PEDS Exam 4
Chapter 45
Infectious Disorders
•
Macule-A macule is a flat, distinct, discolored area of skin. It usually does not
include a change in skin texture or thickness
•
Papule-A papule is a solid or cystic raised spot on the skin that is less than 1 centimeter
(cm) wide.
•
Annular-The term “annular” stems from the Latin word “annulus,” meaning ringed. The
lesions appear as circular or ovoid macules or patches with an erythematous
periphery and central clearing.
•
Pruritus-itching
•
Vesicle, pustule-A vesicle is a small fluid-filled blister on the skin. Pustules are small,
inflamed, pus-filled, blister-like sores (lesions) on the skin surface
•
Scaling, plaques-Scales are a visible peeling or flaking of outer skin layers. These
layers are called the stratum corneum. A skin plaque is an elevated, solid, superficial
lesion that is typically more than 1 centimeter in diameter
•
Hypo-, hyperpigmented-Hyperpigmentation is when areas of skin are darker than
normal for your skin tone. It is caused by increased melanin production. In the
opposite way, hypopigmentation occurs when melanin production is lower in certain
areas of your skin, causing patches of lighter-colored skin.
•
Erythematous-Reddening of the skin. Erythema is a common but nonspecific sign of
skin irritation, injury, or inflammation. It is caused by dilation of superficial blood vessels
in the skin.
Infectious Disorders (Bacterial)
Disorder
Nonbullous impetigo:
follows some type of skin
trauma or may arise as a
secondary bacterial infection
of another skin disorder, such
as atopic dermatitis.
Bullous impetigo:
a sporadic occurrence
pattern and develops on
intact skin, resulting from
toxin production by S.
aureus.
Folliculitis:
infection of the hair follicle,
most often results from
occlusion of the hair follicle. It
may occur as a result of poor
hygiene, prolonged contact
with contaminated water,
maceration, a moist
environment, or use of
occlusive emollient products.
Cellulitis:
localized infection and
inflammation of the skin and
subcutaneous tissues and is
usually preceded by skin
trauma of some sort
Periorbital cellulitis is a
bacterial infection of the
eyelids and tissue
surrounding the eye. The
bacteria may gain entry to the
skin via an abrasion,
laceration, insect bite, foreign
body, or impetiginous lesion
Staphylococcal scalded skin
syndrome
Skin Findings
Papules progressing to
vesicles, then painless
pustules with a narrow
erythematous border
Honey-colored exudate when
the vesicles or pustules
rupture, which forms a crust
on the ulcer-like base
• Red macules and bullous
eruptions on an
erythematous base
Usual Treatment
• Limited amount: treat
topically with mupirocin
ointment
• If numerous lesions, oral
first-generation cephalosporin
is indicated
• Clindamycin may be
needed for MRSA
• Remove honey-colored
crust with cool compresses
twice daily
• Oral first-generation
cephalosporin
• Good hygiene
• Size may be from a few
millimeters to several
centimeters
• Red, raised hair follicles
• Treat with aggressive
hygiene: warm compresses
after washing with soap and
water several times a day
• Topical mupirocin is
indicated; occasionally oral
antibiotics are required
• Localized reaction:
erythema, pain, edema,
warmth at site of skin
disruption
Redness, swelling, and
infiltration of the skin by the
inflammatory mediators
occur.
• Flattish bullae that rupture
within hours
• Mild cases are usually
treated with cephalexin or
amoxicillin/clavulanic acid
• More severe cases and
periorbital or orbital cellulitis
require IV cephalosporins
progression to orbital cellulitis
occur: conjunctival redness,
change in vision, pain with
eye movement, eye muscle
weakness or paralysis, or
proptosis.
• Mild to moderate cases are
treated with oral cephalexin,
• Red, weeping surface is
left, most commonly on face,
groin, neck, and axillary
region
CA-MRSA
CA-MRSA most commonly
occurs as a skin or soft tissue
infection, such as cellulitis or
an abscess.
Risk factors for CA-MRSA
are turf burns, towel sharing,
participation in team sports,
or attendance at day care or
outdoor camps.
dicloxacillin, or
amoxicillin/clavulanic acid
• Severe cases are managed
similar to burns with
aggressive fluid management
and IV oxacillin or
clindamycin
If the child presents with a
moderate to severe skin
infection or with an infection
that is not responding as
expected to therapy, it is
important to culture the
infected area for MRSA.
Nursing Assessment




History of skin disruptions
Fever?
Inspect skin noting location, distribution and drainage
Assess for pain
Therapeutic Management
 Therapeutic management of most bacterial skin infections includes topical or systemic
antibiotics and appropriate hygiene.
Nursing Management
 Soak impetiginous lesions with cool compresses or Burow solution to remove crusts
before applying topical antibiotics.
 In children with scalded skin syndrome, reduce the risk of scarring by minimal
handling, avoiding corticosteroids, and applying soothing ointments as the skin heals.
 For periorbital cellulitis, apply warm soaks to the eye area for 20 minutes every 2 to 4
hours. Instruct parents to call the physician or nurse practitioner or have the child
evaluated again if the child is not improving, the child cannot move his eye, proptosis
occurs, or if perceived visual acuity lessens. It can progress to orbital cellulitis.
 Stress the importance of cleanliness and hygiene.
o
Teach the family to keep the child’s fingernails cut short and to clean the nails
with a nail brush at bath time.
o
When a skin disruption such as a cut, scrape, or insect bite occurs, teach the
family to clean the area well to prevent the development of cellulitis.
o
 Folliculitis may be prevented with diligent hygiene and avoidance of occlusive
emollients.
Fungal Infections
Tinea is a fungal disease of the skin occurring on any part of the body.
Disorder
Tinea pedis: fungal infection on
the feet (athlete’s foot)
Skin Findings
Red, scaling rash on soles
and between the toes
Tinea corporis: fungal infection on
the arms or legs (ringworm)
• Annular lesion with raised
peripheral scaling and
central clearing (looks like
a ring)
• Superficial tan or
hypopigmented oval scaly
lesions, especially on
upper back and chest and
proximal arms
Tinea versicolor: fungal infection
on the trunk and extremities
• More noticeable in the
summer with tanning of
unaffected areas
Tinea capitis: fungal infection on
the scalp, eyebrows, or eyelashes
Tinea cruris: fungal infection on
the groin
Usual Treatment
• Topical antifungal cream,
powder, or spray
• Appropriate foot hygiene
• Topical antifungal cream
is required for at least 4
weeks
• Apply selenium sulfide
shampoo all over body
(from face to knees) and
allow to stay on skin
overnight, rinsing in the
morning, once a week for
4 weeks (this may cause
skin irritation)
• Patches of scaling in the
scalp with central hair loss
• Topical antifungals in the
imidazole family may be
used instead
• Oral griseofulvin for 4–6
weeks
• Risk of kerion
development (inflamed,
boggy mass that is filled
with pustules)
• Selenium sulfide
shampoo may be used to
decrease contagiousness
(adjunct only)
• Erythema, scaling,
maceration in the inguinal
creases and inner thighs
(penis/scrotum spared)
• No school or day care for
1 week after treatment
initiated
• Topical antifungal
preparation for 4–6 weeks
Diaper candidiasis (also called
monilial diaper rash)
• Fiery red lesions, scaling
in the skin folds, and
satellite lesions (located
further out from the main
rash)
• Topical nystatin with
diaper changes for several
days
• See section on diaper
dermatitis for additional
information
Nursing Assessment
 Note if exposure to pet or another person with infection (fungi often carried by pets)
 Recent visit to the barber (tinea capitis)
 Note contact with damp areas such as locker rooms and swimming pools, use of nylon
socks or nonbreathable shoes, or minor trauma to the feet (tinea pedis).
 Document a history of wearing tight clothing or participating in a contact sport such as
wrestling (tinea cruris).
 Inspect the skin and scalp, noting the location, description, and distribution of the rash
or lesions
 Scraping and KOH preparation show branching hyphae which will identify fungal
infection.
 For tinea capitis, the Wood lamp will fluoresce yellow-green if it is caused by
Microsporum, but not with Trichophyton.
 A fungal culture of a plucked hair is more reliable for diagnosis of tinea capitis.
Nursing Management
 Tinea corporis is contagious, but the child may return to day care or school once
treatment has begun.
 Counsel the child with tinea capitis and parents that hair will usually regrow in 3 to 12
months. Wash sheets and clothes in hot water to decrease the risk of the infection
spreading to other family members.
 Instruct the child with tinea pedis to keep the feet clean and dry.
o Rinse feet with water or a water/vinegar mixture and dry them well, especially
between the toes.
o Encourage the child to wear cotton socks and shoes that allow the feet to
breathe.
o Going barefoot at home is allowed, but flip-flops should be worn around
swimming pools and in locker rooms.
 Inform the child with tinea versicolor that return to normal skin pigmentation may take
several months.
 Counsel the child or adolescent with tinea cruris to wear cotton underwear and loose
clothing. It is important to maintain good hygiene, particularly after sports practice or a
sporting event.
 For diaper candidiasis, change diaper frequently and allow child to go diaperless.
o Topical products such as ointments or creams containing vitamins A, D, and E;
zinc oxide; or petrolatum are helpful to provide a barrier to the skin.
Acne Vulgaris
 Begins as early as 7 to 12-16 years old.
 Face, chest, back.
 Risk factors for the development of acne vulgaris include preadolescent or adolescent
age, male gender (due to the presence of androgens), an oily complexion, Cushing
syndrome, or another disease process resulting in increased androgen production.
Therapeutic Management
 Therapeutic management focuses on reducing P. acnes, decreasing sebum production,
normalizing skin shedding, and eliminating inflammation.
 Teach the adolescent to cleanse the skin gently twice a day.
 Medication therapy may include a combination of benzoyl peroxide, salicylic acid,
retinoids, and topical or oral antibiotics. Isotretinoin may be used in severe cases.
Nursing Assessment





History of onset of acne.
Determine medication use.
Document any endocrine disorder.
Note presence, distribution, and extent.
Note if happening at time of menstruation.
Nursing Management
 Avoid oil-based cosmetics and hair products, as their use may block pores, contributing
to noninflammatory lesions
 Headbands, helmets, and hats may exacerbate the lesions by causing friction.
 Dryness and peeling may occur with acne treatment.
 Avoid excessive scrubbing and harsh chemical or alcohol-based cleansers.
 Avoid picking or squeezing the lesions.
 Using a noncomedogenic sunscreen with an SPF of 30 or higher is recommended
Classification
Mild acne
Moderate acne
Manifestation
Primarily noninflammatory lesions
(comedones)
Comedones plus inflammatory lesions such
as papules or pustules (localized to face or
back)
Severe acne
Lesions similar to moderate acne, but more
widespread, and/or presence of cysts or
nodules. Associated more frequently with
scarring
Restoring and Maintaining Fluid Volume p1672
 Fluid calculation based on the body surface area burned (Fig. 45.22)
 Use of a crystalloid (Ringer’s lactate) during the first 24 hours; in smaller children, a
small amount of dextrose may be added
 Administration of most of the volume during the first 8 hours (amounts and timing of fluid
volume resuscitation will vary from child to child)
 Reassessment of the child and adjustment of the fluid rate accordingly; fluid
requirements greatly decrease after 24 hours and should be adjusted to reflect this.
 Administration of a colloid fluid later in therapy once capillary permeability is less of a
concern
 Monitoring of the child’s urine output as part of ongoing assessment of response to
therapy, expecting at least 1 mL/kg/hr
 Daily weights obtained at the same time each day (the best indicator of fluid volume
status)
 Monitoring of electrolyte levels (particularly sodium and potassium) for their return to
normal levels
Chapter 46
Preventing Infection in Children Receiving Chemotherapy for Cancer




Practice meticulous hygiene (oral, body, perianal).
Avoid known ill contacts, especially persons with chickenpox.
Immediately notify the physician or nurse practitioner if exposed to chickenpox.
Avoid crowded areas.
 Do not let the child receive live vaccines.
 Do not take the child’s temperature rectally or give medications by the rectal route.
 Administer twice-daily trimethoprim–sulfamethoxazole for 3 consecutive days each week
as ordered for prevention of Pneumocystis pneumonia.
Lymphomas
 Lymphomas, or tumors of the lymph tissue (lymph nodes, thymus, spleen), account for
about 10% to 15% of cases of childhood cancer
Hodgkins disease
o
o
o
o
o
Hodgkin disease tends to affect lymph nodes located closer to the body’s
surface, such as those in the cervical, axillary, and inguinal areas,
There appears to be a link to Epstein–Barr virus infection
Hodgkin disease is rare in children younger than 5 years of age and is most
common in adolescents and young adults; in preadolescents, it is more common
in boys than girls.
Complications of Hodgkin disease include liver failure and secondary cancer
such as acute nonlymphocytic leukemia and NHL.
Chemotherapy, usually with a combination of drugs, is the treatment of choice for
children with Hodgkin disease. Radiation therapy may also be necessary. In the
child with disease that does not go into remission or in the child who experiences
relapse, HSCT may be an option.
Nursing Assessment
o
o
Common signs and symptoms, which may include recent weight loss, fever,
drenching night sweats, anorexia, malaise, fatigue, or pruritus. Elicit the health
history, determining risk factors such as prior Epstein–Barr virus infection, family
history of Hodgkin disease, genetic immune disorder, or HIV infection.
Palpate for enlarged lymph nodes; they may feel rubbery and tend to occur in
clusters (most common sites are cervical and supraclavicular)
Nursing Management
o
o
o
o
o
o
Nursing management of the child with Hodgkin lymphoma focuses on addressing
the adverse effects of chemotherapy or radiation.
Nausea & vomiting
 Antiemetics, smaller meals, hydration
Constipation
 Fiber, laxatives
Diarrhea
 Intake/output, oral and IV hydration, antidiarrheal meds
bleeding risk
 avoid trauma and active play, avoid rectal temp, avoid IM injections.
infection risk
o
 assess temp, cough, pain etc to identify potential infection.
 Maintain meticulous hand hygiene.
 Strictly observe medical asepsis
 Promote nutrition and rest.
Healthy oral mucosa
 Assess for ulcers, lesions, redness, bleeding
 Ice chips
 Soft toothbrush
 Lubricate lips
 No hot, spicy foods, acidic foods.
o
Stage
I
Clinical Findings
One group of lymph
nodes is affected.
II
Two or more groups on
the same side of the
diaphragm are affected.
III
Groups of lymph nodes
above and below the
diaphragm are affected.
IV
Metastasis to organs
such as the liver, bone, or
lungs
A
Absence of systemic
symptoms at diagnosis
Systemic symptoms
present at diagnosis
(fever, night sweats,
weight loss)
B
Non Hodgkin Lymphoma
o
NHL results from mutations in the B and T lymphocytes that lead to uncontrolled
growth.
o
o
o
NHL tends to affect lymph nodes located more deeply within the body. NHL
spreads by the bloodstream and in children is a rapidly proliferating, aggressive
malignancy that is very responsive to treatment.
Ninety percent of children with localized NHL have disease-free long-term
survival after treatment.
Complications include metastasis and the development of a secondary
malignancy later in life.
Nursing Assessment
o
o
o
o
Children with NHL are usually symptomatic for only a few days or a few weeks
before diagnosis because the disease progresses so quickly.
Note onset and location of pain or lymph node swelling.
Document history of abdominal pain, diarrhea, or constipation
Computed tomography (CT) scan, chest radiography, and bone marrow results
may be used to determine the extent of metastasis.
Nursing Management
o As with Hodgkin lymphoma, nursing management of NHL is directed toward
managing the adverse effects of chemotherapy.
o Nausea & vomiting
 Antiemetics, smaller meals, hydration
o Constipation
 Fiber, laxatives
o Diarrhea
 Intake/output, oral and IV hydration, antidiarrheal meds
o bleeding risk
 avoid trauma and active play, avoid rectal temp, avoid IM injections.
o infection risk
 assess temp, cough, pain etc to identify potential infection.
 Maintain meticulous hand hygiene.
 Strictly observe medical asepsis
 Promote nutrition and rest.
o Healthy oral mucosa
 Assess for ulcers, lesions, redness, bleeding




Ice chips
Soft toothbrush
Lubricate lips
No hot, spicy foods, acidic foods.
Chapter 48
Growth Hormone Deficiency
 GH deficiency, also known as hypopituitarism or dwarfism, is characterized by poor
growth and short stature. GH is vital for postnatal growth.
 Children may start with a normal birth weight and length, but within a few years, the child
is less than the third percentile on the growth chart.
Therapeutic Management
 Treatment of primary GH deficiency involves the use of supplemental GH. Secondary
GH deficiency requires removal of any tumors that might be the underlying problem,
followed by GH therapy.
 Biosynthetic GH, derived from recombinant DNA, is given by subcutaneous injection.
 The goal of growth promotion is for the child to demonstrate an improved growth rate, as
evidenced by at least 3 to 5 in in linear growth in the first year of treatment without
complications.
 Treatment stops when the epiphyseal growth plates fuse.
Nursing Assessment
 The focus of the evaluation for GH deficiency is to rule out chronic illnesses such as
renal failure, liver disorders, and thyroid dysfunction
o Bone age (as shown by radiographs) will be two or more deviations below
normal.
o or MRI scans rule out tumors or structural abnormalities.
o Pituitary function testing confirms the diagnosis. This test consists of providing a
GH stimulant such as glucagon, clonidine, insulin, arginine, or L-dopa to
stimulate the pituitary to release a burst of GH. Peak GH levels below 7 to 10
ng/mL in at least two tests confirm the diagnosis.
 Physical exams, health history, growth chart
Nursing Management
 Promote growth, enhance self esteem associated with short stature, and provide
appropriate education about this disorder.
 3-5 inches of growth shows an improved growth rate.
 Emphasize the child’s strengths and assets.
 Explain how to prepare the medication and give the correct dosage. Encourage rotation
of sites
Precocious Puberty
 In precocious puberty, the child develops sexual characteristics before the usual age of
pubertal onset
 Secondary sex characteristics develop in girls before the age of 8 years and in boys
younger than 9 years.
 The disorder is more common in females and the majority of the time the cause is
unknown in females, while in males a structural CNS abnormality is often present.
 Other causes include benign hypothalamic tumor, brain injury or radiation, a history of
infectious encephalitis, meningitis, congenital adrenal hyperplasia (CAH), and tumors of
the ovary, adrenal gland, pituitary gland, or testes.
 overproduction of sex hormones. The condition results in increased end-organ sensitivity
to low levels of circulating sex hormones and leads to premature pubic hair and breast
development.
 If left untreated, the child may become fertile. In addition, the hormones stimulate rapid
growth. Therefore, the child may appear taller than peers but will reach skeletal maturity
and closure of the epiphyseal plates early, which results in overall short stature
Therapeutic Management
 The clinical treatment for precocious puberty first involves determining the cause. For
example, if the etiology is a tumor of the CNS, the child undergoes surgery, radiation, or
chemotherapy.
 The treatment for central precocious puberty involves administering a GnRH analog.
 This analog stimulates gonadotropin release initially but when given on a long-term basis
will suppress gonadotropin release.
 The overall aim of treatment is to halt or even reverse sexual development and rapid
growth as well as promote psychosocial well-being.
 When treatment is discontinued, puberty resumes according to appropriate
developmental stages.
Nursing Assessment
 Health history may indicate headache, and other difficulties as well as visual problems
due to circulating hormones.
 Risk factors may reveal exposure to exogenous hormones, history of CNS trauma or
infection, or a family history of early puberty.
 Physical examination may show The Tanner staging of breasts, pubic hair, and genitalia
reveals advanced maturation and acne with adult body odor.
 Radiologic examinations and pelvic ultrasound identify advanced bone age, increased
uterus size, and development of ovaries consistent with the diagnosis of precocious
puberty.
 Laboratory studies include screening radioimmunoassays for LH, FSH, estradiol, or
testosterone. The child’s response to GnRH stimulation confirms the diagnosis of central
precocious puberty versus gonadotropin-independent puberty.
Nursing Management
 In general, nursing management of the child with precocious puberty focuses on
educating the child and family about the physical changes the child is experiencing and
how to correctly use the prescribed medications and helping the child to deal with selfesteem issues related to the accelerated growth and development of secondary sexual
characteristics
Diabetes Insipidus
 Central DI results from a deficiency in the secretion of ADH
 With a deficiency in ADH, the kidney loses massive amounts of water and retains
sodium in the serum.
 Central DI is characterized by excessive thirst (polydipsia) and excessive urination
(polyuria) that is not affected by decreasing fluid intake.
Therapeutic Management
 Unless a tumor is present (in which case it is removed by surgery), the usual treatment
of central DI involves a low solute diet (low sodium and low protein), daily replacement of
ADH, and/or use of a thiazide diuretic .The drug of choice for home treatment is DDAVP,
a long-acting vasopressin analog, typically given intranasally.
 Monitor blood pressure closely when initiating vasopressin.
Nursing Assessment
 Endocrine issues: The most common initial symptoms reported are polyuria and
polydipsia.
Physical Examination
 Observation and inspection may reveal weight loss or failure to thrive in the young infant.
Inspection may also reveal signs of dehydration, such as dry mucous membranes or
decreased tears.
 Diagnostics & Labs: Diagnostic tests used to evaluate DI include:
o
o
o
o
o
Radiographic studies such as CT scan, MRI, or ultrasound of the skull and
kidneys can determine whether a lesion or tumor is present.
Urinalysis: urine is dilute, osmolality is less than 3,000 mOsm/L, specific gravity
is less than 1.005, and sodium is decreased.
Serum osmolality is greater than 300 mOsm/L.
Serum sodium is elevated.
Fluid deprivation test measures vasopressin release from the pituitary in
response to water deprivation. Normal results will show decreased urine output,
increased urine specific gravity, and no change in serum sodium
Nursing Management
 Promoting Hydration: The goal of treatment is to achieve hourly urine output of 1 to 2
mL/kg and urine specific gravity of at least 1.010.
 Promote activity
 Educate family
Hyperthyroidism
 Hyperthyroidism is the result of hyperfunction of the thyroid gland. This leads to
 Graves disease is an autoimmune disorder that causes excessive amounts of thyroid
hormone to be released in response to human thyroid stimulator immunoglobulin.
Therapeutic Management
 Therapeutic management is aimed at decreasing thyroid hormone levels. Current
treatment involves antithyroid medication, radioactive iodine therapy, and subtotal
thyroidectomy. First-line treatment involves methimazole (MTZ, Tapazole), which blocks
the production of T3 and T4.
 Subtotal thyroidectomy is used when drug therapy is not possible or other treatments
have failed. Risks include hypothyroidism, hypoparathyroidism, or laryngeal nerve
damage.
Nursing Assessment
 Many children with hyperthyroidism are first seen in the outpatient setting with a history
of a problem with sleep, school performance, and distractibility.
 They become easily frustrated, overheated, and fatigued during physical education
class. The child may complain of diarrhea, excessive perspiration, and muscle
weakness. The history may also reveal hyperactivity, heat intolerance, emotional lability,
and insomnia.
 Elevated pulse and blood pressure may also be noted. Laboratory and diagnostic tests
reveal that serum T4 and T3 levels are markedly elevated while TSH levels are
suppressed.
 Thyroid Storm: The sudden release of high levels of thyroid hormones results in thyroid
storm, which progresses to heart failure and shock. Immediately report the signs of
thyroid storm, which include sudden onset of severe restlessness and irritability, fever,
diaphoresis, and severe tachycardia.
Nursing Management
 educate the family and child about the medication and potential adverse effects, the
goals of treatment, and possible complications. Monitor for adverse drug effects such as
rash, mild leukopenia, loss of taste, sore throat, GI disturbances, and arthralgia.
 Help the child and family to cope with symptoms such as heat intolerance, emotional
lability, or eye problems. Explain these symptoms to the school or day care personnel
and make sure that they understand that the child should take more frequent rest breaks
in a cool environment, and should avoid physical education classes until normal
hormone levels are attained.
 If surgical intervention is chosen, provide appropriate preoperative teaching and
postoperative care. Provide supportive measures such as fluid maintenance, nutritional
support, and electrolyte correction. Monitor red blood cell count and liver function tests.
Close monitoring for signs and symptoms of hypothyroidism is important.
 Explaining about the radioactive iodine procedure would be part of the teaching plan for
a child with hyperthyroidism because this is a less invasive type of therapy for the
disorder.
Diabetes Mellitus
 Type 1, which is caused by a deficiency of insulin secretion due to pancreatic β-cell
damage. This deficiency of insulin leads to an inability of cells to take up glucose. The
end result is hyperglycemia, glucose accumulation in the blood, and the body’s inability
to use its main source of fuel efficiently. The kidneys try to lower blood glucose, resulting
in glycosuria and polyuria, and protein and fat are broken down for energy. The
metabolism of fat leads to a buildup of ketones and acidosis.
 If DM goes unrecognized or is inadequately treated (especially type 1 DM), diabetic
ketoacidosis (DKA) or fat catabolism develops (a deficiency or ineffectiveness of insulin
results in the body using fat instead of glucose for energy), resulting in anorexia, nausea
and vomiting, lethargy, stupor, altered level of consciousness, confusion, decreased skin
turgor, abdominal pain, Kussmaul respirations and air hunger, fruity (sweet-smelling) or
acetone breath odor, presence of ketones in urine and blood, tachycardia, and, if left
untreated, coma and death.
 Type 2, which is a consequence of insulin resistance. The pancreas usually produces
insulin but the body is resistant to the insulin or there is an inadequate insulin secretion
response (the body can produce insulin but not enough to meet the body’s needs).
Eventually, insulin production decreases (resulting from the pancreas working overtime
to produce insulin), with a result similar to type 1 DM.
Therapeutic Management
 Vasopressin is given for Diabetes Insipidus. SIADH, although rare in children, is a
potential complication of excessive administration of vasopressin.
 Established glucose control is essential in reducing the risk of long-term complications
associated with DM. Therefore, general goals for therapeutic management include:
 Achieving normal growth and development
 Promoting optimal serum glucose control, including fluid and electrolyte levels
and near-normal hemoglobin A1c or glycosylated hemoglobin (which is
hemoglobin that glucose is bound to and it monitors long-term control of blood
sugars and diabetes) level
 Preventing complications
 Promoting positive adjustment to the disease, with ability to self-manage in the
home
 Monitoring Glycemic Control: Two important methods for monitoring glycemic control
include blood glucose monitoring and monitoring hemoglobin A1c levels.
 Blood Glucose monitoring: short term glycemic control, before meals. Selfmonitoring of blood glucose (SMBG) at home is essential to improve glycemic
control, to provide self-management of this disease, and to help to prevent
complications such as severe hypo/hyperglycemia
 A1C: Hemoglobin A1c (HbA1c) provides the physician or nurse practitioner with
information regarding the long-term control of glucose levels. the targets for
HbA1c in children have become lower in recent years. Currently, the American
Diabetes Association (2019) recommends that children and adolescents have a
target HbA1c <7.5%
 Monitoring for and Managing Complications
Hypoglycemia
Behavioral changes (tearfulness,
irritability, naughtiness), confusion,
slurred speech, belligerence
Diaphoresis
Tremors
Palpitations, tachycardia
Hyperglycemia
Mental status changes, fatigue,
weakness
Dry, flushed skin
Blurred vision
Abdominal cramping, nausea,
vomiting, fruity breath odor
 Hypoglycemia=<70mg/dl
 monitor for signs of complications such as acidosis, coma, hyperkalemia or
hypokalemia, hypocalcemia, cerebral edema, or hyponatremia.
 Assess for the development of hypo- or hyperglycemia every 2 hours.
 If the child has a severe hypoglycemic reaction, administer glucagon (a hormone
produced by the pancreas and stored in the liver) either subcutaneously or
intramuscularly.
 Any child exhibiting signs and symptoms of hyperglycemia requires insulin.
 Nursing Assessment
 detailed history of family patterns and problems in school related to some of the
mental and behavior changes that may occur in a hyperglycemic state (e.g.,
weakness, fatigue, mood changes).
 The child or parent may report unusual or excessive thirst (polydipsia) coupled
with frequent urination (polyuria). The child may also complain of blurred vision,
headaches, or bedwetting.
 The child with type 1 DM may have a history of poor growth.
 Labs & Diagnostics: the use of fasting plasma glucose levels, 2-hour
postprandial glucose levels, and/or hemoglobin A1c as reliable sources to
diagnose diabetes,
 A fasting glucose level greater than or equal to 126 mg/dL
 a 2-hour plasma glucose level greater than or equal to 200 mg/dL during an oral
glucose tolerance test
 a random glucose level greater than or equal to 200 mg/dL (accompanied by
typical symptoms of diabetes)
 a hemoglobin A1c greater than 6.5% are laboratory criteria for the diagnosis of
DM.
 an endocrine disorder involving the posterior pituitary gland. What care would the nurse
expect to implement? The nurse would teach the parents how to administer
desmopressin acetate, which treats diabetes insipidus, a disorder related to the posterior
pituitary gland.
 The most common symptoms of arginine vasopressin deficiency (diabetes insipidus) are
polyuria (excessive urination) and polydipsia (excessive thirst)
 The nurse is preparing a teaching plan for a 10-year-old girl with hyperthyroidism.
Explaining about the radioactive iodine procedure would be part of the teaching plan for
a child with hyperthyroidism because this is a less invasive type of therapy for the
disorder.
 Hypothyroidism is manifested by weight gain, fatigue, cold intolerance, and dry skin.
Screening results that show a low T4 level and a high TSH level indicate congenital
hypothyroidism. Levothyroxine is used to treat hypothyroidism. Thyroid storm may
result from over administration of levothyroxine.

 Nervousness, heat intolerance, and smooth velvety skin are associated with
Hyperthyroidism. Methimazole is an antithyroid drug that is used to treat
hyperthyroidism.
 SIADH, although rare in children, is a potential complication of excessive administration
of vasopressin.
 Manifestations of hypoglycemia include behavioral changes, confusion, slurred speech,
belligerence, diaphoresis, tremors, palpitation, and tachycardia.
 Blurred vision; dry, flushed skin; and fruity breath odor suggest hyperglycemia.
 Signs and symptoms of type 1 diabetes mellitus include polyuria, polydipsia, polyphagia,
enuresis, and weight loss.
 Insulin for diabetic ketoacidosis is given intravenously. Only regular insulin can be
administered by this route.
Management of Complications
 Another important aspect of therapeutic management includes monitoring and managing
complications. The American Diabetes Association (2019) has developed
recommendations for standards of medical care to help monitor complications and
reduce risk. These include:
Retinopathy:
 Type 1 diabetes: eye examination by ophthalmologist (with expertise in diabetes) once
child is 10 years old or puberty has started (whichever is earlier) and has had diabetes
for 3 to 5 years; eye examinations every 1 to 2 years unless different recommendation
by professional
 Type 2 diabetes: eye examination by ophthalmologist (with expertise in diabetes) shortly
after diagnosis; annual examinations unless different recommendation by professional
Nephropathy:
 Type 1 diabetes: annual screening for microalbuminuria (which occurs when the kidneys
leak small amounts of albumin into the urine) once child is 10 years old or puberty has
started and has had diabetes for 5 years
 Type 2 diabetes: screen at diagnosis and annually thereafter for microalbuminuria
Neuropathy:
 Type 1 diabetes: annual foot examination once child has reached puberty or ≥10 years
old and has had diabetes for 5 years
 Type 2 diabetes: foot examination at diagnosis and annually
Dyslipidemia:
 Type 1 diabetes: obtain a lipid profile in children ≥10 years old at time of diagnosis (once
glucose level has been stabilized); if normal, repeat every 3 to 5 years
 Type 2 diabetes: obtain fasting lipid panel at diagnosis (once glucose level has been
stabilized), then annually
Hypertension: blood pressure measured at each routine visit
 In addition, children with type 1 diabetes should be screened for additional autoimmune
disorders such as celiac disease (screen after diagnosis and then after 2 years and
again after 5 years, screen more often if symptoms or family history present) and
hypothyroidism (screen after diagnosis, once glucose level has been stabilized, and
every 1 to 2 years or sooner if symptoms are present)
 Assess for psychosocial and diabetes-related distress generally starting around 7 to 8
years old
 Screen for eating disorders starting at 10 to 12 years old.
Chapter 49
Major Congenital anomalies p1836
 A major anomaly is an anomaly or
malformation that creates significant
medical or cosmetic problems and
requires surgical or medical
management

 Chromosomal abnormalities
 Omphalocele; Gastrochisis
 Cleft lip
 Renal agenesis/hypoplasia
 Cleft palate
 Absent or limb deficiencies
 Congenital heart disease, structural
and conduction disorders
 Generalized dysmorphism
 Ambiguous genitalia
 Neural tube defects, such as
myelomeningocele
 Nursing management of these disorders will be mainly supportive and will focus on
providing support and education to the family and child, with an emphasis on
developmental and educational needs.
 Referral to genetic counseling and appropriate resources is an important nursing
function.
Inborn Errors of metabolism and Odors p.1836
 group of hereditary disorders with Most following an autosomal recessive inheritance
pattern.
 They are caused by gene mutations that result in abnormalities in the synthesis or
catabolism of proteins, carbohydrates, or fats. The body cannot convert food into energy
as it normally would.
 PKU, Galactosemia, maple syrup urine disease, and Tay-Sachs are considered inborn
errors of metabolism.
 Newborn screening is used to detect these disorders before symptoms develop.
 Screening tests for genetic and inborn errors of metabolism require a few drops of blood
taken from the newborn's heel.
Phenylketonuria
Mousy or musty
Maple syrup urine disease
Tyrosinemia
Trimethylaminuria
Maple syrup, burnt sugar, or curry
Cabbage-like, rancid butter
Rotting fish
Nursing Assessment
 A newborn who was healthy at birth will often present with lethargy, poor feeding, apnea
or tachypnea, recurrent vomiting, altered consciousness, failure to thrive, seizures,
septic appearance, or developmental delay.
 Physical changes that may be seen include dysmorphology, cardiomegaly, rashes,
cataracts, retinitis, optic atrophy, corneal opacity, deafness, skeletal dysplasia,
macrocephaly, hepatomegaly, jaundice, or cirrhosis.
 Labs & Diagnostics:
o Glucose: may be elevated.
o Ammonia: may be elevated.
o Blood gases: may have low bicarbonate and low pH, metabolic acidosis
(respiratory alkalosis may also be seen, especially when high ammonia levels
are present).
Nursing Management
 Ensure that the diet prescribed for the infant or child is followed.
 Nursing management will focus on education and support for the family, who will need
thorough knowledge about the child’s disease and management.
 Refer the child and family to a dietitian and appropriate resources, including support
groups.
 In addition, monitor the child’s developmental progress and begin therapies as soon as a
concern arises.
Chapter 50
ADHD
Therapeutic Management
 Medication management of ADHD includes the use of psychostimulants, nonstimulant
norepinephrine reuptake inhibitors, and/or α-agonist antihypertensive agents.
 These medications are not a cure for ADHD but help to increase the child’s ability to pay
attention and decrease the level of impulsive behavior.
 Determine if there is a family history of ADHD.
 Question the parent about school behavior. The school-age child may be unable to stay
on task, talks out of turn, leaves his or her desk frequently, and either neglects to
complete in-class and homework assignments or forgets to turn them in.
 The adolescent may be inattentive in school, poorly organized, and forgetful.
 Several behavioral checklists are available that may assist in the diagnosis of ADHD.
 They may be completed by the child’s teacher and/or parent and focus on behavior
patterns related to conduct or learning problems, social competence, anxiety, activity
level, and attention.
Nursing management
 Having a child with ADHD can be frustrating as the child’s inattention, high activity level,
impulsivity, and distractibility are often very difficult to deal with.
 Teach families and school personnel to use behavioral techniques such as time-out,
positive reinforcement, reward or privilege withdrawal, or a token system.
 Refer families to local support groups and the national ADHD support group
 Explain that stimulant medications should be taken in the morning to decrease the
adverse effect of insomnia.
 Some children may experience decreased appetite, so giving the medication with or
after the meal may be beneficial.
Presence of six or more of the following
in the child 17 years of age and younger:
• Easily distracted
• Failure to pay close attention
• Forgetful
• Careless mistakes on schoolwork
• Fidgety or squirmy
• Difficulty paying attention to tasks or play
• Often out of seat
• Doesn’t listen
• Activity inappropriate to the situation
• Doesn’t follow through
• Cannot engage in quiet play
• Doesn’t complete tasks
• Always on the go
• Doesn’t understand instructions
• Talks excessively
• Poorly organized
• Blurts out answers
• Avoids, dislikes, or fails to engage in
activities requiring mental effort
• Has difficulty waiting his or her turn
• Often interrupts or intrudes on others
• Loses things needed for task completion
 Additionally, symptoms have been present in two or more settings, at least two of the
symptoms occurred prior to age 12, persistence of symptoms beyond 6 months and to a
degree inconsistent with developmental level or negatively interferes with social or
academic performance, and symptoms are not associated with purely oppositional
behavior or as a component of a psychotic disorder and cannot be explained by the
diagnosis of a different mental health disorder.
Eating Disorders
 Eating disorders include pica, rumination, anorexia nervosa, and bulimia.
 Pica, which occurs most frequently in 2- to 3-year-olds, is an eating disorder in which the
child ingests (over at least a 1-month period) a nonnutritive material such as paint, clay,
or sand.
 Rumination is an eating disorder occurring in infants in which the baby regurgitates
partially digested food or formula and expels or swallows it.
 Anorexia nervosa is characterized by dramatic weight loss as a result of decreased food
intake and sharply increased physical exercise.
 Bulimia refers to a cycle of normal food intake, followed by binge eating and then
purging. Typically, the adolescent with bulimia remains at a near-normal weight.
 Complications of anorexia and bulimia include fluid and electrolyte imbalance,
decreased blood volume, cardiac arrhythmias, esophagitis, rupture of the esophagus or
stomach, tooth loss, and menstrual problems.
Nursing Assessment
 noting risk factors such as family history, female gender, Caucasian race, preoccupation
with appearance, obsessive traits, or low self-esteem. Adolescents with anorexia may
have a history of constipation, syncope, secondary amenorrhea, abdominal pain, and
periodic episodes of cold hands and feet.
 Parents usually note the chief complaint as weight loss.
 Note history of depression in the child with bulimia. Evaluate the child’s self-concept,
noting multiple fears, high need for acceptance, disordered body image, and
perfectionism.
 Perform a thorough physical examination. The anorexic is usually severely underweight,
with a body mass index (BMI) of less than 17.
 Note cachectic appearance, dry sallow skin, thinning scalp hair, soft sparse body hair,
and nail pitting.
 Measure vital signs, noting low temperature, bradycardia, or hypotension.
 The adolescent with bulimia will be of normal weight or slightly overweight.
 Inspect the hands for calluses on the backs of the knuckles and split fingernails. Inspect
the mouth and oropharynx for eroded dental enamel, red gums, and inflamed throat from
self-induced vomiting.
Nursing Management
 Those with anorexia who display severe weight loss, unstable vital signs, food refusal, or
arrested pubertal development or who require enteral nutrition will need to be
hospitalized.
 Refeeding syndrome (cardiovascular, hematologic, and neurologic complications) may
occur in the severely malnourished adolescent with anorexia if rapid nutritional
replacement is given. Therefore, slow refeeding is essential to avoid complications.
 Give phosphorus supplements as ordered.
 Assess vital signs frequently for orthostatic hypotension, irregular and decreased pulse,
or hypothermia.
 Assess the child’s need for medical intervention for concomitant depression or anxiety
(some anorexics also require psychotropic medications).
 Provide emotional support and positive reinforcement to the child and family.
Preventing Depression and Suicide
 Establish a trusting relationship with the children and adolescents with whom you
interact.
 Screen all healthy and chronically ill preteens and teens for the development of
depression.
 When a potential problem is identified, immediately refer the child for mental health
assessment and intervention.
 Provide appropriate observation for any child exhibiting suicidal ideation