reduce the number of hydrogen ions, the
lungs conserve carbon dioxide and water by slowing
respiration (hypopnea)
The excessive carbon dioxide retained by this
maneuver dissolves in the blood as carbonic acid and
is then converted into excessive hydrogen and
bicarbonate.
With metabolic alkalosis, therefore the serum
bicarbonate invariably will be high. The higher the
value, presumably, the more chloride ions have been
lost. Or the more extensive the vomiting has been
The child will experience/symptoms:
○ Slow, shallow breathing
○ Elevated pH (near or more than 7.45)
○ HCO3 level near or more than 28 mEq/L
When alkalosis occurs from vomiting, a secondary
electrolyte problem often occurs.
○ As the kidneys begin to conserve hydrogen
ions, potassium ions are exchanged for
hydrogen ions, that means potassium ions
are excreted in order to retain the hydrogen
ions. As a result of this loss of potassium into
the urine, low potassium levels invariably
accompany metabolic alkalosis, which results
in hypokalemia.
DIAGNOSTIC PROCEDURES AND RELATED SPECIAL
CONSIDERATIONS
Many of the specimens needed for diagnostic examination for
children are collected in the same way they are for adults. Older
children are able to cooperate if given proper instruction
regarding what is expected of them, However, infants and small
children are unable to follow directions or control body function
sufficient to help in collecting specimens.
Fundamental Steps Common to All Procedures:
1) Assemble the necessary equipment
2) Identify the child
3) Always perform hand hygiene
4) Follow aseptic technique and standard precautions
5) Explain the procedure to the parents and child
6) Prepare the area
7) Place specimen in appropriate containers
8) Apply patient ID label to the specimen container in the
present of child and family
9) If there are any puncture devices, discard those in a
safe labeled area
10) Remove gloves and perform hand hygiene after the
procedure. Have children wash their hands as well (if
they helped in the procedure)
11) Praise the child for helping and document any pertinent
aspects of the procure
STOOL EXAMINATION AND STOOL OPEH
DEFIN
ITION
●
●
●
●
Frequently collected from children to
identify ova and parasites and other
organisms that cause diarrhea
It also is needed to assess gastrointestinal
function and check for occult blood.
Ideally stool should be collected
without contamination of urine but in
children wearing diapers this is rather
difficult unless a urine bag is applied.
Children who are toilet trained should
urinate first and flush the toilet and then
defecate into the toilet or a bedpan, or a
commercial potty hat or by placing a
collector cup device on a toilet
●
●
●
●
N/CO
NSIDE
RATIO
NS
●
●
●
Stools specimen should be large enough
to obtain ample sampling, not only a fecal
fragment
The specimens are placed in an
appropriate container covered with label
if several specimens are needed, always
mark with date and time collected and
keep them in a specimen refrigerator
Always exercise care in handling
specimens because of the risk of
contamination.
If you need to obtain a stool specimen, you
can place a plastic wrap over the toilet
bowl before defecation. After that, you can
use a tongue depressor or disposable
spoon/ knife to collect the stool
Always be certain the stool specimens are
sent to the lab promptly so that they do not
dry and have to be collected a second
time, since doing this again will be difficult
because you need to wait at least 24 for
more hrs
If the stool specimen is for ova and
parasites, see that it arrives in the lab in
less than an hour. Do not refrigerate ova
and
parasite
specimens
because
refrigeration would destroy the organisms
to be analyzed
○
○
X-RAY STUDIES
DEFINI
TION
●
●
BACTERIAL CULTURE
DEFINI
TION
It is a test to confirm whether a child has a
bacterial infection.The test can also identify what
type of bacteria caused the infection such as food
poisoning and sepsis, which helps guide
treatment decisions.
SPECI
MENS
A health care provider will take a sample of blood,
stool, urine, skin, mucus or spinal fluid for the
bacterial culture test.
PROCE
DURE
The HCP will take a small substance from the
body of the child and send this sample to the
laboratory. Once at the laboratory, experts in the
field would use special techniques to deliberately
encourage any microorganisms in the sample to
grow and multiply. They would then examine the
sample under a microscope to identify a bacteria
or yeast.
TYPES
CONSI
DERATI
ONS
Stool culture, blood culture, CSF fluid culture,
throat culture or throat swab, sputum culture, urine
culture and wound culture.
●
●
●
To prepare the client, you must assist
them physically. We should also help
prepare the client emotionally and
psychologically.
With pediatrics, we use age appropriate
therapeutic communication techniques
to explain the procedure, what to expect,
the risks, the time frame for receiving
results, and so on.
When a client asks,
○ “How do I prepare for a
bacterial culture test?” You
could answer that they don’t
necessarily
require
any
preparation but it is an option to
ask the HCP whether there are
any special instructions.
“What are the risks of this test?”
Bacterial culture tests have a
very low risk of any
complications, except for
blood and CSF. These cultures
would involve a small chance of
infection and bleeding because
these tests would involve a
needle puncture in the skin.
“When will I know the result of
the bacterial culture test?” After
the sample goes to the lab, lab
staff would use specific
techniques to make the cells
multiply and grow, the process
may take 1-5 days, depending
on the type of bacteria.
A variety of x-ray studies are used to
inspect internal body tissues. These
range from simple x-rays to more
complicated computed tomography (CT
scan) or Dye contrast study.
Flat plate radiographs could be used
both to diagnose illness and check
placement on apparatus such as
Gastrointestinal feeding tubes.
○ As a rule, children accept
radiographs well because an xray machine can be compared
with a camera - an instrument
they are familiar with.
○ Caution children that although
their parent can accompany
them to the x-ray department,
they are not allowed to stay in
the room when the picture is
taken, if it's necessary for the
parent to restrain the child,
don’t do this without a lead
apron
and
lead
glove
protection, such protection is
necessary
for
portable
radiographs taken at the child’s
or infants bed side.
DYE CONTRAST STUDIES
To visualize a body cavity, some type of radiopaque dye may
be swallowed or injected into the body cavity and then
examined on radiography
BARIUM CONTRAST STUDIES (UPPER GI SERIES)
DEFINI
TION
●
●
●
●
●
●
PROCE
DURE
●
aka Barium Swallow
Barium may be swallowed to observe the
outline of the GI tract or instilled to outline
the lower portion
Type of test: X-ray (with the GI being in
focus)
Normal findings: No structural or
abnormal findings
Results time frame: within 24-48 hrs
Consent form: Not required
An upper GI series involves swallowing a
barium mixture or a dye preparation that
would show up in the x-ray.
●
●
As the client swallows this mixture, xrays or fluoroscopic pictures are made of
the upper GI tract.
The form, position, any peristaltic action,
function and abnormalities can be
visualized in the esophagus, duodenum,
and Upper portion of the jejunum.
●
will be light colored for around 24-72
hours.
After post-procedure monitoring is
completed and per HCP order, the
pediatric client is discharged with an
adult who is given further instructions.
CT- SCAN (X-RAY PROCEDURE)
GENER
AL
●
●
CONSI
DERATI
ONS
●
●
●
INDICA
TIONS/
CONTR
AINDIC
ATION
S
●
●
●
●
Caution child that barium is flavored but
does not necessarily taste good.
Try not to use the word “Dye” while
describing the procedure to prevent
young children from worrying that they
will be dyed like an easter egg, or
actually “die”, instead say medicine.
Children easily grow bored with this type
of procedure because of the time
required for the dye to reach a specific
organ to be studied. Have a child do a
long activity to make time pass faster.
If children are not allowed to eat for the
duration of a long procedure, be certain
that they receive supervision, because
they may decide to snack.
Ensure that parents understand that
children do not radiate x-rays or
radioactivity after the procedure so that
they will not be afraid to hold a child
closely for comfort.
●
●
Aspiration of contrast materials
Constipation
NURSI
NG
CARE +
PEDIA
CONSI
DERATI
ONS
●
Before the test, you may need to explain
the procedure and purpose of the test.
Instruct the client that it is important to
remain as still as possible during the test.
It is necessary to remove any jewelry,
eyeglasses, or any metal objects such as
hair clips.
Instruct the client to eat a light meal in
the evening before the test and have to
fast for 12 hours prior to the procedure.
Then during the test, need to adhere the
standard precautions, the barium is
often found to have a chalky unpleasant
taste
The client is instructed to have a deep
breath or to exhale and not to breathe as
the x-ray is taken.
After the test, instruct the client to take
laxatives due to the constipation
produced by the barium. Instruct the
client to rest and explain that the stools
●
●
●
●
●
●
●
This could diagnose ulcers, any hiatal
hernia, diverticula, gastritis, enteritis, any
strictures, varices, pyloric stenosis, and
vulgulus of the stomach.
It can evaluate and monitor any tumors
present, identify esophageal reflux, and
also detect foreign bodies.
Contraindications: Pregnancy unless
the benefit of the fetus outways the
potential risks, any suspected ileus
obstruction or GI perforation.
Sedation is recommended for infants
and children.
○ Place them on a blanket for
comfort.
POTEN
TIAL
COMPL
ICATIO
NS
●
DEFINI
TION
●
●
●
●
●
●
●
●
Computed tomography
An x-ray procedure in which many views
of an organ or a body part is obtained to
represent what the organ would look like
if it were cut into thin slices.
The procedure may require an injection
of an iodine based contrast medium.
If a radioisotope is added, the study is
referred to as “PET scan or SPECT
scan”
○ PET scan: Positron Emission
Tomography
○ SPECT scan: Single Photon
Emission
Computed
Tomography
Since a CT scan involves so many films,
it is a lengthy procedure. The machine is
complex,
large
and
potentially
frightening.
Children must lie still during the long
procedure to avoid creating shadows in
the film. To help them lie still for an
extended period, they may be given
sedatives such Chloral hydrate before
the procedure to make them sleepy.
○ Conscious sedation also may
be used.
You can assure parents that the radiation
exposure from CT scan occurs for a long
period, such low doses are used that the
actual exposure is comparable to a
regular x-ray.
Repeated CT scans can however carry a
threat of excessive radiation exposure
Abdominal CT-Scan
Pelvic CT-Scan
ULTRASOUND
DEFINI
TION
●
●
A painless procedure in which images of
internal tissue and organs such as the
appendix are produced by the sound by
the use of sound waves.
It is non-invasive which is why children
accept it easily and may even enjoy
●
●
●
●
●
watching the oscilloscope screen during
the procedure.
The transducer that is used on the body
surface to pick up internal images can be
compared to a television camera.
Be certain that parents understand that
ultrasound is not an x-ray and appears to
have no long term effects.
○ Can be repeated over and over
for serial determinations
Alert a child that a gel will be applied to
the skin over the body part to be studied
to create a sound conduction. The gel
can feel cold and sticky.
Body systems and functions to be
examined: GI system
Doppler ultrasonography is a noninvasive test that uses ultrasound waves
to identify occlusions of the veins or
arteries.
●
●
●
●
MRI OR MAGNETIC RESONANCE IMAGING
DEFINI
TION
●
●
ABDOMINAL ULTRASOUND
DEFINI
TION
●
●
●
●
●
PROCE
DURE
INDICA
TIONS
NURSI
NG
CARE +
PEDIA
CONSI
DERATI
ONS
The type of test that uses sound wave
imaging of abdominal structures
Would visualize all the upper abdominal
organs or the test may be ordered by a
specific abdominal organ or region.
Normal findings: Normal abdomen and
surrounding structures
Test results: 24 hrs
Consent form: Required
Ultrasound waves are transmitted and received
from the transducer while it is placed over the
circulatory system circulations. The returning
echoes are amplified and images are recorded on
a video and script recorder.
● Help the client in a supine position,
expose the abdomen and drape. Always
allow for privacy.
● The technician then lubricates the
abdominal surface with an acoustic (?)
gel. It would allow maximum penetration
of the ultrasound.
● The technician would position a
transducer over various regions of the
abdomen, while images would appear on
the screen that are eventually saved for
analysis.
Diagnosing of abdominal aneurysm, monitoring
small abdominal aneurysm overtime, differentiate
abdominal aneurysm from a thrombus.
●
●
●
●
●
Before the test, explain the test
procedure and purpose of the test.
Always assess the client’s knowledge
about the test
Instruct the client that there will be no
discomfort
Assist clients in removing clothing and
always provide for privacy.
Instruct the client to fast for 12 hrs before
the procedure, but encourage fluid
intake.
○ Fasting allows the stomach to
be small and empty and allows
gall bladder to be visualized
○ A full bladder helps to push
intestinal contents, especially
gas, out of the way.
During the test, adhere to standard
precautions. Assist the technician in
positioning the client and provide
emotional support while the test is being
performed.
After the test, you may wipe away the
water soluble gel and reclothe the client
when ultrasound is finished.
Encourage the client to verbalize fears in
terms of test results.
For infants and children, they will need
assistance in remaining still during the
procedure.
●
●
POTEN
TIAL
Electrodiagnostic test
Magnetic field + Radiofrequency +
computer tech to produce diagnostic
images to aid in the diagnosis of
disorders.
Newer, more open MRI machines are
able to alleviate the feeling of
claustrophobia associated with the
procedure.
Consent form: Required
Claustrophobia
COMPL
ICATIO
NS
PROCE
DURE
Child lies in a moving pallet that is pushed into the
core of the machine.
● Has an advantage over radiography
since it has no apparent effects, it can
reveal clear structural defects and soft
tissue, and if a contrast medium is
required, it is not iodine based (danger of
a reaction is minimal)
INDICA
TIONS/
CONTR
AINDIC
ATION
S
●
NURSI
NG
CARE +
PEDIA
CONSI
DERATI
ONS
●
●
●
Metal may deflect the magnetic
waves, children with a metal prosthesis
or metal dental braces may be poor
candidates for the procedure.
Hair pins and eye make up which often
have a metallic base, watches or other
jewelry should be removed.
When radio waves are turned on and off
during the procedure, a booming noise
may occur, always preparing children for
this sound (compared to the sound of
drums) as well as the feeling of
claustrophobia
that
they
may
experience.
Since the procedure may take up to 45
mins, some children need a sedative or
conscious sedation so that they can lie
quietly for the duration of the procedure.
BIOPSY
DEFINI
TION
●
Biopsy is the surgical removal of tissue
cells for laboratory analysis. Most
children with a possible diagnosis of
cancer will have a biopsy performed, to
confirm their initial diagnosis.
●
●
●
Although they are classified as minor
surgeries and are usually done on an
ambulatory basis, do not treat them
lightly.
Carry a definite surgical risk if conscious
sedation or general anesthesia is used
Anxiety producing procedure for parents
and child
CONSI
DERATI
ONS
●
●
●
LIVER BIOPSY
DEFINI
TION
●
●
●
●
●
●
●
POTEN
TIAL
●
●
COMPL
ICATIO
NS
PROCE
DURE
INDICA
TIONS/
CONTR
AINDIC
ATION
S
●
●
NURSI
NG
CARE +
PEDIA
●
●
a.k.a. As Percutaneous liver Biopsy or
Percutaneous Needle Biopsy of the
Liver
Type of test: tissue
It would examine the hepatobiliary
system
Normal findings: Absence of abnormal
cells and tissue
Test results: within 24-48 hrs
Invasive, surgical setting
Consent form: Required
●
Bleeding and bruising at the site of
biopsy
Puncture of the kidney, lung or colon,
gallbladder associated with bile leakage
and peritonitis
●
An invasive procedure performed in a surgical
setting. An incision or needle punches a small
sample of liver tissues taken under sterile
technique and examined microscopically for cell
morphology and tissue anomalies.
● May be done with an ultrasound or CT
guidance.
● Place the client in supine or LLR with the
right arm over the head, the skin is then
cleansed and a local anesthetic is
injected into the skin, over the biopsy
site. A specimen of tissue is biopsied by
excision or needle biopsy.
● Label the specimen and place it in a
container. Correctly identify the client
and the test to be performed.
● During the incision and biopsy, the client
must hold their breath for approximately
10 seconds to prevent pneumothorax.
● Afterwards, you may send specimen to
the labs
●
●
Performed to diagnose or confirm the
cause of chronic liver disease and liver
tumors and after liver transplants to
determine the cause of elevated liver
tests and determine if rejection is
occurring.
Used to help evaluate and monitor
benign tumors, malignant tumors,
abscess, cyst, hepatitis, metabolic
disorders and accumulation of bile.
Contraindications:
decrease
prothrombin time or platelet count,
inability to hold breath for 10 secs, any
anemia or hemangioma, any infections,
marked ascites, bleeding disorders or
obstructive jaundice.
Check for thrombin time and hemoglobin
PTP (prior to the procedure/test)
●
●
●
Repeat post-operative instructions since
anxious parents do not necessarily hear
well the first time
Before the test, always explain the
procedure.
If they would get sedation or analgesia,
provide this beforehand.
Help transport clients to the OR or
procedure room and drape clients
appropriately.
Instruct client that they need to be on
NPO for 12 hrs PTP
Inform the client, to hold breath for 10-15
seconds.
During the test, adhere to sterile
techniques and standard precautions.
Always provide reassurance, any calm
atmosphere during the procedure.
After the test, clean the site of the biopsy,
provide analgesia as necessary, apply
pressure dressing, and access the site
for potential bleeding.
Assess VS frequently and keep client on
bed rest for observation
Sedation is recommended for infants
and children. Place them on a blanket
for comfort and after post-procedure
monitoring is completed as per HCP’s
order, the pediatric client is discharged.
With the adult who is given further
instructions.
DIRECT VISUALIZATION PROCEDURES
DEFINI
TION
●
●
Observation of an internal body cavity by
way of a thin tube inserted through a
body surface opening.
Types: Endoscopy, colonoscopy and
bronchoscopy
FIBER OPTIC ENDOSCOPY
DEFINI
TION
●
●
●
●
●
PROCE
DURE
NSG
CONSI
DERATI
ONS
Involves an endoscope, passed through
the mouth to examine the GI tract.
It has become a common method of DX
for GI disorders in children
When
it
was
first
developed,
endoscopes were straight, stiff metal
instruments so their use was quite
limited. Now, endoscopes are fiber
optic, meaning they are more flexible
and easy to maneuver and brightly lit.
This procedure is often frightening,
however, as manipulation is necessary.
A child can easily understand an
explanation of the procedure but the
child may be uncomfortable with the
thought of someone doing it.
Endoscopy is also used as an
emergency measure to remove objects,
like quarters or safety pins, often
swallowed by children.
The physician will need to extend the child’s head
and pass the tube down into the child’s stomach
for direct observation.
●
Before the test, children are placed in
NPO for 4 hrs and may need a sedative
or conscious sedation so they can lie
quietly for the time needed.
●
●
●
Good support during the procedure is
also important. Ask whether the child
can have a digital photograph taken
during the procedure to have as a
souvenir.
After an endoscopy, edema may occur
from the pressure of the scope on the
esophagus and pharynx which means
the child requires close observation
afterwards to be certain that it is not
interfering with vital functions such as
respiration or causing discomfort
After the procedure, it is important to
always check the child’s gag reflex if it
has returned before offering any fluid for
them to drink. Observe closely the first
time the child drinks after the procedure
to ensure that gag reflex is intact despite
throat edema from the procedure or the
effect of local pharyngeal anesthetic that
may have been sprayed to the throat
PTP.
DERATI
ONS
●
●
●
●
●
●
COLONOSCOPY
DEFINI
TION
●
●
●
●
●
INDICA
TIONS/I
MPLIC
ATIONS
●
●
●
Endoscopic examination of the large
intestine with a flexible fiberscope
inserted through the anus and advanced
as far as the ileocecal valve.
Air is then blown into the bowels, to
expand the bowel walls. This technique
would allow colon walls to be visualized.
If there are any abnormalities,
photographs can be taken for analysis.
Normal findings: Normal colon
Test results: Within 24-48 H
Consent form: Required
III. COMMON GI SYMPTOMS OF ILLNESS
●
●
Vomiting and diarrhea in children commonly occur as
symptoms of disease in the GI tract, as well as
symptoms of disease in other body systems
Box 45.3. Assessing a child with altered GI function
○ For the History, you are going to look for:
■ Chief Concern
■ Past Medical History
■ Family History
○ For physical examination:
■ Start form head all the way down to
toes
Used to Dx inflammatory bowel disease,
or certain biopsies or obtain biopsy if a
malignancy is suspected.
Dx tumors, any ulcerations and
inflammations,
diverticula,
colitis,
discover any origin of bleeding,
hemorrhoids, or diverticulosis, AV
malformations and any strictures
Recommended for clients with obvious
or occult blood in stool, any abdominal
pain, Lower GI bleeding or any change
in bowel habits.
CONSI
DERATI
ONS
●
●
Unstable medical condition
Massive
intestinal
bleeding
suspected perforation of the colon
PROCE
DURE
●
Involves examination of the large
intestine from the anus to the cecum with
a fiber optic or video colonoscope.
Place the client in Lateral decubitus
position and if necessary, endoscopic
surgeries performed through removal of
any tissue, like biopsy.
●
saline laxative that would cause fluid
diarrhea so that the bowel is clean for the
procedure.
Conscious sedation is also used during
procedure to reduce discomfort.
If done on an ambulatory basis,
children are discharged 2H after the
procedure.
Children may also pass a great deal of
flatus in the first 12H because of the air
introduced during the procedure.
Be certain that parents have instructions
on what to observe after they return
home, such as abdominal pain, blood in
stool, weakness or paleness. Especially
if a polyp was removed or a biopsy
specimen was obtained.
Even
with
conscious
sedation,
colonoscopies are difficult procedures
for children to accept. Give generous
praise afterward for their cooperation, on
both preparation and actual procedure.
Sedation is recommended for infants
and children.
and
●
●
For example, pneumonia or otitis media may present
first with vomiting or diarrhea. The danger is that either
would lead to disturbance in hydration, electrolyte or
acid-base balance.
In many infants, these secondary disturbances can be
more threatening to the child than the primary disease.
VOMITING
POTEN
TIAL
COMPL
ICATIO
NS
●
●
●
●
●
●
Bowel perforation
Bleeding from biopsy sites
Mucosal tears
Tearing of spleen
Volvulus of the colon (rare)
Over
sedation
and
respiratory
depression (post-potential complication)
DEFINI
TION
The forceful ejection of gastric contents through
the mouth. It is a well-defined complex coordinated
process that is under CNS control and is often
accompanied by nausea and retching.
NSG
CONSI
●
Before the procedure, children are given
a clear liquid diet for 24H and isotonic
CAUSE
S
It has many causes including infectious diseases,
toxic ingestions, food and tolerances and allergies,
mechanical obstruction of GI tract, and metabolic
disorders, as well as others.
ASSES
SMENT
●
●
●
COMPL
ICATIO
NS
●
●
THERA
PEUTI
C
MGMT
●
●
●
●
●
○
NSG
MGMT
●
●
●
Characteristics of the emesis and
pattern of vomiting help determine the
cause. The color and consistency of the
emesis vary according to the cause
Characteristic,
pattern,
color,
consistency
○ Green bilious vomiting =
bowel obstruction
○ Curdled, mucus, fatty = poor
gastric emptying/high intestinal
obstruction
○ Forceful = pyloric stenosis
Associated symptoms
○ Fever & diarrhea = infection
○ Constipation
=
anatomical/functional
obstruction
○ Localized abdominal pain =
inflammation, PUD or peptic
ulcer disease (appendicitis,
pancreatitis)
May occur including acute fluid volume
loss (dehydration), and electrolyte
disturbances, malnutrition and aspiration
In all forms, vomiting is always potentially
serious because a metabolic alkalosis
and dehydration may result.
This is directed toward detection and
treatment of the cause of vomiting and
prevention of complications such as
dehydration and malnutrition, and if
vomiting leads to dehydration, oral
rehydration or parenteral fluids may
be required.
Antiemetic drugs may be indicated.
○ Ondansetron (Zofran) is an
antiemetic with limited adverse
effects and is beneficial when
the child is not able to tolerate
anything orally.
For children who are prone to motion
sickness, it is helpful to administer an
appropriate dose of dimenhydrinate
(Dramamine) before a trip.
The treatment for vomiting is to withhold
food from the stomach for a time as if
there is nothing in the stomach.
Vomiting cannot occur.
Most parents treat vomiting in the
opposite way. Everytime a child vomits,
they attempt to feed the child again. The
child vomits again and they feed again
and so on. This prolongs the vomiting
and intensifies the potential for
electrolyte imbalance.
The major emphasis of nursing care of
the vomiting infant and child is an
observation and reporting of vomiting
behavior and associated symptoms
and on the implementation of measures
to reduce the vomiting.
Accurate assessment of the type of
vomiting, appearance of the emesis, and
the child’s behavior in association with
vomiting, helps to establish a diagnosis.
The cause of the vomiting determines the
nursing interventions.
●
The nurse should direct efforts towards
maintaining hydration and preventing
dehydration in a vomiting child.
○ Administration of a glucose
electrolytes solution is also
important as well as including
carbohydrates to spare body
protein and to avoid ketosis
resulting from exhaustion of
glycogen stores.
○ Small frequent feedings of fluid
or foods are preferred.
○ And after vomiting has stopped,
offer more liberal fluids followed
by gradual resumption of the
regular diet.
Position the vomiting infant or child on
the side or semi-reclining to prevent
aspiration and observe for evidence of
dehydration.
○ Emphasize the need for the
child to brush the teeth or rinse
the mouth after vomiting to
dilute hydrochloric acid that
comes in contact with the teeth.
○ Carefully monitor fluid and
electrolyte status to prevent an
electrolyte disturbance.
DIFFERENTIATION BETWEEN REGURGITATION &
VOMITING
CHARA
CTERI
STIC
REGURGITATI
ON
VOMITING
TIMING
Occurs with feeding
Timing unrelated to
feeding
FORCE
FULNE
SS
Runs out of mouth
with little force
Forceful: Often
projected 1 ft away form
the infant: projectile
vomiting - projected as
much as 4ft (most often
related to Increased ICP
in newborn infants age
4-6 wks, possibly
because of pyloric
stenosis)
DESCR
IPTION
Smells barely sour;
only slightly curdled
Extremely sour smelling,
appearing curdled,
yellow, green, clear or
watery, or black; perhaps
fresh blood or old blood
staining from swallowed
maternal blood (in
newborns)
DISTR
ESS
Nonpainful; child
does not appear to
be in distress and
may even smile as
if sensation is
enjoyable
Possible crying just
before vomiting as if
abdominal pain is
present, and after
vomiting as if the force
of action is frightening
DURAT
ION
Occurs once per
feeding
Continuing until
stomach is empty;
followed by dry retching
AMOU
NT
1-2 tsp
Full stomach contents
DIARRHEA
Diarrhea
● Is a symptom that results from D/O (disorders)
involving digestive, absorptive, and secretory
functions.
● Diarrhea is caused by abnormal intestinal water and
electrolyte transport.
● Worldwide, there are an estimated 1.7 billion
episodes of diarrhea each year.
○ The incidence of morbidity in diarrhea is more
prominent in low-income countries such as
areas of Asia and Africa and among children
younger than 5 years old.
● Diarrhea caused by a virus is the major cause of
infant gastroenteritis in developing countries.
○ The most common viral pathogens that
invade the GI tract include Rotaviruses and
Adenoviruses.
○ The most common bacterial pathogens
would
include
Campylobacter
jejuni,
Salmonella, Giardia lamblia, and Clostridium
difficile.
○ Diarrhea may also be caused by Escherichia
Coli infection or E. coli.
○ It can easily be spread by common diaper
changing areas in daycare centers or airport
restrooms.
● Diarrheal disturbances involve the stomachs and
intestines (gastroenteritis), or the small intestine
(enteritis), the colon (colitis), or the colon and
intestines (enterocolitis).
● Diarrhea is classified as acute or chronic.
Two
preventive
vaccines
available
1) ACUTE DIARRHEA
● Is usually associated with infection.
● Defined a sudden increase in frequency and a change
in consistency of stools, often caused by an infectious
agent in the GI tract.
● It may be associated with upper respiratory or urinary
tract infections, antibiotic therapy, or laxative use.
● Acute infectious diarrhea or infectious gastroenteritis is
caused by a variety of viral, bacterial, and parasitic
pathogens.
●
●
VIRAL AGENT
●
AGENT
PATHOLOGY
CHARACTE
RISTICS
COMMENTS
Inclubatio
n:
48 hours
Fecal
oral
transmission
Mild
moderate
fever
Most
common
cause
of
diarrhea in
children
younger than
5 years old;
infants 6 to
12
months
old
most
vulnerable;
affects
all
ages; usually
milder
in
children older
than 3 years
old
Diagnosi
s: EIA
Seven groups
(A to G): most
group A virus
replicates
in
mature
villus
epithelial cells
of
small
intestine, leads
to
(1) imbalance
in
ratio
of
intestinal fluid
absorption to
secretion and
(2)
malabsorption
of
complex
carbohydrates
to
Vomiting
followed by
onset
of
watery stools
Fever
and
vomiting
generally
abate
in
apprx. 2 days,
but diarrhea
persists 5 to 7
days.
Immunocom
promised
children
at
greater risk
for
complication
s
Peak
occurrences
in
winter
months
important
cause
of
nosocomial
infections
●
●
●
●
●
●
The major goals in the management of acute
diarrhea include an assessment of fluid and
electrolyte imbalance, rehydration, maintenance
fluid therapy, and reintroduction of an adequate diet.
Treat infants and children with acute diarrhea and
dehydration first with oral rehydration therapy or
ORT. This is more effective, safer, less painful, and
less costly than IV rehydration.
These oral rehydration solutions (ORS) enhance
and promote the reabsorption of sodium and water
and studies indicate that these solutions greatly
reduce vomiting, volume loss from diarrhea, and the
duration of the illness.
After rehydration, ORS may be used during
maintenance fluid therapy by alternating the
solution with a low sodium fluid such as breastmilk,
lactose-free formula, or half strength lactosecontaining formula.
In older children, or as can be given, an irregular diet
continues.
You may also continue feeding or early
reintroduction of a normal diet after rehydration
because this has no adverse effects and actually
lessens the severity and duration of the illness. It
also improves weight gain when compared with the
gradual reintroduction of foods.
Infants who are breastfeeding should continue to do
so and ORS should be used to replace ongoing
losses in these infants.
Formula-fed infants should resume their formulas
as well.
In cases of severe dehydration and shock, IV fluids
are initiated whenever the child is unable to ingest
sufficient amounts of fluid and electrolytes in order
to meet ongoing daily physiologic losses, replace
previous deficits, and replace ongoing abnormal
losses.
○ The type of fluid normally used is a saline
solution containing 5% dextrose in water.
Sodium bicarbonate may also be added
because acidosis is usually associated
with severe dehydration
○ After the severe effects of dehydration are
under control, you may begin specific
diagnostic and therapeutic measures to
detect and treat the causes of the diarrhea.
●
It's good to know that the use of antibiotic therapy in
children with acute gastroenteritis is rather
controversial.
○ Antibiotics may shorten the course of some
diarrheal illnesses, especially those
caused by Shigella organisms; however,
most bacterial diarrheas are self-limiting
and the diarrhea often results before the
causative organism can be determined.
Nursing Care Management (Acute Diarrhea)
● This would take place in the home with education of
the caregiver.
○ Teach caregivers to monitor for s/s of
dehydration
○ Monitor intake-output of the child - assess
the amount of fluids taken by mouth and
assess the frequency and amount of stool
losses.
○ Education relating to ORT, including the
administration of maintenance fluids and
replacement of ongoing losses is
important.
○ ORS should also be administered in small
quantities at frequent intervals.
○ If the child with acute diarrhea and
dehydration is hospitalized, the nurse must
obtain an accurate weight and carefully
monitor intake and output.
○ Monitoring the IV infusion is also an
important nursing function. The nurse must
ensure that the correct fluid and electrolyte
concentration is infused and that the flow
rate is adjusted to deliver the desired
volume in a given time and that the IV site
is maintained.
○ Accurate measurement of output is
essential to determine whether renal blood
flow is sufficient to permit the addition of
potassium to the IV fluids.
○ Take care when obtaining and transporting
stools to prevent possible spread of
infection.
2) CHRONIC DIARRHEA
● Is more likely related to a malabsorption or
inflammatory cause.
● Is an increase in stool frequency and increased water
content with adoration of more than 14 days.
● It is often caused by chronic conditions such as
malabsorption syndromes, inflammatory bowel
disease, immunodeficiency, food allergies, lactose
intolerance, or chronic nonspecific diarrhea, or a result
of inadequate management of acute diarrhea.
3) INTRACTABLE DIARRHEA OF INFANCY
● A syndrome that occurs in the first few months of life,
persists for longer than 2 weeks with no recognized
pathogens.
● The most common cause is acute infectious diarrhea
that is not managed adequately.
4) CHRONIC NONSPECIFIC DIARRHEA (CNSD)
● Also known as irritable colon of childhood and toddler’s
diarrhea.
● Common cause of chronic diarrhea in children 6 to 54
months old.
● These children have loose stools, often with
undigested food particles, and diarrhea lasting longer
than 2 weeks’ duration.
● Children with CNSD grow normally and have no
evidence of malnutrition, no blood in their stool, and no
enteric infection.
Diarrhea in infants is always serious because infants have
such a small ECF reserve that sudden losses of water
quickly exhaust the supply. Breastfeeding may actively
prevent diarrhea by providing more antibodies and possibly
an intestinal environment less friendly to invading organisms
and should be advocated.
5) SEVERE DIARRHEA
● This may result from progressive mild diarrhea or it
may begin in a severe form.
● Infants with severe diarrhea are obviously ill.
● Rectal temperature is often as high as 39.5 to 40
degrees Celsius; PR & RR are weak and rapid; the
skin is pale and cool; infants may appear
apprehensive, listless, and lethargic.
● They have obvious s/s of dehydration such as a
depressed fontanelle, sunken eyes, and poor skin
turgor.
● The episodes of diarrhea usually consist of a bowel
movement every few moments.
● STOOL: liquid green perhaps mixed with mucus and
blood, and it may be passed with explosive force.
● URINE OUTPUT: scanty and concentrated.
● LAB FINDINGS: elevated hematocrit, hemoglobin,
and serum protein levels, because of dehydration.
○ Electrolyte determinations will indicate
metabolic acidosis.
● It is difficult to measure the amount of fluid a child has
lost but an estimate can be derived from the loss in
body weight, if it is known.
○ For example: If a child weighed 10.4
kilograms yesterday at a health maintenance
visit and today weighs only 8.9 kg, then the
child has lost more than 10% of their body
weight.
○ Mild Dehydration occurs with a loss of 2.5 to
5% of body weight. In contrast, severe
diarrhea quickly causes a 5 to 15% loss. Any
infant who has lost 10% or more body weight
requires immediate treatment.
THERAPEUTIC MANAGEMENT
●
●
●
●
Treatment focuses on regulating electrolyte and
fluid balance by oral or IV rehydration therapy.
Initiating rest for the GI tract.
Discovering the organism responsible for
Diarrhea.
All children with severe diarrhea or diarrhea that
persists longer than 24 hours should have a stool
culture taken so that a definite antibiotic therapy
can be described.
○ Stool culture may be taken from the rectum
or from stool in a diaper or a bedpan.
○ If a child can drink, the most effective way
to replace fluid is by offering ORT (oral
rehydration therapy).
○ For a child who will not drink, an IV solution
such as normal saline or 5% glucose in
normal saline is begun.
○
disease are: dehydration, acid-base imbalance with
acidosis, and shock that occurs when dehydration
progresses to the point that circulatory status is
seriously impaired.
Although infants usually have a potassium
depletion, potassium cannot be given until
it is established that they are not in renal
failure. Giving potassium IV when the body
has no outlet for excessive potassium, can
lead to excessively high potassium levels
and heart block. Before this initial IV fluid is
changed
to
a
potassium
solution,
therefore, be certain that the infant/child
has voided → this is proof that the kidneys
are functioning.
ETIOLOGY & PATHOPHYSIOLOGY
●
●
●
●
●
●
●
●
●
●
●
Most pathogens that cause diarrhea are spread by
the fecal-oral route through contaminated food or
water.
Or it may be spread from person to person where
there is close contact (e.g. daycare centers)
Major Risk Factors (esp. for bacterial/parasitic
pathogens): Lack of clean water, crowding, poor
hygiene, nutritional deficiency, and poor sanitation
○ Infants are more often susceptible to
frequent and severe bouts of diarrhea
because their immune system has not
been exposed to many pathogens and has
not acquired protective antibodies.
Worldwide, the most common cause of acute
gastroenteritis:
infectious
agents,
viruses,
bacteria, and parasites.
Rotavirus is the most important cause of serious
gastroenteritis
and
diarrhea-associated
hospitalization among children with 28% of all cases
causing fatality. Almost all children are affected with
rotavirus at least once by 5 years old.
Common bacterial pathogens: Salmonella,
Shigella, and Campylobacter.
○ Are the most frequently associated isolated
bacterial pathogens in the US. These
organisms are gram negative bacteria and
they can be contracted through raw or
undercooked food, contaminated food, or
water, or through the fecal-oral route.
Antibiotic administration: is frequently associated
with diarrhea because antibiotics alter the normal
intestinal flora which would result in an overgrowth
of other bacteria.
○ Clostridium difficile is the most common
bacterial overgrowth and accounts for
approx. 20% of all antibiotic-associated
diarrhea.
Pathogens invade GIT → increased intestinal
secretion as a result of enterotoxins, cytotoxic
mediators, or decreased intestinal absorption
secondary to intestinal damage/inflammation.
Enteric pathogens attach to the mucosal cells →
form cuplike pedestal where bacteria rest
Pathogenesis depends on whether the organism
remains attached to the cell surface resulting in a
secretory toxin (non-inflammatory type diarrhea) pr
penetrates the mucosa (systemic diarrhea)
○ Non-inflammatory diarrhea - is the most
common diarrheal illness resulting from the
action of enterotoxin that is released after
the attachment to the mucosa.
The most serious and immediate physiologic
disturbances associated with severe diarrheal
DIAGNOSTIC EVALUATION (for the child with Acute
Gastroenteritis)
1) HISTORY - begin with a careful history that seeks to
discover the possible causes of diarrhea.
● Also to assess the severity of symptoms and the risk
of complications, to elicit information about current
symptoms indicating other treatable illnesses that
could be causing diarrhea.
● Hx should include: questions regarding recent
travels, exposure to untreated drinking or washing
water sources, contact with animals or birds,
daycare center attendants, recent treatment with
antibiotics or recent diet changes.
● Hx. questions should also explore the presence of
other symptoms such as fever and vomiting,
frequency & character of stools, urinary output,
dietary habits, and recent food intake.
● Extensive laboratory evaluation is not indicated in
children who have uncomplicated diarrhea and no
evidence of dehydration because most diarrheal
illnesses are self-limiting.
● Laboratory tests are indicated for children who are
severely dehydrated and receiving IV therapy.
2) STOOL EXAM, CULTURE, OPEH - neutrophils or red
blood cells in the stool would indicate bacterial gastroenteritis
or IBD.
● The presence of eosinophils suggests protein
intolerance or parasitic infection.
● Stool culture should be performed only when are
present in stoblood, mucus, or polymorphonuclear
leukocytes ol.
● When symptoms are severe when there is a hx of
travel to a developing country and when a specific
pathogen is expected.
3) GROSS BLOOD/OCCULT BLOOD - may indicate
pathogens such as Shigella, Campylobacter, or hemorrhagic
Escherichia coli strains.
● An enzyme-linked immunosorbent assay
(ELISA) may be used to confirm the presence of
Rotavirus or Giardia organisms.
● When bacterial and viral culture results are negative
and when diarrhea persists for a few days, then you
may go ahead and examine stools for ova and
parasites.
4) OTHER TESTS - obtain a Complete Blood Count (CBC),
serum electrolytes, creatinine, and BUN in the child who has
moderate to severe dehydration or who requires
hospitalization.
● The hemoglobin, hematocrit, creatinine, and BUN
levels are usually elevated in acute diarrhea and
should normalize with rehydration.
BACTERIAL INFECTIOUS DISEASES THAT CAUSE
DIARRHEA & VOMITING IN CHILDREN (or aka):
BACTERIAL ENTERITIS
●
●
●
●
●
●
Salmonella
E. coli
C. difficile
V. cholerae
Shigellosis
Staphylococcal food poisoning
○ Most
common
microorganisms
responsible for diarrhea in children.
are
SALMONELLA
AGE
NT
PATH
OLOG
Y
CHRC
TRST
CS
Salmonella groups (nontyphoidal)
● Gram-negative rods, non-encapsulated,
non sporulating
● Incubation: 6 to 72 hours
● Diagnosis: gram stain, stool culture
●
●
●
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●
●
●
CMMT
S
●
●
●
●
Invasion of mucosa in the small and large
intestines
Edema of the lamina propria
Focal acute inflammation with the
disruption of the mucosa and micro
abscesses
Nausea, vomiting, colicky abdominal pain,
bloody diarrhea, fever
Headache and cerebral manifestations
(e.g., drowsiness confusion, seizures)
Infants may be afebrile
May result in septicemia and meningitis
(complications)
TRST
CS
●
●
CMMT
S
●
●
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●
PREV
ENTIO
N
●
●
Incidence would be higher in the summer
months wherein foodborne outbreaks are
common
Person to person transmission via
undercooked meats or poultry (especially
raw chicken & eggs)
○ About half of the cases caused
by poultry or poultry products
Related to pets
○ Dogs, cats, hamsters, turtles
○ Is communicable as long as
organisms are excreted
Not
recommended:
antibiotics,
antimotility agents
○ Antibiotics not for uncomplicated
cases
○ Antimotility agents are also
prohibited since this would
prolong transit time and carry
your state.
●
●
Abdominal pain, diarrhea,
vomiting, high fever, lethargy
Ttt (treatment): antibiotics
nausea,
Incidence much lower in developed
countries;
rampant
in
developing
countries
Most common MOT: ingestion of fecescontaminated food & H2O
Possible congenital and intrapartum
transmission
3 vaccines available
It is always best to prevent Salmonella
from occurring. Complications such as
meningitis, bronchitis, and osteomyelitis
may occur with this type of infection
To prevent salmonella or listeria-caused
gastroenteritis, this is generally good food
preparation because the source of
salmonella generally is infected food so
caution parents to:
○ Wash hands well
○ Wash utensils and cutting boards
used to prepare food especially
raw chicken and eggs with hot,
soapy water; prepare chicken
last if possible
○ Refrigerate food (ref. chicken
and eggs always; cook eggs
thoroughly)
○ Wash raw vegetables thoroughly
Avoid certain foods:
○ Soft cheeses (e.g., feta, brie,
camembert, mexican fresco
queso cheese)
○ Always cook leftover foods or
ready to eat foods (e.g., hotdogs)
○ Avoid foods prepared from
delicatessen counters such as
prepared
salads,
meats,
cheeses
○ Pates, meat spreads
○ Raw, unpasteurized milk
Proper turtle handling
SALMONELLA TYPHI
ESCHERICHIA COLI
AGE
NT
PATH
OLOG
Y
Salmonella typhi
● This produces enteric fever so there is a
systemic syndrome that means a
systemic disease characterized by fever
and abdominal pain.
● Incubation could be 7 to 1 days but could
be 3 to 30 days depending on size of
inoculum.
● Diagnosis: (+) blood stool & urine cultures
● Late Stage: (+) bone marrow culture
●
●
CHRC
●
There is bloodstream invasion with
Salmonella type so after ingestion, the
organism would attach to the microvilli of
ileal brush borders and bacteria will
invade the intestinal epithelium via the
peyer's patches.
Organism is transported to intestinal
lymph nodes and enters the bloodstream
via thoracic ducts. Eventually the
circulating
organism
reaches
reticuloendothelial cells and causes
bacteremia.
Manifestations would depend on the age
AGE
NT
PATH
OLOG
Y
CHRC
TRST
CS
E.coli
●
●
Incubation: 3 to 4 days
Diagnosis: Sorbitol MacConkey agar
positive for blood, but fecal leukocytes
absent or rare
E. coli strains produce diarrhea as a result of
enterotoxin production, adherence, or invasion
(enterotoxigenic-producing
E.coli,
enterohemorrhagic E.coli, enteroaggregative E.
coli).
●
●
Watery diarrhea 1 to 2 days, then severe
abdominal cramping and bloody diarrhea
Can progress to hemolytic uremic
syndrome (read more daw)
○ Hemolytic uremic syndrome
(HUS) is a condition that can
occur when the small blood
vessels in your kidneys become
damaged and inflamed. This
damage can cause clots to form
in the vessels. The clots clog the
filtering system in the kidneys
CMMT
S
PREV
ENTIO
N
and lead to kidney failure, which
could
be
life-threatening.
(Google)
PATH
OLOG
Y
●
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Foodborne pathogen
Traveler’s diarrhea
Highest incidence in summer
Nurser epidemics
Symptomatic treatment
AVOID Antibiotics, antimotility agents, &
opioids
CHRC
TRST
CS
●
●
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●
Food handling precautions
Proper handwashing
Good hygiene
Avoid eating raw or unpasteurized food
Drinking water only from reputable
sources
Cook food thoroughly
When in doubt, don’t eat or drink it
●
●
Enterotoxins: Invades the
superficial mucosal ulceration
●
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CMMT
S
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PREV
ENTIO
N
●
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epithelium
with
Children appear sick
Symptoms begin with fever, fatigue,
anorexia
Crampy abdominal pain preceding watery
or bloody diarrhea
Symptoms usually subside in 5 to 10 days
Most cases in children <9 years old, with
about ⅓ of cases in children 1-4 weeks old
Antibiotics
Risk for dehydration
Acute symptoms may persist for 1 week
Avoid antidiarrheal medications - risk for
toxic megacolon
Food handling precautions
Proper handwashing
Good hygiene
Avoid eating raw or unpasteurized food
Drinking water from safe sources
Cook food thoroughly
When in doubt, don’t eat or drink it
VIBRIO CHOLERAE
STAPHYLOCOCCAL FOOD POISONING
AGE
NT
V. Cholerae
● Gram-negative, motile, curved bacillus
living in bodies of salt water
● Incubation: 1 to 3 days
● Diagnosis: Stool culture
PATH
OLOG
Y
●
CHRC
TRST
CS
●
●
●
AGE
NT
Enters via oral route in contaminated
food or water
If it survives an acid stomach
environment, it travels to the small
intestine where it will adhere to the
mucosa and produce toxins.
●
Onset abrupt
Vomiting,
watery diarrhea without
cramping or tenesmus (= a feeling that
you have to pass stools even though your
bowels are already empty)
Dehydration can occur quickly
CMMT
S
●
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●
More prevalent in developing countries
Rehydration (most important)
Antibiotics (can shorten diarrhea)
No vaccine
PREV
ENTIO
N
●
●
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●
Ensure safe drinking water
Avoid defecating in bodies of water
Food handling precautions, esp. Seafood
Proper handwashing
Clean bathrooms & laundry areas well
Good hygiene
SHIGELLOSIS (Dysentery)
AGE
NT
Shigella groups:
● Gram-negative non motile anaerobic
bacilli
● Incubation: 1 to 7 days
● Diagnosis: Stool culture
● MOT: Contaminated food, water, milk
PATH
OLOG
Y
CHRC
TRST
CS
Staphylococcus aureus
● Gram positive, aerobic
● Staphylococcal enterotoxin
● Incubation period: 1 to 7 hours
● SFP is caused by ingesting preformed
heat stable staphylococcal enterotoxin food can be contaminated with
staphylococcal carriers or people with
active skin infections.
● In food that is incompletely cooked or
left at room temperature, staphylococci
reproduce and elaborate enterotoxin.
● Many foods can serve as growth media
and despite contamination, they have a
normal face or older. Organisms are most
often spread through cream foods such as
potato salad.
● MOT: ingestion of contaminated food
● Diagnosis: gram stain & culture of
infected material or contaminated food.
○ Unfortunately, it is often difficult
to culture causative organisms
from the contaminated food
because
although
the
staphylococci may have been
destroyed by cooking, the
enterotoxin that usually causes
the disorder would not have been
destroyed.
● SFP is usually suspected because of case
clustering - that means it’s within families
or attendees of a social gathering or
customers of a restaurant that have it
together.
Enterotoxins: invades the
superficial mucosal ulcerations
●
●
epithelium
with
Children appear sick
Symptoms begin with fever, fatigue,
anorexia
●
●
●
CMMT
S
●
●
●
●
●
PREV
ENTIO
N
●
●
●
●
●
●
Crampy abdominal pain preceding watery
or bloody diarrhea
Symptoms usually subside in 5 to 10 days
With SFP, a child has severe vomiting and
diarrhea, abdominal cramping, excessive
salivation, and nausea within 2 to 6 hours
of eating
Most cases in children >9 years old, with
about ⅓ of cases in children 1-4 weeks old
Antibiotics
○ Antibiotic resistance
Risk for dehydration
Acute antidiarrheal medications - risk for
toxic megacolon
The child needs intensive support
therapeutic
food
and
electrolyte
replacement and perhaps administration
of a drug effective against staphylococcus
such as cefotaxime.
SFP can be prevented with proper food
preparation and proper refrigeration of
food.
Food handling precautions:
○ People with staphylococcal skin
infections should not handle
food
○ Consume food immediately or
refrigerate and not just kept at
room temperature.
Proper handwashing
Good hygiene
Strict aseptic precaution in hospitals
Antibiotic resistance is something to watch
out for - many staphylococcal strains
produce penicillinase - an enzyme that
inactivates several beta-lactam antibiotics
so they strains are resistant to penicillinG,
ampicillin,
amoxicillin,
antipseudomonal penicillin.
●
●
S/S
●
●
DEFIN
ITION
ANKYLOGLOSSIA (TONGUE-TIE)
DEFIN
ITION
Embryogenic fault that leaves a cyst formed at the
base of the tongue - drains a fistula to the anterior
surface of the neck.
●
S/S
●
●
●
Ankyloglossia
Thyroglossal cyst
Cleft lip and palate
Tracheoesophageal atresia & fistula
●
●
●
Abnormal restriction of
the tongue caused by
abnormal
tight
frenulum
(the
membrane attached to
the lower anterior tip
of the tongue)
Normally in NBs, the
frenulum
appears
short and is positioned near the tip of the
tongue. As the anterior portion of the
infant’s
tongue grows, the frenulum
becomes located further back. In most
instances, an infant suspected of being
tongue-tied has a normal tongue at birth,
it just seems short to parents who are
unaware of the newborn’s appearance.
Rarely causes speech difficulty or
destructive pressure on gingival tissue
Difficulty lifting the tongue to the upper
teeth or moving the tongue from side to
side.
The child would also have trouble sticking
out the tongue past the lower front teeth.
A tongue that appears notched or heartshaped when they try to stick it out.
THYROGLOSSAL CYST
IV. DISORDERS OF MOUTH AND ESOPHAGUS
Outline
1.
2.
3.
4.
●
Otherwise, may affect the way a child
eats, speaks and swallow, interfere with
breastfeeding
Surgical release (rare)
MGMT
●
It may occur as a dominantly inherited
trait
May involve the hyoid bone or may contain
aberrant thyroid gland tissue
As the cyst fills with fluid, swelling and
obstruction can lead to respiratory
difficulty from pressure on the trachea
If infected, the cyst appears swollen and
reddened with drainage of mucus or pus
from the anterior neck.
Surgical removal prevents the risk of
developing thyroid carcinoma
○ This cyst is surgically removed to
avoid future infection of the
space or if thyroid tissue is
present,
the possibility of
developing thyroid carcinoma
later in life.
Post-operative care
● One should observe infants closely in the
immediate postoperative period for
respiratory distress because the upper
tip area may develop some edema from
surgical trauma.
● Position infants on their side so
secretions drain freely from their mouths.
● IV fluid therapy given after surgery until
the edema at the incision recedes
somewhat and swallowing is safe once
more. This is approximately in 24 hrs.
● If the mother is breastfeeding but the
infant is NPO, encourage the mother to
express milk manually to preserve her
milk supply.
●
●
Observe infants closely the first time they
take fluid orally to ensure they do not
aspirate - prevent aspiration.
Be certain that parents feed their infant
before the infant is discharged from the
surgical unit so they can see that the infant
is swallowing safely.
CLEFT LIP & PALATE
DEFIN
ITION
●
●
●
ADDT
L
INFO
●
●
●
●
●
TTT/
MGMT
Facial malformations that occur during
embryonic development.
They may appear separately or more
often together
The most common congenital deformities
especially in the US
The palate can be divided into the primary
and secondary palates.
The primary palate consists of the medial
portion of the upper lip and the portion of
the alveolar ridge that contains the central
and lateral incisors.
The secondary palate consists of the
remaining portion of the hard palate and
all of the soft palate
Cleft lip may vary from a small notch in the
upper lip to a complete cleft extending into
the base of the nose including the lip and
the alveolar ridge.
Cleft lip can also be unilateral or bilateral
Therapeutic management
● Treatment involves cooperative efforts of
a multidisciplinary HC team including
pediatrics, plastic surgery, orthodontics,
otolaryngology (for ENT), speech and
language pathology, audiology, nursing
and social work.
● Focus:
○ Closure of the cleft(s)
○ Prevention of complications
○ Facilitation of normal growth
and development in the child
● If a cleft lip is discovered while the infant
is in utero, fetal surgery can repair the
condition although this procedure is not
usually attempted.
● If the disorder is not discovered until birth,
a CL is surgically repaired shortly
thereafter, often at the time of the initial
hospital stay or between 2 and 10 weeks
of age
● Some infants may have a nasal mold
apparatus applied before surgery to
shape a better nostril
● Because the deviation of the lip interferes
with nutrition, infants may be at better
surgical risk at birth than they are after a
month or more of poor nutrition.
● Early repair also helps infants experience
better suckling as soon as possible.
Surgery
● Because facial contours change as the
child grows, a revision of the original repair
or a nasal rhinoplasty to straighten a
deviated nasal septum may be necessary
when the child reaches 4-6 years old
(Straighten nasal septum at 4-6 years old)
● The optimal time of repair for CP is
controversial as early repair increases
speech development but may result in a
necessary second stage repair as the
child's palate arch grows
● 2 stage palate repair
○ Soft palate: 3-6 mo
○ Hard palates: 15-18 mo
● Because palate repair narrows the upper
dental arch, there may be less space in
the upper jaw in the eruption of teeth
causing poor teeth alignment.
○ All children born with CP need
follow-up treatment with a
periodontist or a dentist skilled in
children’s dental problems so
that as the child grows,
extraction or realignment of teeth
can be done as indicated.
● They also need a follow up to detect
speech or hearing difficulties occur
● Surgery: Cleft lip
○ typically: 2-3 mos
○ Common repairs:
■ Fisher repair
■ Millard
rotational
advancement
technique
○ Surgeons
often
use
a
combination of techniques to
address individual differences.
○ Nasoalveolar molding may be
also used to bring the cleft
segments
together
before
definitive left lip repair - this may
reduce the need for CL revision.
● Surgery: Cleft palate
○ Typically occurs <12 mos to
enhance
normal
speech
development
○ Most common repair/ technique:
■ Veau-Wardill-Kilner VY pushback procedure
■ Furlow
doubleopposing Z-plasty
○ Approximately 20%-30% of
repaired CP children will need
secondary surgery to improve
velopharyngeal speech.
■ The
velopharyngeal
valve includes the soft
palate as well as the
pharynx and the side
and back walls of the
throat. The purpose of
these structures is to
separate the oral and
nasal cavities during
swallowing and speech.
○ Secondary procedures may
include palatal lengthening,
pharyngeal
flat,
posterior
pharyngeal wall augmentation,
amount others
○ If a child is not a candidate for
surgical revision to improve
velopharyngeal
function,
prosthetic management should
be considered.
○
Post-op Logan Bar
● After CL surgery, the suture line
is held in close approximation
by a logan bar.
● A logan bar is wire-bow taped to
both cheeks or an adhesive
bandage such as band-aid
simulating a bar that brings
together the incision line but
does not cover the incision.
PROG
NOSIS
●
●
●
●
NURSI
NG
MGT
●
●
●
●
●
●
●
●
Multiple surgeries to achieve optimal
aesthetic outcomes (but are not at risk for
increased speech problems)
Speech impairment/speech therapy
Extensive
orthodontics
and
prosthodontics may be needed
○ to correct malpositioning of the
teeth and maxillary arches
Monitor academic achievement, social
adjustment, and behavior particularly in
children with syndromic cleft conditions.
The immediate nursing problem for an
infant with CP/CL deformities are related
to feeding.
Client education
○ Parents of NBs with cleft place
high priority in learning how to
feed their infants and identify
when they are sick but they also
express interest in learning the
infant's normal features.
Referrals to multidisciplinary team
Feeding support
○ An infant with a cleft presents a
challenge to nurses and parents.
Growth failure in infants with
CP/CL has been attributed to
preoperative feeding difficulties.
After surgical repair, most infants
who have isolated CL/CP with no
associated syndromes gain
weight or achieve adequate
weight and height for their age.
○ Cheek support
○ Breast or bottle
■ The cleft lip may
interfere
with
the
infant's
ability
to
achieve an adequate
anterior lip seal. An
infant with an isolated
CL typically has no
difficulty BF because
breast tissue is able to
conform to the cleft.
■ If bottle-fed, an infant
with an isolated CL may
have greater success
using bottles with a
wide base of the nipple
such as a playtex
nurser or NU tape
orthodontic nipple.
Position modifications
○ Help infants with CP feed more
efficiently
PREOP/P
OSTOP
CARE
Begin by positioning the child
with CP in an upright position
with the head supported by the
caregiver’s hand or cradled in the
arm. This position will allow
gravity to assist with the flow of
the liquid so that it is swallowed
instead of resulting in the loss of
liquid through the nose.
Bottle selection
Supportive techniques
Pause & burp
○ Infants with clefts tend to swallow
excessive air during feedings so
it is important to pause during
feedings and burp the infant.
○ Some cleft palate specialists
advocate for the use of feeding
obturators to assist with feeding.
These devices may increase
compression services within the
oral cavity but do not improve
feeding efficiency or growth
within the first year of life.
○ Regardless of the feeding
method used, the mother should
begin feeding the infant as soon
as possible, preferably after the
initial nursery feeding.
PRE-OP Care
● Parents may be taught to use alternative
feeding systems (e.g. syringes) several
days before surgery.
POST-OP Care
● Major effort: protecting the operative site
● For CL, parents are advised to use
petroleum jelly to the operative site for
several days after surgery.
● For CL/CP/CL&CP, elbow immobilizers
may be used to prevent the infant from
rubbing or disturbing the suture line. They
are applied immediately after a surgery
and may be used for 7 to 10 days.
● Syringe feeding
● Analgesia - required to relieve
postoperative
pain
and
prevent
restlessness. Feeding is resumed when
tolerated.
● Infant seat (upright) - especially in
infants who are having difficulty handling
secretions. Avoid the use of suction or
other objects in the mouth such as tongue
depressors or mouth thermometers,
pacifiers, spoons and straws.
● The older child may be discharged with a
blenderized soft diet. (Older child: soft
diet)
○ Parents are cautioned against
allowing the child to eat hard
items that can damaged the
repaired palate (e.g. toast, hard
cookies, potato chips)
LONG
TERM
CARE
●
●
●
●
●
●
Children with CL/CP often require a
variety of services during recovery.
Family support and encouragement is of
utmost importance.
Speech therapy
The use of orthodontic appliances
Proper and good mouth care
Development of a health personality and
self-esteem
NURSI
NG
DX
●
●
●
●
Risk for imbalanced nutrition: less than
body requirements related to feeding
problem caused by cleft lip or palate
Impaired tissue integrity at incision line
to cleft lip or cleft palate surgery
Risk for ineffective airway clearance
related to oral surgery
Risk for infection related to surgical
incision
TRACHEOESOPHAGEAL ATRESIA & FISTULA
DEFIN
ITION
●
●
●
●
●
●
Congenital esophageal atresia (EA) or
tracheoesophageal fistula (TEF) are
rare malformations that represent failure
of the esophagus to develop as a
continuous passage and a failure of the
trachea and esophagus to separate into
distinct structures.
These defects may occur as separate
entities or in combination.
Without early diagnosis and treatment,
they pose a serious threat to the infant’s
well being.
Between weeks 4 and 8 of intrauterine
life: laryngotracheal groove develops into
INCID
ENCE
& RF
●
●
●
●
●
●
PATH
OPHY
SIOLO
GY
ASSE
SSME
NT
Anomalies involving the trachea and esophagus
are caused by:
● Defective separation
● Incomplete fusion of tracheal fold after the
separation
● Altered cellular growth during embryonic
development
●
→ larynx, trachea, and beginning lung
tissue.
The esophageal lumen forms parallel to
this.
A number of anomalies may occur if the
trachea and esophagus are affected by
some teratogen that does not allow the
two organs to separate but remain
connected.
Esophageal atresia is obstruction of the
esophagus. Often a fistula or opening occurs
between the closed esophagus and the trachea.
The five usual types of esophageal atresia that
occurs are:
1) The esophagus ends in the blind pouch,
there is a tracheoesophageal fistula
between the distal part of the esophagus
and the trachea.
2) The esophagus ends in a blind pouch and
there is no connection to the trachea
3) A fistula is present between an otherwise
normal esophagus and trachea.
4) The esophagus ends in a blind pouch, a
fistula connects the blind pouch of the
proximal esophagus to the trachea.
5) There is a blind end portion of the
esophagus. Fistulas are present between
both widely spaced segments of the
esophagus and trachea.
These are all very serious disorders because during
a feeding, milk can fill the blind esophagus and
overflow into the trachea or a fistula can allow the
milk to enter the trachea resulting in aspiration.
TEF: 1 in 3000 live births
EA: 1 in 4000 live births
Slightly higher incidence in males
Birth weight significantly lower than
average
Unusual high incidence of preterm birth
with EA; subsequent increased mortality
History of maternal polyhydramnios
●
●
●
TEF ruled out in infants born to a woman
with hydramnios or excessive amniotic
fluid
○ Hydramnios occurs because
normally
a fetus swallows
amniotic fluid during intrauterine
life. A fetus with TEF cannot
swallow so the amount of
amniotic fluid (AF) can grow
abnormally large.
○ Many infants with TEF are born
preterm
because
the
accompanying
hydramnios
compounding
their
original
problem with immaturity.
○ The infant needs to be examined
carefully for other congenital
anomalies that could have
occured from the teratogenic
effect at the same week of
gestation such as vertebral,
esophageal, renal and limb
anomalies.
○ If not diagnosed in utero,
diagnosing a child who has TEF
before the infant’s first feeding is
important. Otherwise, the infant
will cough, become cyanotic,
and have obvious difficulty
breathing as fluid is aspirated.
NBs that have so much mucus in their
mouths that appear to have “blowing
bubbles” should be suspected of having
TEF.
The disorder can be diagnosed with
certainty if a catheter cannot be passed
through the infant’s esophagus to the
stomach or the stomach contents cannot
be aspirated. If doing this, use a firm
catheter because a soft one will curl in a
blind end of the esophagus and appear to
have passed.
Radiopaque catheter
○ If this is used, it can be
demonstrated coiled in the blind
●
●
●
●
C/F
●
●
●
●
●
end of the esophagus on
radiography.
Flat-plate radiograph of the abdomen
○ Also may reveal a stomach
distended with the air that is
passing from the trachea into the
esophagus and unto the
stomach
Ultrasound - (same with flat plate
radiograph)
Barium swallow (BS)
Bronchial endoscopy (BE)
○ Either the BS or BE can also
reveal the blind end esophagus
and fistula
●
●
●
●
PEPTIC ULCER DISEASE
DEFIN
ITION
Excessive frothy mucus from nose and
mouth
Three Cs
○ Coughing
○ Choking
○ Cyanosis
Apnea
Increased respiratory distress during
feeding
Abdominal distention
●
●
●
●
●
V. DISORDERS OF STOMACH AND DUODENUM
Disorders of the upper GI tract in children tend to involve
inadequate valve function or infection.
Outline:
1. Gastroesophageal reflux (GER)
2. Peptic ulcer disease
3. Pyloric Stenosis
4. Esophageal Varices
5. Gastrointestinal Bleeding
GASTROESOPHAGEAL REFLUX
DEFIN
ITION
Regurgitation of stomach secretions into the
esophagus through cardiac valve
● Occurs most frequently after meals and at
night.
● GER is different from GERD, GERD
represents symptoms of tissue damage
that result from GER.
S/SX
Symptoms in Infants
● Spitting up, regurgitation, vomiting
excessive crying, irritability, arching of the
back with neck extension, stiffening
● Weight loss, failure to thrive
● Respiratory problems
● Hematemesis
● Apnea or apparent life threatening event
Symptoms in Children
● Heartburn
● Abdominal pain
● Non-cardiac chest pain
● Chronic cough
● Dysphagia
● Nocturnal asthma
● Recurrent pneumonia
Complications
● Esophagitis
● Esophageal stricture
Laryngitis
Recurrent pneumonia
Anemia
Barrett esophagus
○ In this, normal tissue lining the
esophagus changes to tissues
that resemble the lining of the
intestine.
It
thickens
and
becomes red.
INCID
ENCE
& RF
S/SX
&
COMP
LICAT
IONS
PATH
OPHY
SIOLO
GY
●
●
●
Shallow excavation formed in the mucosal
wall of the stomach, the pylorus, or the
duodenum
Gastric ulcer: involves mucosa of the
stomach; infants
Duodenal ulcer: involves pylorus or
duodenum; adolescents
Primary: idiopathic or associated with
Helicobacter pylori infection, tend to be
chronic occurring more frequently in the
duodenum
Secondary: result from the stress of a
severe underlying disease or injury (e.g.
severe burns, sepsis, increased ICP,
severe trauma, multisystem organ failure)
and are more frequently gastric with an
acute onset.
1% to 2% of children
More frequently in males
Adolescents associated factors:
○ Infection from H. pylori
○ Genetic tendency
○ Use of NSAIDs
○ Alcohol
○ Caffeine
○ Cigarettes
The small ulceration of the gastric or duodenal
lining leads to:
● Pain, blood in the stool (melena), and
vomiting with blood (hematemesis)
● If left uncorrected, complications may
include:
○ Bowel or stomach perforation
with acute hemorrhage or pyloric
obstruction
● Chronic ulcer conditions may lead to
anemia from constant, gradual blood loss.
● The exact cause of PUD is unknown
although
infectious,
genetic
and
environmental factors are important.
● There is an increased familial incidence
likely due to H. pylori, which is known to
cluster in families.
● In addition to ulcerogenic drugs, both
alcohol and smoking contribute to ulcer
formation.
● An ulcer occurring in a neonate usually
presents with hematemesis or melena.
Such ulcers are usually superficial and
heals rapidly although they can rupture
with the symptoms of respiratory stress,
abdominal distention, vomiting, and if
extensive, cardiovascular collapse.
●
●
Imbalance between destructive (cytotoxic)
factors & defensive (cytoprotective)
factors in GI tract
Cytotoxic (mechanisms):
○
○
○
●
●
●
Acid
Pepsin
Medications (e.g., aspirin and
NSAIDs)
○ Bile acids
○ H. pylori infection
Cytoprotective:
○ Mucus layer
○ Local bicarbonate secretion
○ Epithelial cell renewal
○ Mucosal blood flow
Prostaglandins play a role in mucosal
defense because they stimulate both
mucus and alkaline secretion.
Primary mechanism (prevents PUD):
secretion of mucus from the epithelial and
mucus glands throughout the stomach
○ Thick mucus layer: diffuse acid
from the lumen to the gastric
mucosal
○
surface
→
protects
gastric epithelium
Stomach
and
duodenum
produce
bicarbonate
→
decrease acidity in epithelial
cells → minimizing effects of low
○
○
pH
With abnormality: mucosa is
vulnerable to damage from acid
and pepsin
Exogenous
factors
(e.g.,
aspirin and NSAIDs) → cause
ulcers
by
inhibition
of
prostaglandin synthesis
Zollinger-Ellison Syndrome
● RARE
● Children who have multiple, large or recurrent ulcers
● Hypersecretion of gastric acid, intractable ulcer
disease, and intestinal malabsorption caused by a
gastrin-secreting tumor of the pancreas.
DX
Eval
●
●
●
●
Diagnosis is based on the history of
symptoms, physical examination, and
diagnostic testing
The focus is on S/S such as:
○ Epigastric abdominal pain
○ Nocturnal (?) pain
○ Oral regurgitation
○ Heartburn
○ Weight loss
○ Hematemesis
○ Melena
Laboratory studies
○ CBC (to detect anemia)
○ Stool analysis (for occult blood)
○ Liver function tests (LFTs),
sedimentation rate, or CRP (to
evaluate IBD)
○ Amylase and lipase (evaluate
pancreatitis)
○ Gastric acid measurements
(identify hypersecretion)
○ Lactose breath tests (detect
lactose intolerance)
Radiographic studies
○ Upper GI series (evaluate
obstruction
or
malrotation
●
THER
APEU
TIC
MGMT
although rarely helpful in
identifying ulcers in children)
○ Fiber optic endoscopy (most
reliable procedure to detect PUD
in children)
Biopsy - determine the presence of H.
pylori
Major Goals of Therapy:
● Relieve discomfort
● Promote healing
● Prevent complications
● Prevent recurrence
Medical mgmt (primary)
● Consists of administration of medications
to treat the infection and to reduce or
neutralize gastric acid secretion
● Medications combinations
● Teens:
○ Antibiotics (amoxicillin and
clarithromycin (Biaxin))
○ Proton
pump
inhibitors
(omeprazole (Prilosec))
○ Bismuth subsalicylate (or
Pepto-Bismol) - soothing and
may be prescribed concurrently
● Younger
children:
cimetidine
(Tagamet)
○ Safe levels of omeprazole have
yet to be established for this age
group
● Antacids - beneficial medications to
neutralize gastric acid
● Histamine-receptor antagonists (H2
blockers) - act to suppress gastric acid
production
○ Cimetidine,
ranitidine
and
famotidine
○ Few side-effects
● PPI - act to inhibit the H-ion pump in the
parietal cells thus blocking the production
of acid.
○ Ex: omeprazole, lansoprazole,
pantoprazole and esomeprazole
○ Effective
in
children
and
adolescents
○ Not effective in infants
● Mucosal protective agents (sucralfate
and Bismuth-containing preparations)
may be prescribed for PUD
● Triple drug therapy is the standard firstline treatment regimen for H. pylori
○ 90% effectiveness in eradication
for H. pylori
● Common side-effects include:
○ Diarrhea
○ N&V
● Warn adolescents about gastric irritation
associated with alcohol use and smoking
●
●
●
Acute ulcer with complications (e.g.,
hemorrhage) - require emergency care;
administration of the ff depends on the amt
of blood loss:
○ IV fluids
○ Blood
○ Plasma
Replacement with whole blood or
packed cells may be necessary for
significant blood loss
Surgery - required for complications (e.g.,
hemorrhage, perforation, gastric outlet
obstruction)
○
○
○
NURSI
NG
MGMT
●
●
●
●
Ligation
Closure of perforation
Vagotomy and pyloroplasty may be indicated in children with
recurring
ulcers
despite
aggressive treatment
■ A vagotomy is a type of
surgery that removes all
or part of your vagus
nerve. Vagotomies are
traditionally done to
treat peptic ulcers by
reducing the amount of
acid your stomach
produces.
■ Pyloroplasty is surgery
to widen the opening in
the lower part of the
stomach (pylorus) so
that stomach contents
can empty into the
small
intestine
(duodenum).
Pyloroplasty may also
be done at the same
time as a vagotomy.
This
procedure
removes part of your
vagus nerve to help
with
peptic
ulcer
disease. This nerve
controls your digestive
system.
Primary Nursing Goal:
○ Promote healing of the ulcer
through compliance with the
medical regimen.
If an analgesic or antipyretic is needed:
○ Acetaminophen (not aspirin or
NSAIDs) is used
Critically-ill neonates, infants and children
in ICU should receive H2 blockers to
prevent stress ulcers.
Stress - Consider for non-hospitalized
children with chronic illness
○ In children, many ulcers occur
secondary to other conditions
and the nurse should be aware of
family
and
environmental
conditions that may aggravate or
precipitate ulcers.
○ Psychological
counseling
referrals - children may benefit
from this and from learning how
to cope constructively with
stress.
○ Stress management techniques
●
●
●
Full name: Hypertrophic pyloric stenosis
(HPS)
Obstruction of the pyloric lumen due to the
muscular pyloric hypertrophy
Occurs when the circumferential muscle
of
the
pyloric
sphincter
becomes
thickened → elongation and narrowing of
the pyloric channel → outlet obstruction +
compensatory dilation + hypertrophy +
●
hyperperistalsis of the stomach
Infants at 4-6 weeks of age vomit almost
immediately after each feeding → grows
increasingly
forceful
until
projectile
(possibly projecting as much as 3 to 4 feet)
→ dehydration, metabolic acidosis and
failure to thrive (FTT) may occur
ETIOL
OGY
●
●
Specific: UNKNOWN
Likely cause: Multifactorial inheritance
INCID
ENCE
& RF
●
Boys are affected 4 to 6 times more
frequently than girls
Most frequently seen:
○ First-born white male infants
Less frequently seen:
○ African-American and Asian
infants
○ Breastfed infants than in formulafed infants
Formula-fed infants typically begin having
s/s at approx 4 weeks of age
Breast-fed infants begin having s/s at 6
weeks because the curd of breastmilk is
smaller than cow’s milk and passes
through a hypertrophied muscle more
easily
●
●
●
●
PATH
OPHY
SIOLO
GY
The circular muscle of the pylorus thickens as a
result of hypertrophy → severe narrowing of the
pyloric canal between the stomach and duodenum
→ partial obstruction of the lumen → inflammation
and edema further reduce the size of the opening
→ complete obstruction.
● Hypertrophy pylorus may be palpable as
an olive-like mass in the upper abdomen
● Not a congenital disorder
● It is believed that local innervation is
involved in the pathogenesis
ASSE
SSME
NT
●
●
PYLORIC STENOSIS
DEFIN
ITION
●
●
●
●
Assessment: made primarily from the
history
Whenever parents say that their baby is
vomiting or spitting up, be certain to get a
full description. Examples:
○ What is the duration?
○ What is the intensity?
○ What is the frequency
○ What is the description of the
vomitus?
○ Is the infant ill in any other way?
Duration: Begins at 6 weeks of age
Intensity: Projectile vomiting
Frequency: Immediately after eating
Description of vomitus: Sour but
contains no bile
○
●
●
●
●
C/F
●
●
●
●
●
●
●
●
THER
APEU
TIC &
NURSI
NG
MGMT
●
●
Because it has reached the
stomach and has been in contact
with stomach enzymes
○ There is never bile in the vomitus
because the feeding does not
reach the duodenum
Is the infant ill in any other way? No.
Many infants have signs of dehydration
from vomiting when they are first seen.
Common signs:
○ Lack of tears
○ Dry mucous membranes of the
mouth
○ Sunken fontanelles
○ Fever
○ Decreased urine output
○ Poor skin turgor
○ Weight loss
A definitive diagnosis can be made by
watching the infant drink.
○ As the infant drinks, attempt to
palpate the RUQ for a pyloric
mass
○ If present, it feels round and firm,
approximately the size of an
olive.
○ As the infant drinks, gastric
peristaltic waves pass from left to
right across the abdomen. Olivesized lump becomes more
prominent.
●
●
●
●
SURGICAL CORRECTION
● Muscle of the pylorus is split down to the
mucosa allowing for a larger lumen.
● The procedure is often performed using a
laparoscope and consists of a longitudinal
incision through the circular muscle fibers
of the pylorus down to, but not including,
the submucosa.
● Laparoscopic surgery through a small,
single incision often results in a shorter
surgical time, more rapid postoperative
feeding and shorter hospital stay.
● Although the procedure sounds simple, it
is technically difficult to perform and there
is a high risk of infection following surgery
because the abdominal incision is near
the diaper area.
Projectile vomiting
Infant hungry, avid feeder; eagerly
accepts a second feeding after vomiting
episode
No evidence of pain or discomfort except
that of chronic hunger
Weight loss
Signs of dehydration
Distended upper abdomen
Readily palpable olive-shaped tumor in
the epigastrium
Visible gastric peristaltic waves
Surgical or laparoscopic correction
(pyloromyotomy)
○ Performed
for
electrolyte
imbalance from the vomiting or
hypoglycemia from the lack of
food occurs
○ The surgeon makes an incision
in the wall of the pylorus. The
lining of the pylorus bulges
through the incision, opening a
channel from the stomach to the
small intestine.
Pre-Op: NPO, IV fluids
○ Before surgery, if electrolyte
imbalance, dehydration, and
starvation have occurred, these
must
be
corrected
by
administration IV fluid, usually
isotonic saline or 5% glucose in
saline.
○ Oral feedings are withheld to
prevent
further
electrolyte
depletion.
○ Infant generally needs a
pacifier while receiving only IVF
to meet non-nutritive sucking
needs and be comfortable
○ Infant also needs additional
potassium if tetany is present,
verified by a low calcium level
(hypocalcemia)
and
blood
analysis.
○ IV calcium must also be
administered.
Post-Op: Feedings 4-6 hours later (full
feeding in 48 hours)
○ Beginning with small frequent
feedings of water or electrolyte
solution.
○ If clear fluids are retained about
24 hours after surgery, formula is
started in the same small
increments.
○ The amount and intervals
between feedings are gradually
increased until a full feeding
schedule is reinstated which
usually takes about 48 hours
Risks: Infection
Nursing Management: Observation for
clinical features that help establish the
diagnosis, careful regulation of fluid
therapy, and reestablishment of normal
feeding patterns
Assessment: Based on observation of
eating behaviors and evidence of other
characteristic clinical manifestations,
hydration, and nutritional status.
ESOPHAGEAL VARICES
DEFIN
ITION
●
●
●
Distended veins in the esophagus
A frequent complication of liver disorders
such as cirrhosis
Generally formed at the distal end of the
esophagus near the stomach
○
●
●
●
●
Because of back pressure on the
veins there caused by increased
blood pressure in the portal
circulation
May bleed if children cough vigorously or
strain to pass stool.
Rupture of esophageal varices is an
emergency → IV vasopressin or
nitroglycerin
○ Gastric
reflux
into
the
esophagus may irritate and
erode the fine covering of the
distended
vessels
causing
rupture
○ This is an emergency because
children can lose a large amount
of blood because of the
engorged vessels.
○ IV
vasopressin
or
nitroglycerine may be given to
lessen hypertension and reduce
hemorrhage
○ Injection of a sclerosing agent
in the veins may be attempted to
decrease their size
○ Iced saline, nasogastric lavage
may be instituted to promote
vasoconstriction
Sengstaken-Blakemore tube or LintonNachlas catheter
○ May be passed into the stomach
○ After insertion, balloons on the
sides of the catheter are inflated
to apply pressure on the bleeding
vessels
○ As with external tourniquette, the
compression must be reduced
for 5 to 10 minutes every 6 to 8
hours or tissue necrosis may
result
Monitor children for future bleeding
episodes
○ Frequent V/S measurement,
testing of stool and vomitus with
the presence of blood will
indicate
new
esophageal
bleeding.
●
●
●
●
●
●
A symptom of a D/O in the digestive tract
Upper GI Bleeding: above ligament of
Treitz
○ Causes: PUD and Esophageal
Bleeding
Lower GI Bleeding: below ligament of
Treitz
○ Causes:
■ Anal fissure
■ Allergic, necrotizing, or
infectious enterocolitis
■ Malrotation w/ volvulus
■ Intussusception (part of
the intestine slides into
an adjacent part of the
intestine)
■ Meckel’s diverticulum
(bulge in the lower part
of small intestine)
■ Juvenile polyps
■ IBD
Bleeding can be visible or occult
○ No visible evidence
○ Detected by fecal occult blood
test or signs of iron deficiency
anemia
○ Blood often appears in stool or
vomit but isn’t always visible
The level of bleeding can range from mild
to severe and life-threatening.
Finding the cause of GI bleeding can be
difficult. However, sophisticated imaging
technology can usually locate the
problem,
and
minimally
invasive
procedures often can fix it.
PEDIATRIC GI BLEEDING: NEONATES
Well-Appearing & Hemodynamically Stable
● Swallowed maternal blood → apt downey test (to
differentiate between maternal and fetal blood)→
resolves on its own
GASTROINTESTINAL BLEEDING (PEDIATRIC)
DEFIN
ITION
●
(google)
Anal Fissure
○ Primary/midline → no workup → selfhealing
○
Secondary to infection/lateral → further
testing → ttt of infection
●
Food-induced allergic proctocolitis → eliminate
cow and soy milk proteins
Ill-Appearing & Hemodynamically Unstable
●
Necrotizing enterocolitis → abdominal x-ray
(shows pneumatosis intestinalis), Bell’s criteria →
gastric decompression, IV fluids, antibiotics, surgery
●
Intestinal malrotation with volvulus → UTZ, upper
GI → IV fluids, antibiotics, Ladd surgery
Up to 5 yo
● Infectious colitis → ORS & IV therapy, antibiotics
-
(e.g., azithromycin, ciprofloxacin)
●
Meckels’ diverticulum → technetium 99 scan for
diagnosis → removed surgically
●
Intussusception → UTZ → Barium air enema,
●
surgery
○ Shows red currant jelly stool
○ UTZ: target sign
Juvenile polyposis → colonoscopy, prophylactic
surgery
●
Peptic ulcers → endoscopic thermocoagulation,
hemostatic clips, epinephrine injections
Older children + adolescents
● Mallory-Weiss syndrome, Dieulafoy lesion →
endoscopic thermocoagulation, hemostatic clips,
●
epinephrine injections
○ Mallory-Weiss syndrome refers to a tear or
laceration of the mucous membrane, most
commonly at the point where the
esophagus and the stomach meet
(gastroesophageal junction).
○ Dieulafoy lesion is an abnormally large
artery in the lining of the gastrointestinal
system.
Inflammatory bowel disease → stool calprotectin
(marker for inflammation) → ttt depends on severity
●
& extent
Occult GI bleeding with iron deficiency anemia
→ upper endoscopy, colonoscopy, wireless capsule
endoscopy
PEDIATRIC GI BLEEDING: HISTORY
History is the key to identifying the bleeding source. The
following questions should be answered:
1) Is it really blood, and is it coming from the GI tract?
Remember that a number of substances would
stimulate hematochezia and melena.
The presence of blood should be confirmed
chemically
Genitourinary problems, coughing, tonsillitis, lost
teeth, or epistaxis may cause what appears to be GI
bleeding
An adolescent female may also be experiencing
menarche
2) How much blood is there and what is its color and
character?
Identify the sites of GI bleeding and the S/S.
Example: Effortless bright red blood from the
mouth would be located as a bleeding lesion in the
nasopharyngeal or oral area; could be tonsillitis,
esophageal viruses, lacerations of esophageal or
gastric mucosa, or the Mallory-Weiss syndrome.
Vomiting of bright red blood or coffee grounds
would be a lesion proximal to ligament of Treitz
Melanotic stool could be a lesion proximal to
ligament of Treitz, upper small bowel, and blood
loss in excess of 50-100mL/24 hours.
Bright red or dark red blood in stools may be a
lesion in the ileum or colon with a massive upper GI
bleeding
A streak of blood on outside of the stool could be
a lesion in the rectal ampulla or anal canal.
3) Is the child acutely or chronically ill?
The PE should be thorough
Important: physical signs of portal hypertension,
intestinal obstruction or coagulopathy
Nasal passages should be inspected for signs of
recent epistaxis, the vagina for menstrual blood, and
the anus for fissures or hemorrhoids.
Older children: systolic BP of < 100mmHg +pulse
> 100 bpm → at least 20% reduction of blood volume
-
PR increase of 20 bpm or drop in systolic BP
>10mmHg when px sits up → sensitive index of
significant volume depletion
4) Is the child still bleeding?
Serial determinations of V/S and hematocrit are
essential to assess ongoing bleeding.
Detection of blood in gastric aspirate confirms
bleeding site proximal to ligament of Treitz
Stool testing for occult blood will help in monitoring
ongoing loss of blood
HEPATIC DISORDERS
These are liver-related conditions.
Outline:
1. Hepatitis (A, B, C, D, E)
2. Chronic Hepatitis
3. Biliary Atresia
The liver lies immediately under the diaphragm on the right side.
In infants, 1 or 2 cm of liver is readily and normally palpable.
The organ has multiple essential functions, including:
● Normal metabolism of carbohydrates, proteins, and
fats
● Conversion of indirect bilirubin → direct bilirubin
● Detoxification of harmful, absorbed substances
● Manufacturing of bile, fibrinogen, prothrombin and
heparin, among others
Because the liver, a life-sustaining organ performs all of these
functions, any disorder involving the liver is always serious.
LIVER FUNCTION TESTS
Serum
Bilirubin
Indirect bilirubin found in large quantities in
the bloodstream indicates that the child is
not converting it to direct bilirubin; hence,
liver cell function may be impaired; the
normal value of total bilirubin and serum is
1.5 mg per 100 ml; if large amounts of
direct bilirubin are found in serum, it implies
obstruction of the bile duct preventing the
excretion of the converted substance.
Stool and
urine
bilirubin
If bile pigments can be obtained from stool
(excreted as urobilinogen in stool and
urine) it is evidence that bile is being
manufactured and excreted from the liver;
without the presence of bile pigment stool
appears light in color (clay colored). Even
trace amounts of bilirubin in urine are
abnormal,
possibly
indicating
liver
dysfunction.
HEPATITIS C, D, E
Hepatitis D (HDV)
● Occurs rarely in children; must occur in individuals
already infected with HBV
● This is a defective RNA virus that requires the helper
function of HBV
● Incubation period: 2-8 weeks; with co-infection
incubation period is similar to HBV infection
● Transmission: Blood and sexual contact
● Risk Factors:
○ Drug users
○ Individuals with hemophilia
○ Persons migrating from endemic areas
● Delta form is similar to HBV in transmission,
although it apparently requires a coexisting HBV
infection to be activated.
● S/S: mild
● High incidence of fulminant hepatitis after the initial
infection
Alkaline
phosphatase
An enzyme produced by the liver and bone
and excreted in the bile; with bile duct
obstruction increased levels of alkaline
phosphatase will be in the blood.
Prothrombin
time
This test is associated with blood
coagulation. In chronic liver disease, the
level of prothrombin produced by the liver
may fall so severely that the prothrombin
time is increased; Where there is little
change and prothrombin time in mild or
short-term liver disease.
Aspartate
transaminas
e (AST;
serum
glutamicoxaloacetic
transaminas
e [SGOT])
AST (SGOT) is an enzyme found in the
heart and liver; when there is acute cellular
destruction in either organ the enzyme is
released into the bloodstream from the
damaged cells; the blood levels are
increased by 8 hours after injury; the level
reaches a peak in 24 or 36 hours and then
falls to normal and 4 to 6 days.
Alanine
transaminas
e (ALT;
serum
glutamate
pyruvate
transaminas
e [SGPT]
ALT (SGPT) is an enzyme found mostly in
the liver; it rises for the same reason as AST
(SGOT) but is not a sensitive and indicator
of liver damage.
Hepatitis E
● Previously known as Non-A, Non-B Hepatitis
● Uncommon in children, does not cause chronic liver
disease, not chronic condition, no carrier state
○ Can be a devastating disease among
pregnant women with unusually high
fatality rate
● Incubation period: 15-60 days, avg. of 40 days
● Transmission:
○ Fecal-oral route
○ Enterically, similarly to hepatitis A (fecally
contaminated water)
● S/S: mild, except in pregnant women (severe)
Lactic
dehydrogena
se (LDH)
LDH is another enzyme found in the heart
and liver; it is a relatively insensitive
indicator of liver destruction, however;
infectious mononucleosis is the one disease
with which increased levels of LDH are seen
frequently.
PATH
OPHY
SIOLO
GY
Serum
albumin
Albumin, a serum protein, is chiefly
synthesized in the liver; most acute or
chronic liver disease will cause decreased
serum albumin.
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Acute or chronic inflammation of the liver
that can result from infectious or
noninfectious reasons
Common causes:
○ Epstein-Barr virus
○ Cytomegalovirus
Other causes:
○ Nonviral abscess
○ Amoebiasis
○ Autoimmune
○ Metabolic
○ Drug-induced
○ Anatomic (such as colodocal?
duct cyst, biliary atresia)
○ Hemodynamic
(shock,
congestive heart failure)
○ Idiopathic
(sclerosing
cholangitis, Ray syndrome)
Determining the cause of acute or chronic
hepatitis is important in determining the
treatment and prognosis for the child.
(primarily)
in
degrees of swelling + infiltration of liver
cells by mononuclear cells + subsequent
degeneration, necrosis, and fibrosis.
●
●
●
changes
parenchymal cells of the liver → variable
HEPATITIS
DEFIN
ITION
Pathologic
●
●
Structural changes within the hepatocyte
→ altered liver functions such as:
○ Impaired bile secretion
○ Elevated transaminase levels
○ Decreased albumin synthesis
Disorder may be self-limiting w/
regeneration of liver cells w/o scarring
→ complete recovery
However, some forms of hepatitis do not
result in complete return of liver function.
○ Fulminant
hepatitis
characterized by a severe acute
course with massive destruction
of liver tissue, causing liver
failure and high mortality w/in 12 weeks.
○ Subacute or chronic active
hepatitis
characterized
by
progressive liver destruction,
uncertain regeneration, scarring,
and potential cirrhosis.
Progression of liver disease
(1) mononuclear inflammatory cells
surrounding small bile ducts
(2) proliferation of small bile
ductules
(3) fibrosis or scarring
(4) Cirrhosis
ASSESSMENT FOR HEP A-E
No matter which virus is involved, hepatitis is a generalized
body infection w/ specific intense liver effects. Type A occurs
in children of all ages and accounts for approx 30% of
instances. Hep B tends to occur in newborns from placental
fetal transfer and in adolescents after intimate contact or the
use of contaminated syringes for drug injection
● Headache, fever, anorexia
● HEP A: mild
○ Jaundice occurs as liver function slows
and last approx 1 week
○ Symptoms fade w/ full recovery
● HEP B: more marked
○ Generalized aching, RUQ pain
○ Headache
○ Low-grade fever
○ Feeling ill
○ Irritable and fretful from pruritus
○ Dark urine, jaundiced sclerae →
generalized jaundice
■ After 3-7 days of such
symptoms, urine becomes darker
due to excretion of bilirubin. In
another 2 days, sclerae of the
eyes becomes jaundiced and
soon becomes generalized
○ White/gray stools
■ Because generalized jaundice
causes little secretion of bilirubin
into stool
○ ICTERIC VS OVERT JAUNDICE
■ Some children have an icteric
form of infection wherein they
develop beginning symptoms but
do not develop jaundice. They are
still as infectious as children with
overt jaundice
● Delta form is similar to HBV in transmission,
although it apparently requires a coexisting HBV
infection to be activated.
● S/S: mild
● High incidence of fulminant hepatitis after the initial
infection
LAB
STUDI
ES
●
THER
APEU
TIC
MANA
GEME
NT
●
●
●
●
●
●
●
●
Elevations: liver enzymes AST (SGOT) &
serum alanine transaminase
Increased levels: bilirubin in urine
Decreased: bile pigments in stool
Increased: serum bilirubin levels
(+) anti-HAV antibody test
○ mononuclear inflammatory cells
surrounding small bile ducts
○ proliferation of small bile
ductules
○ fibrosis or scarring
○ Cirrhosis
Goals: early detection, support &
monitoring of the dse, recognition of
chronic liver dse, & prevention of spread
of the dse
Steroids to treat chronic autoimmune
hepatitis
Hospitalization for coagulopathy or
fulminant hepatitis
Therapy depends on severity of
inflammation and cause of disorder
○ HAV: supportive care
○ HBV & HCV: human interferon
alpha
○ HBV: lamivudine
■
Well tolerated w/ so
significant side effects;
approved for children
>3 yo
○ Combined
therapy
of
lamivudine & HIA reduces rate
of antiviral resistance compared
to lamivudine alone
○ HBV: adefovir for children >12
yo; entecavir for adolescents
>=16 yo
● All HC providers should receive
prophylaxis against hepatitis with
hepatitis vaccine
● Infants: routine immunization against
HBV
● Screening for women during pregnancy
for HBsAg
● Infants born to Hepatitis (+) mothers
receive
both
HBIG
and
active
immunization @ birth to prevent
contracting dse
● Hep A vaccine is available for HC
providers
& included
in routine
immunization program for infants starting
1 yr of age
● Mandatory: strict handwashing &
infection control when caring for infants
with hepatitis
○ Feces must be disposed
carefully bec type A can be
cultured from feces
○ Syringes & needles must be
disposed w/ caution bec type B
can be transmitted by blood
● Contacts should receive IG; hepatitis A
or B IG as appropriate
● Treatment for Hep A:
○ Increased rest
○ Maintenance of good calorie
intake
○ Low fat diet not required (difficult
to enforce)
● Treatment for Hep B:
○ Lamivudine, epivir, & antiviral
agent effective for reducing viral
replication
● Prevention:
○ HBIG (prevents Hep A for preexposure & w/in 2 wks exposure)
○ Vaccines
● Nursing responsibilities
Nursing objectives depend largely on the severity
of the hepatitis, the medical treatment, and factors
influencing the control and transmission of the dse.
○ Pt education
■ Because children with
mild viral hepatitis are
frequently cared for at
home, it is often the
nurses responsibility to
explain any medical
therapies and infection
control measures
■ Encourage a wellbalanced diet and a
schedule of rest and
activity adjusted to the
child's condition
○ Med administration
○ Standard precautions
■ Followed when children
are hospitalized
■
Hand washing is the single most effective
measure in preventing and control of
hepatitis in any setting
waiting
for
transplantation
produced considerable stress. In
addition,
extended
hospitalizations, pharmacologic
therapy, and nutritional therapy
can impose significant financial
burdens on the family as with any
chronic condition.
CHRONIC HEPATITIS
DEFIN
ITION
●
●
●
●
●
●
Persists for longer than 6 months
Most often the result of hep B, D, or C
infection
Abnormal liver enzyme levels and a
liver biopsy establish the diagnosis and
can also predict the severity
Fatty infiltration & bile duct damage can
occur
May progress to cirrhosis and eventually
liver failure
Supportive therapy to compensate for
decreased liver function
VIDEO 2
INTESTINAL DISORDERS
Because the intestines are a long body system, several either
congenital or acquired disorders can occur.
1)
2)
3)
4)
5)
6)
7)
Diaphragmatic hernia
Omphalocele
Gastroschisis
Intussusception
Malrotation
Volvulus
Necrotizing enterocolitis
(NEC)
8) Appendicitis
9) Meckel’s Diverticulum
10) Celiac Disease
11) Umbilical Hernia
BILIARY ATRESIA
DEFIN
ITION
●
●
AKA extrahepatic biliary atresia
Progressive inflammatory process that
causes intrahepatic & extrahepatic bile
●
●
●
MGMT
●
●
●
●
duct fibrosis → eventual ductal
obstruction
Incidence: approx 1 in 10,000-15,000 live
births
Associated malformations: polysplenia,
intestinal atresia, and malrotation of the
intestine
Untreated: cirrhosis, liver failure, and
death
Support of the family before, during, and
after surgical procedures
Pt education regarding the treatment
plan
○ Med administration
○ Nutritional
therapy
administration
○ In the postoperative period of a
hepatic
portoenterostomy,
nursing care is similar to that
following any major abdominal
surgery. Teaching includes the
proper
administration
of
medication, administration of
nutritional therapy including
special formulas, vitamin and
mineral
supplements,
gastrostomy
feeding,
or
parenteral nutrition. The nurse
teaches caregivers how to
monitor
and
administer
nutritional therapy at home.
Comfort measures for pruritus
○ Pruritus may be a significant
problem that is addressed by
drug
therapy
or
comfort
measures such as baths,
colloidal oatmeal compounds,
and trimming of the fingernails.
Psychosocial support
○ These children and their families
also require special psychosocial
support.
The
uncertain
prognosis,
discomfort,
and
INTESTINAL DISORDERS IN DETAIL
DIAPHRAGMATIC HERNIA
DEFIN
ITION
●
●
●
●
●
●
ETIOL
OGY
●
●
●
●
A diaphragmatic hernia is a protrusion of
an abdominal organ, usually the stomach
or intestines, through a defect in the
diaphragm into the chest cavity.
This results from a defect in the formation
of the diaphragm, allowing the abdominal
organs to be displaced into the thoracic
cavity.
Usually occurs on the left side, causing
cardiac displacement to the right side of
the chest and collapse of the left lung.
Occurs in approximately 1 in 2,000 -4,000
live births
Despite
improvements
in
care
management, the mortality rate remains
high at about 35%
No difference between male and female
incidence
Unknown
However, it is not uncommon to find
concomitant chromosomal anomalies
especially trisomies 12, 18 and 21, as
well
as
abnormalities
of
the
gastrointestinal, genitourinary, and central
nervous systems
Intestinal malrotation is also associated
with diaphragmatic hernia
Approximately 70% of the hernias occur
on the left side in the posterior diaphragm
known
as
the
FORAMEN
OF
BOCHDALEK
○ Poorer outcomes are associated
with left-sided defects
●
●
●
●
NOTE: assessment to prognosis not discussed
(glitch while exporting ig)
PROG
NOSIS
DX
MGMT
●
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●
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●
Mortality rate of children w/ diaphragmatic
hernia: 25-40%
○ Death often occurs bc of
association anomalies of the
heart, lung, & intestine
●
Detected in utero by a sonogram
X-ray finding
○ Loops of intestine in the
thoracic cavity (refer to pic)
○ Absence of intestine in the
abdominal cavity
NOTE! Surgery performed soon after birth.
Post-op Nursing Care
● Silastic silo or patch - If complete closure
is impossible because of the small size of
the defect and a large amount of viscera
to be replaced, a silastic silo or patch is
placed
○ R: this protects the contents as
they are gradually placed back
into the abdominal cavity &
minimizes s/s of resp distress as
increasing
intra
abdominal
pressure pushes against the
diaphragm.
● Reduction process usually takes 7-10
days
○ Defect is closed surgically after
exposed contents have been
reduced
● Prognosis: depends on the size of defect
& presence of associated anomalies
● Complications: feedings difficulties,
dysmotility, or short-gut if substantial
amount of intestine was removed
○ Generally expected!
Emergency surgical repair of the
diaphragm and replacement of the
herniated intensive back into the abdomen
○ Laparoscopy
○ Difficult repairs: thoracic incision
& placement of chest tubes
○ Large Teflon patch
Therapy w/ high-frequency oscillatory
ventilation, inhaled nitric oxide, or
extracorporeal membrane oxygenation
(ECMO)
OMPHALOCELE & GASTROSCHISIS
DEFIN
ITION
●
●
●
More common congenital defects of the
abdominal wall
Omphalocele: occurs in approximately 2
of every 10,000 live births
Gastroschisis: nearly 5 in 10,000 live
births
OMPHALOCELE
DEFIN
ITION
●
●
●
N/MG
MT &
CARE
Pre-op Nursing Care:
Exposure of the viscera causes problems with
thermoregulation and fluid and electrolyte balance
● Immediately after birth, the neonate’s
torso should be placed in an
impermeable, clear plastic bowel bag
○ R: to decrease insensible water
loss, maintain thermoregulation,
& prevent contamination of
exposed viscera
Assess the exposed viscera frequently
○ R: to detect any change in
perfusion to exposed abdominal
contents
Side-lying position & viscera supported w/
a blanket roll
○ R:
to
prevent
vascular
compromise
Cover viscera w/ sterile moistened saline
gauze & plastic wrap
Gastric decompression w/ a Replogle
tube connected to low intermittent wall
suction
○ R:
to
prevent
aspiration
pneumonia, and allow as much
bowel as possible to placed in
the abdomen during surgery
Antibiotics,
fluid
&
electrolyte
replacement, thermoregulation
○ R: physiologic support
●
●
●
Protrusion
of
abdominal
contents
through the abdominal
wall at the point of the
junction
of
the
umbilical cord and
abdomen
The herniated organs are usually the
intestines, but they may include stomach
and liver
Usually covered and contained by a thin
transparent layer of amnion and chorion
with the umbilical cord protruding from the
exposed sac
“Hernia of the umbilical cord” = defect is
> 4 cm
“True omphalocele” = < 10 cm
Many of the infants born with omphalocele
are preterm
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●
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●
Nearly 50% have an underlying
chromosomal abnormality usually trisomy
12, 18, or 21
Congenital heart defects are often
associated with omphalocele
The condition occurs because at
approximately weeks 6-8 of intrauterine
life, fetal abdominal contents growing
faster than the fetal abdomen are
extruded from the abdomen into the base
of the umbilical cord. At 7-10 weeks when
the abdomen has enlarged sufficiently, the
intestine returns to the abdomen.
Omphalocele occurs when the abdominal
contents fail to return in the usual way.
The occurrence is associated with
chromosomal aberrations
○
●
PATH
OPHY
SIOLO
GY
●
Infants younger than 1 year:
intussusception generally occurs
for idiopathic reasons
○ Infants older than 1 year: a “lead
point” on the intestine likely cues
the
invagination:
Meckel’s
diverticulum,
a
polyp,
hypertrophy
of
Peyer's
patches or bowel tumors
The point of the invagination is generally
at the juncture of the distal ileum and
proximal colon
Proximal segment of the bowel telescopes
into a more distal segment, pulling the
mesentery with it → mesentery is
compressed & angled → lymphatic and
GASTROSCHISIS
venous obstruction → increasing edema
→ increasing pressure within the area →
DEFIN
ITION
●
●
●
●
●
●
●
●
Condition similar to
omphalocele except
that the abdominal
wall disorder is a
distance from the
umbilicus, usually to
the right, and the
abdominal
organs
are not contained by a membrane but
rather spill freely from the abdomen
Greater amount of intestinal content tends
to herniate increasing the potential for
volvulus and obstruction
The incidence of gastroschisis is
increasing worldwide and is 3-4 times
more common than omphalocele
For unknown reasons, it is increasing in
incidence from about 2 in 10,000 births to
4.5% per 10,000 births, particularly in
young mothers
Gastroschisis is not usually associated
with other major congenital anomalies or
syndromes
The care and surgical procedure are the
same as omphalocele
Children with gastroschisis often have
decreased bowel motility and even after
surgical correction, may have difficulty
with absorption of nutrients and
passage of stool
Long-term follow-up may be necessary to
ensure that nutrition and elimination are
adequate
pressure equals the arterial pressure →
arterial blood flow stops → ischemia +
pouring of mucus into the intestine
●
mucus into the intestinal lumen → currant
jelly-like stools
C/M
●
●
This
is
the
invagination of one
portion of the intestine
into another
It is the most common
cause of intestinal
obstruction in children
between 5 months
old and 3 years old
○ More common in males than in
females
○ More common in children
younger than 2 years old
●
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●
Sudden acute abdominal pain
Child screaming and drawing the knees
onto the chest
Child appearing normal and comfortable
between episodes of pain
Vomiting
Lethargy
Passage of red, currant jelly-like stools
Tender, distended abdomen
Palpable sausage-shaped mass in RUQ
Empty right quadrant (Dance sign)
Eventual fever, other s/s of peritonitis
Discussion: After the peristaltic wave that caused
the discomfort, they are symptom free and play
happily. In approx 15 mins, the same phenomenon
of intense pain starts. Vomitus begins to contain
bile bec obstruction is below the ampulla of Vater
(the point in the intestine where bile empties into the
duodenum). After approx 12 hrs, blood appears in
stool & possibly in vomitus described as currantjelly appearance. The abdomen becomes
distended as the bowel above the intussusception
distends. If necrosis occurs, children generally
have an elevated temperature, peritoneal irritation,
their abdomen would feel tender & would guard it
by tightening their abdominal muscles, an
increased WBC count, and often a rapid pulse.
INTUSSUSCEPTION
DEFIN
ITION
Venous engorgement → leaking of blood &
DX
●
●
Ultrasonography
○ Subjective findings lead to the
diagnosis
which
can
be
confirmed by ultrasonography
Rectal examination
○
MGMT
Reveals mucus blood
occasionally
a
intussusception itself
and
low
MALROTATION & VOLVULUS
DEFIN
ITION
●
Therapeutic Management
● Surgical emergency
○ Reduction done immediately
● Conservative treatment
○ Radiologist-guided
pneumoenema w/ or w/out
water-soluble contrast
○ Utz-guided hydrostatic (saline)
enema (no ionizing radiation
needed)
● IV fluids, NG decompression, &
antibiotic therapy
○ May be used before hydrostatic
reduction is attempted
● Surgery is done before necrosis of the
affected portion of the bowel occurs
Nursing Management
● Proper assessment (history taking, PE)
○ The nurse can help establish a
diagnosis by listening to the
parents description of the child's
physical
and
behavioral
symptoms.
○ It is not unusual for parents to
state
that
they
thought
something was seriously wrong
before others shared their
concerns.
○ The description of the child's
severe colicky abdominal pain
combined with vomiting is a
significant
size
of
intussusception.
○ As soon as possible diagnosis of
intussusception is made, the
nurse prepares parents for the
immediate
need
for
hospitalization, the non surgical
technique
of
hydrostatic
reduction, and the possibility of
surgery
● Pt education
○ It is important to explain the basic
defect of intussusception
● Pre-op & post-op care
○ Physical care of the child does
not differ from that for any child
undergoing abdominal surgery
○ BEFORE SURGERY:
■ IV fluids,
systemic
antibiotics, and bowel
decompression
■ Fluid
volume
replacement
and
restoration
of
electrolytes may be
required for some
■ Nurse monitors all
stools
○ AFTER SURGERY:
■ Observation of VS, BP,
intact
sutures
and
dressing, and the return
of bowel sounds
●
ASSE
SSME
NT
●
●
DX
●
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●
T/MG
MT
Malrotation: failure of the
bowel to assume its
normal place in the
abdomen
during
intrauterine development
○ Caused
by
abnormal
rotation of the
intestine around
the
superior
mesenteric
artery
during
embryologic development
○ May manifest in utero or
asymptomatic throughout life
○ Infants may have intermittent
bilious vomiting, distension, or
lower GI bleeding
○ The most serious type of
intestinal obstruction because
if the intestine undergoes
complete
volvulus,
a
compromise in the blood supply
will result in intestinal necrosis,
peritonitis, perforation, & death
Volvulus: twisting of the intestine around
itself
○ Leads to obstruction of the
passage
of
feces
and
compromise of the blood supply
to the loop of intestine involved
Symptoms are those of intestinal
obstruction & occur during the first 6
months of life
Intense crying & pain, pulling up the legs,
abdominal distension, and vomiting
History
Abdominal examination (mass)
Ultrasound
Lower barium x-ray
○ Both UTZ and x-ray reveals
obstruction
Upper GI series
○ Most accurate imaging study
Therapeutic Management
● Surgery
○ Surgery is used to relieve
volvulus and reattach the bowel
so it is no longer so free-moving
○ This must be done promptly
before necrosis of the intestine
occurs from a lack of blood
supply to the involved loop of
bowel
○ Indicated to remove the affected
area
● Pre-op prep:
○ IV fluids
○ NG decompression
○ Systemic antibiotic
○ Deteriorating infant requires fluid
volume
resuscitation
&
vasopressors for stabilization
● Post-op:
○ Similar to other abdominal
surgeries
● Post-op complication:
○
Short-bowel syndrome (SBS)
because of the extensive nature
of some lesions
■ Short bowel syndrome
is a condition in which
your body is unable to
absorb
enough
nutrients from the foods
you eat because you
don't have enough
small intestine.
●
areas → pneumotosis intestinalis (a
radiologic finding reflecting the presence
of gas in the submucosal or subserosal
surfaces of the bowel)
S/S
NECROTIZING ENTEROCOLITIS (NEC)
DEFIN
ITION
●
●
●
Acute inflammatory dse of the bowel
Increased incidence in preterm infants;
develops in approximately 5% of all
infants in intensive care nurseries
Bowel develops necrotic patches →
●
●
●
ETIOL
OGY
●
●
●
●
paralytic ileus
Perforation & peritonitis may occur
Necrosis appears to result from ischemia
or poor perfusion of blood vessels in
sections of the bowel
Ischemic processes may occur. When
going to shock/hypoxia, there is
vasoconstriction of blood vessels to
organs such as the bowel
Entire bowel may be involved, or localized
There is a lower incidence of the condition
in infants who are breastfed than in those
who are formula-fed because intestinal
organisms grow more profusely with cow’s
milk than breastmilk (cow’s milk lack
antibodies)
Nonspecific Clinical Signs
● Lethargy
● Poor feeding
● Vomiting
● Hypotension
● Apnea
● Decreased urinary output
● Unstable temperature
● Jaundice
Specific Signs
● Distended (often shiny) abdomen
● Blood in the stools or in gastric contents
● Gastric retention (undigested formula)
● Localized abdominal wall erythema or
induration
● Bilious vomitus
interfering w/ digestion & leading to a
●
●
Signs of NEC usually appear in the first week of life.
The stool may be positive for occult blood. Signs
of blood loss because the intestinal bleeding such
as lowered blood pressure and inability to stabilize
temperature also may be present. Abdominal x-ray
film shows a characteristic picture of air
invading the intestinal wall.
DX
●
●
Precise cause still uncertain but it appears
to occur in infants w/ GIT vascular
compromise
Intestinal ischemia is of unknown
etiology
Immature GI host defenses, bacterial
proliferation, & feeding substrate are now
believed to have a multi-factorial role in
the etiology of NEC
Prominent risk factor: prematurity
●
MGMT
●
●
●
PATH
OPHY
SIOLO
GY
●
●
Significant damage to mucosal cells lining
bowel wall
Diminished blood supply to these cells →
death in large numbers → stop secreting
lubricating mucus → unprotected bowel
●
wall attacked by proteolytic enzymes
Bowel wall continues to swell & break
down → unable to synthesize protective
IgM
→
mucosa
macromolecules (e.g.
defenses are down
permeable
exotoxins)
to
→
Gas-forming bacteria invade the damaged
Radiographic studies
○ Sausage-shaped dilation of the
intestine
○ Pneumotosis intestinalis
■ “soap suds”
Laboratory findings
○ Anemia
○ Leukopenia
○ Leukocytosis
○ Metabolic acidosis
○ Electrolyte imbalance
○ Severe coagulopathy (DIC) or
thrombocytopenia
Blood culture
○ Gram-negative organisms
Prompt recognition of the early warning
signs of NEC
Assists with diagnostic procedures and
implements the therapeutic regimen
Vital signs, including BP, are monitored for
changes that might indicate bowel
perforation, septicemia, or cardiovascular
shock, and measures are instituted to
prevent possible transmission to other
infants
○ Avoid rectal temperatures
because of the increased danger
of perforation
○ To avoid pressure on the
distended abdomen, facilitate
continuous observation. Infants
are often left undiapered and
positioned supine or on the
side.
○ Observe for indications or early
development
of
NEC
by
checking the appearance of
the abdomen for distention.
●
●
●
●
●
We could measure abdominal
girth, measuring residual gastric
contents before feedings and
listening to bowel sounds, as well
as
performing all routine
assessments for high risk
neonates.
Nutritional and hydration needs
Antibiotics (administered as prescribed)
○ The time at which oral feedings
are
reinstituted
varies
considerably but is usually at
least 7-10 days after diagnosis
and treatment. Feeding is
usually reestablished using
human milk if available.
Infection control
○ Strict handwashing is the
primary barrier to spread and
confirm multiple cases are
isolated. Persons with symptoms
of
gastrointestinal
disorder
should not care for these or any
other infants.
Pre-op and post-op care
Ostomy care
○ Infants who require surgery
require the same careful
attention and observation as any
infant with abdominal surgery
including ostomy care.
●
●
PATH
OPHY
SIOLO
GY
●
into the abdomen, causing peritonitis, a
potentially fatal condition.
Perforation of the appendix can occur
within an approx. 48 hours of the initial
complaint of pain and occurs in 20%40% of children w/ appendicitis.
Causes: obstruction of the lumen of the
appendix, Enterobius vermicularis
○ Obstruction is usually by
hardened fecal material
○ Swollen
lymphoid
tissue
frequently occurring after a viral
infection can also obstruct the
appendix
○ Rare cause of obstruction:
Enterobius
vermicularis
(pinworms), a parasite that can
obstruct the appendiceal lumen
Acute obstruction: blocked outflow of
mucus secretions → pressure builds within
lumen → compression of blood vessels →
ischemia → ulceration of the epithelial
lining + bacterial invasion
●
Subsequent necrosis → perforation or
rupture → bacterial contamination of the
peritoneal cavity → peritonitis (esp. In
young children who are unable to localize
APPENDICITIS
DEFIN
ITION
●
●
●
●
●
●
●
●
ETIOL
OGY
●
Inflammation of
the vermiform
appendix
Most common
cause
of
emergency
abdominal
surgery
in
childhood
Occurs most frequently in school-age
children and adolescents although it can
occur in preschoolers and even in
newborns
Average age of children with appendicitis
is 10 years old
Boys and girls equally affected before
puberty
Appendix may become inflamed because
of an upper respiratory or other body
infection, but the cause is generally
obscure.
In most instances, fecal material
apparently enters the appendix, hardens,
and obstructs the appendiceal lumen.
Inflammation and edema develop leading
to compression of blood vessels and
cellular malnutrition, necrosis and pain
result.
First symptom of appendicitis is
periumbilical pain (pain at the
anatomical region of the body around the
navel). This pain would be followed by
nausea, right lower quadrant pain, and
alter vomiting with fever. If the condition is
not discovered early enough, the necrotic
area will rupture and fecal material will spill
●
infection) → ileus
○ Progressive
peritoneal
inflammation results in functional
intestinal obstruction of the small
bowel because intense GI
reflexes severely inhibit bowel
motility.
Loss of ECF to the peritoneal cavity →
electrolyte
imbalance
+
hypovolemic
shock
ASSE
SSME
NT
●
●
●
●
●
Most parents assume that appendicitis
begins w/ sharp pain so they may dismiss
a child’s early symptom for sometimes a
simple gastroenteritis. In actuality, pain is
a late symptom.
History: anorexia for 12-24H
○ Children don’t eat or act like their
usual selves.
Nausea and vomiting
Abdominal pain: first diffuse then
localizes to RLQ
McBurney’s point: point of sharpest pain
- one third of the way between anterior
superior iliac crest and the umbilicus
○ Until the pain becomes localized,
appendicitis
is difficult
to
distinguish
from
acute
gastroenteritis. Often, it is difficult
to palpate children's abdomens
because they guard their
abdomen or make abdominal
muscles stiff and hard by tensing
them. Although this interferes
with abdominal examination, it is
in itself an important sign that
children have abdominal pain.
○
●
●
DX
To assist in the diagnosis of a
painful abdomen, always palpate
the anticipated tender area last.
Fever is a late symptom
Rebound tenderness
○ Is a phenomenon in which a child
feels relatively mild pain when
the area over the appendix is
palpated,
but
when
an
examiner’s hand is withdrawn,
the child experiences acute pain
caused by the shifting of
abdominal contents.
○ Diagnostic for appendicitis but it
should be only done in children
when it is necessary because it
does cause acute pain. Caution
children that the maneuver may
cause pain.
The following tests help diagnose appendicitis:
Rebound tenderness (also psoas and obturator
signs)
● Supine position with knees flexed
● Place your hands gently @ McBurney’s
point
● Slowly, deeply dip your fingers into the
area; then release the pressure in a quick,
smooth motion.
● Pain on release - rebound tenderness - is
a positive sign. The pain may radiate to
the umbilicus.
Auscultation
● Bowel sounds will be reduced (only 1 or
2 are heard in the same length of time that
30 are normally heard)
○ Absence:
peritonitis
or
ruptured appendix
Laboratory
● CBC: leukocytosis
○ Blood cell count = 10,00-18,000
(low for the extent of the infection
that may be present)
● Elevated ketone levels in the urine as a
symptom of starvation from poor intestinal
absorption
● Ultrasound, ct-scan: swollen appendix
MGMT
Therapeutic Management
● Surgical removal of the appendix before it
ruptures
○ More difficult in young children
■ whose hx is not as
accurate and do not
have the words to
describe symptoms or
who will not relax their
blood muscles enough
to allow for manual
examination
○ Wall of the appendix is thinner
and perforates more readily
● Pre-op: antibiotics, IV fluids & electrolytes
(often required before surgery esp. when
the child is dehydrated in result to the
marked
anorexia
characteristic of
appendicitis)
● Right lower quadrant incision (open
appendectomy)
● Laparoscopic surgery: non-perforated
acute appendicitis
○ Advantages: reduced time in
surgery and anesthesia and
reduced risk of post-operative
wound infection
● Post-op: same as for most abdominal
procedure
Ruptured Appendix
● Potential for peritonitis increases greatly if
appendix is ruptured
● Severely ill
● WBC > 20,000/mm
● Semi-fowler's
position,
IV
fluids,
antibiotics
○ Semi-fowler’s position so that the
infected drainage from the
cecum drains down more in the
pelvis rather than upward toward
the lungs.
○ IV fluids is for hydration
○ Antibiotics will be started
preoperatively or as soon as
ruptured appendix is confirmed
● Post-op: IV fluids, antibiotics, NG tube on
low continuous gastric decompression,
NPO until intestinal activity returns
○ Sometimes, surgeons close the
wound after irrigation of the
peritoneal cavity.
○ At other times, the wound is left
open to prevent wound infection
(delayed closure)
Nursing Management
● Pain assessment & management
○ Younger nonverbal children will
assume a motionless side-lying
posture with the knees flexed on
the abdomen and there is
decreased ROM on the right hip.
○ Older children may exhibit all
these
behaviors
while
complaining of abdominal pain
and refusing to play.
● Post-operative care for the nonperforated appendix is the same as for
most abdominal procedures. Care of a
child with appendicitis or peritonitis
involves more complex care and the
course of recovery is longer. Child is
maintained on IV fluids and antibiotics, is
●
●
●
on NGO, and the NG tube on low
continuous gastric decompression until
there is evidence of intestinal activity.
Bowel activity monitoring
○ Listening for bowel sounds and
observing for other signs of
bowel activities such as passage
of flatus or stool, are part of the
routine assessment
Dressing changes w/ meticulous skin care
are essential to prevent excoriation of
the are surrounding the surgical site
Management of pain is an essential part
of a child's care
MECKEL’S DIVERTICULUM
C/F
●
●
●
●
Painless, tarry (black) stools or grossly
bloody stools
Diverticulum may serve as the lead point
causing an intussusception; abdominal
pain, currant-jelly stools
Hypotension
A fibrous band extending from the
diverticulum pouch to the umbilicus acts
●
MGMT
●
●
DEFIN
ITION
as a constricting band → bowel
obstruction
The hx of the child suggests the diagnosis.
Because the pouch is small, it does not fill
and therefore it may not be evident on xray or ultrasound
Laparoscopy
Exploration and removal of the vestigial
structure
CELIAC DISEASE
●
●
●
●
●
A remnant of the fetal omphalomesenteric
duct, which connects yolk sac w/ the
primitive mid gut during fetal life
Normally, the structure is obliterated
between the 5th and 9th week of
gestation when the placenta replaces the
yolk sac as the source of nutrition for the
fetus
○ Becomes a vestigial ligament as
infants reach term
In 2% or 3% of all infants, a small pouch
of this duct remains, located off the ileum,
approx. 18 inches from the ileum colon
junction
True diverticulum because it arises from
the antimesentery border of the small
intestine and includes all layers of the
intestinal wall
Usually found within 40-50cm of the
ileococeal valve
Rule of 2s
● Occurs in 2% of the population
● 2:1 male to female ratio
● Located within 2 feet of the ileocecal valve
● 2 cm in diameter and 2 inches in length
● Contains 2 types of ectopic tissue
(pancreatic and gastric)
● More common before the age of 2
PATH
OPHY
SIOLO
GY
DEFIN
ITION
●
●
●
●
●
●
MD: misplaced gastric mucosa → secretes gastric
acids → flow into the intestine → irritate the bowel
●
wall → ulceration + bleeding
●
●
Aka malabsorption syndrome gluteninduced/gluten-sensitive enteropathy
Immunologically mediated disease in
genetically susceptible people caused by
intolerance to gluten
A
symptom
complex
with
four
characteristics:
(1) steatorrhea (fatty, foul, frothy, bulky
stools)
(2) general malnutrition
(3) abdominal distention
(4) secondary vitamin deficiency
Basic problem: sensitivity or abnormal
immunologic
response to protein,
particularly the gluten factor of protein
found in grains (wheat, rice, barley)
Permanent intestinal intolerance to dietary
gluten
Seen more frequently in Europe and US;
rarely recorded in Asians or African
Americans
As adults, it is more prevalent in women
than in men and there is an equal
distribution of cases among children.
Although the exact cause is unknown, it is
generally accepted that celiac disease is
an immunologically mediated small
intestine enteropathy
The mucosal lesions contain features that
suggest both humoral and cell-mediated
immunologic overstimulation
CELIAC CRISIS
●
●
●
When children w/ celiac disease develop
any type of infection, a crisis with extreme
symptoms may occur
○ Vomiting and diarrhea become
acute
○ Quickly experience electrolyte
and fluid imbalances
Need intensive therapy to correct them
Gradually, they are placed back on a
gluten free diet.
○
●
●
PATH
OPHY
SIOLO
GY
●
●
Ingest gluten? Changes occur in their iIr
intestinal mucosa or villi → prevent the
DX
Gluten should not be excluded from the diet until
the diagnostic evaluation is complete so that proper
identification would occur.
● Serological blood test
○ Tissue transglutaminase
○ Antiendomysial antibodies in
children 18 months old or older
● Positive serological markers → upper GI
endoscopy with biopsy
THER
APEU
TIC
MGMT
Dietary management
● Gluten-free diet for life
○ Because there is a suggestion
that these children are more
prone to GI carcinoma later in
life if they do not continue the diet
into adulthood
○ Just low in gluten because it is
quite impossible to remove every
source of this protein.
○ Corn, rice, and millet become
substitute grain foods.
○ Patients with untreated celiac
disease may have lactose
intolerance especially if their
mucosal lesions are extensive.
Lactose intolerance usually
improves as the mucosa heals
with gluten. Specific nutritional
deficiencies such as iron folic
acid, and vitamin deficiencies are
treated
with
appropriate
supplements.
absorption of foods, especially fat, across
the intestinal villi into the bloodstream →
●
●
●
●
●
●
●
●
C/F
●
●
develop steatorrhea + deficiency of fatsoluble vitamins ADEK + malnutrition +
distended abdomen
Rickets or loss of calcium from bones
may occur
○ Because of vit. D loss
Hypoprothrombinemia
○ From loss of vit. K
Hypochromic anemia,
hypoalbuminemia
○ From poor protein absorption
Early recognition, early support and
nutritional guidance for the parents
Occurs most frequently in children of a
northern European background
○ Dominantly inherited illness
although children have different
degrees of involvement
Increased incidence: type 1 DM, IgA
deficiency, Down syndrome
Characterized by venous atrophy in the
small intestine in response to the protein
gluten
○ When individuals are unable to
digest the gliadin component of
gluten, this is an accumulation of
toxic substance that is damaging
to the mucosal cells and damage
to the mucosa of the small
intestines lead to villous atrophy,
hyperplasia of the crypts, and
inflation of the epithelial cells w/
lymphocytes.
○ Villous atrophy leads to
malabsorption caused by the
reduced absorptive surface area.
Genetic prediscription is an essential
factor in the development of celiac
disease.
Impaired Fat Absorption
○ Steatorrhea (excess fat in feces)
○ Exceedingly foul-smelling stools
Impaired Nutrient Absorption
○ Malnutrition
Muscle
wasting
(especially
prominent in legs and buttocks);
soundly extremities
○ Anemia
○ Anorexia
○ Abdominal distention
Behavioral Changes
○ Irritability
○ Uncooperativeness
○ Apathy
Celiac Crisis
○ Acute, severe episodes of
profuse watery diarrhea and
vomiting
○ May be precipitated by:
■ Infections
(esp.
gastrointestinal)
■ Prolonged fluid and
electrolyte depletion
■ Emotional disturbance
These may happen in very young
children
PROG
NOSIS
●
●
Chronic disease; severity varies greatly
among children
○ The most severe symptoms
usually occur in early childhood
and again in adult life.
○ Most children who comply with
dietary management are healthy
and remain free of symptoms
and complications
Children evaluated annually for
○ Nutrition deficiencies
○ Impaired growth
○ Delayed puberty
○ Reduced bone mineral density
NURSI
NG
CARE
MGMT
●
●
Helping the child adhere to the dietary
regimen
○ Diet high in calories and
proteins
○ Simple carbohydrates such as
fruits and vegetables
○ Low in fats
○ Other diet alterations may be
necessary such as lactose free
diets
which
necessitates
eliminating all milk products may
be temporarily needed.
○ In general, dietary management
includes a diet high in calories
and
proteins with simple
carbohydrates such as fruits and
vegetables but low in fats.
○ Because the bowel is inflamed,
the child must avoid high fiber
foods such as nuts, raisins, etc.
Patient education
○ Nurse must advise parents the
necessity of reading all labeled
ingredients carefully to avoid
hidden sources of gluten.
○ Many of children’s favorite foods
contain gluten including bread,
cake, cookies, crackers, donuts,
etc. and these can be eliminated
from an infant’s or young child’s
diet fairly easily but monitoring a
school-aged child or adolescent
is more difficult.
●
●
LOWER BOWEL DISORDERS
CONSTIPATION
DEFIN
ITION
●
●
●
●
●
UMBILICAL HERNIA
●
●
●
●
Protrusion of
a
portion
of
the
intestine through
the umbilical ring,
muscle, & fascia
surrounding
the
umbilical cord
Common hernia observed in infants esp.
in African American children and occurs
most in girls than in boys
Usually is an isolated defect, but it may be
associated
with
other
congenital
anomalies (such as Down syndrome)
Rarely noticeable at birth but becomes
increasingly noticeable at health care
visits during the first year
INCID
ENCE
●
●
African American children
More often in girls
C/F
●
The structure is generally 1-2 cm in
diameter but maybe as large as an orange
when the child cries or strains.
MGMT
●
The size of protruding mass is not as
important as the size of the fascial ring
through which the intestine protrudes. If
this fascial ring is < 2 cm, closure will
usually occur spontaneously and no repair
of the disorder may be necessary. If the
disorder is > 2 cm, surgery for repair will
generally be indicated to prevent
herniation and intestinal obstruction or
bowel strangulation. This is usually done
when the child is 1 to 2 years of age.
Difficulty passing hardened stools
Alteration in the frequency, consistency,
or easy or passing stool
Decrease in bowel movement frequency
or increased stool hardness for > 2 weeks
Most children: average of 1.7 stools/day
@ 2 YO
○ An average of 1.2 stool per day
@ > 4 YO
Cause anal fissures → child represses
the nest urge to defecate → larger, firmer
●
DEFIN
ITION
Surgery is accomplished on an
ambulatory outpatient basis. The child
returns from surgery with a pressure
dressing which remains in place until the
sutures are well healed. Remind parents
to sponge bath the child until they return
for a post-op visit and the dressing is
removed.
If the child is not potty trained, diaper
should be folded down below the dressing
to prevent contamination of the suture line
with stool.
ETIOL
OGY
●
●
●
●
●
●
NEWB
ORN
PF
●
●
and causes more anal pain
Children hold stool for psychological
reasons.
Structural disorders of the intestine
○ Structures
○ Ectopic anus
○ Hirschsprung disease
Systemic disorders
○ Hypothyroidism
○ Hypercalcemia resulting from
hyperparathyroidism or vitamin D
excess
○ Chronic lead poisoning
Use of drugs
Spinal cord lesions may be associated
with loss of rectal tone and sensation
○ Affected children are prone to
chronic fecal retention and
overflow incontinence
Majority of children: idiopathic or
functional constipation
Chronic constipation: environmental or
psychosocial factors, or a combination or
both
Normal: first meconium stool within 24-3
6hr of birth
Alteration assess for evidence of intestinal
atresia or stenosis, Hirschsprung disease,
hypothyroidism,
meconium
ileus
meconium
→
early
plug,
or
surgical
intervention
INFAN
CY
●
●
●
Onset of constipation frequently occurs
during infancy, organic causes
Often related to dietary practices
Less common in bf infants
CHILD
HOOD
●
●
●
ASSE
SSME
NT
●
●
●
MGMT
Environmental changes, stresses and
changes in toileting patterns
Withhold stool
Fear of using the school bathrooms
●
●
Be certain to have parents describe what
they mean by constipation
Examine the circumstances that may have
led to constipation
Anal fissures
Therapeutic Management
● Goal: softening stool
● good/regular bowel habits
● Treatment depends on the cause and
duration of symptoms
● Provide more fiber and fluids
● Eliminating certain foods
● Stool-softening glycol
● Chronic constipation
○ Regular evacuation of stool
○ Shrinking the distended rectum
to its normal size
○ Promoting a regular toileting
routine
Nursing Management
● Hx of bowel habits, how more events, diet,
shrinking the culture,
● Pt education
HIRSCHSPRUNG DISEASE
DEFIN
ITION
●
●
●
●
●
●
Protrusion usually in boys
Appears as a lump in the left or right groin
Apparent only on crying
Pain at the site implies that the bowel has
become incarcerated in the sac, an
emergency situation
Diagnosis by hx
○ If present, herniated intestine
can be palpated in the inguinal
ring on PE
Ttt: laparoscopy surgery
○ <1 YO
○ Post-op keep suture line dry and
free of urine or feces assess leg
circulation, dressing change
●
●
●
●
●
INCID
ENCE
AND
RF
INGUINAL HERNIA
DEFIN
ITION
PATH
OPHY
SIO
●
●
●
●
absence of ganglion cells in affected
●
areas of the intestine (myenteric plexus of
Auerbach and the submucosal plexus of
Meissner) → loss of recto sphincteric reflex
+ abnormal microenvironment of cells of
●
C/F
●
ASSE
SSME
NT
●
Extremely hard portion of meconium that
has completely blocked the intestinal
lumen → bowel obstruction
○ Form in the lower end of the bowl
○ Associated
with
intestinal
lumen
○ Meconium with reduced water
content
○ Evacuated
after
digital
examination
●
Abdominal distention and vomiting may
not occur for at least 24 hours
○ no meconium passage and is
past 24 hours of age.
“Congenital Aganglionic Megacolon”
Congenital anomaly → mechanical
obstruction from inadequate utility of part
of the intestine
Absence of ganglionic innervation to the
muscle of a section of the bowel– in most
instances, the lower portion of the sigmoid
colon just above the anus
Chronic constipation or ribbonlike stools
Portion of the bowel proximal to the
obstruction
dilates
->
distended
abdomen
¼ of all cases of neonatal intestinal
obstruction; 1 in 5000 live births
higher in the siblings of a child with the
disorder
4x more common in males than in females
allows a familial pattern
MECONIUM PLUG SYNDROME
DEFIN
ITION
Gentle rectal examination = hardened
stool, although the plug may be too high
up in the bowel to be palpated.
Radiograph or sonogram = distended
air-filled loops of bowel up to the point of
obstruction, slightly hypertonic watersoluble contrast agent enema, also
therapeutic.
●
●
affected intestine
80% of cases: aganglionosis is restricted
to the internal sphincter, rectum, and a few
centimeters of the sigmoid colon
○ short-segment disease
○ Normally, when a stool bolus
enters the rectum, the internal
sphincter relaxes and the stool is
evacuated. In hirschsprung
disease, the internal sphincter
does not relax.
Newborn Period
○ Failure to pass meconium within
24 to 48 hours after birth
○ Refusal to feed
○ Bilious vomiting
○ Abdominal distention
Infancy
○ Failure to thrive - 0
○ Constipation - 0
○ Abdominal distention
○ Episodes of diarrhea and
vomiting
○ Signs of enterocolitis
○ Explosive, watery diarrhea
○ Fever
○ Appears significantly ill
Childhood
○ Constipation
○ Ribbonlike, foul-smelling stools
○ Abdominal distention
○
○
○
NSG
CARE
MGMT
●
Focus
○
○
○
○
DX
●
●
●
●
●
ASSE
SSME
NT
●
●
●
●
●
THER
APEU
TIC
MGMT
●
●
●
●
●
COMP
LI
●
●
Visible peristalsis
Easily palpable fecal mass
Undernourished,
anemic
appearance
○
Help parents adjust to a
congenital defect in their child.
Foster infant-parent
Bonding Prepare them for the
medical-surgical intervention
Prepare parents to assume care
of the child after surgery
Biopsy
Barium enema (use with caution)
By anorectal manometry
○ You lie on your left side. Your
physician inserts a small, flexible
tube into the rectum. The tube
has a balloon attached. Your
doctor inflates the balloon in the
rectum to evaluate the reflexes.
measure abdominal circumference with a
paper tape measure
Post-op
○ Involve parents in the care of the
child:
■ Feeding
■ Observe for signs of
wound infection or
irregular passage of
stool
■ Daily anal dilatations
■ Colostomy care
What is the duration of the
constipation? It may have been a
problem from birth.
What
do
parents
mean
by
constipation? Children do not have a
bowel movement more than once a week
What is the consistency of the stool?
Ribbonlike or watery
Is the child ill in any other way?
Children with aganglionic disease of the
intestine tend to be thin and
undernourished, sometimes deceptively
so because their abdomen is large and
distended
Digital exam rectum is empty
Surgery
○ Surgical repair megacolon
○ Two-stage surgery:
1) temporary colostomy is
established
2) bowel repair at 12-18
months
Fluid and electrolyte replacement
Transanal Soave endorectal pull-through
procedure
Post-op complications: anal stricture,
recurrent enterocolitis prolapse, perianal
abscess, incontinence
Permanent colostomy
Enterocolitis
Emergency preoperative care
○ frequent monitoring of VS
○ monitoring fluid & electrolyte
replacements, as well as plasma
or other blood derivatives
observing for symptoms of bowel
perforation
■ Fever
■ Increasing Abdominal
Distention
■ Vomiting
■ Increased Tenderness
■ Irritability
■ Dyspnea
■ Cyanosis
INFLAMMATORY BOWEL DISEASES
Chronic Intestinal Inflammation
IBD should not be confused with IBS. IBD is a term used to refer
to two major forms of chronic intestinal inflammation such as:
● ULCERATIVE COLITIS
● CROHN’S DISEASE
Crohn disease and ulcerative colitis have similar
epidemiologic, immunologic, and clinical features but they are
distinct disorders.
Both:
●
●
●
●
●
●
●
●
involve the development of ulcers of the mucosa or
submucosa layers of the colon and rectum
occur most frequently in young adults and
adolescents
occur more frequently in males than in females
show familial tendencies
alteration in immune system response or are
autoimmune processes
increased immunoglobulins IgA & IgG on intestinal
mucosa; IgE immunoglobulins & eosinophil count
Secondary: psychological problems
CROHN'S: Smoking, antibiotics, aspirin
Comparison of Crohn’s Disease and Ulcerative Colitis
Comparison
Factor
Crohn’s Disease
Ulcerative Colitis
Ileum
Colon and rectum
Nature of
lesions
Intermittent
Continuous
Diarrhea
Moderate
Severe and bloody
Anorexia
Severe
Mild
Weight loss
Severe
Mild
Growth
retardation
Marked
Mild
Anal and
perianal lesions
Common
Rare
Associations
with carcinoma
Rare
Common
Part of bowel
affected
CROHN’S DISEASE
● Inflammation of segments of the intestine; commonly
involves terminal ileum
● Inflamed segments are separated by normal bowel
tissue
●
Colon wall becomes thickened and surface is inflamed
→ a “cobblestone” appearance of mucosa
ULCERATIVE COLITIS
● Colon and rectum are involved distal colon and rectum
most severely affected
● Inflammation involves continuous segments
IBD is a chronic disease. Relatively long periods of quiescent
disease may follow exacerbations. The outcome is influenced
by the regions and severity of involvement as well as
appropriate therapeutic management. Malnutrition, growth
failure, and bleeding are serious complications. The overall
prognosis for ulcerative colitis is good. The development of
colorectal cancer is a long-term complication of IBD.
IMPERFORATE ANUS
INFLAMMATORY BOWEL DISEASES
THERAPEUTIC MANAGEMENT
The natural history of the disease continues to be unpredictable
and characterized by recurrent flare ups that can severely impair
a patient's physical and social functioning.
●
●
●
●
●
●
●
●
●
GOALS
○ Control the inflammatory process
○ Reduce or eliminate the symptoms
○ Obtain long-term remission
○ Promote normal growth and development
○ Allow as normal a lifestyle as possible.
Treatment is individualized and managed according to
the type and severity of the disease, its location, and
their response to therapy.
Crohn disease is more disabling, has more serious
complications and is often less amenable to medical
and surgical treatment than is also ulcerative colitis.
Ulcerative colitis: Colectomy
Resting Period
○ Enteral or total parenteral nutrition
The child's bowel heals best if it is allowed to
rest for a time. Enteral and total parenteral
nutrition is usually provided for nutrition
during the resting period. A child can remain
home during this period as long as parents
have thorough education about the child's
nutritional needs.
○ After: high-protein, high-carbohydrate,
high-vitamin diet
When food is reintroduced after the resting
period, a high protein, high carbohydrate,
high vitamin diet is prescribed to replace
nutrients.
Monitor I/O
Children may eat cautiously at first to avoid
reintroducing diarrhea so assess intake and output.
Drugs of choice:
○ Prednisone
○ Sulfasalazine
○ Azathioprine
○ Monoclonal antibodies
○ Ulcerative colitis: Cyclosporine
A combination of anti-inflammatory drugs such as
Prednisone, sulfasalazine, azathioprine or monoclonal
antibodies generally bring about a great improvement
in symptoms. For ulcerative colitis, cyclosporine may
be used. If medical therapy is ineffective, bowel
resection to remove a portion of the bowel or
colectomy followed by an ileoanal pull through may be
necessary.
Bowel surgery
Bowel surgery is a serious step because it reduces the
possibility of the child’s developing decimal cancer in
association with ulcerative colitis, it may be necessary
in children whose disease is running a long-term
debilitating course that does not improve.
Yearly colonoscopy
Children who recover from inflammatory bowel
disease should have a colonoscopy yearly for the rest
of their lives.
PROGNOSIS: Chronic disease; relatively long periods of
quiescent disease may follow exacerbations
DEFIN
ITION
●
●
●
●
●
ASSE
SSME
NT
●
●
●
●
Stricture of the
anus
(meaning
the opening to the
anus is missing or
blocked).
When 2 sections
of the bowel fail
to meet @ week 7
of
intrauterine
life
In week 7 of
intrauterine
life,
the upper bowel
elongates
the
pouch and combines with a pouch
invaginating from the perineum.
These two sections of bowel meet, the
membranes between them are absorbed,
and the bowel is then patent to the
outside.
If this motion toward each other does not
occur or if the membrane between the two
surfaces does not dissolve, an imperforate
anus occurs.
Relatively minor or much more severe
The disorder can be relatively minor
requiring just surgical incision of the
persistent membrane or much more
severe, involving sections of the bowel
that are many inches apart with no anus.
Accompanying fistula to the bladder in
boys and to the vagina in girls, further
complicating a surgical repair.
1 in 5000 live births, more commonly in
boys than in girls
The problem occurs in approximately 1 in
5000 live births, more commonly in boys
than in girls. Imperforate anus may occur
as an additional complication of spinal
cord disorders because both the external
anal canal and the spinal cord arise from
the same germ tissue layer.
Inspection: Anus can appear normal and
the condition can still exist far inside
Membrane filled with black meconium
protruding from anus
Occasionally, the condition may be
revealed because a membrane filled with
black meconium can be seen protruding
from the anus.
(-) "wink" reflex
A wink reflex will not be present if sensory
nerve endings in the rectum are not intact.
This wink reflex is touching the skin near
the rectum should make it contract.
Inability to insert a rubber catheter into
the rectum
If these methods fail to detect the
condition, it can be discovered in a
newborn by the inability to insert a rubber
catheter into the rectum, no stool will be
●
●
passed, and abdominal distention will
become evident.
No stool will be passed after 1st 24Hr
Abdominal distention
●
DX
●
●
●
MGMT
●
●
●
●
Detected with prenatal sonogram or at
birth
The condition may be detected by a
prenatal sonogram. It is definitely
discovered at birth when inspection in a
newborn anal region reveals that no anus
is present, although this observation may
not be helpful because the anus can
appear normal, and the condition still exist
far inside so that it is missed on simple
inspection.
Radiograph
Urine specimen = (+) meconium x
Collect a urine specimen on infants with
imperforate anus so it can be examined for
the presence of meconium. This is to help
determine whether the child has a rectal
bladder fistula. Placing a urine collector
bag over the vagina in girls may reveal a
meconium stain discharge or a rectal
vaginal fistula.
Simple anastomosis
For therapeutic management, the degree
of difficulty in repairing an imperforate
anus depends on the extent of the
problem. If the rectum ends close to the
perineum, below or at the level of the
levator ani muscle and the anal sphincter
is formed, repair involves simple and
anastomosis of the separated bowel
segments.
Complicated repairs:
○ End of the rectum is at a
distance from the perineum
○ Fistula to the bladder or
vagina is present
The repair becomes complicated
if the end of the rectum is at the
distance from the perineum
above the levator ani muscle or
the anal sphincter exists only in
an underdeveloped form.
Extensive repair:
○ Temporary colostomy
All repairs are complicated if a
fistula to the bladder or vagina is
present. If the repair will be
extensive, the surgeon may
create a temporary colostomy
anticipating final repair when the
infant is somewhat older around
6 to 12 months.
Pre-op:
○ NPO
Postoperative care would involve
keeping the infant NPO to avoid
further bowel distention,
○ NGT
A nasogastric tube attached to
low intermittent suction for
decompression will be inserted this is to relieve vomiting and
prevent pressure from other
abdominal organs or the
diaphragm from the distended
intestine.
○ IV or TPN
IV therapy or TPN (Total
Parenteral Nutrition) will be
started to maintain fluid and
electrolyte balance.
Post-op:
○ Small oral feedings of glucose
water, formula, or breastmilk
The newborn will return from
surgery with a nasogastric tube
still in place. So for postoperative
care, when bowel sounds are
present and the NGT is removed,
small oral feedings of glucose,
water, formula or breast milk
can be begun.
○ Some infants: Colostomy care
○ Avoid unrefined rice & grains,
vegetables with fibers, or
fruits with peels.
Some infants who are scheduled
for repair in a second stage
operation and will have a
temporary colostomy are not
permitted high residue foods to
lessen the bulk of stools.
However, this is rarely a problem
with infants because their diet
naturally is a low residue one.
DISORDERS CAUSED BY FOOD,
VITAMIN, & MINERAL DEFICIENCIES
KWASHIORKOR
DEFIN
ITION
●
●
●
●
●
Disease caused by protein deficiency
Occurs most frequently in children ages
1 to 3 years old
This is a disease caused by protein
deficiency, and occurs most frequently in
children ages 1 to 3 years. This is because
this age group requires a high protein
intake.
It is a disease found almost exclusively in
developing countries in Africa, Asia and
Latin America, although it does occur in
the United States.
Occur after weaning
It tends to occur after weaning when
children change from breast milk to a diet
consisting mainly of carbohydrates.
Ga language: "the sickness the older
child gets when the next baby is born"
Taken from the Ga language in Ghana,
the word kwashiorkor means “the
sickness the older child gets when the
next baby is born.”
This aptly describes the syndrome that
develops in the first child when weaned
from the breast after the second child is
born. Growth failure is a major symptom.
but primarily emotional. Marasmus may
be seen in infants as young as three
months old if breastfeeding is not
successful and there are no other
suitable alternatives.
MARASMIC KWASHIORKOR
DEFIN
ITION
●
●
NUTRITIONAL MARASMUS
DEFIN
ITION
●
●
●
●
●
●
Caused
by
a
deficiency of all food
groups
General malnutrition
of both calories and
protein
Nutritional marasmus
is caused by a
deficiency of all food
groups - basically a
form of starvation.
Marasmus
results
from
general
malnutrition of both calories and protein.
Common in underdeveloped countries
It is common in underdeveloped countries
during times of drought, especially in
cultures where the adults would eat first,
the remaining food is often insufficient in
quality and even quantity for these
children.
Grossly neglected children
Although it is most commonly seen in
developing countries where food supplies
are short, it can also be seen in grossly
neglected children or those with failure
to thrive in developed countries such as
the United States.
Less than 1 year old, esp as young as
3 months - same symptoms as children
with Kwashiorkor
These children are most commonly
younger than one year of age, and they
may have the same symptoms as children
would Kwashiorkor including growth
failure, muscle wasting, irritability, iron
deficiency anemia, and diarrhea.
Whereas children with Kwashiorkor are
anorectic, children with nutritional
marasmus are invariably hungry,
they're starving and they will suck at
any object offered to them such as a
finger or even their clothing.
A syndrome of physical and emotional
deprivation
Marasmus is usually a syndrome of
physical and emotional deprivation and
it's not confined to geographic areas
where food supplies are inadequate. It
may be seen in children with growth failure
in whom the cost is not solely nutritional
●
●
Marasmic kwashiorkor is a form of SAM
(Severe Acute Malnutrition) in which
clinical findings of both kwashiorkor and
marasmus are evident. The child has
edema, severe wasting, and stunted
growth.
In marasmic kwashiorkor, the child has
inadequate
nutrient
intake
and
superimposed
infection,
fluid
and
electrolyte disturbances, hypothermia and
hypoglycemia associated with a poor
prognosis.
Marasmic kwashiorkor
○ Edema
○ Severe wasting
Marasmus is characterized by
gradual wasting and atrophy of
body tissues, especially of
subcutaneous fat.
○ Stunted growth
Marasmus: gradual wasting & atrophy of
body tissues, especially subcutaneous fat
○ Very old, with loose and wrinkled
skin (Unlike the child with
kwashiorkor, who appears more
rounded from the edema)
○ Fat
metabolism
is less
impaired than in kwashiorkor,
thus deficiency of fat soluble
vitamins is usually minimal or
absent.
○ In
general,
the
clinical
manifestations of marasmus are
similar to those seen in
kwashiorkor
except
with
marasmus, there is no edema
from hypoalbuminemia or
sodium
retention
which
contributes to a severely
emaciated appearance.
○ There is no dermatosis caused
by vitamin deficiencies, there is
little or no depigmentation of skin
or hair, moderately normal fat
metabolism and lipid absorption
is noted and a smaller head size
and slower recovery after
treatment.
○ The child is fretful, apathetic,
withdrawn and so lethargic
that frustration frequently occurs.
Intercurrent infection with
debilitating diseases such as TB
or tuberculosis, parasitosis, HIV,
and dysentery is common.
NSG
MGMT
MGMT
●
●
●
●
●
●
●
DIET:
High-quality
proteins,
carbohydrates, vitamins, and minerals
Treatment is a diet rich in all nutrients.
When SAM occurs as a result of
persistent diarrhea, three management
goals are identified:
1. Rehydration (ORS) - There's
rehydration with an oral rehydration
solution
that
also
replaces
electrolytes
2. Antibiotics - Administration of
antibiotics to prevent intercurrent
infections
3. Breastfeeding
or
a
proper
weaning diet - Provision of
adequate
nutrition
by
either
breastfeeding or a proper weaning
diet
3-phase treatment protocol:
1. Acute or initial phase in the first 210 days
○ Initiation of treatment for oral
rehydration,
diarrhea,
and
intestinal parasites
○ Prevention of hypoglycemia and
hypothermia
○ Subsequent
dietary
management
2. Recovery or rehabilitation (2-6
weeks) focusing on increasing
dietary intake and weight gain
3. Follow-up phase, care after
discharge in an outpatient setting to
prevent relapse and promote weight
gain,
provide
developmental
stimulation, and evaluate cognitive
and motor deficits.
Acute phase
○ Prevent fluid overload; the child
is observed closely for signs of
food or fluid intolerance.
○ Refeeding syndrome - Which
may occur when carbohydrates
are administered too rapidly.
This would cause severe
hypophosphatemia that may
cause sudden death in a child
who has been malnourished.
Vitamin and mineral supplementation
○ Recommended: Vitamin A,
zinc, and copper
○ Careful with Iron - Iron
supplementations
are
not
recommended until the child is
able to tolerate a steady food
source.
Observe for signs of skin breakdown
Breastfeeding, partial supplementation
with modified cow's Milk-based
formula
●
●
●
●
Because SAM appears early in childhood,
primarily in children 6 months to 2 years
old and is associated with early weaning,
a low protein diet, delayed introduction of
complementary foods and frequent
infections, it is essential that nursing care
focuses on prevention of SAM through:
○ Parent
education
about
feeding practices
○ Nutritional health of pregnant
women - Prevention should also
focus on the nutritional health of
pregnant women because this
will directly affect the health of
their unborn children.
○ Breastfeeding - Breastfeeding
is the optimal method of
feeding for the first 6 months.
The immune properties naturally
found in breast milk not only
nourish infants but also help
prevent opportunistic infections
which may contribute to SAM.
Focus on essential physiologic needs
○ Essential physiologic needs
■ Appropriate
nutrient
intake
■ Protection
from
infection
■ Adequate hydration
■ Skin care
■ Restoration
of
physiologic integrity
Patient education
○ Administration of
childhood
vaccinations
○ Promote nutrition and well being
for the lactating mother
○ Encouraging and participating in
well child visits for infants and
toddlers
○ Appropriate food sources for
children being weaned from from
feeding
○ Sanitation practices to prevent
childhood GI diseases
Ready-to-use therapeutic food (RUTF) This is basically a paste based on
peanuts, powdered milk, sugar and
vegetable oil which requires no mixing
with water or milk. The packaged RUTF
can be stored without a refrigerator and
studies have demonstrated improved
survival
rates
in
malnourished
children.
VITAMIN AND MINERAL DEFICIENCIES
NUTRITIONAL IMBALANCES
● Vitamin Imbalances
● Mineral Imbalances
One study, the 2008 feeding infants and toddlers study or
FITS found that usual nutrient intake of infants, toddlers and
preschoolers from 0 to 47 months old met or exceeded energy
protein requirements based on the dietary reference intakes.
So according to the study, a small but significant number of
infants were at risk for an adequate intake of iron and zinc.
Dietary fiber intakes in toddlers and preschoolers were low and
saturated fat intakes exceeded recommendations for the
majority of preschoolers. The findings of these studies and other
similar reports are important for nurses who work with infants
and children.
Nurses: Promote healthy nutrition habits early in children's
lives
● Proper education of families and children about
healthy lifestyle habits
○ Diet
○ Exercise for health promotion
○ Prevention of morbidities associated with
poor micronutrient intake & sedentary lifestyle
●
●
●
VITAMIN IMBALANCES
Although true vitamin deficiencies are rare especially in
developed countries, subclinical deficiencies are commonly
seen in population subgroups in which either maternal or child
dietary intake is imbalanced and contains inadequate
numbers or amounts of vitamins.
VITAMIN A DEFICIENCIES
MGMT
DEFIN
ITION
VITAMIN D DEFICIENCY
DEFIN
ITION
R/F
●
Primary Vitamin A Deficiency
● Prolonged dietary deprivation
● Endemic in areas such as southern &
eastern Asia, where rice (devoid of betacarotene) is the staple food
● Xerophthalmia due to primary deficiency
= common cause of blindness among
young children
Secondary Vitamin A Deficiency
● May
be
due
to:
Decreased
bioavailability
of
provitamin
A
carotenoids
● Interference with absorption, storage, or
transport of vitamin A
Vitamin D deficiency is Rickettsiae, once rarely
seen because of the widespread commercial
availability of commercial VItamin D fortified milk
has increased before the turn of the century.
●
●
●
●
Children exclusively
breastfed
by
mothers
with
inadequate intake
of vitamin D or are
BF exclusively >6
months
without
adequate maternal
vitamin D intake or
supplementation
Children with dark
skin
pigmentation
who are exposed to minimal sunlight
Children with low Vit D & calcium diets
Individuals who use milk products not
supplemented with vitamin D
THALASSEMIA
Children who are overweight or obese
Inadequate maternal ingestion of
cobalamin (vitamin B12) may contribute
to infant neurologic impairment when
exclusive breastfeeding is the only source
of infant’s nutrition.
At risk for vitamin deficiencies secondary
to disorders or their treatment.
○ Vitamin deficiencies of fatsoluble vitamins A and D:
malabsorptive disorders (ie.
cystic fibrosis, short bowel
syndrome)
○ Preterm infants may develop
rickets in the 2nd month of life
from inadequate intake of vitamin
D, calcium, and phosphorus.
○ Children receiving high doses
of salicylates may have
impaired vitamin C storage
○ Environmental tobacco smoke
exposure
=
decreased
concentrations of vitamin A, E,
and C in infants
○ Children with chronic illnesses
resulting in anorexia, decreased
food intake, or possible nutrient
malabsorption
=
multiple
medications
evaluated
for
adequate vitamin & mineral
intake in some form (parenteral
or enteral).
APA recommends 400 IU of vitamin D
beginning shortly after birth to prevent
rickettsiae and vitamin D deficiency
○ Vitamin D supplementation to
continue until the infant is
consuming at least 1 L/day of
vitamin D-fortified formula (or 1
quart/day).
○ Non-breastfed infants taking
<1 L/day of vitamin D-fortified
formula ➡️ receive a daily
vitamin D supplement of 400
IU.
DEFIN
ITION
Mild thalassemia may not
need treatment, but if the
child has a more severe
form of thalassemia, they
may need regular blood
transfusions. An older
child may take steps on
their own to cope with
fatigue such as choosing a healthy diet and
exercising regularly.
● Inherited blood disorder characterized
by less hemoglobin and fewer RBCs
than normal
● Alpha-thalassemia,
beta-thalassemia
intermedia.
Cooley's
anemia
and
Mediterranean anemia
● Suboptimal intakes of vitamins A, D, E,
and K, folate, calcium, and magnesium
and the inadequacies continue to increase
with advanced age.
Macrominerals
● Daily requirements greater >100 mg; include calcium,
phosphorus, magnesium, sodium, potassium, chloride,
and sulfur
Microminerals, or trace elements
● Daily requirements <100 mg and include several
essential minerals and those whose exact role in
nutrition is still unclear.
MINERAL IMBALANCES
INFOS
●
●
●
NOTE!
●
●
●
S/S
R/F
●
●
●
●
●
●
●
●
Most common vitamin deficiency:
Vitamin D
Most common mineral deficiency:
Zinc, Iron
●
Children
with
intestinal
failure
transitioned from parenteral nutrition
to enteral nutrition = at least one
vitamin and mineral deficiency
Some babies show s/s of thalassemia at
birth while others may develop s/s during
the first 2 years of life.
Some people may only have one affected
hemoglobin gene don’t experience any
thalassemia symptoms
●
Fatigue
Weakness
Pale appearance
Jaundice
Facial bone deformities
Slow growth
Abdominal swelling
Dark urine
●
●
Family History of thalassemia - passed from
parents to children through mutated hemoglobin
gene
COMP
LICAT
IONS
●
●
●
●
●
●
Iron overload
Infection
Bone deformities
Splenomegaly
Slowed growth rates
Heart problems
TTT
●
MILD: Minor or little ttt may need no
treatment; occasionally, there may be
need for blood transfusion particularly
after surgery (if adolescent has baby or to
manage complications that arise), treat
iron overload (if one has Betathalassemia intermedia)
MODERATE to SEVERE: Frequent blood
transfusions, stem cell transplant or bone
marrow transplant
●
MINERAL IMBALANCES
●
R/F
●
●
●
●
●
●
●
NSG
MGMT
●
Greatest concern with minerals is
deficiency, especially iron-deficiency
anemia
Other minerals that may be inadequate in
children's diets even with supplementation
could include calcium, phosphorus,
magnesium, and zinc
When there are low levels of zinc in
particular, it can cause Nutritional
Failure To Thrive (FTT)
Some of the macro minerals may be
inadvertently overlooked when a child with
intestinal failure or recent surgery is
making the transition from total
parenteral intake to enteral intake.
An imbalance in the intake of calcium and
phosphorus may occur in infants who are
given whole cow's milk instead of
infant formula. Neonatal tetany may be
observed in such cases.
The regulation of mineral balance in the
body is a complex process. Dietary
extremes of mineral intake can cause a
number of mineral to mineral interactions
that could result in unexpected
deficiencies or even excesses.
Deficiencies
○ Megadosing 1 mineral causes
inadvertent
deficiency
of
another
○ When various substances in
the diet interact with minerals
(Iron, zinc, and calcium can form
insoluble complexes with fitates
or oxalates which impair the
bioavailability of the mineral.
These fitates or oxalates can be
found in plant proteins.)
Greater risk for growth failure
○ Bone mineral deficiency
■ Treatment
of
the
disease
■ Decreased
nutrient
intake
■ Decreased absorption
of necessary minerals
Children receiving or have received
radiation and chemotherapy for cancer
Children with HiV
Sickle cell disease
Cystic fibrosis
Gastrointestinal (Gl) malabsorption
Nephrosis
Extremely low in birth weight (ELBW) &
very low birth weight (VLBW) preterm
infants
Initial nursing goal: Identification of
adequacy of nutrient intake
○
●
●
Assessment based on a dietary
history
○ Physical examination for signs
of deficiency or excess
Standardized growth reference charts
to compare and assess growth
parameters
○ Head circumference, height, and
weight references
Patient education
○ Breastfeeding for the 1st 6
months or preferably for a year
○ Solid food introduction for
about 4-6 months
○ Receive iron fortified cereal for
at least 18 months
○ Vitamin B12 supplementation
is
recommended
if
the
breastfeeding mother’s intake of
the vitamin is inadequate or if
she is not taking any vitamin
supplements
○ A variety of foods should be
introduced during the early years
to ensure a well balanced intake.
○ Infants who have a particular
nutritional deficit should be
identified and this is a
multidisciplinary approach.
○ Proper nutrition
○ Adequate g&d
PICA
DEFIN
ITION
Eating disorders in young children would consist of
pica, rumination and feeding disorders.
In older children, eating disorders could include
anorexia nervosa and bulimia.
● Eating disorder: a child would
persistently eat non-food substances
● Pica is the Latin word for magpie (a bird
that is an indiscriminate eater)
● Dirt, clay, paint chips, crayons, yarn, or
paper
● Primary danger lies in the possibility of
accidental poisoning when a child is
ingesting non food substance
● Often is not diagnosed until a child
presents with a pica-induced complication
such as blood poisoning
R/F
2-6 YO; may be present into adolescence
● Incidence increases in children who are
cognitively challenged (inability to
distinguish from edible to non edible
substances as early as other children),
● High incidence in pregnant teenage girls
(may also be iron deficient)
○ Highly associated with any may
be caused by Iron deficiency
anemia
C/M
●
●
●
●
Constipation
Gl malabsorption
Fecal impaction
Intestinal obstruction
TTT
●
●
Correcting anemia may also correct pica
Individualized therapy plan needs to be
devised to meet the child’s needs until the
phenomenon fades
●
Keeping the child safe from ingesting
inedible
substances
is
a major
responsibility until then
DIFFERENCE BETWEEN:
NEPHROGENIC DIABETES INSIPIDUS
AND CENTRAL DIABETES INSIPIDUS
NDI
Inability to concentrate urine
in response to vasopressin
Central DI
Lack of vasopressin
NURSING CARE MANAGEMENT 109
NURSING CARE OF A CHILD W RENAL, GU &
REPRO DISORDER
THE NEPHRON
Clinical Instructor: Isabella R. Dobluis
VIDEO 1
Overview & Assessment of RENAL FUNCTION Pediatric
variations & Nursing care of the child with a Renal Disorder,
Genitourinary alteration & Reproductive disorder
I.
ANATOMY & PHYSIOLOGY
OVERVIEW OF THE URINARY SYSTEM & PEDIATRIC
VARIATIONS
FUNCTIONS OF THE URINARY SYSTEM
●
●
●
Kidneys produce urine, ureters transport urine to the
urinary bladder, urinary bladder stores urine, urethra
transports urine to the outside of the body.
Kidneys eliminate waste, regulate blood volume,
blood pressure, ion concentration, and pH
Kidneys are involved with RBC and Vitamin D
production.
THE URINARY SYSTEM
Figure 26-1. (Picture above)
The function unit of the kidney is the nephron. The parts of a
nephron are the renal corpuscle, proximal convoluted
tubule, the loop of Henle, and the distal convoluted
tubule.
The renal corpuscle consists of a Bowman capsule and a
Glomerulus. Fluid leaves the blood in the Glomerulus →
enters the Bowman Capsule → Nephron empties to the Distal
convoluted tubule → into a collecting duct → empties into
papillary ducts → empties into minor calyces (calyx).
The Bowman capsule has an outer parietal layer and an inner
visceral layer consisting of podocytes. The filtration
membrane consists of the endothelium of glomerular
capillaries, a basement membrane, and podocytes.
In the Glomerulus, water and solutes are filtered from the
blood. This passage of water and solutes from the blood into
the glomeruli is effective only as long as the blood pressure
in glomerular arteries exceeds that in the tubule.
INTERNAL ANATOMY & PHYSIOLOGY OF THE KIDNEYS
The smaller efferent arterioles normally cause back
pressure in the glomerular arterioles, increasing the existing
pressure and allowing filtration to occur readily. If blood
pressure in these arterioles should fall below the tubular
pressure or the tubular pressure should rise above that of the
arterioles, little or no filtration will occur. For this reason, renal
function must be assessed carefully in children who are
hemorrhaging or are in shock with lower BP for any reason.
The solution that filtered into the tubule from afferent
arterioles → passess through the proximal portion → loop of
Henle → Distal portion.
Beginning with the loop of Henle → water and electrolytes
diffuse back into blood capillaries → reducing the volume of
filtrate by approximately 90%.
Glomerular filtrate enters the proximal tubule at a rate of
approximately 120 mL/min. Most water is reabsorbed, that
the final end product which is urine, left in the tubule, is
excreted at a rate of only approximately 1 mL/min.
Figure 23.3. (Picture above)
The two layers of the kidney are the cortex and medulla. The
renal columns extend into the medulla between the renal
pyramids. The tips of the renal pyramids project to the minor
calyces (calyx). The minor calyx opens → major calyx which
opens → renal pelvis → leads to ureter.
The proximal portion of the tubules reabsorbs most of the
water, glucose, sodium chloride, phosphate, sulphate, and
some bicarbonate ions. This is a passive process, not
particularly affected by body needs. In contrast, the distal
portion of the tubules responds selectively to the body's
needs. If necessary, sodium and bicarbonate ions and
additional water can be reabsorbed.
urine give a good indication of healthy function and are often
requested by health practitioners when assessing child health
or illness
ARTERIES AND VEINS OF THE KIDNEYS
Amount of urine excreted in a 24H period depends on fluid
intake, kidney health and age. A significant decrease in urine
production is called oliguria. The absence of urine production
is anuria.
When renal disease occurs and glomerular or tubular function
becomes impaired, non-protein microgenus substances such as
CREATININE, UREA, AMMONIA, and PURINE BODIES are
retained in the blood, rather than being excreted.
ASSESSM
ENT
COLOR
Figure 46.2 (picture above)
The renal artery enters the kidney and branches many times
forming afferent arterioles which supply the glomeruli.
Efferent arteries from the glomeruli supply the peritubular
capillaries and vasa recta. The peritubular capillaries and
vasa recta join small veins that converge to form the renal
vein which exists in the kidney. The juxtaglomerular
apparatus consists of the granular cells of the afferent
arterioles and the macula densa - part of the distal convoluted
tubule.
APPEARA
NCE
NORMAL
FINDING
DESCRIPTION/
IMPLICATIONS
Pale yellow
●
Influenced by
concentration and
ingredients
Clear
●
Bacteria, excessive
crystals, or cells =
cloudiness
High protein content =
foams like beer when
poured.
●
pH
4.6-8.0
●
Alkaline (pH>7) = UTI/
severe alkalosis
●
Urine @ room temp →
alkaline
URINE PRODUCTION
●
●
●
●
●
PROCESSES:
○ Filtration
○ Tubular reabsorption
○ Tubular secretion
Breakdown of amino acids by the liver → UREA
○ Amount of urea in urine: indirect indication of
kidney & liver function
Product release during Muscle cell metabolism →
CREATININE
○ The amount excreted in urine normally
remains constant regardless of the amt. of
protein in the diet or body processes.
○ Lesser amount: impaired kidney fx
■ Impaired kidney function, not only is
Creatinine level reduced, but also
some constituents that normally are
retained, which includes albumin,
glucose, blood, bile pigments and
casts that will be allowed to enter
urine.
Bile pigments that stain urine a green or yellow or
brown color appear in the urine when the child has
elevated levels of indirect or direct bilirubin in the
plasma.
Casts are formed when there is an abnormal condition
that causes kidney tubules to become lined with
protein formed from red and white blood cells,
epithelial cells or fatty cells that harden into the shape
of the tubule.
○ After urine washes the casts out, it can be
detected by microscopic examination of urine
Children need to void regularly to excrete waste produced
from their body metabolism. The volume and constituents of
SPECIFIC
GRAVITY
1.0031.030
●
●
Elevated = dehydration
Decreased =
overhydration
PROTEIN
0
●
Protein molecules pass
into urine due to
inflammation
Adolescent girls:
pregnancy
Orthostatic proteinuria
●
●
KETONES
0
●
Released after
breakdown of body
protein: starvation
GLUCOSE
0
●
●
Symptom of DM
Adolescent girls:
pregnancy
< 1 PER
HPF, (-) on
dipstick
●
●
(+) in glomerulonephritis,
UTI, trauma
(+) in Systemic disease
<5 per
HPF
●
(+) with bacteriuria
0
●
●
●
Proteinuria
Fatty casts = nephrosis
Other casts = urine
stasis, proteinuria
RBC
WBC
CASTS
CRYSTALS
Possibly
present or
not
●
●
●
Uric acid, cystine,
calcium oxalate crystals
Phosphate crystal in
alkaline urine: infx
Sulfur crystals = child
receiving sulfa drug
PROCESSES
1) Filtration
● GFR = amount of filtrate produced per minute
● The filtrate is plasma minus blood cells, platelet, and
blood protein. Most (99%) of the filtrate is reabsorbed
● Filtration pressure is responsible for filtrate
formation.
○
3) Atrial Natriuretic Hormone (ANH)
● Heart (increased BP)
● Inhibits Na+ reabsorption in the kidneys, resulting in
increase urine volume and decreased blood volume
and blood pressure
● Inhibits ADH secretion and dilates arteries and veins
URINE MOVEMENT
●
2) Regulation of Glomerular Filtration Rate
● Autoregulation
○ Dampness the systemic blood pressure
changes by altering afferent arteriole
diameter
● Sympathetic stimulation
○ Decreases renal blood flow and afferent
arteriole diameter.
3) Tubular Reabsorption
● There is a medullary concentration gradient from
the cortex to the tip of the renal pyramids.
● Filtrate (reabsorbed) → by diffusion, facilitated
diffusion, active transport, symport, and antiport from
●
the nephron and collecting ducts → peritubular
●
capillaries and vasa recta
Waste products and
concentrated in the urine.
toxic
substances
are
4) Tubular secretion
● Substance → secreted in the proximal or distal
●
convoluted tubules and the collecting ducts
Hydrogen ions, potassium and some substances not
produced in the body are secreted by antiport
mechanism
stimulating increased synthesis of enzymes,
carrier proteins, and channel proteins.
Regulates the body’s water content by
regulating the body’s sodium content
●
Anatomy and histology of the ureters, urinary
bladder, and urethra
○ The walls of the ureter and urinary bladder
consist of the epithelium, lamina propria, a
muscular coat, and fibrous adventitia.
○ The transitional epithelium permits changes
in size.
○ Contraction of the smooth muscle moves
urine.
○ The urethra is lined with transitional and
stratified squamous epithelium.
○ Males have an internal urethral sphincter with
smooth muscle that prevents retrograde
ejaculation of semen.
○ An external urethral sphincter of skeletal
muscle also allows voluntary control of
urination.
Urine flow through the nephron and ureters
○ A pressure gradient causes urine to flow from
the Bowman capsule → ureters.
○ Peristalsis moves urine through the ureters.
Micturition Reflex
○ Stretch of the urinary bladder stimulates a
reflex that causes the urinary bladder to
contract and inhibits the external urethral
sphincter.
○ Higher brain centers can stimulate or inhibit
this reflex.
○ Voluntary relaxation of the external urethral
sphincter permits urination and contraction
prevents it.
5) Maintaining the Medullary Concentration Gradient
● Necessary for the production of concentrated urine
● The addition of solutes increases the medullary
interstitial fluid concentration.
● The vasa recta is a counter current mechanism that
removes reabsorbed water and solutes without
disturbing the medullary concentration gradient
HORMONAL REGULATION OF URINE
CONCENTRATION AND VOLUME
1) Antidiuretic Hormone (ADH)
● Secreted by posterior pituitary
● Increases water permeability in distal convoluted
tubules and collecting ducts
● ADH regulates blood osmolality by altering water
absorption
2) Renin-Angiotensin-Aldosterone
●
●
●
Renin (produced by kidneys) → conversion of
angiotensinogen to angiotensin I
Angiotensin-converting enzyme → angiotensin I into
BODY FLUIDS
angiotensin II → stimulates aldosterone secretion from
When talking about intracellular fluid (ICF), that means it is
fluid inside the cells. Extracellular fluid (ECF) on the other
hand, is outside the cells and it also includes interstitial fluid and
plasma.
adrenal cortex
Aldosterone
○ Na+, Cl-, and H+ transport in distal
convoluted tubules and collecting ducts by
1) Regulation of Intracellular Fluid Composition
● Substances used or produced inside the cells and
substances exchanged with the extracellular fluid
determine the composition of intracellular fluid.
●
●
○
ICF is different from ECF because the plasma
membrane regulates the movement of materials.
The difference between ICF and ECF concentrations
would determine water movement
2) Regulation of Body Fluid Concentration and Volume
● Water input
○ Ingested (90%)
○ Produced in metabolism (10%)
■ Habit and social setting influence
thirst
and
an
increase
in
extracellular
osmolality
or
a
decrease
in
blood
pressure
stimulates the sense of thirst
● Water output
○ Water is lost through evaporation from the
respiratory system and the skin (insensible
perspiration and sweat) - 35%
○ Water loss to the gastrointestinal tract small; around 4%
○ Kidneys: primary regulator of water excretion
- around 61%
● Regulation of Extracellular Fluid Osmolality
○
●
●
Extracellular fluid osmolality → thirst and ADH
secretion
■ Resulting to an increased fluid
intake
and
increased
water
reabsorption in the kidneys
■ Decrease in extracellular osmolality
●
→ inhibits thirst and decreases ADH
●
secretion → decreased fluid intake +
REGULATION OF ACID-BASE BALANCE
decreased water reabsorption in the
●
kidneys
Regulation of Extracellular Fluid Volume
○ Decreased extracellular fluid volume →
increased aldosterone secretion, deceased
ANH secretion, increased ADH secretion, and
increased sympathetic stimulation of the
afferent arterioles
○
Increased
extracellular
fluid volume
→
decreased aldosterone secretion, increased
ANH secretion, decreased ADH secretion, and
decreased sympathetic stimulation of the
afferent arterioles
REGULATION OF SPECIFIC ELECTROLYTES IN THE
EXTRACELLULAR FLUID
●
●
●
Regulation of Sodium Ions
○ Kidneys
■ The major route by which sodium is
excreted.
○ Aldosterone and ANH
■ Sodium ions are regulated by these.
○ 90-95% of extracellular osmotic pressure
■ Sodium ions are lost in sweat and
association anions together with
sodium ions are responsible for 9095% of extracellular osmotic
pressure.
Regulation of Chloride Ions
○ ECF
■ These ions are dominant negatively
charged ions in the ECF.
■ They are regulated by the
mechanism of regulating cations.
Regulation of Potassium Ions
Reabsorbed from the proximal convoluted
tubule
○ Secreted into the distal convoluted tubule
○ Aldosterone
■ Increases the amount of potassium
secreted
Regulation of Calcium Ions
○ Parathyroid hormone
■ Increases extracellular calcium
levels
■ Increases osteoclast activity
■ Increases calcium reabsorption from
the kidneys
■ Stimulates
active
vitamin
D
production
○ Vitamin D
■ Stimulates calcium uptake in the
intestines
○ Calcitonin
■ Decreases extracellular calcium
levels by inhibiting osteoclast
Other Ions
○ Phosphate ions, sulfate ions, and
magnesium ions
■ These are reabsorbed by active
transport in the kidneys.
Acids release H+ into solution, and bases remove
them
BUFFER SYSTEMS
○ Respiratory Regulation of Acid Base
■ Takes minutes
■ Carbonic acid/bicarbonate buffer
system
● As carbon dioxide levels
increase, pH decreases/
● As carbon dioxide levels
decrease, pH increases
■ hypoventilation/hyperventilation
○ Renal Regulation of Acid-Base Balance
■ May take hours to days
■ Regulate pH precisely
■ H+: HCO3■ Hydrogen phosphate (HPO42-) and
ammonia (NH3): major nonbicarbonate bases in the filtrate
● H+ + HPO42- and NH3 =
the filtrate is buffered;
additional H+ secreted
● H+ + HPO4 and NH3 = a
new HCO3 is added to the
blood
■ Glutamine metabolism = HCO3CHILD HEALTH ASSESSMENT
●
●
For newborns and infants, it is rather easy to perform
palpation on babies because they generally like to be
touched. Kidneys may be located by deep abdominal
palpation in newborns and infants.
Always remember that the right kidney is slightly lower
than the left and it is also easier to locate the optimal
time to palpate the kidney of a newborn is during the
first few hours of life before the bowel begins to fill with
air and obscures palpation.
●
●
To palpate the kidneys, you can place a hand under an
infant’s back just below the 12th rib, press upward,
and then with the other hand, on that side of the
abdomen, just below the umbilicus, is where you put
your other hand. Then, press deeply and locate the
kidney which can be felt as a firm mass approx. the
size of a walnut between the hands.
For the preschooler and school-aged child,
children’s abdomen at this age are often ticklish, so
they’re the opposite of infants, and children may tense
or guard their abdominal muscles when touched,
making it difficult to palpate.
COMMON DIAGNOSTIC PROCEDURES & RELATED
SPECIAL NURSING CONSIDERATIONS
Assessment of kidney and urinary tract integrity, and diagnosis
of renal or urinary tract disease are based on several evaluative
tools. Physical examination, history taking, and observation
of symptoms are the initial procedures. In suspected urinary
tract diseases or disorders, further assessment by laboratory,
radiologic and other evaluative methods are carried out. A
variety of diagnostic tests may be performed either in an
ambulatory department or on an in-patient basis to document
renal or urinary tract disease.
A. URINE TESTS OF RENAL FX
1) Laboratory Tests
● Both urine and blood studies contribute vital
information for detection of renal problems. The single
most important task is probably routine urinalysis,
specific urine and blood tests provide additional
information. Because nurses are usually the ones who
collect the specimens for examination, and often
perform most of the screening tests, they should be
familiar with the test, its function, and factors that can
alter or distort the results of the test.
2) Urinalysis
● One of the most revealing tests of kidney function; also
one of the simplest.
● For best results, specimens collected should be fresh
because urine that stands at room temperature for any
length of time changes composition.
● A chemical region strip can be used to detect
glucose, protein, and occult blood, and to measure pH.
3) Specific gravity
● is best determined by the use of a refractometer, and
it only requires a single drop of urine.
4) Urine culture
● Will come in handy if you are trying to detect the
presence of bacteria in urine, as in UTI.
● So because bladder catheterization can introduce
bacteria to the bladder and also is painful and intrusive,
most urine specimens in children are obtained by a
clean catch procedure or sterile suprapubic aspiration.
Several instant read-commercial kits for culturing urine
are available for use in ambulatory settings.
OBTAINING URINE SPECIMENS
1) Routine U/A
● Requires only a single voiding specimen
● The specimen will be analyzed for appearance,
glucose, specific gravity, and microscopic analysis.
● Specimens must be collected in clean containers to
prevent contamination.
Collection guidelines:
● Infant/toddler, especially a child who’s not yet toilet
trained, can’t be expected to urinate on command.
So it is necessary to attach a collecting device to a
girl’s perineum or boy’s penis and scrotum to collect
the next voiding (upper left).
● For preschoolers or school-aged children, it may
be difficult to obtain routine urine specimens from
older children or toilet-trained toddlers because they
can void only when they feel a definite urge to do so,
they can’t do it on demand.
● Another problem is language. It is not
unprofessional to use words such as “peepee” if this
is what the child would understand.
● You can provide a potty chair if one is available and
if not, you may put a urine collection cap device on
a toilet.
● For adolescence, they’re usually knowledgeable
and cooperative and avoid providing urine
specimens.
2) 24-HR Urine Specimens
● May be necessary to determine how much the
substance is excreted during a day
● To begin a 24-HR urine collection, you ask the child to
void or with an infant, you can attach a collecting bag
and wait for the child to void. This specimen is called
the discard specimen, it is then thrown away so that a
specific time for the ensuing collection is noted. You
can start recording the collection period as the time of
the discarded urine. Save all the urine voided for the
next 24 hours and place it in one collection bottle.
● For an infant you can use a 24 hour rather than a
single specimen urine collector.
● To keep a bacterial count to a minimum, 24-hr
collections are generally kept on ice or poured into a
container that is then refrigerated during the 24-hour
period until they can be transported to the laboratory
for analysis.
3) Clean Catch Specimens
● Is ordered when a urine culture for a bacteria is
desired.
● The objective of the specimen is to obtain urine that is
uncontaminated by external organisms that would
increase the organism’s count in the urine. The type of
specimen requires that the urinary meatus and the
surrounding structures be cleaned before voiding.
●
●
The technique for obtaining a clean catch urine
specimen from an older child is the same for that as of
an adult.
Some modifications are necessary for that of a young
child or infant as it is not always possible to obtain a
midstream urine specimen from young children.
pH
5) Urinalysis
Urine Tests of Renal Function
Protein
level
NORMAL
RANGE
DEVIAT
IONS
Concentrated
Red
Trauma
Weak
acid or
neutral
If assctd w/ metabolic
acidosis, suggests
tubular acidosis
Alkaline
If assctd w/ metabolic
alkalosis, suggests
potassium deficiency
Chemical Tests
4) Suprapubic Aspiration
● Withdrawal of urine by insertion of a sterile needle into
the bladder through the anterior wall of the abdomen.
● It is used to obtain cultures for infants who can’t void
on command.
● Although suprapubic aspiration for urine appears
complicated, it is not. The bladder is the most anterior
of abdominal organs and when distended with urine, is
easily accessible just under the abdominal wall. (left
lower image)
TEST
Dark
Newborns:
5 to 7
Thereafter:
4.8 to 7.8
Average: 6
Urinary infection
Metabolic alkalosis
Absent
Present
SIGNIFICANCE OF
DEVIATIONS
Abnormal glomerular
permeability (e.g.
glomerular disease,
changes in blood
pressure)
Most kidney disease
Physical Tests
Orthostatic in some
individuals
Volume
Age related
Newborn:
30 to 60 ml
Polyuria
Oliguria
Children:
Bladder capacity
(oz) = Age
(years) + 2
Specific
gravity
With normal fluid
intake: 1,016 to
1,022
Newborn: 1,001
to 1,020
Others: 1,001 to
1,030
Osmotic factors (urinary
glucose level in
diabetes mellitus)
Glucose
level
Absent
Glomerulonephritis
Inadequate bladder
emptying cause by
neurogenic bladder or
obstructive disorder
Anuria
Obstruction of urinary
tract; AKI
High
Dehydration
Presence of protein or
glucose
Presence of radiopaque
contrast medium after
radiologic examinations
Diabetes mellitus
Infusion of concentrated
glucose-containing
fluids
Retention cause by
obstructive disease
Low
Impaired tubular
reabsorption
Ketone
levels
Absent
Present
Conditions of acute
metabolic demand
(stress)
Diabetic ketoacidosis
Leukocy
te
esterase
Absent
Present
Can identify both lysed
and intact WBCs via
enzyme detection
Nitrites
Absent
Present
Most species of
bacteria convert nitrates
to nitrites in the urine
Urinary tract
inflammatory process
Allograft rejection
Excessive fluid intake
Distal tubular
dysfunction
Microscopic Tests
Insufficient ADH
WBC
count
<1 or 2
Newborns: 50 to
600 mOsm/L
Fixed at
1,010
Chronic glomerular
disease
>5
polymor
phonucl
ear
leukocyt
es/field
Thereafter: 50 to
1400 mOsm/L
High or
Low
Same as for specific
gravity
Lympho
cytes
Diuresis
Osmolali
ty
Present
Malignancy
More sensitive index
than specific gravity
Appeara
nce
Clear pale
yellow to deep
gold
Cloudy
Contains sediment
Cloudy
reddish
pink to
reddish
brown
Blood from trauma or
disease
Light
Dilute
RBC
count
<1 or 2
4 to
6/field
in
centrifu
ged
specim
en
Myoglobin after severe
muscle destruction
Trauma
Stones
Glomerular injury
Infection
Neoplasms
Presenc
e of
Absent to a few
>100,00
0
UTI
bacteria
●
Before the test, always explain the procedure and
purpose. Assess the client’s knowledge of the test.
After the test, apply pressure to the venipuncture site.
Explain that some bruising, discomfort, and swelling
may appear at the site and warm moist compresses
can alleviate this.
ALYSSA START @ 00:32:37
● Monitor for signs of infection.
organis
ms/ml
in
centrifu
ged
specim
en
Presenc
e of
casts
Occasional
Granula
r casts
Tubular or glomerular
disorders
Cellular
casts
Degenerative process
in advanced renal
disease
WBC
Pyelonephritis
RBC
Glomerulonephritis
Hyaline
casts
Proteinuria, usually
transient
3) Creatinine
● Glomerular filtration rate is the rate at which
substances are filtered from the blood to the urine. It is
measured by the amount of creatinine excreted at 24
hours as determined by a 24-hour urine sample. A
venous blood sample is taken during a 24-hour period
and compared with the urine findings.
○ A normal creatinine clearance rate is 100
ml/minute.
○ A normal urine creatinine level is 0.7-1.5
mg/100 ml.
○ Creatinine in blood serum rarely exceeds 1
mg/dl.
B. BLOOD TESTS OF RENAL FUNCTION
TEST
BUN
NORMAL
RANGE (MG/DL
DEVIAT
IONS
SIGNIFICANCE OF
DEVIATIONS
Newborn: 4 to
18
Infant, child: 5 to
18
Elevate
d
Renal disease: Acute or
chronic (the higher the
BUN, the more severe
the disease)
RADIOLOGIC TESTS AND OTHER TESTS
1) Kidney-Ureter-Bladder (KUB) X-Ray
Increased protein
catabolism
Dehydration
Hemorrhage
High protein intake
Corticosteroid therapy
Uric
Acid
Child: 2.0 to 5.5
Increas
ed
Severe renal disease
Creatinin
e
Infant: 0.2 to 0.4
Child: 0.3 to 0.7
Adolescent: 0.5
to 1.0
Increas
ed
Renal impairment
●
●
1) BUN (Blood urea nitrogen)
● Measures the level of urea in the blood and is used to
assess glomerular function on how well the kidneys
can clear this from the bloodstream.
● However, this level may not increase until approx. 50%
of glomeruli are destroyed because the remaining
glomeruli can increase in size and function to
accommodate urine production.
● A normal value is shown in the table.
2) Uric Acid
● Type of blood test to assess the renal or neurological
system.
● Uric acid level tends to vary from day to day and
between various laboratories and therefore uric acid
levels are often repeated.
● Uric acid is the product of protein breakdown, both
dietary and body protein. The kidneys excrete uric
acid as a waste product.
● Excess uric acid may be caused by kidney failure,
which produces an increase in uric acid due to the
inability of the kidneys to excrete uric acid,
●
A plain, flat plate abdominal x-ray film can provide
information about the size and contour of the kidneys.
This radiograph may be referred to as a KUB (kidneyureters-bladder).
A small kidney, shown this way, is generally a
hypoplastic or an underdeveloped organ.
A large kidney may indicate hydronephrosis or a
polycystic kidney.
Nursing Considerations
● Usually no food, fluid, activity, or medications are
restricted unless specified by the physician
2) Ultrasound
●
●
●
This could be a renal and bladder ultrasonography.
This is the transmission of ultrasonic waves through
renal parenchyma along the urethral course and over
the bladder.
This allows visualization of renal parenchyma and
renal pelvis without exposure to external beam
radiation or radioactive isotopes. Visualization of
dilated ureters and bladder wall is also possible.
This is a non-invasive procedure.
3) Cystogram (Radionuclide Cystogram)
●
●
●
●
The radionuclide-containing fluid is injected through
urethral catheter until the bladder is full.
Images are generated before, during, and after
voiding.
This is an alternative to voiding cystourethrography to
evaluate reflux although visualization of anatomic
details is relatively poor.
This is used in some institutions for follow-ups.
Nursing Considerations
So there will be introduction of radionuclide fluid to visualize
anatomical structures so always assess allergies to dye and
prepare the child for catheterization.
4) MRI and CT- Scan
● CT-Scan
Nursing Considerations
● MRI often requires sedation in infants and children
due to the need to stay still, typically in an enclosed
space.
● Always follow NPO guidelines depending on the
time of study.
● Assist with IV access if indicated.
● Any magnetic devices or implants may be unsafe for
MRI including cochlear implants and permanent
pacemakers, so be sure to assess for these.
5) Cystoscopy
●
●
●
●
○
This is a narrow beam x-ray and computer
analysis providing precise reconstruction of
the area. Computed tomography (CT) scan of
the kidneys are used to show the size and
density of kidney structures and adequacy of
urine flow.
Nursing Considerations
● Conscious sedation may be given before a CT-Scan
because a child needs to lie still for an extended
time during a procedure.
● The size of a CT-Scanner can be frightening, and
the fact that it surrounds the child with it’s medium
iodine base, be certain about allergies to iodine
before the study
● Because a support person is not allowed in the room
during the procedure, thoroughly prepare the child
so that they can comfortably remain still for the
procedure.
●
Nursing Considerations
● NPO-PM
● Liquids 4-6 hrs prior
● Anesthesia use
6) Renal Biopsy
●
MRI
●
●
○
The image seen uses strong magnetic fields
and radio waves to form images. An
ultrasound or a magnetic resonance imaging
(MRI) scan can detect differing sizes of
kidneys or ureters and can differentiate
between solid or cystic kidney masses; they
don’t involve x-rays and so may be repeated
at frequent intervals for follow up without the
danger of radiation exposure.
Examination of the bladder and ureter opening by
direct examination of a cystoscope introduced through
the urethra is done to evaluate for possible
Vesicoureteral reflux or urethral stenosis.
Radiopaque dye may be introduced to the bladder at a
time of cystoscopy so the bladder can be visualized on
radiography.
Small catheters also can be threaded into the ureters
for the introduction of dye to outline them (retrograde
pyelography). Because the procedure is painful and
requires the child to lie still, it's usually done under
conscious sedation.
After the procedure the first voiding may be painful,
once allowed to, urge children to drink plenty of fluids
so they urinate frequently to flush out any pathogen
introduced at the time of the procedure.
●
●
This involves passing a thin biopsy needle into the
kidney through the skin over the kidney. The procedure
is used to diagnose the extent of renal disease and
thereby predict disease outcome or progress or reveal
beginning rejection of transplanted kidney.
Renal biopsy may be done in an older child under only
simple local anesthesia but conscious sedation may
be necessary for younger children who cannot
cooperate easily.
The kidney is located first by ultrasound to accurately
locate the place of the biopsy. The child lies prone with
a sandbag under the abdomen for firmness.
If the procedure is done under local anesthetic,
prepare children for the feel of a thin prick as the local
anesthetic is injected. After this they should not feel
any further pain.
Caution children that they need to lie still while the
specimen is taken. If the child moves suddenly, the
needle may puncture a renal artery or vein or tear vital
glomeruli. After the biopsy, press a sterile gauze
square against the biopsy site for approximately 15
minutes to halt bleeding, then apply a pressure
●
●
●
●
dressing. Caution parents that a large dressing will be
used and that the size of the dressing does not reflect
the size of the specimen taken.
The amount of tissue removed is no more than the
lumen of the needle used or approximately the size of
a pencil lead.
If the procedure was done on an ambulatory basis,
children can be discharged 2-4 hours after the
procedure if vital signs are stable and they have
voided.
Measure vital signs and observe the biopsy site every
15 mins for at least the 1st hour, do not lift the
dressing to assess bleeding because doing so
destroys the protective function of pressure dressing
Encourage children to drink a considerable amount
of fluid during the first 24 hours to keep urine flowing
freely and prevent blood from clotting in the kidney
tubules and blocking urine flow. The first voiding after
renal biopsy is invariably blood-tinged.
Nursing Considerations
● Support and positioning
● Patient lies still
● Prevent bleeding
● Encourage fluids
Urodynamics
STRUCTURAL ABNORMALITIES OF THE URINARY TRACT
Because the Urinary Tract is a system of hollow tubes,
congenital disorders can arise from faulty recanalization in
intrauterine life.
Urodynamics are a set of tests that measure lower urinary tract
function. The aim of testing is to reproduce your child’s voiding
pattern to identify any underlying problem. “Uro” refers to urine
and “dynamics” refers to continuous activity.
Assessment Guidelines with Renal and Urinary Disorders
PATENT URACHUS
DEFIN
ITION
When the bladder first forms in utero, it is joined to
the umbilicus by a narrow tube, the urachus. When
this fails to close properly during embryologic
development, a fistula is left between the bladder
and umbilicus. That's what the patent urachus is.
● This occurs more commonly in males than
in females
● Nurses are frequently the ones to discover
this condition as they notice a clear fluid
draining from the base of the umbilical
cord while changing a newborn’s diaper.
● If you test the fluid with nitrazine paper for
pH, its acid content will identify it as urine.
● An ultrasound will confirm the patent
connection. A few patent urachus
abnormalities heal spontaneously but
most require surgical correction to prevent
pathogens from entering the fistula site
and causing persistent bladder infection.
● This can be done in the immediate
neonatal period using only a small
subumbilical incision.
HYPOSPADIAS
●
DEFIN
ITION
●
●
This is a urethral defect in which urethral opening is
not at the end of the penis but on the ventral aspect
of the penis. The meatus may be near the glans,
midway back, or at the base of penis.
Epispadias is a similar defect in which the opening
is on the dorsal surface of the penis. This is
corrected the same way.
ASSE
SSME
NT
●
●
●
T/MG
MT
●
●
●
●
●
●
●
●
NC/M
GMT
●
EXSTROPHY EPISPADIAS COMPLEX
DEFIN
ITION
Be certain to inspect all male newborns at
birth for hypospadias or epispadias as part
of the routine physical examination. The
degree of hypospadias may be minimal or
maximal.
Many newborns with hypospadias have
an accompanying short chordee, a fibrous
band that causes the penis to curve
downward.
Also inspect carefully for cryptorchidism,
often found in
conjunction
with
hypospadias.
Children with hypospadias should not be
circumcised because at the time of repair,
the surgeon may wish to use a portion of
the foreskin for the repair.
In the newborn, a meatotomy is a surgical
procedure where the urethra is extended
to a normal position, may be initially
performed to establish better urinary
function.
When the child is older, at around age 1218 months, adherent chordee may be
released.
If the repair will be extensive, all surgery
may be delayed until the child is 3-4 years
old.
To encourage penis growth and make the
procedure easier, the child may have
testosterone cream applied to the penis
or receive daily injections of testosterone
After surgical repair, a urethral urinary
catheter will be inserted to allow urine
output without putting tension against
urethral sutures. The child may notice
painful bladder spasms as long as the
catheter is in place, around 3-7 days.
An analgesic such as acetaminophen,
tylenol, or an antispasmodic medication
such as oxybutynin (ditropan) may be
prescribed for pain relief.
After hypospadias repair, children can be
expected to have usual urinary and
reproductive
function
unless
accompanying anomalies of the penis are
present.
Neonatal circumcision should be avoided
in hypospadias where there is incomplete
foreskin because this is not conducive to
safe clamp or plastibell circumcision.
Hypospadias repair may require some
type of urinary diversion with a silicone
stent or feeding tube to promote optimal
healing and to maintain the position
patency of the newly formed urethra.
Appropriate administration of prescribed
pain medication for 48-72 hours after
surgery will help control discomfort.
While healing, applying petroleum jelly
or KY jelly to the diaper to prevent penis
from sticking can help prevent bleeding
and increase comfort.
Bladder exstrophy is a severe defect involving the
musculoskeletal system and the urinary,
reproductive, and intestinal tracts; it is one of three
anomalies that define the exstrophy epispadias
complex. The complex includes:
● Bladder exstrophy
● Epispadias
● Cloacal exstrophy
The illustration of the child shows the
episdpasias exstrophy complex
EPISPADIAS
DEFIN
ITION
Where hypospadias is a term for urethral opening
located at the inferior or ventral surface of the penis,
epispadias denotes a urethral opening in the
superior or dorsal surface.
● If more than a slight deviation is present,
repair is usually initiated before schoolage, because such a urethral placement
may interfere with self image if not
corrected
● With adulthood it can interfere with fertility.
BLADDER EXSTROPHY
●
Children who fail to attain urinary continence after
bladder neck reconstruction are offered a continent
diversion.
BLADDER EXSTROPHY
DEFIN
ITION
Bladder Exstrophy - Another disorder of the EEC
is the significant genital abnormalities
● Require lifelong care by a team of
specialists
● Patients may also benefit
from
psychological support as adjustment
problems are common, particularly in
adolescence.
● Parents are taught to recognize the signs
of UTI and to report suspected infection to
the practitioner.
Fig 26-4 Newborn with bladder exstrophy and epispadias.
Fig 26-5 Exstrophy of bladder.
Bladder exstrophy is a more severe defect characterized by an
open large, inside-out bladder with the inner surface exposed
and the dorsal urethra on the lower abdominal wall. This
typically includes findings of diastasis of the symphysis pubis,
lowset umbilicus, anteriorly displaced anus, defects of the
genitalia, and inguinal hernia.
Incidence of Bladder Exstrophy
● Ranges from 3 to 5 per 1,000 live births and is more
common in males than in females.
Objectives of Treatment
● Preserve renal function.
● Attain urinary control.
● Adequate reconstructive repair for acceptable
appearance.
● Prevent UTI.
● Preserve optimum external genitalia with continence
and sexual function.
Two Surgical Approaches to Correct Bladder Exstrophy
1. Modern Staged Repair of Exstrophy (MSRE) - This
typically involves 3 surgeries, beginning with closure of
the bladder and the abdominal wall.
● Involves bladder closure shortly after birth,
followed by epispadias repair at age 6-12
months and bladder neck reconstruction at
age 4-5 years when it is thought that the child
can cooperate with attempting continence
(Google)
2. Complete primary repair of bladder exstrophy is a
single-stage surgical closure combining closure of the
bladder, abdominal wall, partial tightening of the
bladder length, and bilateral ureteral reimplantation to
correct reflux.
Bladder Exstrophy - a midline closure defect that
occurs during the embryonic period of gestation,
that’s the first 8 weeks. As a result, the bladder lies
open and is exposed on the abdomen. It occurs
more frequently in males than females at a ratio of
2:1.
ASSE
SSME
NT
●
●
●
●
●
Nursing Care
● It is important to limit trauma to the exposed mucosa,
and the bladder is covered with a non-adherent film of
plastic wrap or transparent dressing that will not stick
to the bladder but can adhere to the surrounding skin.
Nursing Care After Bladder Closure
● The neonate is monitored for urinary output and for
signs of urinary tract or wound infection.
Post-operative Nursing Care After Bladder Neck
Reconstruction & Anti-Reflux Surgery
● Routine wound care
● Careful monitoring of urinary output from the bladder
and ureteral drainage tubes
●
●
TTT
●
●
Fetal ultrasound
○ Findings: no anterior wall on the
bladder and no anterior skin
covering on the lower anterior
abdomen
Bladder appears bright red and
continually drains from the open surface.
In males, the penis appears unformed or
malformed.
In females, the urethra may be
abnormally formed.
The skin around the bladder quickly
becomes excoriated because of constant
exposure to acid urine.
Untreated bladder exstrophy leads to
kidney infections from ascending
organisms.
When children with this disorder begin to
walk, they may demonstrate a waddling
gait from the effect of the non-fused
pubic arch.
Surgical closure of the bladder and if
necessary, the anterior abdominal wall
and construction of a urethra
To minimize the possibility of the infection
in the bladder while the infant is waiting for
initial surgery, keep the exposed bladder
covered by a sterile plastic bowel bag.
NC/M
GMT
●
To prevent the skin of the abdomen from
excoriation due to the constant irritation of
urine, protect it with a substance, such as
A&D ointment, Karaya Gum, or Maalox.
●
Parents often need support to view their
child as normal in all other ways but the
unusual bladder formation.
In some instances, the bladder repair will
not be done immediately. So, parents will
need instructions on how to care for the
child at home while waiting for surgery.
●
MGMT
Post-Op Interventions
● Surgery is completed as either a one-step
or two-step procedure.
● In the first step, the bladder tissue is
reconstructed, and in the second, a
urethra is created.
● *video was cut out; based on our primary
textbook to finish this part*
● After bladder closure, a suprapubic tube
is placed for urine drainage and will
typically remain in place for 4 to 6 weeks
to allow the bladder to drain continuously
and the surgical anastomoses to heal.
● The infant should be positioned on the
back with the legs raised in traction at 90
degrees.
○ This position is maintained for 4
to 6 weeks after surgery and is
essential to prevent failure of the
closure.
● Approximately 30% of patients with
bladder exstrophy at children’s medical
centers
worldwide
also
undergo
osteotomy at the time of their bladder
closure.
○ Immediately after surgery, urine
draining from the catheter may
be tinged with blood, but this
should clear after the first few
days.
● Children may experience sharp, painful
bladder spasms after surgery.
○ Working with the pain team to
provide adequate analgesia and
anticholinergic
therapy
is
imperative for both the comfort of
the child and the proper healing
of the bladder.
gastrointestinal tract is unaffected. The separated
segment is made into a bladder-like reservoir, and
then the appendix is tubularized to create a
continent channel extending from the dome of the
bladder reservoir to a continent stoma at the site
where the umbilicus would normally lie.
● Urine drains from the kidneys into the
ureters and then into the collecting
bowel segment. The parent or child
catheterizes the abdominal stoma every 3
to 4 hours throughout the day to empty
urine.
● As the child reaches school age and
begins school activities that expose the
condition to others, such as showering,
adjusting to a continent urinary reservoir
can be difficult.
○ Ensure that the child has a plan
and support for peer disclosure,
maintenance, and follow-up care
during the school years and
adolescence so the function of
the reservoir and also the child’s
adjustment can continue to be
assessed and supported.
For children who have a successful initial
closure:
● adequate bladder capacity, pelvic floor
function, and bladder contractility, an
alternate continence procedure, called a
bladder neck reconstruction (BNR),
may be an option
● A BNR reconstructs the bladder neck and
urethra and allows the child to void via the
urethra and achieve continence.
IV. URINARY TRACT INFECTION IN CHILDREN
AND ITS MANAGEMENT
●
●
●
●
●
●
●
For continent urinary diversion, a small segment
of the intestine is separated from the intestinal tract.
The intestinal tract is then reanastomosed so the
As the urinary system drains to the outside of the body,
infection can easily spread to the bladder or kidneys.
UTI is a common and potentially serious problem in
children.
Overall prevalence → app. 7% in infants and young
children. (Although there is variability based on age,
gender, race, and circumcision status.)
Highest
rates:
Caucasians,
females,
and
uncircumcised boys
○ Specifically, girls have a two-fold to fourfold higher prevalence than do circumcised
boys, because the urethra is shorter in girls
and because it is located close to the vagina
and close to the anus from which E. coli
spreads.
○ Uncircumcised males <3 months old and
females <12 months old have the highest
baseline prevalence of UTI
Changing diapers frequently help reduce the risk of
infection in infants.
UTI’s are also a common cause of nosocomial or
healthcare-acquired infections in children with urinary
catheters.
May involve urethra and bladder (lower urinary tract)
or the ureters, renal pelvis, calyces, and renal
parenchyma (upper urinary tract)
○ Because of the difficulty to distinguish upper
from lower tract infections, particularly in
young children, UTI is broadly defined.
○ Upper UTI or kidney infections tend to present
with fever and may lead to renal scarring
that may be assoc. with decreased kidney
function, hypertension, and renal disease
over time.
●
●
●
UTI’s need vigorous treatment in childhood so they do
not spread to involve the kidneys or pyelonephritis.
Girls with more than 3 UTI’s or boys with their first UTI
should be referred to a urologist to determine whether
they have congenital anomalies, such as urethral
stenosis or bladder ureter reflux, that causes recurrent
urinary stasis.
A secondary problem is more likely in boys with a UTI.
Etiology
● Pathogens appear to enter the urinary tract most often
as an ascending infection from the perineum.
● Most urinary pathogens are gram-negative rods.
● A variety of organisms can be responsible for UTI.
○ Main uropathogen: Escherichia coli
■ Prevalence is higher in females than
males.
○ Other gram-negative organisms assoc. with
UTI: Proteus mirabilis, Pseudomonas
aeruginosa, Klebsiella, Enterobacter,
○ Other gram-positive organisms assoc. with
UTI:
Enterococcus,
Staphylococcus
saprophyticus, Staphylococcus aureus
● Viruses and fungi are uncommon causes of UTI in
children.
● Most uropathogens originate in the GI tract, migrate to
the periurethral area, and ascend to the bladder.
● Most pathogens prefer an alkaline medium.
○ Normally, urine is slightly acidic with a
median pH of 6.
○ A urine pH of 5 does not eliminate bacterial
multiplication.
Factors contributing to the development of UTI
● Anatomic, physical, and chemical conditions of
properties of the host urinary tract.
● The single most important host factor influencing the
occurrence of UTI is urinary stasis or the urine
sterile? but at 37℃, it provides an excellent culture
medium.
Typical Symptoms:
● Although it may be possible to locate a UTI precisely,
such as urethritis, cystitis, ureteritis, or pyelonephritis,
the signs and symptoms in young children often are not
clear cut.
● When the exact location or when the extent of the
infection is unknown, it is referred to simply as UTI. On
older children & adults → Pain on urination, frequency,
burning, and hematuria - may not be present
●
●
●
Infection is confined to the bladder (cystitis) → lowgrade fever, mild abdominal pain, enuresis
(bedwetting)
Pyelonephritis symptoms more acute: with high fever,
abdominal or flank pain, vomiting, malaise
Any child with a fever and demonstrable no cause on
PE should be evaluated for UTI
Clinical Manifestations of Urinary Tract Disorders
or Disease
Neonatal Period (Birth to 1 Month Old):
● Poor feeding
● Vomiting
● Failure to gain weight
● Rapid respiration (acidosis)
● Respiratory distress
● Spontaneous pneumothorax or
pneumomediastinum
● Frequent urination
● Screaming on urination
● Poor urine stream
● Jaundice
●
●
●
●
Seizures
Dehydration
Other anomalies or stigmata
Enlarged kidneys or bladder
Infancy (1 to 24 months Old):
● Poor feeding
● Vomiting
● Failure to gain weight
● Excessive thirst
● Frequent urination
● Straining or screaming on urination
● Foul-smelling urine
● Pallor
● Fever
● Persistent diaper rash
● Seizures (with or without fever)
● Dehydration
● Enlarged kidneys or bladder
Childhood (2 to 14 years Old):
● Poor appetite
● Vomiting
● Growth failure
● Excessive thirst
● Enuresis, incontinence, frequent urination
● Painful urination
● Swelling of face
● Seizures
● Pallor
● Fatigue
● Blood in urine
● Abdominal or back pain
● Edema
● Hypertension
● Tetany
Nursing Alert:
● A child who exhibits the following should be evaluated
for UTI:
○ Incontinence in a toilet-trained child
○ Strong-smelling urine in association with
other symptoms
○ Frequency or urgency
○ Pain with urination
Diagnosis
● Urine tests (e.g., urine culture)
○ Urine for culture can be collected by a cleancatch technique, suprapubic aspiration, or
catheterization so that bacteria from the
vulva or foreskin do not contaminate the
sample and give a false reading.
○ Urine obtained from suprapubic aspiration
is generally sterile. So, any growth from this
source is significant.
○ A clean-catch urine specimen is said to be
positive for bacteriuria if the bacterial colony
count is more than 100,000 per mL. A count
of less than 10,000 per mL is considered a
negative culture.
■ Counts between 10,000 and
100,000 per mL are repeated.
○ Usually the urine is positive for proteinuria.
Microscopic examination may indicate the
presence of RBC because of mucosal
irritation.
○ The presence of WBC or RBC in bacteria
tends to make urine more alkaline. So, the pH
will be elevated to greater than 7.
Therapeutic Management
● Objectives: (1) eliminate current infection, (2) identify
contributing factors to reduce the risk of recurrence, (3)
●
●
●
●
●
●
prevent systemic spread of the infection, and (4)
preserve renal function
Antibiotic therapy (on the basis of the identification of
the pathogen, the child's history of antibiotic use, and
the location of the infection): penicillins, sulfonamide
(including
trimethoprim-sulfamethoxazole),
the
cephalosporins, and nitrofurantoin
○ Therapy must be continued for the full
prescription or the infection will return.
○ A repeat clean-catch urine sample is
usually obtained at 72 hrs to assess the
effectiveness of the antibiotic treatment.
Push fluids to flush the infection out of the urinary tract.
If a child experiences moderate to severe pain on
urination that interferes with the ability to void, suggest
the child sit in a bathtub with warm water and void in
the water.
○ Mild analgesics: acetaminophen (Tylenol) to
reduce pain enough to allow voiding
After recurrent UTIs, children may be prescribed a
prophylactic antibiotic for 6 months.
Anatomic defects (e.g., primary reflux, bladder neck
obstruction): surgical correction or urinary prophylaxis
to prevent recurrent infection
The aim of therapy and careful follow-up is to reduce
the chance of renal scarring.
Prognosis
● With prompt and adequate treatment at the time of
diagnosis, the long-term prognosis for UTI is usually
excellent.
● However, the risk of progressive renal injury due to
scarring from a first UTI has been found to be highest
in children with an abnormal renal bladder ultrasound
or with a combination of high fever and an etiologic
organism other than E. coli.
VESICOURETERAL REFLUX
DEFIN
ITION
●
●
●
Refers to the retrograde flow of urine from
the bladder into the upper urinary tract.
○ Primary reflux results from
congenital abnormal insertion of
ureters into the bladder.
○ Secondary reflux occurs as a
result of an acquired condition.
Reflux increases the chance for febrile
UTI but does not cause it. When bladder
pressure is high enough, refluxing urine
can fill the ureter and the renal pelvis
The international reflux study group
developed a classification system that
describes the degree of reflux ranging
from grade 1 to 5, which is important
because higher rates are associated with
renal abnormalities and renal damage
MGMT
●
●
Antibiotic prophylaxis
Surgical correction
N/C
●
●
●
●
Increase compliance of antibiotic regimen
Promote proper hygiene
Schedule frequent voiding
UTI awareness
UTI
MGMT
●
●
●
●
Perineal hygiene
Use cotton underwear
Avoid holding urine
Complete bladder emptying
CYSTITIS
Nursing Care Management
● Patient education
○ Instruct parents to observe for signs and
symptoms suggestive of UTI.
● Careful history taking
○ A high fever without obvious cause should be
signaled to check the urine.
○ A careful history of voiding habits, stool
pattern, feeding tolerance, and episodes of
unexplained irritability may assist in detecting
less obvious cases of UTI.
● When infection is suspected, collecting an appropriate
specimen is essential.
● Specimen collection and support during lab/diagnostic
tests
● Frequently, additional tests are performed to detect
anatomic defects.
○ Children are prepared for these tests as
appropriate for their age.
● Because antibacterial drugs are indicated for UTI, the
nurse advises the parents of proper dosage and
administration.
● Pharmacologic management: antibiotics, patient
education
● Encourage fluids
● Prevention (information dissemination)
○ Proper hygiene; girls wipe front-to-back after
voiding
and
defecating
to
avoid
contaminating the urethra
○ Void immediately after intercourse
○ Don’t hold urine in; void at least every 4hr, try
to empty bladder completely
○ Prevent urine stasis → adequate fluid intake
○ Cotton underwear
URINARY ELIMINATION ABNORMALITIES
DEFIN
ITION
●
●
●
●
●
●
●
EFFE
CTS
“Honeymoon cystitis”
○ Lower UTI caused by initial
coitus
○ Seen in young women shortly
after they initiate their first sexual
relationship
○ Such
infections
occur
in
connection with the local irritation
and inflammation caused by
initial coitus
Antibiotic therapy
Voiding as soon as possible after
coitus may help to flush pathogenic
organisms from the urethra and prevent
such infections.
When seen in adolescent girls, alert
healthcare providers to the possibility that
a girl may possibly sexually active
Personal hygiene measures
Information on:
○ STIs, reproductive planning,
responsibility for her maturing
body
Recurrent UTIs in school-age or
preschool girl may suggest possible
sexual abuse
Maternal, Fetal, and Neonatal Effects
● E. coli, Klebsiella, Proteus
● S/S: dysuria, frequency,
urgency,
suprapubic tenderness
● Ascending infection may lead to →
pyelonephritis
N/C
●
●
Antibiotics used for both asymptomatic
bacteriuria and cystitis
○ Amoxicillin,
ampicillin,
trimethoprimsulfamethoxazole,
nitrofurantoin, or a thirdgeneration cephalosporin
Hygiene measures
●
●
●
Oligohydramnios
Hypertension
Identical cyst in the liver
DX
●
●
UTZ
Transillumination
MGMT
●
Surgical removal (unilateral)
○ Urine
production
will
be
decreased and will not be absent
Renal transplant
Genetic counseling to inform them that
future children may also have this problem
VIDEO 2
DISORDERS OF ALTERED KIDNEY FUNCTION
●
●
RENAL AGENESIS
DEFIN
ITION
●
●
●
RENAL HYPOPLASIA
Agenesis: lack of growth (no organ
formed in the uterus)
Potter’s syndrome
Without kidneys, the fetus cannot void
urine
○ Bilateral absence: incompatible
with life
■ Renal transplantation
■
Non-functioning ling →
unsuccessful
transplantation
DEFIN
ITION
●
●
Hypoplastic kidneys: fewer lobes, small,
underdeveloped
Hypoplasia means reduced growth
S/S
●
●
Hypertension
Poor kidney function
MGMT
●
Kidney transplant (bilateral)
PRUNE BELLY SYNDROME
DEFIN
ITION
●
●
●
●
S/S
A newborn who is missing one or both kidneys
● Unilateral renal agenesis - absence of
one kidney
● Bilateral renal agenesis - absence of
both kidneys
●
●
●
●
●
High Blood pressure
Poorly working kidney
Proteinuria, hematuria
Anasarca
Oligohydramnios- perinatal
DX
●
Prenatal UTZ
MGMT
●
●
Dialysis
Strict physical precaution
NGS
CONS
●
●
Prenatal care
Avoid contact sports
S/S
POLYCYSTIC KIDNEY DISEASE
DEFIN
ITION
●
●
●
●
S/S
●
Autosomal recessive trait
Abnormal development of the collecting
tubules
Kidneys are large and feel soft and
spongy
If the d/o is bilateral, the infant will not pass
urine
Potter syndrome
MGMT
●
Severe urinary tract dilation → backpressure, destruction of kidneys
Occurring mainly in boys
Oligohydramnios
Pulmonary dysplasia
●
●
Deficiency of usual abdominal muscle
tone (wrinkled abdomen)
Bilateral undescended testes
Dilated faulty development of the bladder
and URT
●
Surgical remodeling → repeated UTIs →
end-stage renal disease
NSG
CARE
MGMT
●
Parental education
○ Protect child’s abdomen from
trauma
○ Kidney transplants (school-age)
ACUTE POST-STREPTOCOCCAL
GLOMERULONEPHRITIS (APSGN)
DEFIN
ITION
●
●
●
●
●
●
●
●
Affects primarily early school-age children
(peak age of onset 6-7 yo)
Uncommon <2 yo
Boys outnumber girls 2:1
May occur as a separate entity, but usually
occurs as an immune complex disease
after infection
Tissue damage
igG antibodies may be detected in the
bloodstream of children with acute
glomerulonephritis - proof that the illness
follows a streptococcal infection
Intravascular coagulation
Ischemic damage → scarring, decreased
glomerular function
●
●
Most common of the post-infectious renal
disease in childhood and the one for which
a cost can be established in the majority
of cases.
Inflammation of the glomeruli increases
the
permeability
allowing
protein
molecules to escape into the filtrate
○
LABS
COMP
LICAT
IONS
NSG
CARE
MGMT
●
●
●
●
HPN encephalopathy
AKI
Circulatory congestion
Pulmonary edema
●
●
Bed rest
Absolute I/O and weighing the child
everyday
Regular measurements of v/s is
essential to monitor the progress of the
disease and detect complications that
may appear at any time during the course
of the disease
Record of daily weight - most useful way
of assessing fluid balance
Acute (sometimes severe) hypertension
must be anticipated and identified early
BP measurements taken every 4-6 hrs
Hypertensive and diuretic medications are
used to control hypertension
Antibiotic therapy is indicated only for
children with evidence of persistent
streptococcal infection
Sodium and fluid restriction
○ Low Na and K diet
○ No added salt on diet
Course of acute glomerulonephritis is 1-2
weeks
Parent education and support in
preparation for
homecare include
education in home management, dietary
restrictions, infection prevention, follow up
care and supervision
●
●
●
●
●
●
●
●
●
●
●
MGMT
●
●
●
●
●
●
●
●
●
Unknown
COMP
LICAT
IONS
●
●
●
●
●
●
●
●
●
HPN Encephalopathy
AKI
Circulatory congestion
Pulmonary Edema
Occasionally
follows
acute
glomerulonephritis or nephrotic syndrome;
also occurs as a primary disease
Proteinuria - during routine checkup
Hypertension - further investigation
Alport’s Syndrome - progressive chronic
glomerulonephritis inherited as an Xlinked or autosomal recessive disorder
○ Includes hearing loss + ocular
changes
Will either result in diffused or local
nephron damage
○ Remaining functioning nephrons
will increase their glomerular
U/A
○ Red cell or white cell casts
○ Occult blood
○ Specific gravity: Below normal
Blood studies
○ Increased BUN or creatinine
level
Renal biopsy
○ Permanent
destruction
of
glomeruli membranes
Bed rest
○ If the child has acute symptoms
of
edema,
hematuria,
hypertension, or oliguria
Maintain Normal Activity, including
attending school
○ If chronic symptoms (e.g.,
proteinuria) and feeling well
No competitive activities (e.g., contact
sports)
○ Because of the risk of kidney
injury
Therapy is nonspecific; directed at
symptom relief
○ Because the cause of disease is
unknown
Antihypertensive drugs (increase urine
output)
○ Hydralazine (Apresoline)
Diuretics (increase urine output)
○ Ethacrynic (Edecrin)
Corticosteroid therapy - may reduce or
halt the progress of the d/o → reducing
inflammation
○ Children have difficulty accepting
long-term corticosteroid therapy
because of the side-effects such
as:
■ “Moon face”
■ extra body hair
■ Talk with them about
these body changes
and reassure them that
these changes will
reverse when the drug
is discontinued.
○ Immunosuppression risk
■ Leads to increased risk
of infection
■ Need to be shielded
from other children and
HCP with infection
■ Parents need to learn to
take
the
child’s
temperature
and
recognize and report
earliest signs of infx
Occasionally
follows
acute
glomerulonephritis or nephrotic syndrome;
also occurs as a primary disease
Proteinuria
Hypertension
Alport’s syndrome
ETIOL
OGY
●
●
CHRONIC GLOMERULONEPHRITIS
DEFIN
ITION
●
filtration
rate
(GFR)
to
compensate for those that are
damaged.
At some point, compensatory
mechanisms fail and renal
insufficiency or failure will result.
PROG
NOSIS
Prognosis: Generally poor
● Although the illness may run a long-term
course
● Renal insufficiency and renal failure
● Peritoneal dialysis or hemodialysis
○ May be maintained for long
periods for children
●
Kidney transplantation
○ Possible
Infection (due to loss of
Immunoglobulins in urine)
Coagulability (due to loss of
Antithrombin III in urine)
NEPHROTIC SYNDROME
●
●
DEFIN
ITION
●
●
●
Nephrosis - altered glomerular permeability due to
fusion of the glomerular membrane surfaces
● Causes abnormal loss of protein in urine
(proteinuria)
● Immunologic mechanisms are involved in
setting the process into motion
● Causes:
○ Hypersensitivity to an antigenantibody reax
○ Autoimmune process
○ T-lymphocyte dysfunction
● Highest incidence: 3 years of age
● Occurs more often in boys than in girls
●
●
●
Forms:
1) Congenital NS - autosomal recessive
a) Rare
2) Secondary NS - glomerular damage after
a known cause
a) May be a progression of
glomerulonephritis
b) Or in connection with systemic
diseases such as sickle-cell
anemia or systemic lupus
erythematosus
3) Idiopathic NS (primary)
a) Most common
●
●
●
●
Amount of membrane destruction:
1) Minimal Change Nephrotic Syndrome
(MCNS)
a) Most often seen in children
b) Little scarring of glomeruli occurs
c) Children with this scarring
respond well to therapy
2) Focal glomerulosclerosis (FGS) involves scarring of glomeruli; poorer
response to therapy
3) Membranoproliferative
Glomerulonephritis (MPGN) - involves
scarring of glomeruli; poorer response to
therapy
C/M
Symptoms usually being insidiously
Children develop edema around the
eyes (periorbital), most noticeable when
they wake in the morning from a headdependent position
Edematous fluid collection in the
abdomen (ascites).
○ Parents may notice that clothes
may not fit around the waist
It is easy to dismiss these first symptoms
as those of an URT infection in the normal
paunch belly of a toddler or preschooler
As edema progresses, the child’s skin
becomes:
○ Pale
○ Stretched
○ Taut
Boys:
○ Scrotal
edema
becomes
extremely marked
○ Ascites becomes so extensive
that pressure on the stomach →
anorexia or vomiting
Children may have diarrhea caused by
intestinal edema and poor absorption
caused by the edematous membrane
Because of poor nutrition, growth may
stunt
○ Child may be malnourished but
look deceptively obese because
of the extensive edema
When ascites becomes even more
extensive, children may have difficulty
breathing as the abdominal fluid presses
against the diaphragm → decreased lung
expansion
Parents report that children are irritable
and fuzzy probably due to abdominal
fullness and generalized edema
Increased risk for clotting can occur from
decreased intravascular fluid volume
Laboratory studies:
○ Marked proteinuria
■ Single test: 1+ to 4+
protein in 24H
■ Total urine test: 15g
protein
■ Protein loss is almost
entirely
(different
○
MNEMONICS: NAPHROTIC
Na+ decrease (Hyponatremia)
Albumin
decrease
(Hypoalbuminemia)
Proteinuria >3.5 g/day
Hyperlipidemia
Renal vein thrombosis
Orbital edema
Thromboembolism
○
MGMT
●
●
●
albumin
from
glomerulonephritis →
protein
loss
is
nonspecific)
Some children with NS exhibit
hematuria at the onset but is
minimal compared to acute
glomerulonephritis
Erythrocyte
sedimentation
rate: elevated
Avoid infections (no live vaccines)
Regular diet (in remission), low sodium &
water (edematous)
Corticosteroid therapy
○
●
●
Therapy for a child with NS is
directed to reducing proteinuria
and subsequently edema
○ Prednisone
(IV
methylprednisolone
or
oral
Prednisone) - has the potential to
halt growth and suppress
adrenal
gland
secretions,
however growth is not delayed
when given in alternate days and
there is less alteration of adrenal
steroid production.
■ Initial
dose
of
Prednisone is given
until diuresis without
protein
loss
is
accomplished
■ Dosage
is
then
reduced
to
maintenance
and
continued
for
1-2
months
○ Instruct parents to test the first
urine specimen of the day for
protein with a chemical reagent
strip and keep an accurate chart
showing the pattern of protein
loss.
○ Approximately 1x a week, they
are usually asked to collect a
24H urine specimen so total
protein loss can be measured.
○ After
initial
4
weeks,
prednisone is generally given
every other day instead of every
day
○ Be certain that both the parents
and the child are aware that
Prednisone causes:
■ “Cushingoid
appearance” or moonface
■ Extra fat at the base of
the neck
■ Increased body hair
Immunosuppressants
○ Keep the child free of infection
while
the
child
is
immunosuppressed
○ Some children are prednisoneresistant or do not respond to
corticosteroid therapy
○ A
course
of
stronger
immunosuppressant agents may
be
effective
in
reducing
symptoms or prevent further
relapses:
■ Cyclophosphamide
■ Cyclosporine
■ Mycophenolate mofetil
○ Ensure adequate fluid intake
with these drugs to prevent
bladder irritation and bleeding
Diuretics - not commonly used to reduce
edema
○
Tend to reduce blood volume,
○
which is already decreased →
acute renal failure
Children who fail to respond to
Prednisone however may need
diuretic therapy + furosemide
(Lasix)
■
■
■
●
●
Danger
for
hypokalemia
when
taking furosemide for
too long
Children on long-term
diuretic therapy need
frequent
blood
studies to determine
electrolyte
levels
especially
K
are
adequate
May
need
supplemental K and
eat foods high in K
Human albumin
○ May
be
administered
to
temporarily
correct
hypoalbuminemia
Prognosis: varies
○ MCNS - responds initially to
steroid therapy although they
may have a relapse, but remain
free of the disease
○ FGS & MPGN - have relapses in
frequent and infrequent intervals
over the next several years.
■ Children with frequent
relapses will have poor
chances of ever being
free of the d/o
■ Many develop renal
failure later
■ Kidney transplantation
may be necessary to
sustain life.
■ All children and families
need emotional support
while the disease runs
its long-term course
What is an important nursing intervention for
children with NS?
1) Caution not to eat salt - salt irritates the
bladder
2) Encourage them to walk at least 1 mile
a day for exercise.
3) Teach them how to test urine for
proteinuria
4) Teach them how to take temperature
daily.
N/C
●
●
●
●
●
●
●
Protein-free urine
Prevent acute infections
Absent to minimal edema
Maintained nutrition
Controlled metabolic abnormalities
Absolute I/O
Skin care
HYDRONEPHROSIS
○ To relieve obstruction
○ Urine diversion
Antibiotics
○ For infection resulting from
residual urine in the calyces and
pyelonephritis
Surgical removal of obstructive lesions
Nephrectomy
○ If one kidney is severely
damaged and function is
destroyed
DEFIN
ITION
●
●
●
NEPHROGENIC DIABETES INSIPIDUS
DEFI
NITI
ON
Hydronephrosis - the dilation of the renal pelvis
and calyces of one or both kidneys due to an
obstruction.
●
Obstruction of normal flow of urine →
urine backs up → increased renal pressure
○ Urethra
or
the
bladder
○
●
●
●
●
●
S/S
●
●
●
●
●
MEDI
CAL
MGMT
●
●
●
●
●
to ADH or vasopressing → excretion of large
amounts of dilute urine
● Not to be confused with diabetes insipidus
■ Diabetes insipidus - principal disorder
of posterior pituitary function also known
as
distends pelvis, calyces → kidney atrophy
Compensatory hypertrophy
○ As one kidney undergoes
gradual destruction, the other
kidney gradually enlarges
○ Ultimately, renal function is
impaired.
May not have symptoms if the onset is
gradual
Acute obstruction
○ Aching in the flank and back
Infection
○ Dysuria,
chills,
fever,
tenderness, and pyuria
Hematuria, pyuria - may be present
Both kidneys affected
○ S/S of chronic renal failure
develops
Goals:
○ Identify and correct the cause of
the obstruction
○ To treat infection
○ To restore and conserve renal
function
Nephrostomy
neurogenic
DI
resulting
from
undersecretion of ADH or vasopressin →
obstruction → back pressure
affects both kidneys
Obstruction in one of the
ureters (due to stone or kink)
→ only one kidney is damaged
Partial or intermittent obstruction: renal
stone
○ Renal stone that has formed at
the renal pelvis but has moved to
the ureter
Tumor pressing on the ureter or to bands
of scar tissue resulting from an abscess or
inflammation near the ureter
Odd angle of the ureter as it leaves the
renal pelvis (or to an unusual position of
the kidney) favoring a ureteral twist or
kink
Urine accumulates in renal pelvis → it
Rare hereditary disorder
Primarily males
Cause: unresponsiveness of renal tubules
state of uncontrolled diuresis
Complete DI
Partial DI
○
○
NDI - inability to concentrate urine due to
●
impaired
renal
tubule
response
to
vasopressin → excretion of large amounts of
dilute urine
Inherited NDI
■ X-linked trait = most common +
variable penetrants in heterozygous
females that affect the arginine
vasopressin receptor 2 gene; het.
females may have no symptoms or a
variable degree of polyuria or
polydipsia, or they may be as severely
affected as males
■ Autosomal
recessive/dominant
mutation = rare; affects aquaporin 2
gene; both male and female
○ Acquired NDI (secondary to impaired
renal concentrating ability)
○
■
Disorders or drugs disrupt medulla and
distal
nephrons
concentrating
■
■
→
ability
impair
→
urine
kidney
insensitivity to vasopressin
Include:
● Sickle-cell
neuropathy
● Pyelonephritis
● Autosomal
dominant
polycystic
kidney disease
● Hypercalcemia
● Cancers
(myeloma,
sarcoma)
● Drugs (lithium)
Can also be idiopathic
●
S/S
●
●
DIAG
NOSI
S
●
●
●
●
TTT
○
Large amounts of dilute urine (3 to 20L/day
is the hallmark)
Polyuria
○ In infants, this may be noticed by
the caregiver. If not, the first
manifestation is dehydration.
○ May excrete more than 50
mL/kg/day
S/S
related
to
dehydration,
hypernatremia
○ Good thirst response and serum
sodium is near normal. However,
patients who do not have good
access
to
water/cannot
communicate
thirst
develop
hypernatremia due to extreme
dehydration.
○ Hypernatremia
may
cause
neurologic symptoms such as
neuromuscular
excitability,
confusion, seizures, or coma.
Measurement of 24-hr urine volume and
osmolality changes after water deprivation
test
Serum electrolytes
Administration of exogenous vasopressin
ALPORT SYNDROME
DEFIN
ITION
●
●
Adequate free water intake
○ With low-salt, low-protein diet and
stopping nephrotoxin
●
If symptoms persist despite the above measures:
● Drugs 5 mg PO once/twice a day
● Thiazide diuretics
● NSAIDs or Amiloride
PRO
GNO
SIS
●
Brain damage with permanent intellectual
disability
○ If treatment is not started early
●
DIFFERENCE BETWEEN:
NDI AND CENTRAL DIABETES INSIPIDUS
NDI
Inability to concentrate urine
in response to vasopressin
●
●
Central DI
Lack of vasopressin
HENOCH-SCHONLEIN SYNDROME NEPHRITIS
DEFIN
ITION
●
●
●
●
●
●
AKA
Henoch-Schonlein
Purpura/
Anaphylactoid Purpura
Caused
by:
increased
vessel
permeability
No allergic correlation identified but is
generally
considered
to
be
a
hypersensitivity reaction to an invading
allergen
Approximately one quarter of the children
who develop this type of henoch schonlein
purpura developed renal disease as a
secondary complication
○ Renal involvement: apparent
within a few days after the
manifestations
of
purpuric
symptoms
May show only urinary abnormalities such
as proteinuria or may have a rapidly
progressive glomerulonephritis
Most children recover completely
Only a few develop chronic
symptoms long-term kidney
disease can develop
DX
Is
a
progressive
chronic
glomerulonephritis inherited as an
autosomal dominant disorder
this includes hearing loss and ocular
changes as well as other signs and
symptoms of nephrotic syndrome
Cause: gene mutation affecting type 4
collagen
○ The mechanism by which
collagen alteration causes a
glomerular disorder is unknown
but impaired structure and
function is presumed
In most families, thickening and thinning of
the glomerular and tubular basement
membranes occur with multi lamination of
the lamina densa in a focal or local
distribution = basket weave pattern
Glomerular scarring and interstitial fibrosis
eventually result
Characterized by:
○ Nephritic syndrome
■ Hematuria, proteinuria,
hypertension, eventual
renal
insufficiency
between ages 20 and
30 years old
■ Often
with
sensorineural deafness
(frequently
present
affecting
higher
frequencies; it may not
be noticed during early
childhood),
ophthalmologic
symptoms (cataracts)
but these would occur
less frequently than
hearing loss
Diagnosis is suggested in patients who have
microscopic hematuria on urinalysis or recurrent
episodes of gross hematuria particularly if an
abnormality of hearing or vision or a family history
of chronic kidney disease is present
● Family history
● Urinalysis - usual
● Renal biopsy - usual
● Molecular genetic analysis
TTT
●
●
Same as chronic kidney disease indicated only when uremia occurs
Kidney transplantation
PROG
NOSIS
●
●
HEMOLYTIC-UREMIC SYNDROME
DEFIN
ITION
●
●
●
S/S
●
Lining of glomerular arterioles become
inflamed, swollen, and occluded w/
particles of platelets & fibrin
○ Child's RBC and platelets are
damaged as they flow through
the partially occluded blood
vessels
○ As the damaged cells reach the
spleen, they are destroyed by the
spleen and removed from
circulation
○ This leads to hemolytic anemia
90% of children who develop this have
recently experienced and E. coli GI
infection
○ Most likely source of this E. coli
is undercooked hamburger
because E. coli is found in the
intestine of beef cattle
○ Occurs more frequently and
infants who have their initial E.
coli infection treated with an
antibiotic than those who are not
treated
Occurs most often during the summer
and in children 6 months to 4 YO
●
●
●
LABS
●
●
●
T/MG
MT
●
RENAL FAILURE
1)
2)
Acute kidney injury (AKI)
Chronic kidney disease (CKD)
Renal failure is the inability of the kidneys to excrete waste
material, concentrate urine, and conserve electrolytes.
● It can occur suddenly in response to inadequate
perfusion, kidney disease, or urinary tract obstruction,
or it can develop slowly as a result of long-standing
kidney disease, or an anomaly.
● Terms often used in relation to renal failure: azotemia
and uremia
AZOTEMIA
UREMIA
accumulation of nitrogenous
waste within the blood
more advanced condition in
which the retention of
nitrogenous
products
produces toxic symptoms
not life-threatening
serious condition that often
involves other body systems
ACUTE KIDNEY INJURY
Transient diarrhea → severe fluid loss,
bowel wall necrosis
●
●
Despite the extent of the illness, most
infants with hemolytic uremic syndrome
recover completely
Some children die of the acute illness or
continue
to
have
chronic
renal
involvement
Elevated fever → stupor, hallucinations
Oliguria + proteinuria, hematuria,
urinary casts
Increased serum creatinine, BUN,
extensive edema
Pale (from anemia)
Easy bruising or petechiae from
thrombocytopenia
ETIOL
OGY
injury occurs in either an acute or chronic
Poor renal perfusion
Acute renal injury
Sudden body insult such as severe
dehydration
Other causes of acute renal failure:
● Prolonged Anesthesia
● Hemorrhage
● Shock
● Severe Diarrhea
● Sudden Traumatic Injury
Laboratory studies will show fibrin split
products in the serum as the fibrin
deposits in glomerular vessels are
degraded
Thrombocytopenia is present because
platelets are damaged by the irregular
blood vessels
Increased reticulocyte count indicates that
RBC are rapidly being replaced
Supportive therapy to maintain kidney
and heart function
○ Peritoneal dialysis can treat
extreme oliguria
■ Frightening to parents
and the child because it
involves penetration of
the child's abdomen
■ Ensure that parents
understand
the
importance of follow-up
care and have an
appointment for this
○ Blood transfusions
■ Packed RBC can treat
anemia
Kidney
form
●
●
●
It also can occur in children who:
● Are placed on cardiopulmonary bypass
while undergoing heart surgery
● Receive common antibiotics
● Swallowed poison such as arsenic
● Exposed to industrial waste such as
mercury
S/S
●
●
Oliguria - first noted
○ An indwelling urinary catheter
may be inserted to rule out the
possibility that urinary retention
in the bladder, rather than kidney
dysfunction, is causing the
severe oliguria
Hyperkalemia may occur when K cannot
be excreted
○ Acidosis will follow shortly with
acute renal failure
○ As total output decreases,
phosphorus levels will rise in
the bloodstream
○ A high serum phosphorus level
leads to a low calcium level
■
●
●
●
↓GFR
●
↑BUN may occur and rises progressively
as renal insufficiency continuous and the
breakdown products of protein cannot be
excreted
○ BUN >80-100 mg/100 ml = toxic
and needs correction usually by
dialysis
○ Urine
creatinine
(another
measure that can be used as an
indicator of function because it is
normally excreted at a uniform
rate) <10 mg/100 ml = severe
renal failure
○ As the kidneys become unable to
dilute or concentrate urine, the
specific gravity of urine
becomes fixed at 1.10
Urea crystals accumulate in the skin
Uremic frost, uremic breath, itching, and
urochrome pigment on the skin
Oliguria-polyuria-normal voiding
Edema
Circ. congestion
Hyperkalemia
Seizure (hyponatremia)
●
●
●
●
●
●
●
MGMT
○
Severe hypocalcemia
can lead to muscle
twitching and seizures
■ Chronic
hypocalcemia
can
lead to withdrawal of
calcium from bones or
osteodystrophy
○ An ivp or radioactive uptake
scan can be ordered to
substantiate the lack of kidney
function
Azotemia - elevated blood urea nitrogen
(BUN >28 mg/dL) and creatinine (Cr >1.5
mg/dL) bec of oliguria
Uremia - azotemia with symptoms or
signs of renal failure
●
●
●
●
●
●
●
●
●
N/C
●
●
Because acute kidney failure is a reaction to body
stress caused by acute disease or insult, attempts
to treat it focus on supporting the child's body
systems while correcting the underlying condition.
●
●
●
●
●
Avoid nephrotoxic drugs
TTT of dehydration
○ IV fluid is needed to replace
plasma volume
○ Administer such fluid slowly
enough to avoid heart failure
○ Extra fluid cannot be removed by
the kidneys because they are not
functioning
○ The fluid should not contain
potassium until it is established
that kidney function is adequate
○ Fluid intake may be limited to
prevent heart failure due to
accumulating fluid that cannot be
excreted
Diet: high carbohydrates and fats, low
protein, potassium & sodium
○ To supply enough calories for
metabolism yet limit urea
production and control serum
potassium levels
Calcium gluconate
Sodium bicarbonate
●
●
May cause a shift of potassium
from the bloodstream into cells
Glucose and insulin
Diuretic - furosemide
○ May be ordered in an attempt to
increase urine production
Sodium polystyrene sulfonate
Dialysis
Antihypertensive medications
Weigh children at the same time everyday
with the same scale and the same clothing
Maintain accurate I/O recordings to
evaluate fluid status
○ The increase in urine must be
noted
If children are so ill that they cannot eat,
total parenteral nutrition may be
necessary
○ Regulate amounts carefully to
prevent fluid overload
When recovery from acute renal failure
begins, children generally have a degree
of diuretic as the extra fluid accumulation
by the body this cleared
Absolute I/O
○ Meticulous attention to fluid I/O
○ Mandatory and includes all the
physical
measurements
in
relation to problems of fluid &
balance
Meeting nutritional needs is sometimes
a problem. The child may be nauseated
and encouraging concentrated foods
without fluids may be difficult.
○ When nourishment is provided
by the IV route, careful
monitoring is essential to prevent
fluid overload.
The nurse must be continually alert for
changes in behavior that indicate the
onset of complications.
○ Fluid overload and electrolyte
disturbances can precipitate
cardiovascular
complications
such as hypertension and
cardiac failure.
Monitor electrolytes
○ Fluid and electrolyte imbalances,
acidosis, and accumulation of
nitrogenous waste products can
produce
neurological
involvement
manifested
by
coma, seizures or alteration in
sensorium.
CHRONIC KIDNEY DISEASE
DEFIN
ITION
●
●
ETIOL
OGY
The kidneys are able to maintain chemical
composition of fluids within normal limits
until more than 50% of functional renal
capacity is destroyed by disease or injury.
Chronic renal insufficiency or failure
begins when the diseased kidneys can no
longer maintain the normal chemical
structure of body fluids under normal
conditions.
Results from extensive kidney disease such as
hemolytic-uremic syndrome or glomerulonephritis
R/F
●
●
●
CHAR
ACTE
RISTI
CS
●
●
MGMT
A variety of diseases and disorders that
can result in CKD. The most frequent
cause include:
○ Congenital renal and urinary
tract malformations
○ VUR associated with recurrent
UTI
○ Chronic pyelonephritis
○ Hereditary disorders
○ Chronic glomerulonephritis
○ Glomerulonephropathy
associated
with
systemic
diseases
(e.g. anaphylactoid
purpura
and
lupus
erythematosus)
Defining characteristics
○ Elevated serum creatinine
○ Evidence
of
hyperkalemia,
hyperphosphatemia,
hypernatremia, and uremia
○ Anemia
○ Oliguria
○ Anuria uncommon (except in
obstructive disorders)
Nonspecific (may develop)
○ Nausea
○ Vomiting
○ Headaches
○ Drowsiness
○ Edema
○ Dryness and itchiness of the skin
○ Hypertension
○ Inadequate growth
○ Poor nutritional intake
HEMODIALYSIS
DEFIN
ITION
●
●
INDIC
ATION
S
●
PROC
EDUR
E
●
Hemodialysis removes body wastes by
using an external membrane as the
diffusion surface.
A catheter is inserted into an artery and
blood is removed from the child and
circulated through a dialysis coil. After
diffusion is complete, the blood is returned
to the child’s venous circulation.
It can be done as a continuous process,
but it is so effective that 3 hours of
hemodialysis accomplish as much as 12
hours of peritoneal dialysis.
Children with renal failure or whose
kidneys have been removed while they
await a kidney transplant can be
maintained almost indefinitely by a
hemodialysis session.
○ Hemodialysis session: 2-3x/ wk
● It can be used in infants as well as older
children.
●
Early in the course of progressive renal
failure, the child remains asymptomatic
with
only
minimal
biochemical
abnormalities.
○ Early: Asymptomatic
○ End stage: Uremic Syndrome
Complications:
○ Retention of waste products
○ Water and sodium retention
○ Hyperkalemia
○ Metabolic acidosis
○ Calcium
and
phosphorus
disturbances
○ Anemia
○ Growth disturbance
Therapeutic Management
● Dietary management
○ Calories & protein
○ Dietary phosphorus is controlled
+ calcium carbonate preparation
(inactive), 25- OH vitamin D
and/or (active) 1, 25- dihydroxy
vitamin D
● Alleviation of metabolic acidosis
○ Alkalizing agents
● Accelerate growth
○ Recombinant human growth
hormone
● Regular dental care
● Correct anemia
○ Recombinant human
erythropoietin (rHuEPO)
● Manage HPN
● End-stage renal failure:
○ Dialysis
○ Kidney transplantation
●
●
●
To establish a site of initial blood removal,
children may have a double-lumen central
catheter inserted into a central vein, such
as the subclavian or internal jugular vein.
A permanent technique is subcutaneous
anastomosis of a vein and artery,
creating an arteriovenous fistula (usually
the brachial artery and brachiocephalic
vein [Fig. A]) or internal anastomosis of
the artery and vein using a subcutaneous
graft (Fig B).
The possibility of infection is reduced with
internal
anastomosis
although
unfortunately, two venipunctures, one
from a low point in the haunt to remove the
blood and one high in the shunt to return
it, are necessary for dialysis
○ Use an anesthetic cream
beforehand to reduce pain
The ability to feel a thrill (vibration) or hear
a bruit over the fistula or graft site is proof
that the connection is patent.
RISKS
●
●
Infection introduced with venipuncture
Clotting of the access site, which can lead
to emboli
CLINI
CAL
S/SX
●
During hemodialysis, children may begin
to show signs of confusion, vomiting,
visual blurring or hallucination from, what
is called, a dialysis disequilibrium
syndrome.
The procedure must be temporarily
halted to allow equalization to return.
Muscle cramping may occur from
sodium depletion
Children may grow bored during
hemodialysis, they need entertainment so
help the parents provide stimulating
activities such as playing a board game,
ring step for infants or a ball to throw back
and forth.
When children’s kidneys are removed
prior to transplantation, they must remain
on continuous program of hemodialysis
●
●
●
●
●
●
Allow them to plan special activities to do
during hemodialysis time to help give
them a feeling of control.
●
●
PERITONEAL DIALYSIS
DEFIN
ITION
●
●
●
●
●
●
It
uses
the
membranes of the
peritoneal cavity to
separate
and
remove
solutions
from body fluid
unlike
a
hemodialysis that
uses an outside
synthetic membrane to do this.
Unlike hemodialysis, peritoneal dialysis
does not require elaborate equipment or
expense but it does take more time.
Peritoneal dialysis may be used as a
temporary measure for children who
experience sudden renal failure caused by
trauma or shock.
It is used for fairly long periods with
children with chronic renal disease, both
in hospital and at home, to allow them to
live until a kidney transplantation can be
arranged.
It is usually begun when the serum
creatinine level reaches 10 mg/100 mL
Other indications:
○ Congestive heart failure
○ BUN of more than 100 mg/100
mL
○ Hyperkalemia
○ Uremic encephalopathy
●
Ask children to report any abdominal pain
or diarrhea
Assess of abdominal guarding or
tenderness
Once cycles of dialysis begin, children
need plan interaction
They generally do well on a liquid diet or
small frequent feedings during this time.
CONTINUOUS CYCLING PERITONEAL
DIALYSIS (CCPD)
●
●
●
●
●
●
Allows the procedure to be done at home because
less rigorous monitoring of the procedure is
necessary.
This would allow a children to go to school or
participate in other activities while receiving dialysis.
With CCPD, a permanent dialysis catheter is
inserted and sutured into place at the abdomen.
Each day the child or parent attaches a bag of
dialysis fluid and tubing to this and infuses a
prescribed dialysis solution by gravity drainage; the
bag and tubing are then rolled into a compact
square under the child’s clothes.
○ The infused solution remains in the child
for 4 to 6 hours during the day (8 hours at
night); the dialysate bag is lowered, and
the solution drains from the peritoneal
cavity into it.
○ The bag and fluid are then discarded and
a new bag of dialysate solution is attached
and raised, and a new solution is infused.
CCPD requires careful monitoring and attention by
the child or family
○ They must keep accurate records of
indusions.
Because CCPD is continuous, electrolytes in the
bloodstream are maintained at more constant levels
than when intermittent dialysis is used. Although
because a great amount of potassium is removed,
children may become hypokalemic.
RENAL TRANSPLANTATION
DEFIN
ITION
MGMT
For a child undergoing peritoneal dialysis:
● Monitor v/s at least q 4 hours
● During each new infusion period and while
the solution is in the abdomen, carefully
observe for shortness of breath because
the fluid exerts upward pressure on the
diaphragm
● Elevating the head of the bed a little
usually helps to increase breathing space
and ease respirations.
● If tachycardia or hypotension occurs, this
suggests that hypovolemia is occurring.
● An increasing temperature (after 24
hours) may indicate peritoneal infection
- a serious complication.
● Frequent blood studies are necessary
during periods of peritoneal dialysis to
determine electrolyte concentrations.
● The longer the peritoneal catheter
remains in place, the greater the risk of
infection at the catheter insertion site.
● Assess the insertion site daily for signs of
infection such as redness or drainage.
● Obtain temperature about q 4 hours.
●
●
PREOP
CARE
●
Kidney
transplantation
aids
in
prolonging the life of children with renal
failure.
With complete renal failure, children who
have extensive hypertension may have
their damaged kidneys removed and be
placed on hemodialysis or CCPD to await
kidney transplantation.
Kidney transplantation is most effective or
less likely to be rejected if the kidney is
taken from a living twin, parent, or sibling.
● In these instances, the success rate is as
high as 90%.
● Rejection occurs at a higher incidence if a
kidney comes from a cadaver or recently
deceased child.
● Kidney transplantation donors screening
also comes with its own sets of
challenges. For example:
○ Most people consider that children
should be of legal age to give consent to
supply a kidney for transplantation so
few children have a sibling who is eligible
to donate a kidney.
○ Adult size kidneys may be transplanted
into children although if a child weighs
less than 10 kg, a kidney this large may
lead to hypertension, excessive
diuresis,
and
abdominal
complications because of the lack of
space.
○ Transplanted kidneys are placed in the
abdomen and not in the usual kidney
space.
○ People who cannot donate a kidney
include those with multiple bilateral small
renal arteries, bilateral renal disease,
renal infection, advanced medical
illness, severe obesity, or hypertension.
● Although kidney removal can be done by
laparoscopy, donors must understand
that removal of a kidney involves major
surgery.
● Tests that kidney donors can expect to
have preoperatively include human
leukocyte antigen (HLA) typing, electrolyte
blood analysis, complete blood count,
bleeding time, urinalysis
and urine
culture, 24-hour urine sample for protein,
renal arteriogram and IV pyelography.
● Donors will have urine samples
collected after surgery to assess that
their remaining is capable of maintaining
full function and that they are still in good
health.
● Before surgery, children who are to
receive a transplant may be dialyzed to
clear their body of excessive potassium
and fluid.
● If a donated kidney will be from a relative,
there is adequate time for thorough
preoperative preparation.
● If the donor kidney is from a cadaver, the
announcement of surgery will be sudden,
and time for preoperative instruction and
procedures may be limited.
● Children
who
receive
pretransplantation blood transfusions
have an improve chance of transplant
success. Most children, therefore, receive
at least 5 blood transfusions while
awaiting surgery.
POSTOP
CARE
●
●
●
●
●
●
●
Are a group of antigens found on the
surface of all cells with a nucleus,
including blood components such as
leukocytes and platelets.
Such antigens are inherited from both
parents and are specific for each
individual.
They denote tissue type or determine
which tissue the immune system will
identify as foreign tissue.
Such antigens also serve as a basis for
paternity typing.
Children who are awaiting kidney
transplantation are tissue (HLA) typed,
and this information is circulated to major
medical centers.
When a kidney is available for
transplantation, the child’s tissue type is
compared with the donor kidney.
For tissue typing, lymphocytes from both
the donor and recipient are grown
together into a culture medium and then
examined for like characteristics.
With new immunosuppressive drugs,
however, even unmatched kidneys have a
chance to successfully graft.
●
After renal transplantation, children are
cared for in an environment that is as
sterile as possible.
They are placed on immunosuppressive
therapy
such
as
cyclosporine,
azathioprine
(Imuran),
and
methylprednisolone (Solu-Medrol) to
reduce the possibility of kidney rejection.
Antilymphocyte
globulin
and
antithymocyte globulin may aid in
immune suppression.
Although some transplanted kidneys
begin
to
function
immediately,
hemodialysis may be continued until the
implanted kidney can fully function after
recovering
from the initial insult of
transplantation.
Children with end-stage renal disease
usually fail to grow despite treatment.
Although the rate of growth is improved
after kidney transplantation, they will
probably never reach full height - part of
this growth restriction is the need for
corticosteroid maintenance therapy to
continue immunosuppression.
●
●
●
●
TRANSPLANT REJECTION
●
●
HUMAN LEUKOCYTE ANTIGEN (HLA) TYPING
DEFIN
ITION
●
Acute transplant rejection, if it occurs, usually
develops within the first 3 months after
transplantation.
○ Children may begin to develop fever,
proteinuria
oliguria,
weight
gain,
hypertension, and tenderness over the
kidney. Serum creatinine and BUN levels
will continue to rise.
○ Increasing
the
dose
of
immunosuppressants may be effective
in stopping/relieving this type of rejection.
Rejection may also be chronic, in which the
transplanted kidney gradually loses function after
the first 6 months.
○ Hypertension and anemia result
○ A biopsy result will show vascular changes
such as narrowing of arterial lumens and
interstitial changes such as fibrosis and
tubular atrophy.
○ This type of rejection is difficult to halt,
although it may be such a slow, steady
process that it will be 2 or 3 years before
the kidney fails.
○ If a kidney is rejected, it is removed and the
child is returned to a program of
hemodialysis.
○ Because one kidney was rejected, it does
not mean that a second transplant will also
be rejected. []
VI. MALE REPRODUCTIVE DISORDERS
Outline:
1. Balanitis
BALANITIS
DEFIN
●
aka Balanoposthitis
ITION
●
●
S/SX
●
●
MGMT
●
●
●
●
●
This is the inflammation of the glans and
prepuce of the penis.
It is usually caused by poor hygiene and
may accompany urethritis or regional
dermatitis.
DEFIN
ITION
The prepuce and glans becomes red and
swollen and a purulent discharge may be
present.
The boy may have difficulty voiding
because of crusting at the meatal opening
and because acidic urine touching the
denuded surface of the glans causes pain.
●
●
●
Local application of heat
○ This can be carried out with
warm wet soaks or warm baths.
Local antibiotic ointment
If phimosis appears to be contributing to
the condition, circumcision may be
advocated after the inflammation subsides
to prevent the condition from recurring.
○ Although
balanoposthitis
is
painful, a boy may tolerate the
discomfort for several days
because he is too embarrassed
to discuss the problem.
Patient education of the condition is of
utmost importance that this was not
caused by masturbation or sexual activity
and it is a local problem with no long-term
effect.
On the other hand, in developing
countries, when balanitis can become
chronic because of lack of bathing or
shower facilities, it may be associated
with the development of penile cancer.
●
●
●
●
●
●
●
PHIMOSIS & PARAPHIMOSIS
DEFIN
ITION
●
●
●
Phimosis is the inability to retract the
foreskin from the glans of the penis.
○ The foreskin is tight at birth and
may be held fast by adhesions
so it cannot be retracted in
newborns.
○ After a few months, the
adhesions dissolve and the
foreskin becomes retractable.
If it does not, the infant has
phimosis.
If a foreskin is extremely tight, it can:
○ Interfere with voiding
○ Balanoposthitis may develop
because the foreskin cannot be
retracted for cleaning.
○ Circumcision of newborns is no
longer routinely advised but is
used to relieve phimosis.
Paraphimosis meanwhile is the inability
to replace the prepuce over the glans once
it has been retracted.
○ This is an emergency situation to
address before circulation of the
glans is impaired.
●
●
MGMT
●
●
●
This is the failure of one or both testes to
descend from the abdominal cavity and
into the scrotum.
○ Normally the testes descend into
the scrotal sac during months 7
to 9 of intrauterine life.
○ They may descend anytime up to
6 months after birth and they
rarely descend after that time.
The cause of undescended testes is
unclear although it may be associated with
caffeine intake during pregnancy.
Testes apparently descend because of
stimulation by testosterone hence it is
possible that a lower-than-normal level of
testosterone production prevents descent.
About 17% of premature infants and 3%
to 4% of full-term infants are born with
undescended testes.
Early detection is important because the
warmth of the abdominal cavity may
inhibit development of the testes
ultimately affecting spermatogenesis.
After
puberty,
sperm
production
deteriorates rapidly in undescended
testes and the testes may even undergo a
malignant change.
It is more common for the right testes to
remain undescended than the left one.
In approximately 20% of all boys, both
testes remain undescended.
If the child is supine or the examining room
is chilly, the scrotal sac may appear to be
empty.
Excessive palpation or stroking of the
inner thigh may also stimulate the
cremasteric reflex and cause retraction.
○ In these instances, testes
descend when the child is
standing or after a warm bath.
So, that is most ideal for
assessment.
An undescended testes may be at the
inguinal ring. This is called a true
undescended testes or ectopic which is
still in the abdomen.
Laparoscopy is effective in identifying
undescended testes.
Because the testes sometimes descend
spontaneously during the first year of life,
treatment is usually delayed for 6 to 12
months.
Boys
may
be
given
chorionic
gonadotropin hormone for about 5 days
to stimulate testicular descent.
If necessary, surgery or orhiopexy by
laparoscopy by 1 year of age corrects the
condition.
CRYPTORCHIDISM
●
When a testes descend into the scrotum
in utero, it is preceded by a fold of tissue,
the prosocus vaginalis.
○
○
○
○
○
○
○
○
○
Occasionally, fluid collects in this
fold.
If this occurs, hydrocele can be
revealed by prenatal ultrasound.
At birth, the collection of fluid
makes the scrotum of the
newborn appear enlarged.
On transillumination, that is the
shining of a light through the
scrotal sac (see pic on right), the
area is illuminated by the water
and it shines or it glows.
Ultrasound also can reveal this
fluid collection.
If
the
hydrocele
is
uncomplicated, the fluid will
gradually be absorbed and no
treatment is necessary.
The child’s parents can be
assured
that
the
child’s
hydrocele is only excess fluid
and that the scrotal enlargement
is not caused by an abnormal
testes, tumor, or hernia.
A hydrocele may form later in
life due to inguinal hernia. If this
happens, the hernia must be
repaired for the hydrocele to be
absorbed.
Injection of a drug to decrease
fluid production may also be
effective.
This
is
called
sclerotherapy.
●
●
MGMT
●
●
●
DEFIN
ITION
●
●
●
A varicocele is abnormal dilation of the
veins of the spermatic cord.
It is important to identify varicocele in
adolescence because although it may not
cause a difference, the increased heat
and congestion in the testicles could be a
cause of subfertility.
S/SX
●
The adolescent may report some local
tenderness and edema for a few days
after surgery.
○ Edema can be minimized for the
first few hours postoperatively.
MGMT
●
No treatment is necessary unless fertility
becomes a concern at which time the
varicocele can be surgically removed.
●
TESTICULAR TORSION
DEFIN
ITION
●
●
●
S/SX
●
●
●
Testicular torsion or the twisting of the
spermatic cord.
Although it can be present in newborns, it
occurs most frequently in adolescence or
early adolescence to be more specific.
Usually results from a sports activity.
The boy experiences severe scrotal pain
and perhaps nausea and vomiting from
the severity of the pain.
The testes feel tender to palpation and
edema begins to develop.
If the condition is not recognized promptly
pr within 4 hrs., irreversible change of
Testicular torsion or the twisting of the
spermatic cord is a surgical emergency.
AMBIGUOUS GENITALIA
VARICOCELE
DEFIN
ITION
testes can occur from lack of circulation to
the organ.
The torsion can be reduced manually
under ultrasound guidance.
Laparoscopic surgery however,
is
usually necessary to reduce the torsion
and reestablish circulation.
●
MGMT
●
●
This refers to genitalia that are not clearly
defined in a newborn.
Understanding how reproductive organs
develop in utero is important to the
understanding of why ambiguous genitalia
occur.
Usually, a diagnosis means that the
external sexual organs of the child did not
follow the normal course of devlopment so
that at birth, they are so incompletely or
abnormally formed that it is impossible to
clearly determine the gender of the child
by simple observation.
○ For instance, a male infant with
hypospadias
and
cryptorchidism may appear
more female than male on first
inspection.
○ Meanwhile in the female, a
chromosomal female fetus may
become
masculinized
with
exposure of androgen in utero.
○ So, in such children, the clitoris
may be so enlarged that it
appears more like a penis. When
this occurs the newborn will
appear to be a boy on initial
inspection.
○ Likewise,
under
certain
conditions, a chromosomal male
may become feminized with a
lack of fusion of the labioscrotal
folds and an incompletely formed
penis.
○ The most common cause of
invitroverilization of females is
congenital
adrenocortical
syndrome.
If testosterone was produced in utero but
development of the buliaran duct was not
suppressed, a child may be intersexed. So
this is what is formally termed as a
hermaphrodite.
○ So this child may have both
ovaries and testes and either
male or female external genitalia.
Children with ambiguous genitalia are
often termed “pseudointersexed” or
“pseudohermaphrodites” because as
infants, they may have external features of
both sexes although only either ovaries or
testes or neither are present.
If there is any question about the child’s
gender, karyotyping helps to establish
whether the child is genetically male or
female.
Laparoscopy or the introduction of a
narrow laparoscope into the abdominal
●
●
●
cavity through a half-inch incision under
the umbilicus or possibly exploratory
surgery may be necessary to determine if
ovaries or undescended testes are
present.
IV pyelography or ultrasound can be
used to establish whether a male has a
complete urinary tract.
Once the child’s true chromosomal gender
has been documented,
the extent of
necessary reconstructive surgery is
determined in consultation with the
parents.
If an infant is chromosomally male, but
does not have an adequate penis, a
decision to raise the child as female might
be made although construction of an
artificial penis is more likely.
○
●
●
●
S/SX
●
The most frequent reproductive disorders in females
involve vaginal or menstrual irregularities.
Other disorders are caused by structural alterations of
the reproductive organs.
MENSTRUAL DISORDERS
●
●
“Bloated” feeling, light cramping 24 hrs
before menstrual flow; pain is mainly
noticed, however, when the flow begins
Colicky (sharp) pain is superimposed on
a dull, nagging pain across the lower
abdomen
“Aching, pulling” sensation of the vulva
and inner thighs
Mild diarrhea
Mild breast tenderness, abdominal
distention, nausea & vomiting, headache,
facial flushing
●
●
●
●
VII. FEMALE REPRODUCTIVE DISORDERS
●
Severe - interference with the
majority of everyday activities
As many as 80% of adolescents have
some discomfort of menstruation. In
approximately 10%, the discomfort
seriously interferes with daily living.
Dysmenorrhea is primary if its occurs in
the absence of organic disease
It is secondary if it occurs as a result of
organic disease.
MANA
GEME
NT
2 categories:
○ Menstruation that is painful or uncomfortable
○ Infrequent or too frequent cycles
●
Analgesic: acetylsalicylic acid (aspirin) or
ibuprofen (Advil, Motrin)
NSAIDS: Naproxen sodium (Aleve)
Low-dose oral contraceptives to
prevent ovulation may also be effective if
pregnancy is not desired
Alternative
therapies
for
pain
management
○ Imagery
○ Transcutaneous electrical nerve
stimulation (TENS)
●
●
●
MITTELSCHMERZ
DEFIN
ITION
●
S/SX
●
●
●
●
Abdominal pain during ovulation from the
release of accompanying prostaglandins.
Pain may also be caused by a drop or
two of follicular fluid or blood that spills
into the abdominal cavity.
This pain called a “mittelschmerz” can
range from a few sharp cramps to several
hours of discomfort.
Felt on one side of the abdomen (near an
ovary)
Accompanied by scant vaginal spotting
○ An advantage of mittelschmerz is
it clearly marks ovulation.
○ Usually, this is of limited
discomfort and can be relieved
by a a mild analgesic such as:
Analgesic (acetaminophen)
DYSMENORRHEA
DEFIN
ITION
●
●
●
●
●
Painful menstruation
Pain is caused by the release of
prostaglandins in response to tissue
destruction during the ischemic phase of
the menstrual cycle.
Prostaglandin release causes smooth
muscle contractions and pain in the uterus
Dysmenorrhea can also be a preliminary
symptom of an underlying illness such as
PID,
Uterine
myomas,
or
Endometriosis
Dysmenorrhea can be categorized as:
○ Mild - no interference with
normal activities
○ Moderate - some interference
MENORRHAGIA
DEFIN
ITION
●
●
●
○
○
○
○
●
○
●
●
●
●
●
Abnormally heavy menstrual flow (>80
mL/menses)
It may occur in girls close to puberty and
it occurs again in women nearing
menopause because of unovulatory
cycles
A heavy flow can indicate:
Endometriosis
A systemic disease (anemia)
Blood dyscrasia such as a clotting defect
Uterine abnormality (ie. myoma)
Can be a symptom of infection
TID
Can be an indication of early pregnancy
loss that is coincidentally occurring at the
time of an expected menstrual period
Can occur because of a previously
undiagnosed bleeding disorder such as
von willebrand disease
It is difficult to determine when a menstrual
flow is abnormally heavy but one method
is to ask the girl is:
Assessment: "How long does it take
you to saturate a sanitary napkin or
tampon?"
Determine cause to prevent anemia (need
iron supplements to achieve sufficient
hemoglobin formation)
Excessive blood because of anovulatory
cycles: Progesterone during the luteal
phase to prevent proliferative growth
during this phase of the cycle
○
METRORRHAGIA
DEFIN
ITION
●
●
●
●
●
○
Bleeding between menstrual periods
This is normal in some adolescents who
have spotting at the time of ovulation
Breakthrough bleeding: Teenagers
taking oral contraceptives (first 3-4
months of use)
Vaginal irritation from infection
Refer to doctor: early sign of uterine
carcinoma or ovarian cysts
TTT
●
○
●
●
AMENORRHEA
DEFIN
ITION
●
●
●
●
●
●
●
Absence of a menstrual flow
Strongly suggests pregnancy but is by no
means definitive
Other possible causes: tension, anxiety,
fatigue, chronic illness, extreme dieting, or
strenuous exercise
Athletic women who undergo intensive
sports training causes their periods to
become scant and irregular. This
appears to be associated with their low
ratio of body fat to body muscle which
leads to excessive secretion of prolactin.
Adolescents who wish to maintain a
normal cycle while training for sports
events may take bromocriptine parlodel
which can reduce high prolactin levels by
acting on the hypothalamus and initiating
menstruation each month.
Also occurs among females who diet
excessively, partially as a natural
defense mechanism to limit ovulation and
as a means of conserving body fluid.
Anorexia nervosa or bulimia develop after
3 months of excessive dieting or binging
and dieting. As an athlete, this is caused
by an increase in prolactin.
●
●
●
●
S/S
●
Premenstrual dysphoric disorder or PDD
is a condition that occurs in the luteal
phase of the menstrual cycle and is
relieved by the onset of menses.
It has both behavioral and physiologic
symptoms.
The cause of PDD is unproved but
contrary to previous beliefs, it must be due
to more than a drop in progesterone just
before menses.
Adolescents who think they have PDD
should keep a diary of when symptoms
occur. If they are aware of recurring
patterns that indicate PDD they will be
better able to recognize the cause.
Because of the variety of possible
symptoms, 30% of women experience
some degree of PDD
○ At least 3% experience a cluster of
symptoms: Anxiety, fatigue, abdominal
bloating,
headache,
appetite
disturbance, irritability, and depression
○ For about 3% of these women, these
symptoms are so extreme that they are
incapacitating
Depression? Buspirone (BuSpar)
Use with caution because they may be
responsible for an increase in suicidal
behavior
They should be certain that their diet is
high in vitamins and calcium and low in
salt.
Agents that suppress ovarian functions
such as oral contraceptives or the
GNRH agonist leuprolide may be
prescribed
TOXIC SHOCK SYNDROME (TSS)
DEFIN
ITION
●
●
S/S
PREMENSTRUAL DYSPHORIC D/O (PDD)
DEFIN
ITION
Symptoms vary from cycle to cycle and
throughout life
Therapy: aimed at correcting specific
symptoms
MGMT
Toxic shock syndrome or TSS is an
infection that usually is caused by toxin
producing strains of Staphylococcus
aureus organisms.
Although organisms can enter the body by
other means, they typically enter through
vaginal walls that have been damaged by
the insertion of tampons at the time of a
menstrual period.
Some women have mild diarrhea as a normal
accompaniment to dysmenorrhea but any female
who develops fever with diarrhea and vomiting
during a menstrual period should suspect TSS.
● Temperature greater than 102° F (38.9°
C)
● Vomiting and diarrhea
● A macular (sunburn-like) rash that
desquamates on palms and soles 1 to 2
weeks after illness
● Severe hypotension (systolic pressure
less than 90 mm Ha)
● Shock, leading to poor organ perfusion
● Impaired renal function with elevated
blood urea nitrogen or creatinine at least
twice the upper limit of normal
● Severe muscle pain or creatine
phosphokinase at least twice the upper
limit of normal
● Hyperemia of mucous membrane
● Impaired liver function with increased total
bilirubin and increased serum glutamate
oxaloacetate transaminase (aspartate
aminotransferase) at twice the upper limit
of normal
● Decreased platelet count
● Central nervous system symptoms of
disorientation,
confusion,
severe
headache
●
●
●
●
●
Careful vaginal examination and
removal of any tampon particles
Cervical & vaginal cultures for S. aureus
lodine douches may reduce the number
of organisms present vaginally
Staphylococcus aureus is usually
resistant to penicillin but not to
penicillinase resistant antibiotics such as
the cephalosporins, oxacillins, or
clindamycin
IV Therapy to restore circulating fluid
volume and increase blood pressure
●
Vasopressors such as dopamine may be
necessary to increase the blood pressure
Osmotic therapy to shift fluid back into
the intravascular circulation may be
necessary to prevent renal and cardiac
failure
Recovery occurs in 7-10 days; fatigue
and weakness may remain for months
afterward
Patient education on menstrual hygiene:
●
●
●
●
●
●
●
●
●
●
●
●
What to educate patients:
Use only tampons made of natural
materials such as cotton, not
synthetics such as cellulose or
polyester, and avoid high-absorbency
tampons.
Change tampons at least every 4
hours during use.
Alternate use of tampons with use of
sanitary pads.
Avoid handling the portion of the
tampon that will be inserted vaginally.
Do not use tampons near the end of
a menstrual flow, when excessive
vaginal dryness can result from scant
flow.
Do not insert more than one tampon
at a time, to avoid abrasions and to
keep the vaginal walls from becoming
too dry.
Avoid
deodorant
tampons,
deodorant sanitary pads, and
feminine hygiene sprays; these
products can irritate the vulvar-vaginal
lining.
If fever, vomiting, or diarrhea occurs
during a menstrual period, discontinue
tampon use and immediately consult a
healthcare provider, because these are
symptoms of TSS.
Anyone who has had one episode of
TSS is well advised not to use
tampons again, or at least not until two
vaginal cultures for Staphylococcus
aureus,
the
bacteria
usually
responsible for TSS, are negative.
TTT
PRECOCIOUS PUBERTY
DEFIN
ITION
IMPERFORATE HYMEN
DEFIN
ITION
The hymen is the membranous ring of tissue that
partially obstructs the vaginal opening. An
imperforate hymen totally occludes the vagina
preventing the escape of vaginal secretions and
menstrual blood.
● Before menarche, the child within
imperforate hymen usually has no
symptoms
● Onset of menstruation, the menstrual
flow is obstructed - it builds up in the
vagina causing increased pressure in the
vagina and uterus and eventually
abdominal pain
● Palpation of the abdomen reveals a lower
abdominal mass
● Vaginal examination: intact, bulging
hymen
Surgical incision or removal of the hymenal
tissue; The girl may have local pain after the
incision which can be relieved by a mild analgesic
and warm baths.
ETIOL
OGY
●
Although development of breasts or pubic
hair before age 8 or menses before age 9
may be just early maturation, such
development has traditionally been
considered
precocious
sexual
development.
● Development is limited to breast tissue
or pubic hair growth
○ Can proceed to complete secondary sex
characteristics, spermatogenesis, or
menstrual function
○ Occurs more often in girls than in boys
● This condition is caused by the early
production of gonadotropins by the
pituitary gland. Gonadotropins stimulate
the ovaries or testes to produce sex
hormones.
● In children affected by precocious puberty,
a tumor must be ruled out. If no physical
cause such as a tumor is detected, the
phenomenon appears to occur only
because the gonadostat
of
the
hypothalamus was turned on several
years too early.
Categorized as:
● Central
precocious
puberty
(gonadotropin-releasing
hormone
[GnRH]-dependent)
In
which
gonadotropic hormones are elevated
● Peripheral precocious puberty (Gn-RHindependent) - Which is basically
elevation of sexual steroids produced by
the gonads or adrenals
●
●
●
S/S
●
●
Such condition can occur because of a
pituitary tumor, cyst or traumatic injury
to the third ventricle next to the pituitary
gland.
It can also occur because of estrogen
secreting cysts or tumors of ovary or
testosterone secreting cysts of the testes.
In rare instances, it occurs because of an
estrogen or testosterone secreting
adrenal tumor.
Increased breast and genital development
Accelerated skeletal maturation
●
●
DX
●
Girls: menstrual bleeding with little pubic
or axillary hair because of still low
androgen secretion
Boys: obvious genital growth
Obesity and hirsutism may be presenting
complaints
Possible Symptoms:
● A syndrome of chronic follicular cysts,
anovulation, insulin resistance, and
excess testosterone production leading to
perimenopausal onset of hirsutism,
obesity,
subfertility,
and
elevated
triglycerides.
Serum analysis for estrogen or androgen will be at
adult levels
THER
AP
MGMT
●
●
Synthetic analog to GnRH
○ Leuprolide acetate (Lupron) Desensitizes GnRH receptors
making stimulation by GNRH
ineffective and halts sexual
maturation at the point to which it
has advanced
○ Subcutaneously everyday
○ After it is discontinued at age 12
or 13 years, puberty progresses
normally
Aromatase inhibitors
○ Block the enzyme aromatase,
decrease signs of estrogen
effects
DELAYED PUBERTY
DEFIN
ITION
C/C
●
●
Insulin resistance
Cardiac D/O later in life
MGMT
●
●
●
●
●
Weight loss
Low carbohydrate diet
Metformin
Clomiphene
Antiandrogens
(spironolactone,
finasteride)
When pregnancy is desired, medications
to stimulate ovulation are often effective
Oral contraceptives are also usually
prescribed to treat polycystic ovary
syndrome
●
●
THER
APY
●
Failure of pubertal changes to occur at
the usual age
○ Secondary sex characteristics normally
are present by age 14 years in girls and
15 years in boys
● The family history of many children
reveals a familial tendency for late
maturation. If so, the child needs a
thorough physical examination to
disclose whether some secondary sex
characteristics are present or whether
endocrine stimulation is beginning.
● Girls who haven't menstruated by age 17
years and pathology has been ruled out,
menstrual cycles can be initiated by
administering estrogen
● Boys
may
receive
testosterone
supplements to stimulate pubic hair and
genital growth
Excess testosterone by ovaries leads to inhibition
of FSH and anovulation, Weight loss, reduction in
triglycerides and cholesterol, and clomiphene
citrate therapy to induce ovulation are used as
therapy.
ACCESSORY (SUPERNUMERARY) NIPPLES
DEFIN
ITION
●
●
●
●
●
POLYCYSTIC OVARIAN SYNDROME (PCOS)
●
DEFIN
ITION
●
●
●
●
S/S
●
●
Polycystic ovary syndrome is a complex
condition involving a disorder in the
hypothalamic, pituitary, and ovarian
network or axis resulting in anovulation.
Occurs in women of childbearing age.
Cysts form in the ovaries because the
hormonal milieu cannot cause ovulation
on a regular basis
Onset may occur at menarche or later
Symptoms are related to androgen excess
Irregular periods resulting from lack of
regular ovulation
●
●
These may be found on the chest, on the
abdomen, or in the axilla. As the name
implies, accessory nipples are additional
breast nipples.
They occur along the mammary lines
and can be present in either male or
females.
They are present from birth but usually are
not as protuberant as true nipples.
They also lack areola pigmentation.
Parents should be told what they are so
that they can inform their daughter later
because some growth in accessory
nipples may occur at puberty or during
pregnancy in response to estrogen
stimulation.
Many girls are unaware that they have an
accessory nipple and think that it is just a
large mole until puberty happens.
In a few instances, actual breast tissue is
present beneath the accessory nipple. If
so, it is subject to the same diseases as
other breast tissue.
If the accessory nipple or accessory
breast tissue is cosmetically distressing to
an adolescent, it can be removed by
simple surgical incision.
BREAST HYPERTROPHY
DEFIN
ITION
●
Is abnormal enlargement of breast
tissue.
● In the average girl, breast development
halts after puberty as soon as
progesterone levels rise to mature
strength.
● Progesterone levels are low until
menstruation cycles are fully established.
● However, if this process is a lengthy one,
breast growth may last for several years
resulting in larger than usual breasts.
● Breast hypertrophy can lead to both
physical and emotional stress. A girl may
feel pain and fatigue in the back or
shoulders from attempting to maintain
good posture despite the weight of heavy
breast tissue.
○ She may feel overly self-conscious and
try to minimize her breast size by
slouching resulting in poor posture or
rounded shoulders.
● If breast hypertrophy interferes with a girl's
physical and emotional well-being,
surgical breast reduction is a possibility.
● Adolescents need to seriously consider
the consequences of this procedure,
however, before undertaking it at an early
age.
● If a large amount of glandular tissue is
removed, breast feeding may no longer
be possible.
● An adolescent with large breasts must
conscientiously schedule a yearly breast
examination because it is easier for a
cancerous lesion to escape detection in
large amounts of breast tissue than in a
smaller breast.
BREAST HYPOPLASIA
DEFIN
ITION
●
●
Breast hypoplasia - this is less than
average breast size.
In most instances this does not represent
a decreased amount of glandular or
functional breast tissue but a reduced
amount of fatty tissue.
UNIT 13 (Week 14)
PEDIATRIC VARIATIONS AND NURSING CARE OF THE CHILD WITH A
NEUROLOGIC DISORDER
Anatomy and Physiology Overview of the Nervous System and
Pediatric Variations
●
●
●
●
●
A wide array of problems, rooting from the disorders in your
neurological systems might be from congenital cause, infection, or
trauma.
Prevention must be the highest priority for keeping the nervous
system healthy because in the future, stem cell research may offer
a cure for neurological disorders. For now, because neural tissues
do not degenerate like any other tissue or any other systems in
our body, we need to extend more of our nursing focuses in
preventing or measuring or making strategies for dealing with the
association of loss in mental or physical functioning of our
patients; making the child more comfortable especially in the
hospital stay and providing an environment which is conducive for
the child’s development and self esteem.
It is really of great significance especially reviewing the diseases in
our neurological disorder in pediatrics to have an overview of our
anatomy and physiology of the nervous system.
Nerve cells (neurons) are unique among body cells in that, instead
of being compact, they consist of all cell nuclei and extensions:
one axon and several dendrites. The dendrite transmits impulses
to the cell nucleus (listener); the axon transmits impulses away
from the cell nucleus to body organs(talker).
The nervous system is not fully functioning at birth; it continues to
mature through the first 12 years of life. Two separate systems are
involved: the peripheral nervous system (PNS) and the central
nervous system (CNS). The PNS consists of the cranial nerves, the
spinal nerves, and the somatic and visceral divisions. The CNS
includes the brain and the spinal cord surrounded by the
cerebrospinal fluid (CSF), the skull, and three membranes or
meninges (the dura mater, a fibrous, connective tissue containing
many blood vessels; the arachnoid membrane, a delicate serous
membrane; and the pia mater, a vascular membrane) that protect
the brain and spinal cord from trauma.
●
●
●
●
●
●
Cell body - The cell’s life support system
Neural impulse - Electrical signal travelling down the axon
Myelin sheath - Covers the axon of some neurons and helps
speed neural impulses
● Terminal Branches of Axon - Form junctions with other cells
● Dendrites - Receives messages from other cells
● Axon - Transmits impulses away from the cell or nucleus,
termed as the tracker. It transmits different information from
messages throughout your body.
Slides 4-6 (apil ang slide 6 under sa neurological examinations) Toff
Dura Mater - Outer layer of the meninges lying directly
underneath the bones of the skull and vertebral column. This is
thick, tough, and extensible.
Arachnoid (mater) - Middle layer of the meninges lying directly
underneath the dura mater. Underneath the arachnoid is a space
called “subarachnoid space” which is the site for the lumbar
puncture. It contains cerebrospinal fluid which acts as a cushion of
the brain.
Pia mater - Located under the desk of the arachnoid space. It is
very thin, tightly adhered to the surface of the brain and spinal
cord. It is the only covering to follow contours of the brain which
we call as “gyri” or tissue.
Cerebrospinal Fluid (CSF)
● A clear fluid that surrounds the brain and spinal cord. It serves
as a cushion to the brain and spinal cord from injuries
● serves as a nutrient delivery removal system of the brain
● In the brain there are ventricles, it is important to know these
parts because the ventricle is one of the manufacturers of the
serum and H20.
● we need to know the normal properties to rule out different
diseases
Normal Properties of Cerebrospinal Fluid
Parameter
Normal Findings
Abnormal Findings: Possible
Significance
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
Opening
Pressure
Appearance
Cell Count
Protein
Newborns: 8-10
cm H2O;
Children: 10-18
cm H2O
Clear and
colorless
0-8/mm3
15-45 mg/100 ml
Lowered pressure usually
indicates there is
subarachnoid obstruction in
the spinal column above the
puncture site; Elevated
pressure suggests intracranial
compression (pressure),
hemorrhage, and infection;
Pressure increases if a child
coughs or pressure is applied
to the external jugular vein
(Valsalva Maneuver)
If cloudy, indicates possible
infection with an increased
number of white blood cells
(WBCs); If reddened, color is
probably because of red blood
cells (RBCs)
Glucose
60%-80% of
serum glucose
level
Bacterial meningitis causes a
marked decrease in CSF
glucose, invasion of fungi,
yeast, tuberculosis, or
protozoans into the CSF
results in some decrease in
glucose level; Viral infections
do not cause a decrease in CSF
glucose and may occasionally
cause a slight increase
Albumin/Glob
ulin (A/G)
Ratio
8:1
Increased level suggests
infection or an A/G ratio
neurologic disorder
Neurological Examinations
1.
Cerebral Function
Granulocytes suggest
cerebrospinal fluid (CSF)
infection; Lymphocytes
suggest meningeal irritation
and inflammation; A few RBCs
and WBCs are normally
present in the newborn CSF
due to the trauma of birth
Elevated count (more than
45/100 ml) occurs if RBCs are
present; If both protein
content and RBC count are
elevated, meningitis or
subarachnoid hemorrhage is
suggested; If protein content
alone is elevated, it more
likely suggests a degenerative
process such as multiple
sclerosis
●
●
Orientation
Person, place, and time
Immediate Recall
Recent memory
Remote Memory
Long-term recall
Stereognosis
Ability to recognize object by
touch
Graphesthesia
Ability to recognize shape that
has been traced on the skin
Kinesthesia
Ability to distinguish movement
Immediate recall is the ability to retain a concept for a short
time, such as being able to remember a series of numbers and
repeat them (a child of 4 years can usually repeat three digits;
a child older than 6 years can repeat five digits).
Recent memory covers a slightly longer period of time. To
measure this, show the preschool child an object such as a
key and ask the child to remember it because later you will
ask him or her to tell you what it was. After about 5 minutes,
ask whether the child remembers what object you showed
him or her. Ask older children what they ate for breakfast to
test recent memory.
● Remote memory is long-term recall. Ask preschoolers what
they ate for breakfast that morning or for dinner the night
before because, for them, that was a long time ago; ask older
children what was the name of their first-grade teacher
because most people remember this information their whole
life.
● Stereognosis refers to the ability of a child to recognize an
object by touch; it is a test of sensory interpretation. For this,
ask a child to close his or her eyes and then place a familiar
object, such as a key, a penny, or a bottle cap, in her hand and
ask her to identify it. This is a skill even preschoolers are able
to do successfully.
● Graphethesia is the ability to recognize a shape that has been
traced on the skin. Ask a child to close his or her eyes; trace
first a circle then a square on the back of his or her hand.
● Kinesthesia is the ability to distinguish movement. Have a
child close her eyes and extend her hands in front of her.
Raise one of her fingers and ask her whether it is up or down.
Slides 7-9 (apil ang slide 9 under sa diagnostic testing) Mira (Done)
2. Cranial Nerve Function - Testing for cranial nerve function consists
of assessing each pair of cranial nerves separately.
3.
Cerebellar Nerve Function
● Tests for balance and coordination. To test these, observe the
child walk to assess whether the walk is natural (most children
walk at least a little self-consciously when they know they are
being observed, so watch them also as they enter the exam
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
room and move around for other activities). Ask the child to
attempt a tandem walk (walk a straight line, one foot directly
in front of the other, heel touching toe; walk three steps.
● Ask if the patient can already walk.
● A child as young as 4 years should be able to do this for as
long as 5 seconds.
4. Motor Function - Measured by evaluating muscles size, strength,
and tone. Begin by comparing the size and symmetry of
extremities. If in doubt about either of these, measure the
circumference of the calves and thighs or upper and lower arms
with a tape measure. Palpate muscles for tone. Move the
extremities through passive range of motion to evaluate for
symmetry, spasticity, and flaccidity bilaterally. To test for strength,
ask the child to extend her arms in front of her and then resist
your action as you push down or up on her hands or push them
out to the side. Do the same with the lower extremities.
5. Sensory Function
● If children’s sensory systems are intact, they should be able to
distinguish light touch, pain, vibration, hot, and cold. Have a
child close his or her eyes and then ask the child to point to
the spot where you touch him or her with an object. Light
touch is tested by using a wisp of cotton, deep pressure by
pressure of your finger, pain by a safety pin, temperature by
water bottle filled with hot or cold water.
● Vibration is tested by touching the child’s bony prominences
(iliac crest, elbows, knees) with a vibrating tuning fork. Warn
the child that on pin testing, he will feel a momentary prick.
Otherwise, he may be unwilling to close his eyes again for
further testing.
6. Reflex Testing
● Full range of neurological function
● Deep tendon reflex testing, which is part of a primary physical
assessment, is also a basic part of a neurologic assessment. In
newborns, reflex testing is especially important because the
infant cannot perform tasks on command to demonstrate the
full range of neurologic function.
●
●
Be sure to provide an explanation that includes a description of all
of the sensory experiences the child might undergo—that is, not
only what will be done but also how the child might feel, or what
the child might see or hear or even smell or taste (if appropriate).
Cerebrospinal fluid (CSF) is a fluid that circulates through the
brain. Ventricles (chambers) inside the brain make the fluid.
Normally, the fluid drains out of the brain through the ventricles
and into the spinal column. The body then absorbs the fluid. If CSF
backs up into the brain, the problem is called hydrocephalus. The
buildup causes the ventricles to swell and puts pressure on other
parts of the brain. The head may swell as fluid and pressure build.
The pressure can damage brain tissue. In some cases, a healthcare
provider drains the fluid and protects the brain. Common
treatments are:
○ Lumbar Puncture
Many of these tests are invasive, so it is best to try to schedule the
least invasive procedures first, before the painful or more
frightening procedures are done, to help promote the child’s
cooperation. Lumbar puncture should be performed in the end..
■
■
■
■
■
■
Diagnostic Testing
●
■
■
Involves the introduction of a needle into the
subarachnoid space (under the arachnoid membrane) at
the level of L4 or L5 to withdraw CSF for analysis. The
procedure is used most frequently to diagnose
hemorrhage or infection in the CNS or to diagnose an
obstruction of CSF flow.
Lumbar puncture is contraindicated if the skin over the
needle insertion site is infected (to avoid introducing
■
■
pathogens into the CSF) or if there is a suspected
elevation of CSF pressure. In the latter instance, if fluid is
removed, the higher pressure in the intracranial space
could cause the brainstem to be drawn down into the
spinal cord space, compressing the medulla and
compromising the action of the cardiac and respiratory
centers.
EMLA or lidocaine cream can be applied to the puncture
site 1 hour before the procedure to reduce pain.
Alternatively, the child may receive conscious sedation for
the procedure.
For a lumbar puncture, a newborn is seated upright with
the head bent forward. You might describe the position
as “rolling into a ball” or “folding up like an astronaut in
a small spaceship.”
During a lumbar puncture, the needle will press against a
dorsal nerve root and the child will experience a shooting
pain down one leg. If this happens, reassure the child that
this feeling passes quickly and does not indicate an injury.
The older infant or child is placed on one side on the
examining table. The head is flexed forward, the knees
are flexed on the abdomen, and the back is arched as
much as possible. This position opens the space between
the lumbar vertebrae, facilitating needle insertion.
When the insertion stylet is removed and CSF drips from
the end of the needle, the procedure has been
successful. Lay down for 30 minutes and drink a glass of
water.
To confirm that the subarachnoid space in the cord is
patent with that in the skull, the examiner may ask a child
who is older than 3 years of age to cough, or the
examiner may ask you to press on the child’s external
jugular vein during the procedure.
Either of these measures will cause an increase of CSF
pressure if fluid is flowing freely through the
subarachnoid space. Typically, three tubes of CSF,
containing 2 to 3 mL each, are collected, a closing
pressure reading is taken, and the needle is withdrawn.
If a child had minimally increased CSF pressure at the
time of the puncture, closely observe the child after the
procedure to prevent respiratory and cardiac difficulty
from medulla pressure. An increase in blood pressure or a
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
decrease in pulse and respiration are important signs of
increased intracranial compression. Other important
signs include a change in consciousness, pupillary
changes, and a decrease in motor ability.
○ Ventricular Tap
procedure and prevents the infant from crying
excessively, an action that could increase ICP.
Radiographic Techniques
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Slides 10-12 Cybelle (Done)
Ventriculoperitoneal shunt - CSF fluid is drained out through the
peritoneum. Tube is connected to a catheter, a thin flexible tube then
takes the fluid from the brain to the stomach (abdomen).
Myelography - The x-ray study of the spinal cord following the
introduction of a contrast material into the CSF by lumbar puncture to
reveal the presence of space-occupying lesions of the spinal cord. After
the procedure, keep the head of the child’s bed elevated
(High-Fowler’s) to prevent contrast medium from reaching the
meninges surrounding the brain and causing irritation.
The diagnostic technique involves imaging after injection of
positron-emitting radiopharmaceuticals into a vein. These
radioactive substances accumulate at diseased areas of the brain
or spinal cord. PET is extremely accurate in identifying seizure foci.
Uses a contrast; evaluates the metabolic activity of cells of body
tissues.
Echoencephalography - The ultrasound of the head and spinal cord.
High frequency sound waves above audible range towards the child’s
head and spinal cord, it outlines the ventricles of the brain. It
determines the frequency of sound waves. Non-invasive; no
discomfort; no complications.
Electroencephalography (EEG)
Computed Tomography
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In infants, CSF may be obtained by a subdural tap into a
ventricle through the coronal suture or anterior
fontanelle. A small space on the scalp over the insertion
site is shaved or clipped, and the area is prepared with an
antiseptic.
A ventricular tap may be done if the opening between the
ventricle and spinal cord is completely blocked. The
healthcare provider places a device similar to a rubber
stopper into your baby's skull. This allows access to the
ventricle. A healthcare provider can then draw fluid out
of the ventricle with a needle.
The infant’s head must be held firmly in a supine position
to prevent movement during the procedure, which could
cause the needle to strike and lacerate meningeal tissue.
Fluid must be removed from this site slowly, rather than
suddenly, to prevent a sudden shift in pressure that could
cause intracranial hemorrhage.
After the procedure, a pressure dressing is applied to the
site, and the infant is placed in a semi-Fowler’s position
to prevent prolonged drainage from the puncture site.
After the procedure, comfort the infant or allow the
parents to do so; this both reduces the stress of a painful
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Involves the use of x-rays to reveal densities at multiple levels or
layers of the brain tissue and is helpful to confirm the presence of
a brain tumor or other encroaching lesions.
Diagnose brain tumors, lesions same as with the Magnetic
Resonance Imaging (MRI). Magnet fields are used to show tissue
composition and rule out tumors and any injuries in the brain or
hematoma.
○ Pag lecture sa E: Magnetic Resonance Imaging (MRI) uses
magnetic fields to show differences in tissue composition,
revealing normal versus abnormal brain tissue.
Positron Emission Tomography (PET)
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●
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Most common
Recommended for patients who have seizures. Electrodes are
attached to the brain.
EEG readings reflect electrical patterns of the brain = physical and
chemical interactions at the time
Nursing Considerations (for infants):
○ Instruct the mother nga ang goal is dapat makatulog siya
during the procedure, because, if luhag kaayo bati ang tracing
sa EEG. So dapat stay put jud ang patient.
○ Keep the infant up before the procedure so that matug jd sya
during the procedure.
Patients are sometimes sedated.; Control Anxiety; Modify
behavior and movement
Medications:
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
○ Chloral Hydrate - Increase fast activity
○ Thorazine - Increase the slow activity
○ Chlorpromazine - Increase slow activity (Dili klaro ang tingog
ni miss)
Slides 13-15 (apil ang slide 15 under sa NTD) Tiffany
Increased Intracranial Pressure
● Not a disorder but a group of signs and symptoms that occur with
many neurologic disorders
● Most common causes of increased ICP include the increase in CSF
volume, blood entering the CSF, cerebral edema, head trauma,
and infection. It could also be due to brain tumors, the
development of hydrocephalus, or Guillain-Barre syndrome.
● Symptoms develop which depend on the cause and the ability of
the child’s skull to expand to accommodate the increased
pressure.
● With patients whose fontanelles are not fully closed, they are able
to adapt with the pressure. But with patients who have closed
fontanelles, it can cause severe damage to the brain with
increased pressure. Children with open fontanelles can withstand
more pressure without brain damage than older children, whose
suture lines and fontanelles are closed.
● Assessment: Obtain vital signs, evaluate pupil response, determine
levels of consciousness (motor, sensory function, or it may include
more elaborate electronic monitoring).
● Signs and Symptoms (initial):
○ Headache
○ Irritability
○ Restlessness
○ Pulse and respiratory rate will tend to slow down
○ Increased blood pressure
○ Increased temperature
○ Diplopia (double vision)
○ Papilledema
○ Ocular Changes: Strabismus, nystagmus, and sunset eyes
○ “Doll’s eye” reflex - Abnormal eye reflexes wherein a person’s
eye will look to the right once the head of the person will turn
to the left side, and vice-versa.
○ Pulse Pressure - The gap between the systolic and diastolic
blood pressure.
● Signs and Symptoms:
○ Increased head circumference - The fontanelles of children
are usually closed, so the tendency of this is that there will be
○
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brain damage which is a result from increased intracranial
pressure.
Fontanelle changes
Vomiting (Projectile)
Vital Signs Changes
Pain
Mentation
Common manifestations of brain injury include decorticate
posturing and decerebrate posturing. These manifestations occur
in patients who are having infection.
During the final assessment in ICP, carefully observe the child’s
resting posture because the motor control grows weaker because
of loss of cell function. It is a characteristic posture of the patient,
or primitive reflexes that occur to the patient.
If there is a loss in the cerebral function (cerebral loss), it is shown
mainly by decorticate posturing. The child’s arms are adducted
and flexed on the chest with wrist flexed, and the hands are fisted.
The lower extremities are extended and internally rotated. The
feet are plantar-flexed.
Decerebrate posturing occurs when the midbrain is not
functional. It is characterized by rigid extension, adduction of the
arms, and pronation of the wrist with the fingers flexed. The legs
are held extended with the feet and plantar-flexed.
●
Seizures are a sign of increased ICP. So if there is a seizure in your
patient, the child’s ICP is becoming greatly compromised.
Intracranial Pressure Monitoring
Three methods in monitoring ICP:
● An intraventricular catheter that is inserted through the anterior
fontanelle.
● A subdural screw or bolt that is inserted through a bore hole in
the skull.
● A fiberoptic sensor that is implanted into the epidural space or the
anterior fontanelle in an infant.
○ These methods in monitoring ICP are threaded into the lateral
ventricle filled with normal saline, and then connected to the
external pressure monitoring. As pressure in the ventricles
fluctuate, it registers through the filled catheter into the
oscilloscope screen plus a written printout. This method is
advantageous over simple scanning because it also enables
CSF drainage, and administration of medication through the
catheter.
○ Normal ICP in Children: 1-10 mmHg; if it is more than
15mmHg, it needs further assessment, as blood pressure rises
and falls with the influx of blood through the vessels.
○ On a monitor, there are the A waves which are also referred
to as the ‘plateau waves.’ B waves are referred to as the
‘short duration waves.’ C waves are the ‘small rhythmic
burst’ on the monitor.
○ If brain ischemia is present and there is no oxygen in the
brain, wave pattern changes even before there is a deviation
in blood pressure or pulse rates.
○ It is very important to determine these factors of your patient,
especially the checking of vital signs so as to monitor the
patient’s intracranial pressure.
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
● Management:
○ Increased intracranial pressure must be identified first and
remedied as quickly as possible to prevent brain injury or
compression to the brain stem, which could lead to both
cardiac and respiratory failures.
○ Actions such as coughing, sneezing, and vomiting, or rapid
administration of intravenous fluid increases the ICP. So when
a parent is burping an infant after feeding, caution them to be
really careful not to put pressure on the tubular veins because
this is another action that increases the ICP.
○ Since an increase in intracranial pressure is a sign of an
underlying disorder, after the pressure is reduced, the
underlying cause must be identified, or else, the pressure will
rise again from the original disorder. So it is important to
know the cause of the increased ICP of the patient.
○ Decadron - A dexamethasone medication that treats or
reduces cerebral edema (edematous brain).
○ Mannitol - A diuretic that moves fluids from extravascular to
vascular spaces of the brain, from brain tissue to the blood
vessels. This medication is also used to treat cerebral edema.
It is important to monitor the urinary output of the patient.
●
C.
The causes of this one are your rubella, cytomegalovirus or
toxoplasmosis and different infectious diseases.
● It really affects the infant cognitively because they are
cognitively challenged. And also this patient… (na putol)
infected sila with a virus which is caused by anopheles?? (Not
sure kay di ma klaro) mosquito that could really lead to
infantile microcephaly (infant’s lack of functioning of the brain
tissue), but do not... (na putol si ms)
● (Sige ka putol si ms nya di masabtan) is no brain premature
fusion of the cranial sutures so wala ni fuse gyud ang (na putol
napud) sutures or bone sa imohang brain, so with this one kay
(di masabtan)
Spina Bifida Occulta
● Absence of cerebral hemisphere
● Affects the medulla
● Upper end of neural tube fails to close early in intrauterine life
● Termination of pregnancy is most likely to occur
● putol2 si miss :((
Slides 16-18 Sophia (Ako lang ni ichange)
B. Microcephaly
Neural Tube Disorders (NTD)
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Malformation of the neural tube (forms in the utero as flat plate
then molds to form the brain and spinal cord)
During pregnancy, it is important to acquire 600 mcg of folic acid
since folic acid is proven to reduce the incidence of neural tube
defects.
putol2 si miss huhu will get back on this
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A. Anencephaly
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●
From the word “micro” meaning gamay or slow
The fetal brain grows slowly and falls more than three
standard deviations below normal on a growth chart at birth.
As you can see there is a normal brain at the right, the left is
your microcephaly, gamay siya ug brain and the skull of the
brain is inside the cerebrum and cerebellum.
●
This is a mild form of your neural tube defect: posterior
laminae of vertebrae fail to use.
Malformation caused by non-closure or incomplete closure of
the posterior portion of the vertebrae (na putol)
The spinal cord or the cerebrospinal fluid dili ra gyud siya
affected or wala ra gyud siya ni herniate.
Most affected gyud ani niya is the 5th lumbar and 1st sacral of
the spinal cord.
Surface bone missing and spinal cord intact, missing bone lang
gyud siya the problem of these patients.
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
●
E.
Protrusion at the lower lumbar and lumbosacral region
although it might be present anywhere along the spinal cord.
Myelomeningocele
●
We can really differentiate spina bifida occulta which is
manageable ra siya of a minimal surgery. It could also be
managed if there is no affected na mga sensory sa patient or
motor, non-surgical case ra sya or ma resolve ra siya
especially in the bifida but with your meningocele, as you can
see there is a herniation and your myelomeningocele mas
heavy gyud siya na ni herniate affected ang... (na putol)
Slides 19-21 Trisha (Done)
D. Meningocele
●
Membranes herniate through an unformed vertebrae, they
protrude as a circular mass about the size of an orange.
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also commonly known as Meningomyelocele or Spina Bifida
Most common birth defect affecting CNS and viewed as the
most complicated birth defect.
● Meningoceles - Lesions associated with spina bifida
● Partial or complete paralysis of lower extremities, loss of
bowel and bladder function, club foot, hydrocephalus
● T6-T12: complete flaccid paralysis of the lower extremities;
weakened abdominal and trunk musculature in higher lesions;
kyphosis and scoliosis common; ambulation with maximal
support
● L1-L2: hip flexion present; paraplegia; ambulation with
maximal support
● L3-L4: hip flexion, adduction, and knee extension present; hip
dislocation common; some control of hip and knee movement
possible; ambulation with mod support
● L5: hip flexion, adduction, and varying degrees of abduction;
knee extension and weak knee flexion; paralysis of the lower
legs and feet; ambulation with mod support
● S1-S2: ambulation with minimal support
● S3: mild loss of intrinsic foot muscular function possible;
ambulation without support
Slides 22-23 Bri
F. Encephalocele
A cranial meningocele, so with pediatrics these deal with
occipital where the affected area is the occipital area of the
skull may occur as nasal or nasopharyngeal disorder.
● Encephaloceles generally are covered fully by skin or may be
open or covered only by the dura
● Examinations that could assess via transillumination of the
patient if the disorder is encephalocele or more on the cranial
aspect of the brain. We also have the CT scan, MRI or
ultrasound (maybe your EEGs) will reveal the size of the skull
disorder and help predict the extent of surgery, which will be
needed.
● Encephaloceles happens during intrauterine life: prenatal
ultrasound, fetoscopy, amniocentesis (increased AFP in
amniotic fluid) that is why some of the mothers kay kuhaan
og AFP to know if high or increased ba ang AFP in your
amniotic fluid (mag get og sample ana with your
amniocentesis), or analysis of MAFP.
● Infant should be delivered through cesarean section to avoid
pressure and injury to the spinal cord (especially ingani na
cases na cranial iyahang lesion so ma lessen ang injury to the
infant).
● “Always wet” - We call this disorder “always wet” because the
affected area is, especially meningocele, encephalocele, bifida
occulta, your bowels or bladder functions.
Slides 24-25 Buhay (Done)
Nursing Considerations:
● Need to observe spontaneous movement of lower extremities or
lower motor function.
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
● Usual newborn appears always wet because the normal voiding of
a newborn is 30 mL/day every 2 to 3 hours (that is why we should
check the output of the patient) but with this disease, the diaper is
always wet (you will not find it dry; there is always defecation).
● Before voiding, we have to check the motor function or sphincter
function of the patient.
Management:
● Immediate Surgery: If you prolong the case and you will not do
surgery, this will really affect the function of the patient. there will
be cognitive challenge in the patient; 24 to 48 hours after birth so
that dili mo further damage and further increase the intracranial
pressure in the brain which leads to edema and this lowers BP, RR,
and PR and then there will be anoxia in the brain of the patient
● Replace meninges close gap in the skin to prevent infection
● Large portion of the meninges must be removed by surgery
● Limit absorption of CSF which can lessen build-up of CSF and
hydrocephalus
● Fetoscopic Surgery
○ Performed intrauterinely
○ Insert catheter
○ Not performed in the Philippines kay it needs broad
technology
○ Surgically close up the compressed area especially with spina
bifida
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Most common in adults
Common symptom: Headache
Malformation involves the downward herniation of the caudal
end of the cerebellar vermis through the foramen magnum.
○ Herniation of the lower part of the brain: Cerebellar tonsils
○ “Adult type,” Syringomyelia (common type)
● Chiari Type II
○ Occurs with spina bifida
○ Caused by overgrowth of the neural tube in weeks 16 to 20
fetal life
○ Cerebellum, medulla oblongata, and 4th ventricle project into
the spinal canal at the cervical level which obstructs CSF flow
○ Common in patients with hydrocephalus
○ Lumbar puncture should never be performed if there is
increased intracranial pressure and also with this disorder
because LP increases further increases ICP
○ Brain stem herniation if lumbar puncture is done; naa jud
downward projection to the medulla oblongata
Slides 26-27 (apil ang slide 27 under sa neurocutaneous syndromes)
Joash (Done)
Comparing the normal brain from a brain with Chiari Type I
Malformation, you can clearly see the presence of the downward
herniation. In the normal brain the cerebellum is intact, but in the
other picture kay ni project siya downwardly.
Arnold-Chiari Disorder
● Chiari Type I
If you see the actual patient with this syndrome, it’s more on skin
lesions or a skin disorder, but there is an underlying neurological case
with this disorder. Neurocutaneous syndromes are characterized by
the presence of skin or pigment disorders with CNS dysfunction.
A. Sturge-Weber Syndrome (Encephalofacial Angiomatosis)
● Ig tanaw nimo sa patient, you need to explain to the
significant other or the mother especially with Sturge-Weber
Syndrome so encephalofacial angiomatosis (?? word per word
na gikan ni miss). Ig tanaw niya sa iyahang baby medyo naa
ray angiomas or puwa puwa sa nawng, ingon siya, ah we can
surgically revise that one or we can do a surgery so that
murag facial deformity ra gae ang pagtanaw sa significant
other muthink siya nga dili ra serious ang ing ani na disorder.
But with Sturge-Weber Syndrome, it affects your fifth cranial
nerve.
● Congenital port-wine birthmark on the skin of the upper part
of the face following the distribution of the first division of the
fifth cranial nerve (trigeminal nerve).
● It is divided unilaterally, midline, extending inward at that
point of the meninges and your choroid plexus.
● Signs and Symptoms:
○ Sluggish blood flow leading to anoxia (decreased
oxygenation of the brain). Because of involvement of the
meningeal blood vessels, blood flow is sluggish, and
anoxia may develop in some portions of the cerebral
cortex.
○ Hemiparesis - Half of the body might be paralyzed. The
child may have symptoms of hemiparesis (numbness) on
the side opposite the lesion from destruction of motor
neurons.
○ Intractable seizures
○ Be cognitively challenged (to be expected)
○ Develop blindness because of the glaucoma or the
pressure inside the brain of your patient
Slides 28-29 Shannen (Done)
CT Scan or MRI
Neurocutaneous Syndromes
Neurocutaneous Syndrome can be seen on the surface of your patient.
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
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“Rail-road pattern or double groove pattern”
Calcification of the involved cerebral cortex”
Picture A: Normal brain, nay mga gyri, fissures, grooves
With this disorder, the CT scan or MRI of the brain will show a
“railroad track.” When we say a “railroad track,” mura siyag
straight road, instead with grooves kay straight road na siya or
double groove pattern. Why man? Because there is a calcification
of the involved cerebral cortex of your patient.
Physically inig tanaw sa significant other, maka inggon sila nya
“very light ra guro na nga disorder, ma cure rana.” They will take it
lightly and not seriously, that is why, you have to explain the
disorder to them. You should really have a nursing intervention in
how the significant other will emotionally accept the condition;
they need to adapt to the status of the patient.
● A child with Sturge-Weber Syndrome (Encephalofacial
Angiomatosis) has a congenital port-wine birthmark on the skin of
the upper part of the face that extends inward to the meninges
and choroid plexus.
● The skin manifestation follows the distribution of the first division
of the fifth cranial nerve (trigeminal nerve).
● Because the defect is usually unilateral, the port-wine stain ends
abruptly at the midline.
● In many children, only the ophthalmic branch of the nerve is
involved and the lesion is confined to the upper aspect of the face.
● Because of the involvement of the meningeal blood vessels, blood
flow is sluggish, and anoxia may develop in some portions of the
cerebral cortex.
● The child may have symptoms of:
○ Hemiparesis (numbness) on the side opposite the lesion from
the destruction of motor neurons,
○ Intractable seizures,
○ Be cognitively challenged, or
○ Develop blindness from glaucoma.
● A CT scan or an MRI of the skull usually shows calcification in the
involved cerebral cortex. Such calcification follows a diagnostic
“railroad track“ or double groove pattern.
● When the syndrome is first diagnosed, parents may hope that the
defect does not extend beyond the skin lesion. They may ask to
have the skin lesion surgically removed, in the belief that this will
correct their child’s condition completely. Ensure that parents
understand the need for long term follow – up, particularly if the
child has accompanying seizures that require long-term
anticonvulsant therapy.
Slides 30-31 Cloy (Done)
B. Neurofibromatosis (Von Recklinghausen’s Disease)
● You can see externally of the patient’s lesions but there is an
underlying neurological disease.
● Unexplained development of subcutaneous tumors (Chika
minute with miss: I saw this in one guy walking in colon when I
was a student and ingon ko “unsa mani nga disease oy
●
●
●
●
kanang dghan kay syag skin lesions and ingon ko rare or
usahay ra kayko makakita ug inana and I was so curious and
that disease is this one diay.” And also, it is not just the lesions
ang problem, but naa sd stay psychological or neuro case sd
diay siya. THE END HAHAHAH)
Autosomal dominant trait carried on the long arm of
chromosome 17
Spots appear following paths of cutaneous nerve (>6 larger
than 1 cm in dm are diagnostic)
Acoustic nerve or cranial nerve VIII = Hearing impairment
involvement of optic nerve lead to vision loss
Cognitive challenge-cerebral brain tumor or deterioration
(explain especially to pediatric patients that they have
cognitive challenge that a mother should deal with)
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
First (Top) Picture: Neurofibromas; Second (Bottom) Picture:
Cafe-au-Lait (German language) - Coffee-like feature; some have it as a
birthmark but it is also one feature of your neurofibromatosis.
Slides 32-33 Mary (Done)
Cerebral Palsy (CP)
● A group of progressive disorders of upper motor neuron
impairment that result in motor dysfunction.
● Affected children also may have speech or ocular difficulties,
seizures, cognitive challenges, or hyperactivity (because it involves
the motor functions of your patients). Muscle spasticity can lead
to orthopedic or gait difficulties (If the affected part is on the right
side, so tip-toed gyud na ang patient; some form a scissor gait
which is one type of cerebral palsy. They cannot really stand.)
● Cause:
○ Nutritional deficiencies
○ Drug use
○ Maternal infections such as cytomegalovirus (maternal
patients or pregnant mothers do not really know if they have
this because this virus is asymptomatic man gud so murag
wala ra but inig anak nila, mao na small for gestational age
and there is cognitive difficulties ilahang baby so there are
abnormalities, different birth defects, if infected sila) or
toxoplasmosis
○ Direct birth injury
Slides 34-35 Hannah (Done)
Types of Cerebral Palsy
1. Spastic Type
● Excessive tone in the voluntary muscles that results from loss
of upper neurons.
● Signs and Symptoms:
○ Hypertonic muscles
○ Abnormal clonus
○ Exaggeration of DTR (Deep Tendon Reflexes)
○ (+) Babinski and tonic-clonic reflexes pass the age
c. Diplegia or Paraplegia - Lower extremities
d. Astereognosis - Difficulty identifying objects placed in their
involved hand. If you give the patient with a ball, they are
unable to recognize it.
e. Pseudobulbar Palsy - Impaired speech; note that they have
difficulty in communicating.
2.
3.
4.
Dyskinetic or Athetoid Type
● Dyskinetic = Disorder of a muscle tone
● Athetoid means “worm-like”; abnormal involuntary
movement
● Slow, writhing motions = four extremities: face, neck, and
tongue (e.g. lip smacking, drooling)
● Poor tongue and swallowing movements. Some patients need
to have attachments like NGT to aid nutrition
● Choroid-irregular jerking
● Dyskinetic - d/o muscle tone
Ataxic Type
● Awkward, wide-based gait
● Unable to perform the coordinated motions: finger-to-nose
test (cerebellar function) and tandem walking test
Mixed Type
● Both spasticity and athetoid or ataxic and athetoid, either of
the pair.
● Movements = Severe degree of physical impairment
● Nursing Considerations:
○ Assess their nutrition (e.g. less than body requirement).
○ Feeding via NGT, OGT, or gastrostomy.
Additional Information:
Since their ADLs (Activities of daily living) are affected, some patients
are using crutches depending on the case and type of CP. They need to
have rehabilitation especially in their motor functions, walking and
speech coordination (speech therapist). Minimal type of CP, some
patients can really live a normal life.
“Parachute Reflex”
● Lower then scissor gait-tight adductor thigh muscles; tightening of
heel cord
● Affected Extremities:
a. Hemiplegia - One side, CP more involvement in an arm than
leg
b. Quadriplegia - All four extremities
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
NURSING CARE MANAGEMENT 109
■
NURSING CARE OF A CHILD W NEUROLOGIC D/O
Clinical Instructor: Isabella R. Dobluis
VIDEO 1
Overview & Assessment: Neurologic Fx & Pediatric
Variations; Nursing Care Of The Child With Neurologic D/O
A. GENERAL OVERVIEW
FUNCTIONS OF THE NERVOUS SYSTEM
●
●
Detects external and internal stimuli (sensory output)
Processes and responds to sensory input
(integration)
● Controls body movements through skeletal muscles
● Maintains homeostasis by regulating other systems
● The center for mental activities
** continues to mature first 12 years of life
PARTS OF THE NERVOUS SYSTEM
1) Central Nervous System (CNS)
● Brain, spinal cord, surrounding membranes or
meninges protected by the skull, the vertebral
column, CSF
● Processes, integrates, stores, and responds to
information from the PNS
2) Peripheral Nervous System (PNS)
● Nervous tissue outside the CNS.
● It consists of the: cranial nerves, spinal nerves,
somatic and visceral (ANS) divisions
● Detects stimuli and transmits information to and
receive information from CNS
● Two divisions: sensory division and motor division
Sensory Division Or Afferent Division
● Transmits action potentials from sensory receptors
to the CNS
Motor Division Or Efferent Division
● Carries action potentials away from the CNS in
cranial or spinal nerves
● Somatic Nervous system
○ Innervates Skeletal muscle
● Autonomic nervous system (ANS)
○ Innervates cardiac muscle, smooth
muscle and glands
○ Subdivided
into:
Sympathetic
Parasympathetic and Enteric divisions
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Sympathetic division → most
active during physical activity
Parasympathetic division →
regulates resting functions
Enteric division → controls the
digestive system
CELLS OF THE NERVOUS SYSTEM
1) Neuron / Nerve Cells
● Receive stimuli and transmit action potentials
● Cell nucleus and extensions: one axon and several
dendrites
● 3 components:
○ Cell body/cell nucleus - primary site of
protein synthesis
○ Dendrites - short, branched cytoplasmic
extensions of the cell body that conduct
electric signals/ impulses toward cell body
○ Axon - cytoplasmic extension of the cell
body that transmits action potentials away
from cell nucleus to other cells
● 3 types:
○ Multipolar - have several dendrites and a
single axon; e.g., interneurons and motor
neurons
○ Bipolar - have a signal axon and dendrite
and are found as components of sensory
organs.
○ Unipolar - have a single axon; most sensory
neurons are unipolar
2) Glial Cells of the CNS
● Non-neural cells that support and aid the neurons of
the CNS and PNS
● Astrocytes
○ Provides structural support for neurons and
blood vessels
○ Influence the FX of the blood-brain barrier
and process substances that pass through it
○ Isolate damaged tissue and limit the spread
of inflammation
● Ependymal cells - line the ventricles and central
canal of the spinal cord. Some are specialized to
produce CSF.
● Microglia - phagocytes microorganisms, foreign
substances and necrotic tissue
● Oligodendrocyte - forms myelin sheaths around the
axons of several CNS neurons
3) Glial Cells of the PNS
● Schwann cells - forms a myelin sheath around part
of the axon of a PNS neuron.
● Satellite cells - support and nourish neuron cell
bodies within ganglia
4) Myelinated Axons
● Wrapped by several layers of plasma membrane from
schwann cells or oligodendrocytes. Spaces between
the wrappings are the Nodes of Ranvier
● Conduct action potentials rapidly
5) Unmyelinated Axons
● Conduct action potentials slowly
●
Rest in invagination
oligodendrocytes.
of
schwann
cells
or
●
ORGANIZATION OF THE NERVOUS TISSUE
●
General structure
○ 31 pairs of spinal nerves
○ Cervical and lumbosacral enlargements
→ which spinal nerves of the limbs originate
○ Shorter than the vertebral column
○ Nerves from the end of the spinal cord for
the Cauda equina
Meninges of the Spinal Cord
○ Dura mater - superficial
○ Arachnoid mater
○ Pia mater
The spinal cord consists of the peripheral white matter and
central gray matter. The epidural space in between the
periosteum of the vertebral canal and the dura mater, the
subdural space is between the dura mater and the arachnoid
mater, and subarachnoid space is between the arachnoid
mater and pia mater
REFLEXES
White Matter
● Myelinated axons
● Tracts in the CNS, nerves in the PNS
● Propagates action potentials
● A communication system that helps conduct the
nerves systems.
Gray Matter
● Collection of neuron cell bodies or unmyelinated
axons
○ Axon synapse with neuron cell bodies which
are functionally the site of integration in the
nervous system. This is where the actual
processing happens.
● Cortex and nuclei in the CNS, ganglia in the PNS
● Site of integration in the nervous system
ELECTRICAL SIGNALS
● Electrical properties of cells result from the ionic
concentration differences across the plasma
membrane
and
form
the
permeability
characteristics of the plasma membrane.
● Results from the ionic concentration differences
across the plasma membrane and from the
permeability characteristics of the plasma
membrane
●
●
●
●
●
●
●
●
B. CENTRAL & PERIPHERAL NERVOUS SYSTEMS
Review:
● Spinal cord
● Brain
SPINAL CORD
Stereotypic, unconscious, involuntary responses to
stimuli
Maintain homeostasis
2 general types of reflexes: Somatic and
Autonomic reflexes
Integrated within the brain and spinal cord
Reflex arc → functional unit of the nervous
systems
Sensory receptors respond to stimuli and produce
action potentials and sensory neurons.
○ Sensory neurons then propagate action
potentials to the CNS.
Interneurons of the CNS Synapse with sensory
neurons and motor neurons.
○ Motor neurons carry action potentials
from the CNS to effector organs, such as
muscles or glands respond to the action
potentials.
Higher brain centers can suppress or exaggerate
reflexes.
BRAIN
●
●
Contained in cranial cavity
Control center for many of the body’s functions.
Consists of:
○ Brainstem
○ Cerebellum
Diencephalon
○ Cerebrum
BRAINSTEM
1) Medulla Oblongata
● Continuous to the spinal cord
● Contains ascending and descending tracts
● Medullary nuclei regulate: heart, blood vessels,
breathing, swallowing, vomiting, coughing, sneezing,
hiccuping, balance, and coordination.
● Pyramids (are tracks controlling): voluntary muscle
movement.
CEREBRUM
2) Pons
● Superior to the medulla
● Ascending and descending tracts pass through the
pons; connects the cerebrum and the cerebellum
● Pontine nuclei regulate breathing, swallowing,
balance, chewing, and salivation.
3) Midbrain
● Superior to the pons
● Corpora quadrigemina consists of: four colliculi
○ The 2 inferior colliculi are involved in
hearing and the 2 superior colliculi in
visual reflexes
● Substantia nigra and red nucleus → help regulate
the body movements
● Cerebral peduncles are the major descending
mother pathway
●
●
4) Reticular Formation
● Consist of nuclei scattered throughout the brainstem.
● Reticular system regulates cyclic motor functions,
such as breathing, walking, and chewing.
● Reticular activating system (RAS): maintains
curiousness (consciousness) and regulates the
sleep-wake cycle.
CEREBELLUM
●
●
●
●
Gray matter
● Forms cortex and nuclei of cerebellum
White matter
● Arbor vitae, which connects cerebellum to the rest of
CNS and connects the cerebellar cortex and
cerebellar nuclei
3 parts of Cerebellum and its Functions
● Flocculonodular lobe: controls balance and eye
movements
● Vermis and medial part of the lateral hemispheres:
control posture, locomotion, and fine motor
coordination
● Most of the lateral hemispheres: planning, practice,
learning of complex movements
Cortex of the cerebrum is folded into ridges called:
gyri and grooves called sulci (or fissures)
Longitudinal fissure: divides left and right
hemispheres; each hemisphere has 5 lobes:
○ Frontal - involved in voluntary motor
function, motivation, aggression, and the
sense of smell and mood
○ Parietal - contain the major sensory areas,
receiving sensory input such as touch, pain,
temperature, balance, and taste
○ Occipital - contain the visual centers
○ Temporal - evaluates smell and hearing
input, and are involved in memory abstract,
thought, and judgment
○ Insula - located deep within the lateral
fissure and receives sensory input for the
sense of taste, and is involved with visceral
and autonomic functions
Gray matter: forms cortex and nuclei of cerebrum;
White matter: forms cerebral medulla, which consists
of 3 types of cracks:
○ Association fibers - connects areas of the
cortex within the same hemisphere
○ Commissural fibers - connect the cerebral
hemispheres
○ Projection fibers - connects the cerebrum
to other parts of the brain and spinal cord
Basal nuclei - important in controlling motor functions
○ Corpus striatum
○ Subthalamic nuclei
○ Substantia nigra
Limbic system (includes parts of the cerebral cortex,
basal nuclei, thalamus, hypothalamus, and the
olfactory cortex); involved in:
○ Memory, reproduction, and nutrition
○ Emotional interpretation of sensory input and
emotions in general
MENINGES
Because brain protection is so important, the brain is covered
in 3 separate membranes:
Dura mater
● Fibrous, connective tissue containing many blood
vessels
●
●
Attaches to the skull
Two layers that can separate to form dural folds and
dural venous sinuses
Arachnoid membrane
● Delicate serous membrane beneath the arachnoid
mater
● Subarachnoid space contains CSF that helps cushion
brain
Pia mater
● Vascular membrane
● Attaches directly to the brain
CEREBROSPINAL FLUID
CSF forms in the 2 lateral ventricles in the choroid plexus of
the pia mater and flows to the foramen of monro into the 3rd
ventricle, then through a narrow canal called aqueduct of
sylvius to the 4th ventricle. It leaves the 4th ventricle by the
foramen of magendie and the 2 foramens of luschka and flows
into the sister nomagna(?), a collection pool at the base of the
skull. From the sister nomagna(?), the fluid circulates to the
subarachnoid space, bathing both the brain and the spinal
cord. The fluid is then absorbed by the arachnoid membrane
and this time span for replacement is approx. 6 hours.
Normal Properties of Cerebrospinal Fluid
●
●
●
●
Colorless, alkaline fluid
Specific gravity of approx. 1.004 to 1.008 containing
traces of protein, glucose, lymphocytes, and body
salts
Fluid circulates downward to the level of the second
sacral vertebra (S2)
Infants: spinal cord ends at the third lumbar vertebra
(L3); in adolescents and adults, at L1 or L2 = space
near the cord base containing CSF
○ Tapped safely (lumbar puncture without fear
of causing spinal cord damage.
BLOOD SUPPLY TO THE BRAIN
●
Blood-brain barrier
○ The brain requires tremendous amounts of
blood to function normally.
○ Blood-brain barrier is formed by endothelial
cells and capillaries in the brain. It limits
what substances enter brain tissue.
CRANIAL NERVES
●
●
●
Designated by roman numerals
Sensory: special senses, general senses
Motor: somatic motor, parasympathetic
ASSESSING THE CHILD WITH A NEUROLOGIC D/O
A. HEALTH HISTORY
1) Mother’s pregnancy history
● Since many neurologic problems result from fetal
injury
2) Child’s developmental milestones (and his ability to
perform age-appropriate tasks successfully)
● Denver Developmental Screening Test - which can
indicate whether a parent’s concern about a
preschool child is well founded
● The Denver Developmental Screening Test (DDST)
was devised to provide a simple method of screening
for evidence of slow development in infants and
preschool children. The test covers four functions:
○ gross motor, language, fine motor-adaptive,
and personal-social.
● Older child? Ability to perform well in school
3) Chief concern, past medical hx, family medical hx
B. NEUROLOGIC EXAMINATION
A complete neurologic examination would take at
least 20 minutes. It is imperative to practice station and
demonstrate therapeutic and developmentally appropriate
techniques to keep a child’s attention while observing for
possible indications of neurologic disease. Since our pediatric
population spans the newborn period all the way to late
adolescents, we need to equip ourselves with specific
developmental and age appropriate techniques in assessing
neurologic function in children.
1) NEWBORNS
● Assessment of mental status, gross and fine motor
functions, tone, cry, deep tendon reflexes, primitive
reflexes. (More detailed examination of cranial nerve
function and sensory function or indicated if you
suspect any abnormalities from the history or from the
newborn screening. The neurologic examination can
reveal extensive disease but will not pinpoint specific
functional deficits or mynute lesions.)
● S/S severe neurologic disease:
➔ Extreme irritability
➔ Persistent asymmetry of posture
➔ Persistent extension of extremities
➔ Constant turning of the head to one side
➔ Mark extension of the head, neck, and
extremities
➔ Severe flaccidity and limited response to
pain
➔ Seizures
2) YOUNG & SCHOOL-AGE CHILDREN, OLDER CHILDREN
An Important aspect of examining children is that parents are
usually watching and taking part in the interaction. This would
provide you the opportunity to observe the parent-child
interaction.
●
●
●
So note whether the child: displays age appropriate
behaviors, esp. Interaction with parents
Normal toddlers
○ Are occasionally terrified or angry at the
examiner and are often completely
uncooperative.
Older School-Age Children
○ Have more self-control and prior
experience with clinicians in a generally
cooperative with the examination.
Level
Technique
Patient Response
Alertness
Speak to the
patient in
normal tone of
voice
The alert patient opens
the eyes, looks at you,
and responds fully and
appropriately to stimuli
(arousal intact).
Lethargy
Speak to the
patient in a loud
voice, For
example, call
the patient’s
name or ask
“How are you?”
The patient appears
drowsy but opens the
eyes and looks at you,
responds to questions,
and then falls asleep.
Obtundation
Shake the
patient gently as
if awakening a
sleeper.
The obtunded patient
opens his eyes and
looks at you but
responds slowly and is
somewhat confused.
Alertness and interest
in the environment are
decreased.
Stupor
Apply a painful
stimulus. For
example, pinch
a tendon, rub
the sternum, or
roll a pencil
across a nail
bed. (No
stronger stimuli
needed.)
The stuporous patient
arouses from sleep
only
after
painful
stimuli.
Verbal
responses are slow or
even
absent.
The
patient lapses into an
unresponsive
state
when the stimulus
ceases.
There
is
minimal awareness of
self
or
the
environment.
Coma
Apply repeated
painful stimuli.
A comatose patient
remains unarousable
with
eyes
closed.
There is no evident
response to inner need
or external stimuli.
Beyond infancy, the neurologic examination includes the
components evaluated in adults
● Combine
the:
Neurologic
+
developmental
assessment
6 KEY AREAS (for Neurologic examination):
1) Cerebral Function
Both general and specific cerebral functions are
evaluated.
●
●
General cerebral function
○ is indicated by level of consciousness,
orientation, intelligence, performance,
mood, and general behavior
Specific cerebral function
○ can be measured by assessing language,
sensory
interpretation,
and
motor
integration.
○ Note: when assessing language, listen to
the child’s ability to articulate. Remember
that many preschoolers substitute W to R
saying “WEST TIME” instead of “REST
TIME”
2) Cranial Nerve Function
Testing for Cranial Nerve Function consists of
assessing each pair of cranial nerves separately.
(See Table 49.2 of book)
3) Cerebellar Function
These are tests for normal balance and coordination
4) Motor Function
You will be assessing muscle size, strength, and tone.
Also compare the size of the extremities on each
side.
5) Sensory Function
If children's sensory systems are intact, they should
be able to distinguish light touch, pain, vibration, hot
and cold sensation.
6) Reflex Testing
● Deep Tendon Reflex Testing
Which is part of primary physical
assessment, is also a basic part of a
neurologic assessment
● Newborns
Reflex testing is especially important
because the infant cannot perform tasks on
command to demonstrate the full range of
neurologic function.
Level Of Consciousness
● Is the patient awake, alert, and responsive to you and
others in the environment?
○ If not, promptly assess the level of
consciousness:
■ This primarily reflects the patient’s
capacity
for
arousal,
or
wakefulness.
● Five clinical levels of consciousness with related
techniques for examination are as follows:
LEVEL OF CONSCIOUSNESS (Arousal): Techniques and
Patient Response
●
Increase your stimuli in a stepwise manner depending
on the patient’s response.
C. DIAGNOSTIC TESTING
A variety of diagnostic tests may be ordered.
● To provide more information should any abnormalities
be detected in the health history, physical
examination, or neurologic examination.
● Many of these tests are invasive.
○ So try to schedule the least invasive one first
before any painful or frightening procedures
to help promote the child’s cooperation.
● Important nursing responsibility:
○ Prepare child & family for these procedures.
○ Take into account not just the child’s
chronological age, but also the child’ level of
cognitive functioning when explaining tests.
VENTRICULAR TAP
●
●
●
●
Obtain CSF by a subdural tap into a ventricle
through the coronal suture or anterior fontanelle
in infants.
○ The area for insertion is shaved and
prepared with an antiseptic.
Infant’s head: Supine position
○ Prevent movement during the procedure
which could cause the needle to strike
and lacerate meningeal tissue.
Remove fluid from site slowly
○ To prevent a sudden shift in pressure that
could cause intracranial hemorrhage.
Post-procedure:
○ Pressure dressing
○ Semi-fowler’s
position
(to
prevent
prolonged drainage from the puncture
site.)
RADIOGRAPHIC (XRAY) TECHNIQUES
MYELOGRAPHY
● X-ray study of the spinal cord that involves
introduction of a contrast material into the CSF by
lumbar puncture
● Space-occupying lesions of the spinal cord
● Post-procedure: elevate head of child’s bed
To prevent contrast medium from reaching
the meninges surrounding the brain.
COMPUTED TOMOGRAPHY (CT)
● Reveal density at multiple levels or layers of brain
tissue
● It is helpful in confirming the presence of a brain
tumor or other encroaching lesions
● Single-photon emission computed tomography
(SPECT) - blood flow evaluation
MAGNETIC RESONANCE IMAGING (MRI)
● Uses magnetic fields
● Differences in tissue composition
normal versus abnormal brain tissues.
CEREBRAL ANGIOGRAPHY
● X-ray study of cerebral blood vessels
● Injection of contrast material into extracranial artery
● Serial radiographs are then taken as the dia flows
through the blood vessels of the cerebrum.
● Injection site: femoral artery (carotid artery may
be used)
● Vessel defects or space occupying lesions
occluding cranial blood vessels.
NUCLEAR MEDICINE STUDIES
BRAIN SCAN
● Radioactive material is injected intravenously (IV)
○ Radioactivity levels over the skull are
measured
○ Non-functioning
blood-brain
barrier?
Radioactive material accumulates in
specific areas:
■ Possible tumor
■ Subdural hematoma
■ Abscess
■ Encephalitis
POSITRON EMISSION TOMOGRAPHY (PET)
● A diagnostic technique involving imaging after
injection of positron-emitting radiopharmaceuticals
into the brain
● These radioactive substances accumulate at
diseased areas of the brain or spinal cord
● PET is extremely accurate in identifying seizure
foci.
ECHOENCEPHALOGRAPHY
● Projection of ultrasound toward the child’s head or
spinal cord
● Outline the ventricles of the brain
● Noninvasive, produces no discomfort, and has no
known complications
○ May be repeated frequently to monitor
changes in the size of ventricles or an
invading lesion
● Reflects electrical patterns of the brain
● Summarizes physical and chemical interactions
● Normally: a tracing indicates 4 types of waves:
○ Delta (1 to 3 waves/sec)
○ Theta (4 to 7 waves/sec)
○ Alpha (8 to 12 waves/sec)
○ Beta (13 to 20 waves/sec)
● Child must be cooperative, quiet during procedure
○ To reduce extraneous movements of the
eyes, head, or muscles
○ Traditionally, parents are asked to keep
their child up later than usual the night
before so that the child will be sleepy
○ Good preparation and encouragement are
also important in helping a child relax
○ Caution children that the room will
probably be darkened to help them rest
○ Compare the electrode wires attached to
their scalp with adhesive paste (?) to
those attached to astronauts in space.
Reassure them that these electrodes are
not painful
○ Be careful not to use the word “electrical”
● Unable to lie still?
○ Conscious sedation - px who does not
stay still even after careful explanation
may need conscious sedation although
sedation alters the electrical pattern of the
cortex and should be avoided if possible
○ Chloral hydrate - a frequently used
sedative for this procedure but may
increase the fast activity of brain waves.
■ Chlorpromazine may increase
low activity.
■ Because phenobarbital and
phenytoin sodium also cause
an increase in fast activity, be
sure to inform the person
interpreting the recording what
medications
the
child
is
receiving.
■ Although EEG’s can show
●
●
important information on brain
activity, they are not helpful in all
circumstances
Diagnose absence seizures
Post-EEG: Allow them to sleep as long as needed
NG
○
○
NURSING CARE OF THE CHILD W/ INCREASED ICP
○
INCREASED INTRACRANIAL PRESSURE
DEFIN
ITION
●
●
●
Is not a single disorder and may occur
with many neurologic disorders.
When caring for a child with a potential
neurologic disorder, it is an important
sign to detect
May occur with:
○ Increase in CSF volume
○ Blood entering CSF
○ Cerebral edema
○ Space-occupying lesions (e.g.,
tumors)
●
●
●
ETIOL
OGY
ICP
MONI
TORI
Cerebral loss
○ Is shown mainly by decorticate
posturing
○ The child’s arms are abducted
and flexed on the chest with
wrists flexed, hands fisted, and
the lower extremities extended
and internally rotated and the
feet are plantar flexed.
Non-functional midbrain
○ Decerebrate posturing
○ Is characterized by rigid
extension and adduction of
arms, pronation of the wrists
with the fingers flexed. The
legs are extended and the feet
are plantar flexed.
○ Observe the child carefully for
any seizure activity. However
keep in mind that this is a late
sign in increased ICP.
Causes of ICP:
● Birth trauma or hydrocephalus
● Head trauma from an accident
● Infection
● Brain tumor
● Guillain-Barre syndrome
○ a rare disorder in which your
body's immune system attacks
your nerves
●
Methods of ICP measurement:
○ Intraventricular
catheter
inserted through the anterior
●
fontanelle
Subarachnoid
screw/bolt
inserted through a burr hole in
the skull
Fiberoptic sensor implanted
into the epidural space (or
anterior fontanelle in infant)
Disposable
fiberoptic
transducer-tipped
catheter
inserted through a subarachnoid
bolt into white matter of the
brain
Intraventricular catheters (see pic C)
are threaded into the lateral ventricle filed
with normal saline and then connected to
an external pressure monitor
○ As pressure in the ventricle
fluctuates, it is registered
through the filth catheter or an
oscillous scope screen with a
written print out.
○ This method is advantageous
over simple scanning because it
also enables CSF drainage and
administration of medication
through the catheter.
ICP normally ranges from 1 to 10
mmHg
○ A level greater than 15 mmHg is
considered abnormal.
○ As blood pressure rises and
falls with the influx of blood
through vessels, so does ICP
On a monitor it appears as:
● A waves: 5-20 mins; amplitude 50-100
mmHg
○ Aka plateau waves
○ Are
transient
paroxysmal
elevations
○ If brain ischemia is present,
these waves increase before
other signs such as a change in
blood pressure or pulse rate,
and then become apparent.
■ Brain ischemia - a
condition that occurs
when
there
isn't
enough blood flow to
the brain to meet
metabolic demand
○ Because A waves appear to
reflect brain ischemia, they can
be used to signal when a child
needs more oxygen
● B waves: ½ to 2 min; up to 50 mmHg
○ Short duration waves w/ low
amplitude
● C waves: frequency 6 waves/min
○
○
Small, rhythmic waves
Are related to deviations in the
arterial BP
HYDROCEPHALUS
DEFIN
ITION
●
●
●
○
T/MG
MT
●
●
●
●
●
●
●
●
ICP monitoring also can be used to
estimate cerebral perfusion pressure
(CPP) or cerebral blood flow
○ Normal CPP: at least 50mmHg
Cerebral circulation ceases if ICP ever
exceeds arterial pressure
This obstructs blood flow through the
cerebral vessels
Identify cause of problem
○ Remedied
as
quickly
as
possible to prevent brain injury
○ Local injury + severe pressure
elevation
→
brainstem
compression → cardiac & resp
failure
Keep ff actions to a minimum: coughing,
vomiting, and sneezing (increases ICP)
Infants: do not put pressure on the
jugular veins when burping after feedings
(increases ICP)
Monitor rate of IVF administration
because overhydration can increase
ICP
Semi-fowler ‘s position (use infant seat
for babies) to reduce cerebral pressure
Corticosteroid
○ Dexamethasone (Decadron) to
reduce cerebral edema and
accompanying pressure
Osmotic diuretic
○ Mannitol
■ Given IV to remove
fluid from interstitial
tissue
and
reduce
pressure
■ Since it is hypertonic, it
causes shift of fluid
from
extravascular
compartment into the
vascular stream where
it can be eliminated by
the kidneys
■ Children usually have
an indwelling urinary
catheter
inserted
before
therapy
to
ensure
bladder
emptying from drug
induce rapid diuresis
Excessive fluid in brain’s ventricles =
ventricular tap may be necessary for
immediate pressure reduction
●
●
●
●
●
Excess
CSF
in
ventricles
or
subarachnoid
space
causing
enlargement of infant skull whose cranial
sutures are not firmly knitted
Classified as:
○ Communicating
hydrocephalus
(extraventricular)
OR
obstructive
hydrocephalus
(intraventricular)
○ Congenital OR acquired
Communicating
hydrocephalus
(extraventricular) - If fluid can reach
the spinal cord
Obstructive
hydrocephalus
(intraventricular) - blocked to such
passage of fluid
Congenital - at birth
Acquired - from an incident later in
life
3 Main Reasons For Excess CSF
● Overproduction of fluid by a choroid
plexus in the first or second ventricle
○ As would occur if there is a
growing tumor
○ Rare
● Obstruction of the passage in fluid
aqueduct of sylvius - most common
cause
○ Other
common
sites
of
obstruction:
foramina
of
Magendie and Luschka
● Interference with the absorption of CSF
from subarachnoid space
○ if a portion of the subarachnoid
membrane has been removed,
as occurs with surgery for a
meningocele or after extensive
subarachnoid
hemorrhage,
when portions of the membrane
absorption surface become
obscured.
ETIOL
OGY
ASSS
SMT
Unknown
● Although maternal infections such as
toxoplasmosis or infant meningitis
may be factors
●
●
Occurs in approximately 3 to 4 out of
1,000 live births
With an obstruction present, excessive
fluid accumulates and dilates the
●
●
●
system forward of the point of
obstruction. If the atresia is in the
aqueduct of Sylvius, the first, second,
and third ventricles will dilate. If it is at the
exit from the fourth ventricle, all ventricles
will dilate.
Symptoms may develop rapidly or slowly
depending on the extent of the atresia.
If present prenatally, it can sometimes be
detected in a prenatal sonogram & can
be shunted in utero
Generally not evident during pregnancy
or even at birth bec of the effect of
intrauterine pressure
○ Evident in the first few weeks or
months of life
○ The infant’s fontanelles widen
and appear tense, the suture
lines on the skull separate, and
the head diameter enlarges.
even the best shunting procedure cannot
replace and repair this damage to the
brain cells.
OPERATIVE
● Ventricular endoscopy, tumor removal,
laser surgery, shunting procedure
Destruction of a portion of the choroid plexus
may be attempted by ventricular endoscopy.
If a tumor in that area is responsible for the
overproduction of fluid, removal of the tumor
should provide a solution. Hydrocephalus is
usually caused by an obstruction, however, so
the treatment usually involves laser surgery to
reopen the root of flow or bypassing the point of
obstruction by shunting the fluid to another
point of absorption. As ventricular endoscopy is
perfected and obstructions in the 3rd or 4th
ventricle can be relieved, the next generation of
children with hydrocephalus may not meet
artificial shunting. Children today may still
undergo a shunting procedure, however, and
you may care for many older children or adults
who have shunts in place.
C/M
●
●
●
●
●
DX
TEST
●
●
●
●
●
●
T/MG
MT
●
●
Scalp - shiny
Scalp vein - prominent
Brow - bulges forward (bossing)
Eyes - sunset eyes (the sclera shows
above the iris because of upper lid
retraction)
Symptoms of ICP
○ ↓PR, RR
○ ↑T, BP
○ Hyperactive reflexes
○ Strabismus
○ Optic atrophy
○ Irritable or lethargic with a
typical shrill, high-pitched cry,
and FTT
Ultrasound
CT
MRI
Skull X-ray film will reveal the
separating sutures and thinning of the
skull.
Transillumination (holding a bright light
such as a flashlight or a specialized light
[a Chun gun] against the skull with the
child in a darkened room) will reveal that
the skull is filled with fluid rather than
solid brain tissue.
Assessing ventricular pressure will
document the increased tension and
presence of additional fluid.
The treatment of hydrocephalus depends
on its cause and extent.
Treatment is most effective when the
disorder is recognized early because
once intracranial pressure becomes so
acute that the brain tissue is damaged
and motor or mental deterioration results
A shunting procedure involves threading a
thin polyethylene catheter under the skin from
the ventricles to the peritoneal fluid, then drains
via this route into the peritoneum and is
absorbed through the peritoneal membrane into
the body circulation. This type of shunt usually
has to be replaced as the child grows or it will
become too short. As another complication, it
could become enclosed in a fold of peritoneum
and become obstructed or it could become
infected.
MEDICAL
● Overproduction of fluid
○ Acetazolamide (Diamox): a
diuretic may be prescribed to
promote the excretion of this
excess fluid.
NC/M
GMT
●
●
Observe shunt function/malfunction
Continual testing for dev abnormalities,
mental retardation
Impt. nursing role in ambulatory child settings:
assisting with detection of hydrocephalus
● Early detection is important
○ <2
yo:
record
head
circumference plotted on an
appropriate growth chart @HC
visits so child whose head is
growing abnormally can be
detected
○ Measure HC for all infants
within an hour after birth and
again before discharge to
establish baseline
○ +Older children who suffered
severe head trauma (severe
enough to be seen in medical
facility) should have HC noted at
the time of accident
■ Other symptoms of ICP
appear,
this
HC
measurement may be
a meaningful part of
the stored information
available
concerning
○
child’s condition
+Asymmetry
■ Note bec this may
suggest
point
of
obstruction
■ For example: a skull
that
is
enlarging
anteriorly w/ shallow
posterior
fossa
suggests obstruction is
in the aqueduct or 3rd
ventricle
As the head continues to enlarge, the infant’s
motor function becomes impaired because of both
neurologic impairment and atrophy caused by the
inability to move such a heavy head.
●
DX
●
●
ETHIC
AL
PROB
LEM
●
Even with an extremely enlarged head, therefore,
children’s intelligence may also remain normal,
although fine motor development may be affected.
PROG
NOSI
S
Depends on whether brain damage occurred
before shunting
● Whether the child develops a cerebral
infection, and whether the parents can
accept and recognize when a shunt
needs to be replaced to prevent
increased intracranial pressure
● Referral early in infancy for intervention
services and screening is warranted to
assess the infant’s speech, fine, and
gross motor milestones and detect any
delays.
●
Outline:
1) Anencephaly
2) Microcephaly
3) Meningocele
4) Myelomeningocele
5) Encephalocele
6) Arnold-chiari disorder
Anencephaly is revealed by an elevated
level of alpha-fetoprotein (AFP) in the
maternal serum or on amniocentesis
Confirmed with a prenatal sonogram
When this condition is discovered
prenatally, parents are offered the option
of terminating the pregnancy. An ethical
problem has arisen in several instances
when parents, aware that the child
cannot survive, still elect to carry the
infant to term so the organs can be used
for transplant.
Nurses may need to think through their
feelings for caring for such infants
because it can be difficult to give care to
a child who will most likely die or has
been born only to help others live
MICROCEPHALY
DEFI
NITI
ON
VIDEO 2
IV. NEURAL TUBE DISORDERS
Neural Tube Disorders
Abnormalities that derive from the embryonic neural tube
constitute the largest group of congenital anomalies that are
consistent with multifactorial inheritance. Normally the spinal
cord and the cauda equina are encased in a protective
sheath of bone and meninges. Failure of neural tube closure
produces defects of varying degrees. They may involve the
entire length of the neural tube or may be restricted to a small
area.
is obvious.
Children cannot survive with this disorder
because they have no cerebral
function. Because the respiratory and
cardiac centers are located in the intact
medulla, however, they may survive for
several days after birth.
●
●
ETIO
LOG
Y
●
●
PRO
GNO
SIS
Is a disorder in which
brain growth is so slow
that it falls more than
three
standard
deviations
below
normal
on
growth
charts.
Generally the infant is
cognitively challenged
because of lack of
functioning brain tissue
Might be a disorder in brain development
associated with intrauterine infection such
as:
○ Rubella
○ Cytomegalovirus
○ Toxoplasmosis
Microcephaly may also result from severe
malnutrition or anoxia in early infancy
The prognosis for a normal life is guarded in
children with microcephaly and depends on the
extent of restriction of brain growth and on the
cause.
MICROCEPHALY
ANENCEPHALY
DEFIN
ITION
●
●
●
●
This is the absence of
the
cerebral
hemispheres.
It occurs when the
upper end of the neural
tube fails to close in
early uterine life.
Infants
with
anencephaly may have
difficulty in labor because the
underdeveloped head doesn't engage
the cervix well. Many such infants
present in a breech position.
On visual inspection at birth, the disorder
●
●
●
●
CRANIOSYNOSTOSIS
True microcephaly must be differentiated from
craniosynostosis, which also causes decreased
head circumference.
Craniosynostosis is normal brain growth but
premature fusion of cranial sutures.
Infants with craniosynostosis have abnormally
closed fontanels and often show bossing of the
forehead and signs of increased intracranial
pressure similar to infants with hydrocephalus.
With surgery, craniosynostosis can be relieved
and brain growth will be normal
SPINA BIFIDA OCCULTA
DEFIN
ITION
Myelomeningocele
● The spinal cord and the meninges
protrude through the vertebrae same as
meningocele, the difference is that the
spinal cord ends at that point so motor
and sensory function is absent beyond
this point.
Words under picture: Degrees of spinal cord
anomalies. (A) normal spinal cord. (B) Spina Bifida
Occulta. (C) Meningocele. (D) Myelomeningocele
ETIOL
OGY
●
●
Occurs when the posterior laminae of the
vertebrae fail to fuse.
This occurs most commonly at the fifth
lumbar or first sacral level, but may occur
at any point along the spinal canal.
INCID
ENCE
Simple Spina Bifida Occulta is a benign disorder,
it occurs as frequently as 1 in every 4 children.
S/S
Spina bifida occulta may be noticeable as a
dimpling at the point of poor fusion with abnormal
tufts of hair or discolored skin.
N/C
DX
●
●
ASSS
SMNT
●
●
●
The term spina bifida is often used to denote all
spinal cord anomalies, because of this usage,
parents who will be told that their child has spina
bifida occulta may interpret this as the child having
an extremely serious disorder. Help clarify the
degree of defect for them.
●
●
MENINGOCELE
DEFIN
ITION
Words under picture: Degrees of spinal cord
anomalies. (A) normal spinal cord. (B) Spina Bifida
Occulta. (C) Meningocele. (D) Myelomeningocele
● Occurs if the meninges covering the
spinal cord herniate through unformed
vertebrae.
● The anomaly appears as a protruding
mass, usually approximately the size of
an orange at the center of the back.
● It generally occurs in the lumbar region
although it may be present anywhere
along the spinal canal. The protrusion
may be covered by a layer of skin or only
the clear dura mater.
●
S/S
●
●
●
MYELOMENINGOCELE
DEFIN
ITION
Words under picture:
1.
A
myelomeningocele.
The infant also has
hydrocephaly and a
subluxated hip.
2. Degrees of spinal
cord anomalies. (A)
normal spinal cord.
(B)
Spina
Bifida
Occulta.
(C)
Meningocele.
(D)
●
It is generally difficult to tell from visual
appearance whether the disorder is
myelomeningocele
or
the simpler
meningocele.
CT, MRI, UTZ
Neural tube disorders may be discovered
during intrauterine life by:
○ Prenatal UTZ
○ Fetoscopy
○ Amniocentesis
○ AFP (Alpha fetoprotein) analysis
in maternal serum
Upon discovery in utero, it is possible to
close the lesion by fetoscopic surgery.
Infants may be born by Cesarean birth to
avoid pressure and injury to the spinal
cord.
Observe & record whether an infant born
with a neural tube disorder has
spontaneous movement of the lower
extremities to assess if the child has
slower motor function.
Assess the nature and pattern of voiding
and defecation.
○ A normal infant appears to be
always wet from voiding, but
actually voids in approximate
amounts of 30 mL and then is
dry for 2-3 hours before
voiding again.
○ An infant without motor or
sphincter
control
voids
continually. This pattern is the
same for defecation.
Observing these features aids in
differentiating between meningocele &
myelomeningocele.
The child will have flaccidity and lack of
sensation in the lower extremities and
loss of bowel and bladder control
because this condition results in lower
motor neuron damage.
Infant’s legs are lax, and they do not
move.
Urine and stools continue to dribble
because of lack of sphincter control.
Children have accompanying talipes
(clubfoot) disorders & developmental
hip dysplasia.
Hydrocephalus accompanies myelomeningocele
in as many as 80% of infants because of the lack
of adequate subarachnoid membrane for CSF
absorption. The higher the myelomeningocele
occurs in the cord, the more likely it is that
hydrocephalus will accompany it.
T/MG
NT
●
The management of the child who has a
myelomeningocele
requires
a
multidisciplinary team approach involving
the following specialties:
○ Neurology,
neurosurgery,
pediatrics, urology, orthopedics,
rehabilitation, physical therapy,
●
●
●
occupational therapy, social
services, and intensive nursing
care
Early surgical closure for a leaking CSF
within the first 24-72 hours offers the
most favorable outcomes.
○ Surgical closure within the
first 24 hours is recommended
if the sac is leaking CSF.
A variety of neurosurgical & plastic
surgical procedures are used for skin
closure without disturbing the neural
elements or removing any portion of the
sac.
○ The objective is satisfactory skin
coverage of the lesion and
meticulous closure.
○ Wide excision of the large
membranous covering may
damage functional neural tissue.
Associated problems are assessed and
managed by appropriate surgical and
supportive measures.
○ Shunt procedures provide
relief
from
imminent
or
progressive hydrocephalus.
○
after the infant had survived the
newborn period.
Currently, surgery is done as
soon after birth as possible
(usually within 24 to 48 hours)
■ PREVENT
infection
through
exposed
meninges
ARNOLD-CHIARI DISORDER
DEFIN
ITION
●
●
●
●
●
●
●
Overgrowth of the neural tube in weeks
16 to 20 of fetal life
The specific anomaly is a projection of
the cerebellum, medulla oblongata, and
fourth ventricle into the cervical canal.
Upper cervical spinal cord jackknifes
backward → obstruction of CSF flow →
hydrocephalus
Lumbosacral
myelomeningocele:
present in approximately 50% of children
with this anomaly
The prognosis for the child with an
Arnold-Chiari malformation depends on
the extent of the disorder and the surgical
procedure possible.
Increased risk for aspiration because of
the upper motor neuron involvement
causes an absence of gagging and
swallowing reflexes.
Serious levels of sleep apnea may occur.
A) Myelomeningocele with an intact sac
B) Myelomeningocele with a ruptured sac
V. NEUROCUTANEOUS SYNDROMES
ENCEPHALOCELE
DEFIN
ITION
●
●
●
●
●
T/MG
NT
An encephalocele is a
cranial meningocele
or myelomeningocele.
Occurs most often in
occipital area, but
may occur as a nasal
or
nasopharyngeal
disorder
Generally
covered
fully by skin, but
they may be open or covered only by the
dura
○ It is difficult to tell from the size
of the encephalocele if only CSF
is trapped in the protruding
meninges or whether the brain
tissue is also involved.
Transillumination of the sac will reveal
solid substance or fluid in the sac.
CT, MRI, or ultrasound will reveal the size
of the skull disorder.
Meningocele, Myelomeninogecele, Encephalocele
● Immediate surgery
○ To replace the contents that are
replaceable
○ To close the skin disorder to
prevent infection
○ In the past, surgery for neural
tube disorder was done only
Neurocutaneous Syndromes
These are characterized by the presence of skin or pigment
disorders with CNS dysfunction.
Outline:
1) Sturge-Weber Syndrome
2) Neurofibromatosis (Von
Recklinghausen’s Disease)
STURGE-WEBER SYNDROME
DEFIN
ITION
●
●
AKA encephalofacial
angiomatosis
Congenital port-wine
birthmark on the skin
of upper part of the
face
○ Extends
inward
to
the
meninges
and choroid
plexus
○ Follows the distribution of the
first division of the fifth cranial
nerve (trigeminal nerve)
ASSS
SMNT
●
Infants typically have irregular but
excessive skin pigmentation.
Later in childhood → pigmented nevi or
café-au-lait (“coffee with cream”) spots
appear
○ Tend to follow the paths of
cutaneous nerves
○ Presence of more than six
spots larger than 1 cm in
diameter is suggestive of this
disorder.
Puberty → multiple soft cutaneous
tumors along nerve pathways
Young adulthood → subcutaneous
tumors
○ Acoustic nerve (cranial nerve
VIII) is frequently involved =
hearing loss
○ Optic nerve involvement =
vision loss
15% of children: neurologic complications
such as seizures
8% of children: cognitively challenged
from cerebral deterioration
Symptoms and growth of tumors
increase
at
puberty and during
pregnancy.
●
ASSS
SMNT
●
●
●
●
●
●
DX
●
●
MGNT
Because the defect is usually unilateral,
the port-wine stain ends abruptly at the
midline.
○ In many children, only the
ophthalmic branch of the
nerve is involved, where the
lesion is usually confined to the
upper aspect of the face.
Because of the involvement of the
meningeal blood vessels, blood flow is
sluggish, and anoxia may develop in
some portions of the cerebral cortex
Hemiparesis (numbness) on the side
opposite the lesion from destruction of
motor neurons
Intractable seizures
Cognitively challenged
Blindness from glaucoma
CT scan, MRI → shows calcification in
the involved cerebral cortex
○ “railroad track” or double-groove
pattern
EEG → shows areas of decreased
voltage
●
●
●
●
MGNT
●
●
●
Unexplained
development
of
subcutaneous tumors
○ Can occur as a mutation
○ Can be inherited as an
autosomal
dominant
trait;
carried on the long arm of
chromosome 17
Occurs in approximately 1 of every 4000
live births and may be diagnosed
prenatally (Noll et al., 2007).
“Elephant Man” had a severe case of
neurofibromatosis that also involved
skeletal changes (grey pictures).
●
Little therapy is available to halt the
tumor growth
Mast cell blockers have some effects
If lesions are causing acoustic or optic
degeneration: surgical removal of the
tumors may be attempted
Ensure that parents and child have a
source of emotional support through the
disease’s slow but invariably fatal course.
●
●
Ensure that parents understand the need for
long-term follow-up, particularly if the child has
accompanying seizures that require long-term
anticonvulsant therapy.
NEUROFIBROMATOSIS (VON RECKLINGHAUSEN’S
DISEASE)
DEFIN
ITION
●
●
VI. CEREBRAL PALSY (CP)
DEFIN
ITION
●
●
●
A “group of
permanent
disorders of the
development of
movement and
posture,
causing activity
limitation, that
are attributed
to
nonprogresive
disturbances
that occurred in the developing fetal or
infant brain.”
Most common motor disability of
childhood
Also involves:
○ Disturbances
of sensation,
perception,
communication,
cognition, and behavior.
○
○
Secondary
problem
Epilepsy
musculoskeletal
PREV
ALEN
CE
●
Highest prevalence:
○ Infants born weighing 1000
grams to 1499 grams at birth
○ Higher in infants born prior to
completion of 28 weeks’
gestation
○ Incidence is higher in males
than females
CLAS
SIFIC
ATION
●
CP has been classified in various ways.
Traditionally, it is divided into two main
categories based on the type of
neuromuscular involvement.
Two main categories
○ Pyramidal or Spastic type
■ Approximately 40% of
affected children
■ Stiff
muscles
(spasticity)
○ Extrapyramidal type
■ Dyskinetic or athetoid
● Approx. 30%
● Uncontrollabl
e movement
(dyskinesia)
■ Ataxic
● Approx. 10%
● Poor balance
and
coordination
(ataxia)
■ Mixed
● Approx 10%
●
ASSS
SMNT
●
●
●
DYSKINETIC / ATHETOID TYPE OF CP
●
●
●
●
●
●
Abnormal involuntary movement
Athetoid means “wormlike”
Early in life, the child is limp and
flaccid.
Later, children make slow,
writhing motions
○ May involve in all four
extremities + face, neck,
and tongue
Drools, speech is difficult to
understand
With emotional stress, the involuntary movements
may become irregular and jerking (choreoid) with
disordered muscle tone (dyskinetic).
DX
●
●
●
ATAXIC TYPE
●
●
Awkward, wide based gait
Neurologic, examination - unable to perform:
○ Finger-to-toe test
○ Rapid, repetitive movements (tests of
cerebellar function)
○ Fine coordinated movements
MIXED TYPE
●
●
●
Show symptoms of both spasticity and athetoid
movements
Ataxic and athetoid movements may also be
present together
This combination results in the severe degree of
physical impairment
History and physical assessment
○ Document any episode of
possible anoxia during prenatal
life or at birth
○ Full extend of D/O may only be
recognizable when the child is
older, attempts more complex
motor skills (e.g., walking)
■ Determining the extent
of the involvement of
an infant can be
difficult
because
neurologic assessment
in infants is difficult.
○ All
infants
need
careful
neurological assessment during
the first year of life so that the
small signs of impairment can
be tracked and so that the child
can be monitored closely for
further testing and assessment.
Children with all forms of CP may
have:
○ Sensory
alterations
(e.g.,
strabismus)
○ Refractive disorders
○ Visual perception problems
○ Visual field defects
○ Speech
disorders
(e.g.,
abnormal rhythm or articulation)
○ Attention deficit disorder or
autism
○ Cognitive
challenge
(also
accompany in all types of the
disorder)
○ Recurrent seizures
Deafness
caused
by
kernicterus
(athetoid CP)
○ Kernicterus is a type of brain
damage that can result from
high levels of bilirubin in a
baby's blood. It can cause
athetoid cerebral palsy and
hearing loss.
Skull radiograph or ultrasound: show
cerebral asymmetry
○ However, the skull shape
usually is normal
CT or MRI scan: usually is negative
EEG may be abnormal, but the pattern
the highly variable
○ Abnormality may be asymmetry
or a spike seizure discharge
■ An
abnormality
is
noteworthy but is not
diagnostic in itself
FINDI
NGS
●
●
●
●
●
Delayed motor development
Abnormal head circumference
Abnormal postures
Abnormal reflexes
Abnormal muscle performance and tone
T/MG
MT
●
GOALS: early recognition & promotion of
optimal development
○ To attain normalization
○ To realize potential within the
limits
of
existing
health
problems
Disorder is permanent; therapy is
primarily preventive & symptomatic
5 BROAD GOALS:
●
●
○
●
●
●
➔
➔
Locomotion,
communication,
self-help skills
○ Optimal
appearances
&
integration of motor functions
○ Correct associated defects as
early & effectively as possible
○ Provide
educational
opportunities adapted to needs
and capabilities
○ Promote
socialization
experiences
Multidisciplinary planning and care
coordination among professionals &
child’s family
○ The outcome of the child and
family
with
CP
is
the
normalization and promotion of
self care activities that empower
the child and the family to
achieve maximum potential.
Ankle-foot orthoses (AFOs, braces)
○ Worn by many of these children
○ Used to prevent or reduce
deformity, increase the energy
deficiency of gait, and control
alignment.
○ Manual or powered wheelchairs
allow for more independent
mobility.
Orthopedic surgery may be required:
○ Correct contracture or spastic
deformities
○ Provide stability for an unstable
joint
○ Provide balanced muscle power
Surgical intervention is reserved for
children who do not respond to more
conservative measures but it is also
indicated for children who’s spasticity
causes progressive deformities.
Orthopedic surgery is generally not
performed until the child is 6 years old
PAIN MANAGEMENT
● An important aspect in the care of
children with CP. Intense pain may occur
with muscle spasms in these patients.
● Children with CP may also experience
pain as a result of surgical procedures
intended to reduce contracture of
deformities, body position, GER and
physical therapy.
MEDICATIONS
● Pharmacologic agents given orally have
had limited effectiveness in improving
muscle coordination in children with CP
however they are effective in decreasing
overall spasticity.
● Dantrolene sodium, baclofen (Lioresal),
and diazepam (Valium)
○ Diazepam is used frequently
but should be restricted to older
children and adolescents.
● Intrathecal baclofen therapy
● Antiepileptic drugs: carbamazepine
(Tegretol), divalproex (Valproate sodium
and valproic acid; Depakote)
○ Antiepileptic
drugs
are
prescribed routinely for children
who have seizures.
● Levodopa & Trihexyphenidyl (Artane)
● Reserpine
●
●
Other medications are used to treat
dystonia and hyperkinetic movement
disorders
such as chorea and
athetosis.
All medications should be weighed for
risk-benefit
ratio,
monitored
for
maintained and therapeutic levels, and
avoidance of subtherapeutic or toxic
levels.
DENTAL HYGIENE
● Essential in the care of children with CP
● Regular visits to the dentist and
prophylaxis including brushing fluoride
and flossing should be started as soon
as the teeth erupt.
AIRWAY CLEARANCE
● Help mobilize secretions
ENHANCE EYE/HAND COORDINATION
● By computerised toys and games and
many other electronic devices which
allow independent functioning
NEUROMUSCULAR ELECTRICAL
STIMULATION (NMES)
● There are some evidence that NMES in
addition to dynamic splinting may result
in increased muscle strength, ROM and
function of upper limbs in children with
CP
PHYSICAL THERAPY
● One of the most frequently conservative
treatment modalities
SPEECH LANGUAGE THERAPY
● Involves the services of a speech
language
pathologist who may also
assist with feeding problems.
NC/
MGMT
●
●
●
●
●
Provide frequent rest periods
○ Because children with CP
expend so much energy in their
efforts to accomplish ADLs.
Diet and nutrition - may be challenging
○ The diet should be tailored to
the
child’s
activity
and
metabolic needs.
○ Gastrostomy feedings may be
necessary
■ Or oral feedings may
be
continued
to
maintain
oral-motor
skills as tolerated
Safety precautions are implemented
○ E.g., having children wear
protected helmets if they are
subject to falls or capable of
injuring their heads on hard
objects.
Recreational activities
○ Serve to stimulate the children’s
interest and curiosity helps
them adjust to their disability
and improve their functional
abilities and build self-esteem.
Family support
○ The nursing intervention that is
the most valuable.
■ To help in coping the
emotional aspects of
this disorder.
●
LONG
TERM
CARE
●
●
●
Support hospitalized child
○ Includes CP patients who are
hospitalized as they are usually
admitted for illness or corrective
surgery.
○ To facilitate the care and
management of hospitalized
children with CP, the therapy
program should be continued
while they’re in hospital. This is
considering that their condition
allows.
Help parents to encourage their children
with CP to reach their fullest potential
within the limits of their disorder
Evaluations at health care visits
Support for parents and family members
○
ASSS
SMNT
●
●
●
●
VIDEO 3
NEUROLOGIC INFECTIONS
●
BACTERIAL MENINGITIS
DEFIN
ITION
●
●
●
Infection of the cerebral meninges
Children <24 months of age
○ In the US, it is caused most
frequently by Streptococcus
pneumoniae
or
Group B
Streptococcus
○ In children younger than 2
years of age: Group B
Streptococcus and Escherichia
coli
○ Myelomeningocele
who
develops meningitis?
■ Pseudomonas infection
○ Children who have had a
splenectomy are particularly
susceptible to pneumococcal
meningitis unless they have
received
a
pneumococcal
vaccine.
○ Haemophilus influenzae
■ Was once a major
cause of meningitis but
is now rarely seen
because of routine
immunizations against
this organism
Spread to meninges from:
○ Upper
respiratory
tract
infections
○ Lymphatic drainage possibly
through the mastoid or sinuses
○ Direct introduction through a
lumbar puncture or skull fracture
○ Organisms in meningeal space
multiply
rapidly;
organisms
invade brain tissue through
meningeal folds and extend
down into the brain itself or
spread throughout the CSF.
○ The inflammatory response that
occurs may lead to a thick,
fibrinous exudate that blocks
CSF flow.
○ Brain abscess or invasion into
cranial nerves can result in
blindness, deafness, or facial
paralysis.
○ Pus in the aqueduct of Sylvius
can cause obstruction leading to
●
●
●
●
●
●
●
DX
●
hydrocephalus.
Brain tissue edema can cause
pressure on the pituitary gland
causing increased production of
ADH or antidiuretic hormone
resulting in the syndrome of
inappropriate
antidiuretic
hormone secretion (SIADH)
which causes increased edema
because the body cannot
excrete adequate urine.
Symptoms:
occur
insidiously
or
suddenly
Children usually have had 2 or 3 days of
URTI
Increasingly
irritable
because
of
headaches
Sharp pain on bending head forward
Seizures
○ In some children, seizure or
shock is the first noticeable sign
of illness
Disease
progression:
signs
of
meningeal irritability occur
○ Positive Brudzinski’s (Severe
neck stiffness causes a patient's
hips and knees to flex when the
neck is flexed) and Kernig’s
signs (Severe stiffness of the
hamstrings causes an inability
to straighten the leg when the
hip is flexed to 90 degrees.)
Opisthotonos - children’s back may
become
arched
and
their neck
hyperextended
Cranial nerve paralysis (3rd or 6th
nerves) - the child may not follow the light
through visual fields
If fontanelles are open = they are
bulging and tense may occur
If fontanelles are closed = Papilledema
may occur (optic disk swelling)
If caused by H. influenzae = Septic
arthritis may occur
If caused by Neisseria meningitidis = A
papular or purple petechial skin rash may
occur
Hx. and analysis of CSF obtained by
lumbar puncture
○ A child w/ febrile seizure =
should be assumed to have
meningitis until CSF findings
prove otherwise
○ CSF
results indicative of
meningitis include increased
WBC & protein levels, lowered
glucose levels
In a healthy child, the glucose levels and CSF is
60% of that of the serum glucose. Because
meningitis often spreads and causes septicemia,
blood culture is also done.
● Blood culture
○ Fulminating
(overwhelming)
meningitis → often leads to
leukopenia
● If a child has close association with
someone w/ tuberculosis = A tuberculin
skin test to rule out TB meningitis should
be done
● CT scan, MRI, or ultrasound may be
●
ordered to examine for abscesses
Typically, ICP is severely elevated
○
T/MG
MT
●
●
●
●
●
●
Antibiotic therapy is the primary
treatment measured
○ IV = for rapid effect
○ Intrathecal injections = reduce
infx because the blood brain
barrier may crement antibiotic
from passing freely into the
CSF
○ Per organism
■ H.
influenzae
=
ampicillin (Drug of
Choice)
■ In other instances, a
third-generation
cephalosporin x8-10
days
● Cefotaxime
(Claforan)
● Ceftriaxone
(Rocephin)
■ In some children, it
takes a month before
the CSF cell count
returns to normal
■ A corticosteroid such
as dexamethasone or
osmotic
diuretic
mannitol
may
be
administered to reduce
ICP and help prevent
hearing loss
Respiratory precautions x24 H after the
start of antibiotic therapy to prevent
transmission of the infx
Antibiotics
may
be
prescribed
prophylactically for the immediate family
members of the ill child or for others who
have been in close contact with the child.
Meningitis is always a serious disorder
because it can run in a rapid, fulminating,
and possibly fatal course
However, if symptoms are recognized
early and treatment is effective = a child
may recover with no sequelae
Assess neurologic sequelae after infx
○ Long term consequences
○
DIAG
NOSTI
CS &
TREA
TMEN
TS
●
●
●
TUBERCULOSIS MENINGITIS
DEFIN
ITION
●
●
●
●
●
Mycobacterium tuberculosis are aerobic
bacteria that replicate in host cells.
Therefore, control on these bacteria
depends largely on T-cells mediated
immunity.
These bacteria may infect the CNS
during primary or reactivated infx
In developed countries, meningitis
usually results from reactivated infx.
Reactivation may occur in patients
treated with immunosuppressants such
as
tumor
necrosis
factor
alpha
antagonists
Meningeal symptoms usually develop
over days to a few weeks but may
develop more rapidly or gradually
Characteristically, M. tuberculosis causes
a basilar meningitis that results in 3
complications:
○ Hydrocephalus from obstruction
of the foramina of Luschka or
Magendie or the aqueduct of
Sylvius
Vasculitis → arterial or venous
occlusion, stroke
Cranial nerve deficits - 2nd, 7th,
and 8th
●
●
Diagnosis of tuberculosis meningitis may
be difficult. There may be no evidence of
systemic tuberculosis.
Contrast-enhanced
CT
or
MRI:
Inflammation of the basilar meninges
○ Suggests the diagnosis.
CSF
○ Slight to moderate pleocytosis
or increased WBC (50-300
WBCs/uL, with lymphocytic
predominance)
○ ↓ glucose
○ ↑ protein
○ Detecting
the
causative
microorganism is often difficult
because
CSF
acid-fast
staining is < 20% sensitive,
even using immunofluorescence
techniques CSF mycobacterial
cultures are only about 70%
sensitive and require up to 6
weeks.
○ CSF PCR is only about 50-70%
sensitive
Automated
rapid
nucleic
acid
amplification test - Xpert MTB/RIF;
recommended by WHO for tuberculosis
meningitis detection
○ Detects M. tuberculosis DNA
○ Resistance to rifampicin in CSF
specimens
This infection should be treated based on
clinical suspicion (because tuberculosis
meningitis has a rapid and destructive
course, and because diagnostic tests are
limited)
○ Anti-tuberculosis
drugs
current
recommendation of
WHO
■ Isoniazid,
rifampin,
■
PROG
NOSI
S
●
●
●
pyrazinamide,
ethambutol x2 mos
followed by isoniazid
and rifampin x 6-7
months
Corticosteroids
(prednisone
or
dexamethasone) may
be added (+) if patients
presents with stupor,
coma, or neurologic
deficits
Frontal Lobe
● Hemiparesis (weakness or the inability to
move on one side of the body)
● Aphasia (expressive)
● Seizures
● Frontal headache
Temporal Lobe
● Localized headache
● Changes in vision
● Facial weakness
● Aphasia
Cerebellar Abscess
● Occipital headache
● Ataxia
(inability
to
movements)
● Nystagmus
(rhythmic,
movements of the eye)
Without treatment, the mortality rate in
tuberculosis: 100%
About 2/3rds of patients receiving
treatment survive.
There may be a high incidence of
neurologic
abnormalities
among
survivors if treatments are started late.
PATH
OPHY
SIOL
OGY
●
●
●
●
S/S
A pus-filled swelling in the brain
Relatively rare; immunocompromised
patients
○ It is a complication encountered
in increasingly patients whose
immune systems have been
suppressed
either
through
therapy or disease.
Occur by direct invasion of the brain
from:
○ Intracranial trauma or surgery
○ Spread of infection from nearby
sites (e.g., sinuses, ears, teeth)
○ Spread of infection from other
organs (lung abscess, infective
endocarditis)
To prevent brain abscess, treat
promptly:
○ Otitis
media,
mastoiditis,
sinusitis, dental infections, and
systemic infections
The clinical manifestations of a brain abscess
results from alterations in intracranial dynamics
such as edema or brain shift, infection, or location
of abscess.
●
●
●
●
●
Headaches, usually worse in the
morning, are the most prevailing
symptom
Vomiting is also common.
Focal neurologic signs may occur
depending on the site of the abscess.
Signs include:
○ Weakness of extremity
○ Decreasing vision
○ Seizures
There may be a change in mental status
as reflected in lethargic, confused,
irritable or disoriented behavior.
Fever may or may not be present.
Repeated neurologic examinations and continuing
assessment of the patient are necessary to
determine the location of the abscess.
involuntary
DX
●
Include: CT scan, MRI
○ CT scan = locating the site of
the abscess after the evolution
and resolution of suppurative
lesions and in determining the
optimal
time
for
surgical
interventions.
○ MRI scan = obtain imaging of
the brainstem and posterior
fossa if an abscess is suspected
in these areas.
M/MG
MT
●
Brain
abscess
is
treated
with
antimicrobial therapy
Surgical incision or aspiration:
○ If the abscess is encapsulated,
CT-guided stereotactic needle
aspiration
under
local
anesthesia may be performed
BRAIN ABSCESS
DEFIN
ITION
coordinate
●
N/MG
MT
●
●
●
Focus:
○ Ongoing
assessment
of
neurologic status - alerts the
nurse to changes in ICP which
may indicate a need for a more
aggressive interventions
○ Administering medications
○ Assessing
response
to
treatment
○ Supportive care
Patient
safety
key
nursing
responsibility
○ Injury
may
result
from
decreased
levels
of
consciousness and falls related
to motor weakness or seizures
○ Patient with brain abscess is
extremely ill and neurologic
deficits
may remain after
treatment such as:
■ Hemiparesis
■ Seizures
■ Visual deficits
■ Cranial nerve palsies
Family support
○ The nurse must also assess
their families abilities to express
their distress at the patient’s
condition, cope with the patient’s
illness and deficits, and obtain
the support.
ENCEPHALITIS
○
DEFIN
ITION
●
●
ASSS
SMNT
DX
Symptoms begin gradually or suddenly.
● Headache
● High temperature
● Signs of meningeal irritation
○ Nuchal rigidity (neck stiffness)
○ + Brudzinski's sign
○ + Kernig’s sign
● Ataxia, muscle weakness or paralysis,
diplopia, confusion, irritability – may
occur
● Increasingly lethargic → comatose
(eventually)
●
●
●
●
T/MG
MT
Inflammation of brain tissue, and possibly
the meninges as well
Causes:
○ Protozoan, bacterial, fungal or
viral invasion
■ Enteroviruses
(most
common), followed by
arboviruses
–
mosquitoes
○ Several encephalitis viruses
(such as those that cause St.
Louis encephalitis, West Nile
encephalitis, and Eastern
Equine encephalitis) are borne
by mosquitoes and are mostly
seen
during the summer
months.
■ In
endemic areas,
mosquito repellents are
strongly suggested.
○ Direct CSF invasion during
lumbar puncture
○ Complication
of
common
childhood disease
■ Measles,
mumps,
chickenpox
■ Therefore it is crucial
that children receive
immunization against
these
childhood
diseases
●
●
●
●
○
Encephalitis is always a serious diagnosis
because although the child may recover from the
initial attack without further symptoms, there may
be residual neurologic damage, such as seizures
or learning disabilities.
Parents may find it hard to believe that their child
is so seriously ill at first because at the beginning
of the illness, their child only seemed tired and
had a slight headache.
REYE’S SYNDROME
DEFIN
ITION
●
●
●
●
ASSM
T
History, PE
CSF evaluation
○ Elevated leukocyte count
○ Elevated protein levels
EEG: widespread cerebral involvement
Brain biopsy (temporal lobe)
Primarily supportive
V/S monitoring – take and monitor vital
signs
frequently
as
brainstem
involvement ca