PEDIATRICS CONCEPT
HIGH RISK: NEWBORN
_________________________________________________________________________________________________________
OUTLINE
Problems Related to
Maturity
A. Preterm Newborn
B. Post-term Newborn
II. Problems Related to
Gestational Weight
A. Small for
Gestational Age
B. Large for
Gestational Age
III. Common Acute
Conditions of Newborn
I.
I.
Square Window Sign – by gentle flexing the newborn’s
hand toward the ventral arm until resistance is felt. The
angle formed at the wrist is measured.
90 degrees = immature newborn
0 = 40-42 weeks’ term
A. Respiratory
Distress Syndrome
(RAS)
B. Retinopathy of
Prematurity
C. Hyperbilirubinemia
D. Meconium
Aspiration
Syndrome
E. Sepsis
F. Sudden Infant
Syndrome (SAS)
Scarf Sign – to assess developmental age and muscle
tone in neonates
The tone of the shoulder girdle is assessed by taking the
baby’s hand and pulling the hand to the opposite
shoulder like a scarf
The hand should not go past the shoulder and the elbow
should not cross the midline of the chest
The drawing of the newborn’s arm across the chest to
the opposite shoulder until resistance is felt
In term infants, the elbow should not cross the midline of
the chest. The arm is pulled laterally across the chest; in
the hypotonic infant, the elbow will cross the midline; in a
term infant with normal tone, the elbow will not reach the
midline
PROBLEMS RELATED TO MATURITY
A. PRETERM NEWBORN
A neonate born before 37 weeks of gestation
Primary concern relates to immaturity of all body systems
Cause: unknown
Maternal Factors:
●
Age
●
Smoking
●
Poor nutrition
●
Placental problem – placenta abruption and placenta
previa
●
Preeclampsia/ eclampsia
Fetal Factors:
●
Multiple pregnancy
●
Infection
Other Factors:
●
Poor socioeconomic status
●
Environmental exposure to harmful substance
1.
2.
Assessment
Respirations are irregular with periods of apnea
Body temperature is below normal
Skin is thin, with visible blood vessels and minimal
subcutaneous fat pads, may appear jaundiced
Poor sucking and swallowing reflexes
Bowel sounds are diminished
Poikilothermic – easily take on the temperature of the
environment
Extremities are thin, with minimal creasing on soles and
palms
Extension of extremities and does not maintain flexion
(less muscle tone, weak, feeble)
3.
Abundance of lanugo hair
4.
Labia are narrow in girls
Undescended testes in boys because the testes don’t
pass down from the belly into the scrotal sac until month
7 of a baby’s growth in the uterus. Other causes may
include hormone problems or spina bifida
Square window wrist
o
test which measures wrist flexibility and
resistance to extensor stretching resulting in
angle between the forearm and palm
o
the examiner straightens the infant’s fingers
and applies gentle pressure on the dorsum of
the hand, close to the fingers, and then
estimates the angle between the palm of the
hand and the forearm
o
Preterm to Post-term infant -- the angle
between the palm of the infant’s hand and
forearm is estimated at >90, 90, 60, 45, 30,
and 0 degree
o
Before 26 weeks – wrist CANNOT be flexed
more than 90 degrees
o
Before 30 weeks – wrist CAN be flex no more
than 90 degrees
5.
Common or Special Problem of Preterm Neonates
RESPIRATORY DISTRESS SYNDROME
Aka Hyaline Membrane Disease
Due to lung immaturity = dec gas exchange
Deficient in surfactant
** Surfactants are compounds that lower the surface tension
between two liquids, bet. A gas and a liquid, or bet. Liquid and
solid
** Surfactant is a fatty protein that is high in lecithin, its
presence is necessary for the lungs to absorb oxygen—if
premature, the surfactant level is insufficient
** Respirations increase to 60 bpm or higher (tachypnea)
HYPERBILIRUBINEMIA
High level of bilirubin in the blood, neonate become
jaundice
Due to immaturity of the liver
Kernicterus – staining of brain cells with bilirubin,
causing irreversible brain damage
** Buildup of bilirubin in the blood causing yellow discoloration
of the eyes and skin called jaundice
**Bilirubin – is a yellowish substance in your blood. It forms
after RBC breakdown and travels through the liver,
gallbladder, and digestive tract before being excreted
**Kernicterus – is a rare kind of preventable brain damage
that can happen in newborns with jaundice
**Jaundice – yellow coloring of the skin. It happens when
babies build up too much of a chemical called bilirubin in their
blood
** PHOTOTHERAPY – lowers the bilirubin levels in your
baby’s blood through a process called photo-oxidation.
Photo-oxidation adds oxygen to the bilirubin so it dissolves
easily in water
INFECTION
Not able to receive IgG globulins
COLD STRESS
Less subcutaneous tissue, poikilothermic
** Cold stress is the major risk to naked preterm infants
nursed in a dry incubator. Decreased epidermal and dermal
thicknesses result in increased heat loss from radiation and
conduction. Minimal subcutaneous fat and an immature
nervous system also decrease the premature infant’s ability to
respond to cooling. Cold stress occurs when heat loss
requires an increase in metabolic heat production
ANEMIA
Less iron stores
** Anemia of Prematurity (AOP) refers to a form of anemia
affecting preterm infants with decreased hematocrit
** AOP is a normochromic, normocytic, hypo proliferative
anemia
▪ normochromic – concentration of hemoglobin in the
RBC is within standard range but have insufficient
number of RBC
▪ normocytic – blood problem. Normal-sized RBC but
low number of them
▪ hypo proliferative – inadequate number of
erythrocytes to maintain homeostasis
** The primary mechanism of AOP is a decrease in
erythropoietin
Management
Improving respiratory function
Oxygen therapy
Mechanical ventilator
Maintaining body temperature
Isolette – maintains ideal temperature, humidity and
oxygen concentration isolates infant from infection
Kangaroo Care
** Is a method of holding a baby that involves skin to skin
contact. The baby who is naked except for a diaper and
a piece of cloth covering his/her back (either a receiving
blanket or the parent’s clothing), is placed in a upright
position against a parent’s bare chest
Preventing Infection
Handwashing
Promoting Nutrition
Gavage feeding
o
way to provide breastmilk or formula directly to your
baby’s stomach. A tube placed through your baby’s
nose (NGT) carries breast milk/formula to the
stomach
Milk feeding
o
Breastfeeding/milk feeding – use “preemie” nipple if
bottle fed with strict Ap
Promoting Sensory Stimulation
Gentle touch, speaking gently and softly, music box or
low tuned radio
1.
2.
3.
4.
5.
Nursing Interventions
1. Monitor vital signs every 2 to 4 hours
2. Administer oxygen and humidification as prescribed
** avoid retrolental fibroplasia can cause blindness due to
high O2 usage
3. Monitor intake and output
** easily gets dehydrated with poor electrolyte balance
4. Monitor daily weight
5. Maintain newborn in a warming device
6. Reposition every 1 to 2 hours and handle newborn carefully
7. Avoid exposure to infections
** less antibody production/decreased resistance
8. Provide newborn with appropriate stimulation such as touch
9. Suctioning of secretions as needed
10. Monitor for signs of infection
** fever, poor suck, irritability
11. Provide skincare
** prevent skin breakdown and ulceration, monitor potential
bleeding sites such as umbilicus, injection sites—low clotting
factors
12. Provide complete explanations for parents
** encourage parental involvement in the care
B. POST-TERM NEWBORN
Neonate born after 42 weeks of gestation
About 12% of all infants are post-term
Maternal Factors:
o
Causes of delayed birth is unknown
o
First pregnancies between the ages 15 to 19 years
o
Woman older than 35 years
o
Multiparity
Fetal anomalies
o
anencephaly
**cause – progressively less efficient actions of placenta
**anencephaly – congenital absence of all or major part of the brain
-
1.
2.
3.
4.
5.
6.
Assessment
Depleted subcutaneous fat: old looking “old man facies”
Parchment-like skin (dry, wrinkled, and cracked) without
lanugo
** skin of sheep or goat
Fingernails long and extended over ends of fingers
Abundant scalp hair
Long and thin body
Sign of meconium staining nails and umbilical cord (yellow to
green)
Complications of Post Maturity
The placenta begins to age toward the end of pregnancy, and
may not function as efficiently as before
▪ The failing placental function will place infant at risk for
intrauterine hypoxia during labor and delivery
** Fetal Hypoxia occurs when the fetus is deprived of an adequate
supply of oxygen
** Due to: umbilical cord prolapses, cord occlusion/thrombosis,
placental infarction maternal smoking intrauterine growth restriction
(IUGR)
▪
▪ Meconium Aspiration Syndrome (MAS)
** is the aspiration of stained amniotic fluid which can occur before,
during, or immediately after birth. Meconium is the first intestinal
discharge from newborns, a viscous, dark-green substance
composed of intestinal epithelial cells, lanugo, mucus, and intestinal
secretions
▪
Hypoglycemia
from nutritional deprivation and poor storage of glycogen
at birth
** low blood sugar because the infant has too little glucose stored
▪ Polycythemia
increase circulating RBC
** abnormal
** defined in newborns as a venous hematocrit greater than 65%
** resulted from post maturity, diabetes in the mother, twin to twin
transfusions
-
Management
Ultrasound is done to evaluate fetal development, amount of
amniotic fluids and placenta signs of aging
Suctioning of the mouth and nose is done to reduce the
chance of meconium aspiration, upon delivery of newborn’s
head and just before the baby takes his first breath
▪
▪
Nursing Management
Closely monitor the newborn cardiopulmonary status
Administer supplemental oxygen therapy as needed
Frequent monitoring of blood sugar
** assess for sign of hypoglycemia; shakiness, blue tint to
skin and lips (cyanosis), stopping breathing (apnea),
hypothermia, floppy muscles (poor muscle tone), loss of
appetite, lethargy, seizures
Provide thermoregulated environment
**use of isolette or radiant heat warmer
Monitor for signs of meconium aspiration syndrome
** rapid or labored breathing, retractions or pulling in of the
chest wall, grunting sounds with breathing, bluish skin color
called cyanosis
1.
2.
3.
4.
5.
PRETERM
“relaxed attitude”
limbs more
extended
Ear cartilages are
poorly developed,
may fold easily
Only fine wrinkles
Posture
Ear
Sole
Female genitalia
Male genitalia
Scarf sign
Grasp reflex
II.
-
Clitoris is
prominent; labia
majora poorly
developed
Scrotum is under
developed and not
pendulous, with
minimal rugae
Elbow is easily
brought across the
chest with little or
no resistance
weak
FULLTERM
More flexed attitude
Well-formed
cartilages
Well and deeply
creased
Clitoris is not as
prominent; labia
majora fully
developed
Scrotum is fully
developed ,
pendulous, rugated
With resisting
attempt when
elbow is brought to
the midline of the
chest
Strong, allowing the
infant to be lifted up
from the mattress
PROBLEMS RELATED TO GESTATIONAL AGE
A. SMALL FOR GESTATIONAL AGE
Are those whose birth weight lies below the 10th
percentile for that gestational age
SGA babies may be:
▪ Premature – born before 37 weeks
▪ Full term – 37 to 41 weeks
▪ Post term – after 42 weeks
Intrauterine Growth Restriction (IUGR)
▪ Most common underlying condition leading to
SGA newborn
▪ Describes a reduction of the fetal growth rate
but is not defined by the subsequent birth
weight is used to define SGA.
Some factors that may contribute to SGA are the
following:
●
Maternal factors:
o
High blood pressure
o
Chronic kidney disease
o
Advanced diabetes
o
Heart or respiratory disease
o
Malnutrition, anemia
o
Infection
o
Substance use (alcohol, drugs)
o
Cigarette smoking
o
Placental anomaly is the most
common cause of IUGR
●
Factors related to the fetus
o
Multiple gestation (twins)
o
Infection
o
Chromosomal abnormality
●
●
●
●
●
●
●
●
Assessment
Respiratory distress – hypoxic episodes
Loose and dry skin, little fat, little muscle mass
Wasted appearance
Small liver
Head is larger compared to body
Wide skull sutures
Poor skin turgor
Sunken abdomen
●
●
●
●
●
Problems of SGA Babies (during birth)
Respiratory distress (asphyxia)
Meconium aspiration
Hypoglycemia
Difficulty maintaining normal body temperature
Polycythemia too many red blood cells
●
●
●
●
●
●
-
Nursing Interventions
Observe for signs of respiratory distress
Maintain body temperature
Monitor for infection and initiate measures to prevent
sepsis
Monitor blood glucose levels and for signs of
hypoglycemia
Initiate early feedings and monitor for signs of aspiration
Provide stimulation, such as touch and cuddling
B. LARGE FOR GESTATIONAL AGE
Neonate who is plotted at or above 90th percentile on the
intrauterine growth curve
Weigh more than 4,000 grams
Cause: unknown
Genetic Factors
Maternal conditions
o
Maternal diabetes – is the most widely known
contributing factor increase insulin acts as a
fetal growth hormone
o
Macrosomia – an unusually large newborn with
birth weight of more than 4500grams
o
Occasionally, the arm on the affected side may be
immobilized.
Management
Routine newborn care with special emphasis on the following:
Monitor vital signs frequently, especially respiratory status
Monitor blood glucose levels and for signs of
hypoglycaemia
Initiate early feedings
Note any signs of birth trauma or injury
Monitor for infections and initiate measures to prevent
sepsis
Provide stimulation, such as touch and cuddling
III.
COMMON ACUTE CONDITIONS OF NEWBORN
A.
-
RESPIRATORY DISTRESS SYNDROME (RAS)
Serious lung disorder caused by immaturity and inability to
produce surfactant, resulting in hypoxia and acidosis
** ATELECTASIS - collapse of lung tissue with loss of volume
Assessment
Expiratory grunting – major symptoms
●
is the body’s way of trying to keep air in the lungs so
they will stay open
Tachypnea
Nasal Flaring
Retractions
Seesaw – like respiration (chest wall retracts and the
abdomen protrudes)
Decreased breath sounds
Apnea
Pallor and cyanosis
Hypothermia
Assessment
large, obese
lethargic and limp
May feed poorly
Signs and symptoms of birth trauma
●
Bruising
●
Broken clavicle
●
Evidence of molding
●
Cephalhematoma
●
Caput succedaneum
Problems of LGA Babies
Hypoglycemia (low blood sugar) of baby after delivery
Respiratory distress
Hyperbilirubinemia
Potential complications related to increase in body size
o
Leading cause of breech position and shoulder
dystocia
o
Fractured skull, clavicles, cervical or brachial plexus
injury and erc’s palsy
o
Generally, there is no treatment other than lifting .
child gently to prevent discomfort.
Management
Oxygen therapy
o
Hood, nasal prolong, mask, endotracheal tube
CPAP (Continuous Positive Airway Pressure) or
PEEP (Positive End- Expiratory Pressure) may be
used
**CPAP prevent apnea, certain machine deliver just
enough air pressure to keep upper airway passages
open
**PEEP alveoli pressure, exist at the end of
expiration
●
●
Assessment
Jaundice
Surfactant replacement therapy
Dark concentrated urine
Extracorporeal membrane oxygenation (ECMO)
**Pump circulated blood through an artificial lung
back into the bloodstream
**Support child who is waiting for lung and heart
transplant
Enlarge liver
Muscle relaxants – Pancuronium (Pavulon)
o
Reduces muscular resistance
o
Prevents pneumothorax
o
Prepare Atropine or Neostigmine Methysulfate
Poor muscle tone
Lethargy
Poor sucking reflex
1.
Liquid Ventilation
o
Uses perfluorocarbons – substances used in industry
to assess leaks
Nitric Acid
o
Causes pulmonary vasodilation – increases blood
flow to the alveoli
1.
2.
3.
4.
5.
6.
7.
8.
9.
Nursing interventions
Monitor color respiratory rate, and degree of effort in
breathing.
Support respirations as prescribed
Monitor arterial blood gases and oxygen saturation levels
(arterial blood gases from umbilical artery).
o
So that oxygen administered to the newborn is
at the lowest possible concentration necessary
to maintain adequate arterial oxygenation
Suction every 2 hours or more often as necessary
Prepare to administer surfactant replacement therapy
(instilled into the endotracheal tube)
Administer respiratory therapy (percussion and vibration)
Provide nutrition
Support bonding
Encourage as much parental participation in newborn care
as condition allows
B.
RETINOPATHY OF PREMATURITY
Is simply a blanket which, when wrapped around the
infant’s torso, delivers effective therapy to jaundiced
babies
o
No need to cover the baby’s eyes as all light
treatment is delivered through the blanket
Exchange blood transfusion via umbilical catheter
for very severe cases
infants blood – remove = 5/10 ml at a time
●
2.
Nursing interventions
Expose as much of the newborn’s skin as possible
Cover the genital area, and monitor the genital area for
skin irritation or breakdown
Primarily caused by prematurity and use of supplemental
oxygen (longer than 30 days)
Cover the newborn’s eyes with eye shields or patches;
make sure that eyelids are closed when shields or patches
are applied
Remove the shields or patches at least once per shift
(during a feeding time) to inspect the eyes for infection or
irritation and to allow eye contact and bonding with
parents
Monitor skin temperature closely
Bronchopulmonary Dysplasia – over expanded lungs
prolonged use of O2
Increase fluids to compensate for water loss
C. HYPERBILIRUBINEMIA
An abnormally high level of Bilirubin in the blood; results to
jaundiced
Monitor the newborn’s skin color with the fluorescent light
turned off, every 4 to 8 hours
Physiological jaundiced – occurs on the second day to
seventh day average increase of 2 mg/dl; not exceeding
12mg/dl
Pathological jaundice
o
Any of the following features are characterized:
▪ Clinical jaundice appearing in the first 24
hours, increases in the level of total
bilirubin by more than 12 mg/dl
▪ Therapy is aimed at preventing
Kernicterus, which results in permanent
neurological damage resulting from the
deposition of bilirubin in the brain cells
Causes:
●
●
●
●
Management
Phototherapy
●
Use of intense florescent lights to reduce serum
bilirubin levels
●
Use of blue lights overhead or in blanket – device
wrapped around infant
●
Possible complications / Injury from treatment, such
as:
o
Eye damage
o
Dehydration
o
Sensory deprivation
Vascular disorder involving gradual replacement of retina
by fibrous tissue and blood vessels
Oxygen administration should never be more than 40%
unless hypoxia is documented
a. Any premature newborn who required oxygen
support should be schedule for an eye
examination before discharge to assess for
retinal damage
-
Maternal diabetes
Medications
Immaturity of the liver
Rh or ABO incompatibility
Infections
Birth trauma
Expect loose green stools and green urine
Monitor the skin for bronze baby syndrome, grayishbrown discoloration of the skin
Reposition newborn every 2 hours.
Provide stimulation
After treatment, continue monitoring for signs for
hyperbilirubinemia, because rebound elevations are
normal after therapy is discontinued
Turn off phototherapy lights before drawing blood
specimen for serum bilirubin levels and avoid allowing
blood specimen to remain uncovered under fluorescent
lights (to prevent the breakdown of bilirubin in the blood
specimen)
Monitor the presence of jaundice; assess skin and sclera
for jaundice
o
Examine the newborn’s skin color in natural light
o
o
Press finger over a bony prominence or tip of the
newborn’s nose to press out capillary blood from the
tissues.
Jaundice starts at the head first, speads to the chest,
abdomen, and then the arms and legs, followed by
the hands and feet.
-
Keep newborn well hydrated to maintain blood volume
Facilitate early, frequent feeding to hasten passage of
meconium and encourage excretion of bilirubin
Report to the physician any signs of jaundice in the first 24
hours of life and any abnormal S&S
Prepare for phototherapy, and monitor closely during the
treatment
-
-
D. MECONIUM ASPIRATION SYNDROME
Occurs when infants take meconium into their lungs
during or before delivery
Occurs in term or post-term infants
o
During fetal distress, there is increased intestinal
peristalsis, relaxing the anal sphincter and releasing
meconium into the amniotic fluid
o
Aspiration can occur in utero or with the first breath
Meconium can block the airway partially or completely and
can irritate the newborn’s airway, causing respiratory
distress
Assessment
Respiratory Distress is present at birth:
▪ Tachypnea
▪ Cyanosis
▪ Retractions
▪ Nasal flaring
▪ Grunting
▪ Crackles and ronchi may be present
▪ Infant’s nails, skin and umbilical cord may be stained a
yellow-green color
▪
▪
▪
▪
▪
-
-
-
Assessment Findings
often does not have specific sign of illness
▪ Poor feeding
▪ Irritability
▪ Lethargy
▪ Pallor
▪ Tachypnea
▪ Tachycardia
▪ Abdominal distention
▪ Temperature instability – difficult keeping temperature
within normal range
-
Diagnosis
Blood, urine, and cerebrospinal fluid cultures
Routine CBC, urinalysis fecalysis
Radiographic test
Management
Intensive antibiotic therapy
IV fluids
Respiratory therapy
Nursing Interventions
Routine newborn care with special emphasis on the following:
1. Monitor vital signs, assess for periods of apnea or
irregular respirations
2. Administer oxygen as prescribed
3. Provide isolation as necessary. Monitor and limit visitors
4. Handwashing before after handling neonate
F.
Causes and Risk Factors
Common to post mature
Maternal history of diabetes
Hypertension
Difficult delivery
Poor intrauterine growth
Management
Suctioning must be done immediately after the head is
delivered before the first breath is taken; vocal cords
should be viewed to see if the airway is clear before
stimulation and crying
Extracorporeal membrane oxygenation (ECMO)
o
Cardiopulmonary bypass to support gas
exchange allows the lungs to rest
Contributing factors:
o
Prolonged rupture of membranes
o
Prolonged or difficult labor
o
Maternal infection
o
Cross contamination
o
Aspiration
SUDDEN INFANT DEATH SYNDROME (SAS)
Sudden death of any young child that is unexpected by
history and which thorough post-mortem examination fails
to demonstrate adequate cause of death
Usually occurs during sleep
Diagnosis is made after autopsy
High incidence in preterm infants, infants with
abnormalities in respiration
Unknown cause: may be related to brainstem abnormality
in the neurological regulation of cardio-respiratory control
1.
2.
3.
4.
5.
Nursing role
Care is directed at supporting parents/ family
Provide a room for the family to be alone
Reinforce that death was not their fault
Provide appropriate support referrals
Explain how parents can receive autopsy results
Prevention
Infants should be placed in the supine position for sleep
o
Soft moldable mattresses and bedding, such as
pillows or quilts, should not be used for bedding
o
Stuffed animals should be removed from the
crib when the infant is sleeping
o
Discourage bed sharing (sleeping with an adult)
o
Home apnea monitor to infant with near miss
SIDS
Nursing Interventions
Focuses on:
Observing neonates respiratory status closely
Ensuring adequate oxygenation
Administration of antibiotic therapy
Maintain thermoregulation
-
E. SEPSIS
Generalized infection resulting from the presence of
bacteria in the blood
Major common cause is group B beta-hemolytic
streptococci
**hemolytic can rupture RBC
Kernicterus
▪ If untreated, hyperbilirubinemia can result to kernicterus or
the deposition of bilirubin in the brain
▪ Usually occurs if the bilirubin level are 25 mg/dl or higher
in term infants
▪ Toxicity starts at 8-12 mg/dl in sick or low birth weights
PEDIATRICS CONCEPT
HIGH RISK: INFANT
_________________________________________________________________________________________________________
OUTLINE
Common Health Problem
During Infancy:
A. Failure to Thrive
B. Hydrocephalus
C. Spina Bifida
D. Meningitis
E. Seizure
F. Otitis Media
G. Cleft Lip and Palate
H. Esophageal Atresia/
Tracheoesophageal
Fistula (TEF)
I.
J.
K.
L.
M.
N.
O.
P.
Hypertrophic Pyloric
Stenosis
Hirschsprung’s
Disease
Intussusception
Imperforate Anus
Displaced Urethral
Openings
Down Syndrome
Autism
Attention Deficit
Hyperactivity Disorder
▪
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COMMON HEALTH PROBLEMS DURING INFANCY
A. FAILURE TO THRIVE
A condition in which a child fails to gain weight and is
persistently less than the fifth percentile on standard
growth chart
Persistent deviation from established growth curve
Delay in physical growth and weight gain might lead to
cognitive impairment or even death
4 Principal Factors for Human Growth
1. Food
2. Rest and activity
3. Adequate secretions of hormones
4. Satisfactory relationship with care giver
Classified as:
1. Organic (OFTT) – due to pathologic condition such as
problem in absorption and hormonal dysfunction
2. Nonorganic (NFTT) – due to psychosocial factor
disrupted maternal child relationship
** lack of food, mother can’t provide, not enough formula milk and
not enough money to buy, or mother refuse to bre
3. Idiopathic (IFTT) – unexplained by the usual organic and
environmental etiologies but usually classified as NFTT
**A thorough history is the best guide to establishing the etiology of
the failure to thrive
**Poverty is the greatest single risk factor worldwide and in the US
**Nutritional deficiency is the fundamental cause
▪
▪
▪
▪
▪
▪
▪
Assessment findings
Poor muscle tone, loss of subcutaneous fats, skin
breakdown
Rumination – common characteristic voluntary
regurgitation
Lethargic – unresponsive
Positive delay in G and D
Signs of disturbed maternal-child interaction
Diminished or nonexistent crying
Radar gaze – wide eyed gaze and continual scan of
environment
▪
▪
▪
▪
Characteristics of The Individual Providing Care
Difficulty perceiving and assessing the infant’s needs
Frustrated and angered at the infant’s dissatisfied
response
Frequently under stress and in crisis, with emotional,
social and financial problems
All children with failure to thrive need additional calories
for catch-up growth
Treatment depends on the cause
Medical disorder – specific treatment is given
Parent-child relationship – family counseling
Nutritious, high-calorie feedings
▪
▪
▪
▪
▪
▪
Nursing Interventions
Provide consistent caregiver
Provide sufficient nutrients
Make feeding a priority intervention
Keep an accurate record of intake
Weigh daily
Introduce positive feeding environment
▪
▪
▪
▪
Establish a structured routine
Hold the young child for feeding
Maintain eye to eye contact
Maintain a calm, even temperament
Provide a quiet, non-stimulating environment
Talk to child giving appropriate directions and praise for
eating
Increase stimulation appropriate to the child’s present
developmental level
Provide the parent an opportunity to talk
When necessary, relieve the parent of childrearing
responsibilities until able and ready emotionally to support
the child
Demonstrate proper infant care by example, not lecturing
Supply the parent with emotional support with fostering
dependency
Promote the parent’s self-respect and confidence by
praising achievements with child
B. HYDROCEPHALUS
An imbalance of CSF absorption or production
Caused by: malformations, tumors, hemorrhage,
infections, or trauma
Results in head enlargement and increased ICP
1.
2.
▪
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▪
▪
▪
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Types
Communicating – occurs as a result of impaired
absorption within the subarachnoid space
** no obstruction but there is still increased pressure
Non-communicating – blockage in the ventricular
system that prevents CSF from entering the subarachnoid
space
** obstruction occurs
Assessment
Increased head circumference
Thin, widely separated bones of the head that produce a
cracked pot sound (Macewen’s Sign) on percussion
Anterior fontanel tense, bulging, and non-pulsating
Dilated scalp veins
Sun setting eyes
Behavior changes, such as irritability and lethargy
Headache on awakening
Nausea and vomiting
Ataxia – lack of coordination of the muscle movement
Nystagmus—involuntary movement of the eye
Late signs: high, shrill cry and seizures
▪
Diagnostic tests
CT scan
MRI – for tumors, thorough detailed view of the area
Skull x-ray – changes in formation lng ang Makita
Transillumination – holding a bright light such as a
flashlight or specialized light (Chun gun) against the skull
in a darkened room
A skull filled with fluids rather than solid brain substance
-
Management
Depends on the cause
▪
▪
▪
▪
Surgical Interventions
Goal: Prevent further CSF accumulation by bypassing the blockage
and draining the fluid from the ventricle to a location where it may be
reabsorbed
Ventriculoperitoneal shunt
o
Relieves the pressure in the brain
o
The CSF drains into the peritoneal cavity
Atrioventricular shunt
o
Enables the fluid to pass through -o
CSF drains into the right atrium of the heart
Acetazolamide (Diamox)
o
Promote the excretions of excess fluids
▪
Pre-operative Interventions
Give SFF as tolerated until a preoperative NPO status is
prescribed
§
§
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Reposition head frequently and use an egg crate mattress
under the head to prevent pressure sores
Prepare the child and family for diagnostic procedures and
surgery
Post-operative Interventions
Monitor VS and neurological signs
Position the child on the unoperated side
Observe for signs of increased ICP elevate head 15-30
degrees
Monitor for signs of infection
Measure head circumference
Provide comfort measures; expected level of functioning
Administer medications as prescribed, diuretics,
antibiotics, or anticonvulsants
Instructions on parents re: wound care, shunt revision
Availability of support groups; community agencies
Instruct the parents on how to recognize shunt infection or
malfunction
In an infant, irritability, lethargy, and feeding poorly
In a toddler, headache and a lack of appetite
In older children, an alteration in the child’s level of
consciousness
C. SPINA BIFIDA
A CNS defect results from failure of the neural tube to
close during embryonic development generally in the
lumbosacral region
Taking folic acid decrease incidence of neural tube defect
Causes
▪
▪
▪
▪
1.
2.
-
Actual cause is unknown; multiple factors
Genetic – if a sibling has had neural tube defect
Environmental factors
Medications, viral infection and radiation
Types
Spina Bifida Occulta
Posterior vertebral arches fail to close in the
lumbosacral area
Spinal cord and meninges remains in the normal
anatomic position
Defect may not be visible
Dimple or a tuff of hair on the spine
Asymptomatic may have slight neuromuscular
deficits
No treatment if asymptomatic aimed at specific
symptoms
Spina Bifida Cystica
Protrusion of the spinal cord and/or its meninges with
varying degrees of nervous tissue involvement
a. Meningocele
part of spinal protrudes through opening in
the spinal canal
Sac is covered with thin skin no nerve
roots involved
No motor or sensory loss
Good prognosis after surgery
b. Myelomeningocele (meningomyelocele)
with spinal nerves roots in the sac
Have sensory or motor deficit
Below site of the lesion
80% have multiple handicaps
Assessment
Depends on the spinal cord involvement
1. Visible spinal defect
2. Motor/sensory involvement
a. Flaccid paralysis of the legs
b. Altered bladder and bowel function
c. Hip and joint deformities
d. Hydrocephalus
3. Prenatal – ultrasound, amniocentesis
4. Post-natal
X-ray of spine
CT scan
Myelogram – uses a special dye and an x-ray
(fluoroscopy) to provide a very detailed picture
of the spinal cord and spinal column
Encephalogram
Urinalysis, BUN, Creatinine clearance
Management
Surgery
Closure of sac within 48 hours
Shunt
Orthopedic
Drug therapy
Antibiotic
Anticholinergic
Nursing Management
1. Prevent trauma to the sac
a. Cover with a sterile, moist (normal saline), nonadherent dressing
b. Change the dressing every 2 to 4 hours as
prescribed, keep area free from contamination
c. Place in a prone position to minimize tension on the
sac
d. Head is turned to one side for feeding
e. Administer meds
2. Prevent complication
a. Use aseptic technique to prevent infection
b. Assess the sac for redness, clear or purulent
drainage, abrasions, irritation and signs of infection
c. Clean intermittent catheterization
d. Perform neurological assessment
e. Assess for physical impairments such as hip and joint
deformities
3. Provide adequate nutrition
4. Provide sensory stimulation
5. Provide emotional support to parents and family
6. Provide discharge teachings
a. Wound care
b. ROM, PT
c. Signs of complications
d. Medication regimen
e. Positioning – feeding, diaper change
D. MENINGITIS
Inflammations of meninges of the brain and spinal cord
Cause by bacteria, viruses, other microorganism as a
primary disease or as a result of complications of
neurosurgery, trauma, infection of the sinus or ears, or
systemic infections
H Influenzae Meningitis – the most common form in the
upper respiratory area between 6 to 12 months
1.
2.
-
▪
▪
▪
▪
▪
▪
Types
Bacterial meningitis
1Haemophilus influenza type B, streptococcus
pneumonia, or Neisseria meningitis
Viral meningitis
is associated with viruses such as mumps, herpesvirus,
and enterovirus
Assessment
Stiffness around the neck
Fever, chills, headache
High pitched cry, irritability
Vomiting, poor feeding or anorexia
Bulging anterior fontanel in the infant
Signs of meningeal irritations
o
Nuchal rigidity – stiff neck
o
Positive kernig sign – severe stiffness of the
hamstring muscle causes an inability to
straighten the leg when the hip is flexed to 90
degree
o
Opisthotonos
a. arching of the back
b. head and heels bent backward
c. and body arched forward
o
Brudzinski sign – flexion at the hip in response
to forward flexion of the neck
Signs of Meningeal Irritations
Nuchal rigidity – stiff neck
Positive kernig sign
Severe stiffness of the hamstring muscle causes
an inability to straighten the leg when the hip is
flexed to 90 degrees
▪ Opisthotonos
Arching of the back
Head and heels bent backward and body
arched forward
▪ Brudzinski sign – flexion at the hip in response to forward
flexion of the neck
▪
▪
●
●
●
●
●
●
●
●
●
●
Effects on the Body of Meningitis in Infants
Fever
Turning away from lights
Stiff neck
Arching of the back
Pin-prick rash
Extreme sleepiness bulging fontanel
Irritability, crying, seizures
Shivering
Refusing to feed vomiting
Cold hands and feet
Diagnosis
CSF testing obtained by lumbar puncture
Lumbar Tap
CT Scan
Management/ Interventions
Provide isolation and maintain it for at least 24 hours after
antibiotics are initiated
Administer antibiotics and antipyretics as prescribed
Perform neurological assessment and monitor for seizures
and complications
Assess for changes in level of consciousness and
irritability
Monitor intake and output
Assess nutritional status
Determine close contacts of the child with meningitis
because the contacts will need prophylactic treatment
Meningococcal vaccine is recommended to protect
against meningitis
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
E. SEIZURE
Recurrent sudden changes in consciousness, behavior,
sensations and or muscular activities beyond voluntary and
control cause by excess neuronal discharge.
Normally the neuron send out messages in electrical
impulses periodically and the firing individual neuron is
regulated by an inhibitory feedbaclk loop mechanism
With seizures many more neurons than normal fire in a
synchronous fashion in a particular area of the brain; the
energy generated overcomes the inhibitory feedback
mechanism
Febrile seizures is common in children between 6 months
to 3 years old
the person recovered from seizure; sudden
onset
▪
▪
▪
ENCEPHALITIS
**common cause is virus
--inflammation sa meninges
Contributing factors: seizure disorder
1. Intracranial infection
2. Space occupying lesion
3. CNS defects
1.
2.
3.
4.
1.
2.
Assessment
Restlessness / irritability
Body stiffens and loss of consciousness
Clonic movements – quick, jerking movements of arms,
legs, and facial muscle
Pupils dilate and roll up
Treatment
Drug therapy
a. Diazepam
b. Phenobarbital
c. Dilantin
Diagnostic test:
Blood studies:
To rule out lead poisoning
Hypoglycemia
Infection
Electrolytes imbalance
EEG – to detect abnormal wave
Surgery
Tumor
Hematoma
Interventions
Reduce fever with antipyretics
Give prescribed medication
Generalized seizure precautions
Do not restrain; pad crib rails; do not use tongue blade
Febrile Seizure
Common in 5% of population under 5 years old, familial
Nonprogressive, does not generally result in brain damage
Seizures occur only when fever is rising
o
commonly associated with high fever- 38.9 to
41.1 celsius
some appear to have a low seizures threshold and convulse
when a fever of 37.8 to 39.8
Classification:
1. Partial Seizure
a) Simple – localized motor activity
shaking of arm or leg limited to one
side of the body
b) Complex – psychomotor seizure
memory loss and staring non
purposeful movements
AURA – sensation that signal an attack
After – sleep or confuse; unaware of the seizure
2. Generalized
a) Tonic – clonic
●
Prodromal
●
AURA
●
Tonic
–
muscular
contractions
●
Post ictal
b.) Absence – rarely 20 seconds stares
straight, does not fall
Status Epilepticus
– severe type; keep on seizure without interruption for 5
minutes
**aura – warning
**tonic - starts at one side but sometimes start on both
sides; occur while person is standing; more
on muscular that is prolonged
**post ictal – generalized type of seizure; last for
second, minutes, hours, days (important to
note the duration of seizure); the time where
Absence – abrupt lapses of consciousness
lasting a few seconds
Atonic – abrupt, unexpected loss of muscle tone
Myoclonic – rapid short contractions of one or all
extremities
Observe and record the time of seizure, duration, and body
parts involved.
Suction and administer oxygen after the seizure as
required.
Observe the degree of consciousness and behavior after
seizure
Provide rest after the seizure
F.
OTITIS MEDIA
bacterial or viral infection of the middle ear
common in infants and preschoolers
eustachian is shorter, wider, and straighter; thereby,
allowing nasopharyngeal secretion to enter middle ear
more easily
1.
2.
3.
4.
Assessment
Behavior that would indicate pain
Restless and repeatedly shakes the
head . frequently pulls or tugs at
affected ear
**sharp constant pain
Irritability, cough, nasal congestion, fever
Hearing impairment
Purulent discharges
Diagnosis
Examination of ear with otoscope
**reveal bright red bulging eardrum
Culture and sensitivity of ear discharges
Possible Complication
Permanent hearing loss mastoiditis
1.
2.
Management
Antibiotic, analgesics
Myringotomy
Incision into the tympanic membrane
to relieve pressure and drain the fluid
with/without tube
▪
Variable extension from the uvula and soft and hard palate
-
Nursing Diagnosis
Anxiety
Ineffective airway clearance
Risk for injury
1.
2.
3.
4.
5.
Associated Problems
Feeding problems
URTI (Upper Respiratory Tract Infection)
Ear infection
Speech defect, dental malformation
Body image
Postoperative Interventions
Wear earplugs while bathing, shampooing, and swimming
Diving and submerging under water are not allowed
Child should not blow his or her nose for 7 to 10 days after
surgery
Interventions
Encourage fluid intake
Teach the parents to feed infants in upright position, to
prevent reflux
Management
**determine if patient and parents are ready
**Rule of Ten: The infant must weigh 10 lbs, 10 weeks old,
hemoglobin value of 10
1.
Instruct the child to avoid chewing as much as possible
during the acute period because chewing increases pain
Provide local heat and have the child lie with the affected
ear down
Instruct the parents in the appropriate procedure to clean
drainage from the ear with sterile cotton swabs
2.
Instruct the parents
o
Administration of analgesics or antipyretics
o
Administration of the prescribed antibiotics,
emphasizing that the 10 to 14 day period is
necessary to eradicate infective organisms
o
Screening for hearing loss may be necessary
o
Administering ear medications.
▪ Younger than age 3, pull the lobe down
and back
▪ Older than 3 years, pull the pinna up
and back
Nursing Intervention – Pre-operational – Cleft Lip
Feed in upright position in small frequent feedings
Burp frequently
Use large-holed nipples
Use rubber-tipped syringe - if unable to suck
Gavage feeding as ordered
Finish feeding with water
G. CLEFT LIP AND PALATE
Non union of the tissue and bone of the upper lip and
hard/soft palate during embryonic development
Failure of the maxillary and premaxillary processes to fuse
during fetal development
**palate is intact by 10th week / two months of fetal life
Provide emotional support for parents and family
Nursing Intervention – Post-operative – Cleft Lip
Maintain patent airway
Assess color; monitor for frequent swallowing
Etiology
Primarily genetic environmental factors
▪
▪
Viral infection exposure to radiation
Folic acid deficiency teratogenic factors
1.
2.
3.
Assessment
Facial abnormality
Difficulty sucking and swallowing
Milk escapes through nose
**observe because it may cause nutritional deficiency
Surgical correction
▪ Cheiloplasty – correction of cleft done – 2 months
▪ Palatoplasty – cleft palate surgery done – before
speech development allow for palatal changes
that take place within 12-18 months
▪ Logan bar/steri strips – to take tension off on the
sutures
Team approach therapy
▪ Dental and orthodontist
▪ Audiologist
▪ Speech therapist
▪ Pediatrician
Do not place in prone position
Avoid straining suture lines
Use elbow restraints
Resume feedings as ordered
Provide pain control as ordered
1.
2.
Nursing Intervention – Pre-operative – Cleft Palate
Prepare parents to care for child after surgery
Instruct concerning feeding methods and positioning
Nursing Intervention – Post-operative – Cleft Palate
Suction mucus and saliva gently and do not touch the
sutures
Incision Care
o
Clean suture with sterile cotton swab with half
strength hydrogen peroxide followed by saline
o
Apply antibiotic ointment
Do not displace Logan bar
Do not place in prone position. Place in side lying position
Keep spoons, pacifier, straws, away from child’s mouth for
7 to 10 days post op
Assessment
Cleft Lip
▪ Can range from a slight notch to a complete separation from
the floor of the nose
Cleft Palate
▪ Nasal distortion
▪ Midline or bilateral cleft
Elbow Restrain
o
Special Feeder – syringe with rubber tubing into
side of mouth; Breck feeder (to stimulate
breastfeeding)
H.
ESOPHAGEAL ATRESIA / TRACHEOESOPHAGEAL
FISTULA (TEF)
The esophagus terminates before it reaches the stomach,
ending a blind pouch, and/or a fistula is present that forms
an unnatural connection with the trachea
Preoperative Interventions
**TEF (Tracheoesophageal fistula) abnormal development
birth; Abrnormal tube structure
**Esophagus tube connects to stomach
**Trachea passageway of air / windpipe
**Atresia absence of normal opening
▪
▪
▪
▪
during
Types
Type I / A – lower segments of the esophagus are blind
Type II / B – upper end of esophagus opens the trachea;
blind lower segment
Type III / C – upper end blind; lower end connects into
trachea
Type D kulang sa ppt ni maam
The infant may be placed in an incubator or radiant warmer
with high humidity (intubation and mechanical ventilation
may be necessary if respiratory distress occurs)
Upright position
Maintain an NPO status
Regular suctioning
Maintain IV fluids or hyperalimentation as prescribed
Observe closely for:
o
Vital signs: respiratory behaviour
o
Amount of secretions
o
Abdominal distention
o
Skin color
Postoperative Interventions
Monitor respiratory status
Maintain patent airway; continued use of incubator
Clinical Manifestation (3 C’s)
Excessive amount of secretions constant drooling large
secretion from the nose
Intermittent/ Unexplain Cyanosis
Coughs and Chokes
Fluids returns through nose and mouth regurgitation and
vomiting
▪
▪
▪
2.
Maintain IV fluids, antibiotics, and parenteral nutrition as
prescribed
Maintain adequate nutrition – gastrostomy
Monitor intake and output
Monitor daily weight
Abdominal distention
Inspect the surgical site for signs and symptoms of infection
Inability to pass a small catheter through the mouth or nose
into the stomach
Monitor for anastomotic leaks as evidenced by purulent
drainage from the chest tube, increased temperature and
increased white blood cell count
Diagnostic Evaluation
Maternal history of polyhydramnios (excessive amniotic
fluid)
X-ray of abdomen and chest x-ray
X-ray with radiopaque catheter
Observe for signs of stricture at the anastomosis site
(eg poor/refusal to feed, dysphagia, drooling, regurgitated
undigested food)
Management
1.
Suction as needed, change position frequently; avoid
hyperextension of neck
Includes maintenance of:
o
A patent airway prevention of aspiration
pneumonia gastric or blind pouch decompression
supportive therapy surgical repair.
o
Death is likely to occur without surgical
intervention
Drug Therapy
▪ Antibiotics – for respiratory
Surgery
a) Primary repair - esophageal anastomosis
b) Gastrostomy – feeding
c) Esophagostomy – drain secretions
I.
HYPERTROPHIC PYLORIC STENOSIS
Congenital hypertrophy of the circular muscles of the
pylorus in the stomach; the muscle becomes progressively
thickened and elongated with narrowing of the pyloric canal
The stenosis usually develops in the first few weeks of life,
causing projectile vomiting, dehydration, metabolic
alkalosis, and failure to thrive.
**narrowing of lumen; blockage that interferes with the passage of
stomach contents into the small intestine
Assessment
Vomiting that progresses from mild regurgitation to forceful
and projectile vomiting
Vomitus contains gastric contents such as milk or formula,
may contain mucus, may be blood-tinged, and does not
usually contain bile
The disease may be a familial congenital defect or may be associated
with other anomalies, such as Down syndrome and genitourinary
abnormalities.
Peristaltic waves are visible from left to right across the
epigastrium during or immediately following a feeding
Olive-shaped mass in the epigastrium just right of the
umbilicus
On barium enema, string sign can be seen
Dehydration and malnutrition can occur
Electrolyte imbalances can occur
Management
Assessment
Newborn
Failure to pass meconium staining
Fredet-Ramstedt Pyloromyotomy
o
Splits the hypertrophic pyloric muscle down to
the submucusa, allowing pylorus to expand so
that food may pass
Nursing Interventions
Refusal to suck
Abdominal distention
Bile-stained vomitus
Children
Monitor vital signs
Failure to gain weight and delayed growth
Monitor strict intake and output
Abdominal distention
Obtain daily weights
Vomiting
Monitor for signs of dehydration and electrolyte imbalances
Constipation alternating with diarrhea
Feed by gavage
o
Thickened feedings
o
Slowly upright
o
Burp frequently
Ribbon-like and foul-smelling stools
Diagnostic
-
Rectal biopsy
Prepare the child and parents for surgery
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
6.
Pyloromyotomy – Pre-operative
Monitor hydration status
Correct F/E imbalances
NPO
Monitor character of stools
NGT
Pyloromyotomy – Post-operative
Monitor intake and output
Start SFF
Feed slowly upright
Monitor for abdominal distention
Monitor for signs of infection
Instruct parents on wound care, feeding
J.
HIRSCHSPRUNG’S DISEASE
Also known as – Aganglionic megacolon
Absence of ganglion cells (nerve cells) in a portion of the
large intestine
A parasympathetic nerve cells that regulates peristalsis in
the intestine
Absence of the ganglion cells would result to absence
peristalsis and affected colon becomes dilated and filled
with feces and gas
Management
Surgery
1.
Temporary colostomy
▪ A portion of the large intestine is brought through
the abdominal wall to carry stool out of the body
2. Bowel Repair
▪ Dissection and removal of the affected section
with anastomosis of intestine
▪ Abdominal – perineal pull through
Daily Isotonic Enema
Drug Therapy
▪ Antibiotic, stool softeners
Diet Therapy
▪ Low residue diet
**Low fiber diet
1.
2.
3.
4.
Nursing Management
Administer enema as ordered isotonic solution only
Do not treat loose stools – child is constipated
Administer TPN (Total Parenteral Nutrition)
Instruct parents on colostomy care, correct diet
K. INTUSSUSCEPTION
Invagination or telescoping of a portion of the small intestine
into a more distal segment of the intestine
3 times more likely in boys than girls and the common
cause of intestinal obstruction in childhood
Cause is unknown
Factors:
▪
▪
Hyperperistalsis and unusual mobilit of cecum and ileum
Lesion such as polyp, tumor
3.
It is considered a surgical abdominal emergency in children
Mechanical Bowel Obstruction occurs:
o
Intestinal walls press against each other causing
inflammation, edema and decreased blood flow
o
May progress for necrosis; perforation and peritonitis
gangrene of the bowel
1.
2.
3.
4.
5.
6.
7.
o
1.
2.
o
o
o
o
1.
2.
3.
4.
Clinical Presentation
Sudden onset of abdominal pain (in a healthy baby)
Infant cries out sharply and draws knees up to abdomen
Vomiting occurs and increases overtime (bile stained
vomitus)
Currant jelly stoll
Signs of shock
o
rapid weak pulse
o
pallor
o
marked sweating
+ for occult blood in stools
Sausage-shaped mass in RLQ
Diagnosis
Often based on history and physical examination alone
Barium enema
X-ray that detects changes in intestine and colon
Is definitive (in 75% of cases)
Therapeutic and curative in most cases with less than 24hour duration
Nursing Manangement
Provide routine pre and post operative care for abdominal
surgery
Monitor fluid and electrolyte status
Maintain nutrition and hydration
Resume feedings 24hrs post operative
L. IMPERFORATE ANUS
Congenital malformation in which there is no anal opening
or there is structure of the anus
Etiology is unknown
An arrest is embryonic development on 7th to 8th week of
intrauterine life
A membrane remains and blocks the union between the
rectum and the anus
Blind rectal pouch with normal anus
1.
2.
3.
4.
Clinical Presentation
No stool passage within 24 hrs after birth
Meconium stool from other orifice
Only a dimple indicates the site of the anus
Inabiity to insert thermometer
o
o
o
o
Diagnosis
Digital rectal exam
Ultrasound
Abdominal x rays
Wangesteen-rice method
1.
2.
3.
Management: NPO, NGT
Manual dilation
Surgery anoplasty, temporary colostomy
Antibiotics
1.
2.
4.
M. DISPLACED URETHRAL OPENINGS
Procreation may be interfered with in severe cases
Increased risk of urinary tract infection
HYPOSPADIAS
Males: urethra opens on the lower surface of the penis
Females: urethra opens into the vagina
EPISPADIAS
Only in males
Urethra opens on the dorsal surface of the penis
o
o
Nursing Management
If suspected, do not take rectal temperature
Pre operative care
o
Monitor for the presence of stool in the urine and
vagina (indicates a fostula) and report
immediately
o
Administer iv fluids as prescribed
Management
Circumcision is delayed until surgical repair
Surgical repair – meatotomy
N. DOWN SYNDROME
Chromosomal disorder caused by the presence of all or
part of an extra 21st chromosome
It is named after John Langdon Down, the British doctor
who described the syndrome in 1866
The disorder was identified as a chromosome 21 trisomy
Digital rectal exam
Immediate Treatment
IV fluids
NPO status
Diagnostic barium enema
Surgery
Manual reduction of invagination
Resection with anastomosis
Possible colostomy (gangrenous)
Prepare the child and parents for the surgical
procedures, including the potential for colostomy
Post operative care
o
Expose perineum to air
o
Check bowel sound
o
NGT for gastric decompression
o
Change position frequently
o
Oral feeding started gradually as soon as
peristalsis function returned
Instruct the parents to use only a water soluble lubricant
and to insert the dilator no more than 1 to 2cm
o
1.
2.
3.
4.
5.
6.
7.
Assessment
Small head, flat facial profile
Low set ears
Simian creases
40% congenital heart defects
With moderate retardation
Wide space bet 1st – 2nd toes
Lax muscle tone
Interventions
▪ Clearing the nose
▪ Cool mist vaporizer
▪ Chest physiotherapy
▪ Handwashing and avoiding exposure to infection
** when feeding infants and young children, use a small, straight—
handled spoon to push food to the side and back of the mouth
▪ Encourage fluids and food rich in fiber
▪ Constipation results from decreased muscle tone which
affects gastric motility
▪ Provide good skin care because the skin is dry and prone
to infection
▪ Family education – counseling developmental progress
** Keratoconus – thin cone-shaped cornea
** Brushfield – grayish-brownish spot of the outer part of the iris
O. AUTISM
Severe mental disorder beginning in infancy or
toddlerhood
Pervasive developmental disorder
Disorder apparent to the parents before the child is 3
years old
Characterized by:
1. Severe deficit in language, perceptual and motor
development
2. Defective reality testing
3.
Inability to function in social setting
The cause is unknown and the prognosis may be poor
Possible causes:
1. Unsatisfactory mother – child relationship
2. CNS abnormalities
Diagnosis is established based on symptoms and the use of
specialized autism assessment tools
3 categories:
1. Inability to relate with others
2. Inability to communicate
3. Obvious limited activities/ interest
Clinical Presentation
1.
2.
3.
4.
5.
6.
7.
▪
▪
▪
▪
▪
▪
▪
▪
1.
2.
3.
4.
5.
6.
7.
8.
9.
Infant not responsive to cuddling
No eye contact or facial responsiveness
Impaired / no verbal communication
Echolalia – repetition of what you’ve said
Inability to tolerate change
Fascination with movement
Labile moods
Assessment
Bizarre responses to the environment
o
Intense reaction to minor changes
o
Attachment to objects
o
Intensely preoccupied to moving object
Self-absorbed and unable to relate to others
Repetitive hand movement, rocking, and rhythmic body
movement
Hitting, head banging and biting
Music often holds a special interest for them
No delusions, hallucinations or incoherence
Excellent long-term memory
May play happily alone for hours but have temper
tantrums if interrupted
Nursing Interventions
Provide parents/ family with support and information about
the disorder
Assist child with ADL
Promote reality testing
Encouraged the child to develop relationship with another
person
Maintain regular schedule for activities
Provide constant routine for child
Protect from self-injury
Provide safe environment
Provide seizure precaution
P.
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Developmental disorder characterized by inappropriate
degrees of inattention, over activity, and impulsivity
One of the most common reasons for referral of children to
mental health services
Childhood Problems include:
o
Lowered intellectual development
o
Some minor physical abnormalities
o
Sleeping disturbances
o
Behavioral or emotional disorders
o
Difficulty in social relationships
Diagnosis is established based on:
o
Parent and teacher reports
o
Psychological assessments
o
Always on the go cannot sit still
o
Diagnosable by 36 months
o
3 major characteristic revealed before 7 years of age
▪
▪
▪
▪
▪
▪
▪
▪
Assessment
Fidgets with hands or feet or squirms in the seat
Easily distracted with external or internal stimuli
Difficulty with following through on instructions
Poor attention span
Shifting from one uncompleted activity to another
Talking excessively
Interrupting or intruding on others
Engaging in physically dangerous activities without
considering the possible consequences
Therapeutic Management
Environment
o
Construction of stable environment
Special instruction free from
distractions
Fair but firm and set consistent limits
Medications
▪
▪
▪
Interventions
Provide environmental and physical safety measures
Encourage support groups for parents
Administer prescribed medication; some commonly
prescribed medications include:
o
Methylphenidate hydrochloride
(Ritalin)
o
Permoline (Cylert)
Dextroamphetamine sulfate
(Dexedrine)
Inform the child and parents that positive effects of the
medication may be seen within 1 to 2 weeks
o
▪
PEDIATRICS CONCEPT
HIGH RISK: TODDLER
_________________________________________________________________________________________________________
1.)
Emergent Phase
a) Remove the person from the source of burn
▪ Thermal – smother burn beginning with the
head
▪ Smoke inhalation – ensure patent
airway
▪ Chemicals – remove clothing
▪ Electrical – maintain airway, identify
entry and exit route
b) Wrap in dry, clean sheet
c) Assess how and when burn occurred
d) Provide IV route if possible
e) Transport immediately
2.)
Shock Phase
OUTLINE
High Risk Toddlers:
A. Burns
B. Cerebral Palsy
C. Ingestion of Poison
D. Child Abuse
E.
F.
G.
Iron Deficiency
Anemia
Cystic Fibrosis (CF)
Celiac Disease
HIGH RISK TODDLERS
BURNS
−
−
TYPES
a)
An injury to body tissue caused by excessive heat
**Risk for infection, impaired skin integrity
The most severe form of trauma to the integumentary
system
●
●
●
●
●
Caused by flames, flash, scalding (hot liquid),
contact to hot metal grease
Chemical
−
c)
Inhalation or ingestions of acids, alkalines, or
vesicant
Smoke inhalation
d)
−
Damage of nerves and vessels due to electric
current
Full Thickness
▪ All skin layers and nerve endings; may involve
the muscles, tendons, and bones
▪ Little or no pain
▪ Wound is dry, white leathery, or hard
Eschar – the tough, leathery scab that form over moderate
or severe burn area
to
interstitial
3.)
Sign of dehydration
Blood pressure
Tachycardia
Urine Output
Thirst
Diuretic Phase/ Fluid Remobilization
−
Interstitial fluids return to the vascular space
Assessment Findings
●
Elevated BP, increase urine output
4.)
Convalescent – Wound healing
Assessment Focus
1.
2.
Extent of injury, Rule of 9, Lund and Browder
Severity of burn classification
MINOR
●
●
●
Partial thickness (1st / 2nd degree)
o
Less than 10-15% of body surface
Full thickness (3rd degree)
o
Less than 2% of body surface
No burn on area of face, feet, hands or genitalia
MODERATE
▪ Partial thickness (2nd degree)
o
Between 15-25% of body surface
▪ Full thickness less than 10%
o
Smoke inhalation
MAJOR
▪ Partial thickness
Greater than 25% of body surface
▪ Full thickness
Greater than or equal to 10%
**Rule of 9 Percentage of the burn
**Lund and Browder assessing body surface
Phases / Stages of Burns
causing
**Hyperkalemia – cell destruction
**Hypothermia – loss of skin results to inability to regulate body
temperature
CLASSIFICATION ACCORDING TO DEPTH
1. Partial Thickness
a. Superficial partial thickness
▪ Epidermis, painful, erythema, no
vesicles
b. Deep partial thickness
▪ Epidermis/dermis, very painful, fluid
filled vesicles, red, shiny, wet
2.
plasma
Diagnostic Test
●
Hyponatremia
●
Hypoproteinemia
●
Hyperkalemia
−
Fire, gases, superheated air – smoke causes
respiratory tissue damage
Electrical burn
Fluid shift from
hypovolemia
Assessment Findings
Thermal
−
b)
−
▪ Gauze bandage
B.) MODERATE BURNS:
▪ Do not rupture blisters
▪ Analgesia / antipyretic ointment
▪ Warm water and mild soap
▪ Burn dressing – bulky dressing
Relative Percentages of Areas Affected by Growth
C.) SEVERE BURN
▪ Parameters such as:
o
vital signs (heart rate)
o
urine output
o
adequacy of capillary filling
o
sensorium status determine adequacy of fluid
resuscitation
1.
Area
A = ½ of head
B = ½ of one thigh
C = ½ of one leg
Birth
9½
2¾
2½
Age 1 year
8½
3¼
2½
Age 5 year
6½
4
2¾
2.
3.
4.
5.
6.
Relative Percentages of Areas Affected by Growth
Area
A = ½ of head
B = ½ of one
thigh
C = ½ of one leg
Age 10 year
5½
4½
Age 15 year
4½
4½
Adult
3½
4¾
3
3¼
3½
RULE OF NINES
−
a quick way to estimate the extent of burns in adults through
dividing the body into multiples of nine and the sum total of
these parts is equal to the total body surface area injured.
Comparing Open and Closed Burn Therapy
METHOD
DESCRIPTION
ADVANTAGE
DISADVANTAGE
OPEN
Exposed to air; for
superficial
or
body parts prone
to infection
Burn is covered
with nonadherent
gauze;
for
moderate
and
severe
Allow frequent
inspection
of
site
Requires isolation.
Area may scrape
and bleed easily
Provide better
protection from
injury; easier to
turn
and
position child;
allow
more
freedom to play
Changing dressing
is painful’ possibility
of infection
CLOSED
BASIC BURN TREATMENT
A.) MINOR BURNS:
▪ Antibiotic
▪ Analgesic
▪ Ointment
Supportive therapy: Fluid management
▪ Crystalloid solutions: Lactated Ringer
▪ Colloid solutions such FFP (fresh frozen plasma)
– treat low blood clotting
▪ Catheterization
Wound care
Open or closed burn therapy, hydrotherapy
Drug therapy
▪ Topical antibiotic – Silver sulfadiazine
▪ Systemic antibiotics
▪ Tetanus toxoid / HTG – Human Tetanus Globulin
▪ Analgesics – morphine sulfate
Physical Therapy – to prevent disability caused by
scarring, contracture
Surgery
▪ Escharotomy (an incision made into constricting
eschar to restore peripheral blood circulation)
▪ Debridement **removing of tissue
▪ Skin grafting
Other considerations
a. Hand injuries – each individual finger should be
dressed and movement encouraged
b. Facial burns – open technique with ointment use
only
c. Topical antimicrobials – silver sulfadiazine and
sulfamylon – used only for major burns and
should not be used in outpatients
d. Any burn that does not heal in a month should be
referred to a burn surgeon
PARKLAND FORMULA
**to calculate fluid resuscitation
▪ Lactated Ringer (LR)
4cc x weight (kg) x total BSA%
(deliver ½ over first 8 hours; then other ½ over the next 16
hours)
▪ Fresh Frozen Plasma (FFP) **intravenously
0.5cc x weight (kg) x total BSA%
(deliver over the next four hours following fluids)
▪ Maintenance (D5W)
1cc x weight (kg) x total BSA%
Nursing Intervention
1. Provide relief or control of pain
2. Monitor alterations in fluid and electrolytes
3. Promote maximum nutritional status
4. Prevent wound infection
5.
6.
Prevent GI complications
Provide health teachings
CEREBRAL PALSY
−
−
AGE
CEREBRAL PALSY
G. Cannot lift
head; round
back;
stiff
arms
and
flisted hands
Head
falls
back when
he is pulled
to sitting
H.
Round
back; Poor
use of hands
for play; Stiff
legs, pointed
toes
I.
Difficulty
pulling
to
stand,
still
legs, pointed
toes
By
months
3
By
months
6
B. Sits leaning on
hands;
takes
weight on feet
when
help
in
standing
By
months
9
C.
sits
alone,
reaches
out,
supports self when
placed standing
By
months
12
D. Pulls to stand
holding
something, crawls
well
By
months
18
E. Stands and
walks
alone,
moves into and out
of
sitting;
sits
straight, uses both
hands
Neuromuscular disorder characterized by impaired
movement and posture resulting from an abnormality in
the extrapyramidal or pyramidal motor system
A chronic nonprogressive motor dysfunction caused by
damage to the motor control centers of the developing brain
and can occur during:
▪ Pregnancy – about 75%
▪ Childbirth – about 5%
▪ After birth – 15% up to about age of three
Etiology
a. Prenatal – genetic, mother with rubella, accidents, PIH
b. Perinatal – drugs at delivery, precipitate delivery, breech
deliveries
c. Postnatal – kernicterus, head trauma (falls out of crib, car
accidents)
NORMAL
DEVELOPMENT
A. Lies straight on
stomach;
holds
head up well;
pushes up arms
lies
on
back;
brings two hands
together
The most common cause of Cerebral Palsy is premature
birth or low birth weight
TYPES OF CEREBRAL PALSY
▪ Spastic – tense, contracted muscles (most common type
of CP)
▪ Athetoid – constant, uncontrolled motion of limbs, head,
and eyes
▪ Ataxic – poor sense of balance, often causing falls and
stumbles
▪ Rigidity – tight muscles that resist effort to make them
move
▪ Tremor – uncontrollable shaking, interfering with
coordination
CHARACTERISTIC ACCORDING TO BODY’S TOPOGRAPHIC
RESPONSE
▪ Arm and Leg on One Side (Hemiplegic)
Arm bent; hand spastic or floppy, often or little use
She walks on tiptoe or outside of foot on affected side
Other side is completely or almost normal
▪
▪
Both legs only (Paraplegic) or with slight involvement
elsewhere (Diplegic)
Upper body usually normal or with very minor
signs
Child may develop contractures of ankle and feet
Both arms and both legs (Quadriplegic)
When he walks, his arms, head and even his
mouth may twist strangely
Children with all 4 limbs affected often have such
severe brain damage that they never are able to
walk
The knees press together
Legs and feet turned inward
Child may develop contractures of ankle and feet
F. Still legs;
cannot
lift
head; cannot
push on arms
J. One arm
stiff and bent;
Tiptoe
walking
on
one side poor
standing
balance
K. Pushes
back head
to one side;
one
arm
and
leg
bent,
the
other arm
and
leg
straight;
cannot
bring hands
together
L.
Tiptoe
standing;
arms
pull
back
stiff
legs which
are crossed
like scissors
M. Does not
take weight
on
legs;
poor head
lifting
N. Cannot
crawl, uses
only
one
side of the
body
or
drags self
by
only
using
O.
Uses
mostly one
hand
to
play,
one
leg may be
stiff,
sits
with weight
to one side
Patient Care Management
▪ Promotion of optimal rehabilitation in the areas of
locomotion, communication, and the activities of daily living
▪ Correction of associated disabilities
Medical Management
▪ Drug therapy
✔ Antianxiety
✔ Skeletal muscle relaxants
✔ Local nerve block
▪ Speech / audiotherapy
▪ Physical / occupational therapy
▪ Surgical interventions are reserved for the child who does
not respond to more conservative measures or for the child
whose spasticity causes progressive deformity
Nursing Interventions
−
The goal of management is early recognition and
interventions to maximize the child’s abilities
1. A multidisciplinary team approach
2. Assess the child’s developmental level and intelligence
3. Encourage early intervention and participation in school
programs
4. Prepare for using mobilizing devices
5. Encourage communication and interaction with the child on
his or her developmental level rather than chronological
age level
6. Provide a safe environment
7. Assist in ADL
8. Provide safe appropriate toys for the child’s age and
developmental level
9. Position the child upright after meals
10. Administer medications as prescribed to decrease
spasticity
11. Therapy
INGESTION OF POISONS
Poison
−
Common problems are:
▪ Visual defects (strabismus – not properly aligned,
nystagmus – repetitive, uncontrollable movements,
refractory errors – shape of eye does not bend light
correctly; near/far sightedness; astigmatism)
▪ Hearing loss
▪ Speech or language delay
▪ Seizures
▪ Mental retardation
Dorsal Root Rhizotomy
−
−
A procedure where surgeons locate and severe over
activated nerves that control leg muscles
This reduce muscle spasms or improve muscle tone
Clinical Manifestation
1. Alteration in muscle tone: abnormal posturing & movement,
continued primitive reflex response
**note for patient’s history
2. Delay in gross motor skills like sitting, crawling, walking
3. Fine motor coordination may be affacted (self-feeding &
dressing)
4. Other deficits:
▪ Poor vision
▪ Strabismus or nystagmus
▪ Hearing loss
▪ Cognitive impairments
▪ Speech/ language delay
▪ Seizure
▪ Growth problems
Diagnosis: Based on clinical findings
Treatment: There is no cure of Cerebral Palsy
−
Intervention enable the infant & child to achieve the best
movement, locomotion and communication skills as
possible and encourage self sufficiency
−
any substance that is harmful to the body
Ingestion of toxic substances
−
Common agent in childhood
detergents or cleaner and plants
Modes of exposure:
▪ Ingestion
▪ Inhalation
▪ Spray
–
soaps,
Signs and Symptoms
1. GI disturbances
▪ Vomiting
▪ abdominal pain
▪ anorexia
▪ distinctive odor
2.
Respiratory / circulatory disturbances
▪ Collapse
▪ Shock
▪ unexplained cyanosis
3.
CNS manifestation
▪ Confusion
▪ Disorientation
▪ Sudden loss of conic
▪ Convulsion
General Medical Treatment
▪ Elimination of poisons
▪ Antidote administration
▪ General supportive measures
General Interventions
▪ Elimination of poisons
▪ Antidote administration
▪ General supportive measures
1.
2.
Stabilize child’s condition – patent airway
Prevent absorption
cosmetics,
a.
b.
c.
d.
e.
f.
Determine type of substance ingested
Induced emesis – except caustic material ingestion,
comatose, active seizure or lacking gag reflex
syrup of ipecac – assess patient first
gastric lavage
activated charcoal – emergency
cathartic
Provide treatment and prevention information to parents
Incorporate anticipatory guidance related to the
developmental stage of the child
5. Discuss general first aid measures with parents
Methods of Prevention
1. Child proofing the environment
2. Educating parents and child
3. Anticipatory guidance
4. Understanding and applying the principles of G/D
Specific Poisoning
1. Salicylate poisoning = aspirin (2-4 hours; maximum 8
hours), oils of wintergreen
Toxicity begins at doses of 150 – 200 mg/kg
s/s – CNS depression
▪ vomiting
▪ respiratory failure
15 to 19 mcg/dL
20 to 69 mcg/dL
3.
4.
2.
70 mcg/dL or greater
4.
Acetaminophen poisoning = commonly used analgesics
Risk – liver damage
Antidote – mucomyst (N-Acetylcysteine)
S/S – vomiting, liver tenderness, abdominal pain
Lead poisoning – plumbism (near construction)
Toddlers / preschoolers
Lead interferes with red blood cell function
Lead value of 15 ug/dl – health hazard
Symptoms appear when lead level is – 70 ug/dl
Most serious effect is lead encephalitis
Air, soil, water, houses, ceramic cookware,
solder used in metal cans and pipes
Signs and Symptoms
▪ Abdominal complaints
✔ colicky pain
✔ constipation
✔ vomiting
▪ pallor
▪ irritability
▪ loss of coordination
▪ encephalopathy
▪ + lead in the blood
Nursing Action
1. Administer chelating agents
Dimercaprol (BAL in oil)
▪ Not given if allergy with peanuts (prepared in
peanut oil solution)
▪ Edatate calcium disodium (calcium EDTA)
2. Provide nutritional counseling
3. Aid in eliminating environmental conditions that led to lead
ingestion
Level intervention
Less than 10 mcg/ dL
10 to 14 mcg/dL
Reassess or rescreen in 1 year
or sooner if exposure status
changes
Provide family lead education,
follow-up testing, and social
service referral if necessary
Caustic poisoning
Ingestion of strong alkali
May cause burns and tissue necrosis in the mouth,
esophagus, stomach
Pharyngeal edema may cause airway obstruction -intubation might be necessary
CHILD ABUSE
3.
INGESTION OF LEAD
When lead enters the body, it affects the erythrocytes,
bones and teeth, and organs and tissues, including the
brain and nervous system, the most serious
consequences are the effects on the CNS
Chelation therapy
▪ Removes lead from the circulating blood and
from some organs and tissues
Common route is hand to mouth from contaminated
objects or from eating loose paint chips, crayons, or
pottery that contains lead.
Blood lead level test: Used for screening and diagnosis
Provide family lead education,
follow-up testing, and social
service referral if necessary; on
follow-up
testing,
initiate
actions for blood lead level of
20 to 44 mcg/dL
A blood lead level greater than
20mcg/dL is considered acute;
provide coordination of care,
clinical management, including
treatment,
environmental
investigation, and lead hazard
control (the child must not
remain in a lead-hazardous
environment if resolution is
necessary)
Medical treatment is provided
immediately,
including
coordination of care, clinical
mgt,
environmental
investigation, and lead-hazard
control
−
−
Involves emotional or physical abuse or neglect, as well as
sexual exploitation or molestation by caretakers or other
individuals
Problem – related to parent’s limited ability to cope or relate
to the child
−
Also victims of abuse
Emotional Abuse
●
Speech disorders
●
Habit disorders such as sucking, biting, and rocking
●
Psychoneurotic reactions
●
Learning disorders
●
Suicide attempts
Sexual Abuse
●
Torn, stained, or bloody underclothing
●
Pain, swelling, or itching of the genitals
●
Bruises, bleeding, or lacerations in the genital or anal area
●
Difficulty walking or sitting
●
Unwillingness to change clothes or unwillingness to
participate in gym activities
●
Poor peer relations
Physical Abuse
●
Unexplained bruises, burns, or fractures
●
Bald spots on the scalp
●
Apprehensive child
●
Extreme aggressiveness or withdrawal
●
Fear of parents
●
Lack of crying (older infant, toddler, or young preschool
child) when approached by a stranger
Physical Neglect
●
Inadequate weight gain
●
Poor hygiene
●
Consistent hunger
●
Inconsistent school attendance
●
Constant fatigue
●
Reports of lack of child supervision
●
Delinquency
Goal of Care
1. Client will be safe
2. Child will participate with nurse for emotional support
3. Parents will participate in therapy
Nursing Interventions
1. Attend to the needs of the child
2. Report suspected child abuse case to appropriate agency
3. Provide role models for parents
4. Encourage parents to be involved in child’s care
5. Encourage parents to express their feelings
6. Provide family education
7. Initiate referrals for long term follow-up
CHILD ABUSE: Interventions
1. Support the child during a thorough physical assessment
2. Assess injuries
3. Report case of suspected abuse; nurses are legally
required to report all cases of suspected abuse to the
appropriate local/state agency
4. Place the child in an environment that is safe, thereby
preventing further injury
5. Document information related to the suspected abuse in an
objective manner
6. Assess parent’s strengths and weaknesses, normal coping
mechanisms and presence or absence of support systems
7. Assist the family in identifying stressors, support systems
and resources
8. Refer the family to appropriate support groups
9. If shaken baby syndrome is suspected, monitor the infant’s
level of consciousness
IRON DEFICIENCY ANEMIA
−
Causes
▪
▪
▪
▪
Iron stores are depleted, resulting in a decreased supply of
iron for the manufacture of hemoglobin in RBC
Blood loss
Increased metabolic demand
Syndromes of GI malabsorption
Dietary inadequacy
More common in:
▪ Child bearing women
▪ Poor iron intake
▪ Infants and children in rapid growth
▪ Pregnant / lactating mothers
Assessment
▪ Compensatory tachycardia
▪ Pallor
▪ Weakness, fatigue, irritability
▪ Lab results
Etiology
▪ Decreased production of RBCs
−
▪
▪
−
Effects of Tissue Hypoxia
▪ Pale skin, mucus membranes, lip, nail beds & conjunctiva
▪ Impaired healing and loss of skin elasticity
▪ Thinning & early greying of the hair
▪ Abdominal pain, N/V, anorexia
▪ Low grade fever
Treatment
Twofold:
1. Correction of the underlying problem responsible of iron
deficiency
2. Replacement of depleted iron stores
Management
▪ Food choices: meats, dark green & leafy vegetables, egg
yolks, liver, kidney beans, iron-enriched formula & cereal
▪ Administer iron supplements as prescribed
▪ Teach parents to administer iron supplements:
Between meals
Give with Vit.C
Do not give with antacids or milk
Oral care
Side effects
▪ Monitor signs and symptoms of bleeding
▪ Adequate rest periods
▪ Explanation of all diagnostic test
CYSTIC FIBROSIS (CF)
−
−
−
−
IDA
−
Aplastic anemia
Increase destruction of RBCs
−
Sickle cell anemia
−
IDA
−
Thalassemia
Blood loss
Most common cause of IDA
▪ Inadequate intake of dietary iron in the first few years of life
& adolescence
▪ Blood-school age
▪ In third world country- hookworms
Diagnosis
▪ Based on history
▪ Clinical presentation
▪ Laboratory data
2.
May experience symptoms of moderate anemia
during exertion
Moderate Anemia
▪ Effects on compensatory mechanism
−
3.
The mucus produced by the exocrine glands is abnormally
thick, tenacious and copious, causing obstruction of the
small passageways of the effected organs, particularly
in the respiratory, gastrointestinal, and reproductive
system
A fatal genetic disorder and respiratory failure is the most
common cause of death
There is also a marked electrolytes change in the
secretions of sweat glands
The most common symptoms are:
▪ Pancreatic enzyme deficiency caused by duct blockage
▪ Progressive chronic lung disease associated with infection
and sweat gland dysfunction resulting in increased sodium
and chloride sweat concentrations
Organs Affected by Cystic Fibrosis
The genetic defect underlying cystic fibrosis disrupts the
functioning of several organs by causing ducts or other tubes to
become clogged, usually by thick, sticky mucus or other
secretions
▪
Airways
−
−
−
Generally, asymptomatic
−
A chronic multisystem disorder (autosomal recessive trait
disorder) characterize by exocrine gland dysfunction
Fibrosis – scar tissue
Signs & symptom of Anemia according to severity
1. Mild Anemia
−
Congestive heart failure
▪
Clogging and infection of bronchial passages impede
breathing.
The infections progressively destroy the lungs
Lung disease accounts for most death from cystic
fibrosis
Liver
−
Plugging of small bile ducts impedes digestion and
disrupts liver function in perhaps 5% of patients
Shortness of breath
−
Rapid, pounding heart beat
−
Cardiac murmurs
−
Dizziness, fainting, lethargy, irritability
Severe Anemia
▪ Effects of compensatory mechanism
▪
Pancreas
−
−
Occlusion of ducts prevents the pancreas from
delivering critical digestive enzymes to the bowel in
65% of patients.
Diabetes can result as well
▪
▪
Small intestine
−
Reproductive tract
−
−
▪
Obstruction of the gut by thick stool necessitates
surgery in about 10 % of newborns
Absence of fine ducts, such as the vas deferens,
renders 95%of male infants
Occasionally, women are made infertile by a dense
plug of mucus that blocks sperm from entering the
uterus
Skin
−
−
Malfunctioning of sweat glands causes perspiration to
contain excessive salt (NaCl)
Measurement of chloride in sweat is a mainstay of
diagnosis
▪
Rectal prolapse – due to large, bulky stools and lack of the
supportive fat pads around the rectum (rectum loses its
normal attachment inside the body)
Integumentary system
▪ Abnormally high concentrations of sodium and chloride in
sweat
▪ Parents reporting that the infant tastes “salty” when kissed
▪ Dehydration and electrolyte imbalances, especially during
hyperthermic conditions
Reproductive system
–
Cystic fibrosis: thickened secretions that caused the
blocking
▪ Delay puberty in girls
▪ Infertility (highly viscous cervical secretions)
▪ Sterility – caused by the blockage of the vas deferens by
abnormal secretion or by failure of normal development of
duct structures
Diagnostic tests
1. Quantitative Sweat Chloride Test
−
The most reliable diagnostic test
Pilocarpine – a cholinergic drug that stimulate production
of sweat
**the sweat is collected, and the sweat electrolytes are
measured
Normal – if sweat chloride concentration is 20mEq/L or
lower than 40mEq/L
Chloride concentrations of 50 to 60 mEq/L are highly
suggestive of cystic fibrosis and require a repeat test
A chloride concentration higher than 60 mEq/L is a
positive result
2.
Chest x-ray film
−
3.
Cystic fibrosis
▪ Mucus blocks airways
▪ Mucus blocks pancreatic ducts
▪ Stomach
▪ Pancreas
▪ Pancreatic ducts
▪ Lungs
The four symptoms same with Celiac Disease
▪ Malnutrition
▪ Protuberant abdomen – abdomen sticks out more than
usual
▪ Steatorrhea - increase fat excretion in the stool
▪ Fat-soluble vitamin deficiency (A, D, E, & K)
Respiratory symptoms
▪ Wheezing and dry nonproductive cough
▪ Dyspnea
▪ Cyanosis
▪ Clubbing of the fingers and toes – low blood oxygen
level/cystic fibrosis
▪ Barrel chest – associated with emphysema
▪ Repeated episodes of bronchitis and pneumonia
Gastrointestinal system
▪ Meconium ileus in the neonate – bowel obstruction;
blockage in intestine, meconium is thicker and stickier than
usual
▪ Intestinal obstruction (pain, abdominal distention, nausea
and vomiting)
▪ Steatorrhea (frothy, foul-smelling stools)
▪ Easy bruising and anemia (anemia – check hemoglobin
count)
▪ Malnutrition and failure to thrive
▪ Generalized edema – due to hypoalbuminemia
Pulmonary Function Tests
−
4.
Provide evidence of abnormal small airway function
Stool, Fat, Enzyme analysis
−
5.
Reveals atelectasis (sudden collapse of lungs) and
obstructive emphysema
A 72-hour stool sample is collected to checked that fat
and/or enzyme (trypsin) content (food intake is
recorded during the collection)
Duodenal analysis
−
Nasogastric tube is inserted to aspire duodenal
secretions
Therapeutic Management
1.)
Respiratory system
Goals of treatment include:
−
−
−
a.
b.
c.
Preventing and treating pulmonary infection by
improving aeration
Removing secretions
Administering antimicrobial medications
Chest physiotherapy
Aerosol therapy
●
Bronchodilator
●
Antimicrobial
●
Mucolytic
Use of a Flutter Mucus Clearance Device
−
d.
A small, hand-held plastic pipe with a stainless
steel ball on the side
Use of a ThAIRapy vest device
−
2.)
It provides high-frequency chest wall oscillation
to help loosen secretions
Gastrointestinal system
a.
b.
c.
d.
e.
f.
g.
h.
The goal of treatment for pancreatic insufficiency is to
replace pancreatic enzymes
The amount of pancreatic enzymes administered is
adjusted to achieve normal growth and a decrease in the
number of stools to two or three daily
Enteric-coated pancreatic enzymes should not be crushed
or chewed
Pancreatic enzymes should not be given if the child is NPO
Encourage a well-balanced, high-protein, high-calorie diet;
multivitamins and vitamins A, D, E, and K are also
administered
Assess weight and monitor for failure to thrive
Monitor for constipation and intestinal obstruction
Ensure adequate salt intake and fluids that provide an
adequate supply of electrolytes during extremely hot
weather and if the child has a fever
Home Care
1. Instruct the child and family about the prescribed treatment
measures and their importance
2. Instruct the parents and caregivers to be sure
immunizations are up to date
3. Inform the parents and caregivers that the child should be
vaccinated yearly for influenza; pneumococcus vaccine
may also be prescribed
Diagnosis
▪ Small Bowel Biopsy
▪ Serologic Test
▪ Laboratory Test
Treatment
▪ Lifelong adherence to GLUTEN FREE DIET
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CELIAC DISEASE
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2.
3.
Incidence and etiology;
4.
Incidence varies in different regions and more common in
Europe
A sensitivity or immunologic response to protein,
particularly the gluten factor of protein found in grains of
wheat, barley, rye and oats
Precipitated by infection, fasting, ingestion of gluten
Extreme and acute profuse watery diarrhea and vomiting
occurs
Can lead to electrolyte imbalance, rapid dehydration,
severe acidosis
Intensive therapy to replace fluids and electrolytes is
required
Interventions
A.K.A Gluten-Induced Enteropathy / Malabsorption
Syndrome
Genetic disorder that occurs in all races but most common
to Caucasians
5.
Maintain a gluten-free diet, substituting corn, rice and millet
as grain source
Instruct parents and child about lifelong elimination of
gluten sources such as wheat, rye, oats and barley
Administer mineral and vitamin supplements, including iron,
folic acid and fat-soluble supplements A, D, E & K
Teach the child and parents about a gluten-free diet and
about reading food labels carefully for hidden source of
gluten
Instruct the parents in measures to prevent celiac crisis
Basics of a Gluten-Free Diet
▪ Foods Allowed
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Results in the accumulation of the amino acid-glutamine,
which is toxic to intestinal mucosal cells
Intestinal villi atrophy occurs, which affects absorption of
ingested nutrients
▪
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An inherited condition that prevents the small intestine
from absorbing nutrients, causing malnutrition
What happen?
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Gluten, a protein found in some grains, stimulates
immune system antibodies
Symptoms
▪ Diarrhea
▪ Malnutrition
▪ Weight loss
▪ Skin rash; some people have no symptoms
Microvilli – absorbs nutrients in food
Endothelial cells – covers surface of villi
Villi – tiny projections on inside wall of intestines
Celiac Disease, Endothelial Cells, Villi, Microvilli –
damaged by body’s reaction to gluten
Antibodies attack, damage lining of small intestines
Assessment
1. Acute or insidious diarrhea
2. Steatorrhea
3. Anorexia
4. Abdominal pain and distention
5. Muscle wasting, particularly in the buttocks and extremities
6. Vomiting
7. Anemia
8. Irritability
Meat such as beef, pork and poultry and fish, eggs,
milk and dairy products, vegetables, fruits, rice corn,
gluten-free wheat flour, puffed rice, cornflakes,
cornmeal and precooked gluten-free cereals
Foods Prohibited
Celiac disease
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Nutritional supplement may be use (iron, folate,
calcium, fat soluble vitamins)
Celiac Crisis
1.
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Education about the diet
Commercially prepared ice cream, malted milk,
prepared puddings, grains, including anything made
from wheat, rye, oats, or barley, such as breads rolls,
cookies, cakes, crackers, cereal, spaghetti, macaroni
noodles & beer
Prognosis
▪ Dietary avoidance of gluten results in improvement of
symptoms in 70% of patients within 2 weeks
▪ Serologic antibody titers decrease on a gluten-free diet
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After 3-6 months’ antibody levels may become
undetectable
Complete histological resolution of small bowel
inflammation may take up to 2 years