Table of contents
 Immunization – Schedule page 2
 Hirschrung’s disease - aganglionic area, - Nursing assessment, diagnosis, manifestations, page 2
 Tetrology of Fallot – nursing assessment, interventions page 5
 Anemia – causes, assessment page 7
 SIDS – patient teaching, assessment page 7
 Infectious diarrhea – Education, management; Nursing interventions page 8
 Cystic Fibrosis - postural drainage - Nursing assessment, diagnosis, manifestations, page 10
 Pavlik harness; Bryant’s traction, Boston brace - Parental education page 15
 Bilateral cleft lip – postop Management, preop management page 19 cleft palate 21
 Increased intracranial pressure- interventions; the clinical manifestations, Nursing assessment, management
page 22 GI system – 51/ Esophageal atresia 52
 Diabetes - type 1 diabetes treatment, ketoacidosis, Somogyi phenomenon, insulin administration,
Treatment for Diabetes; effects of different insulin page26
 Gastroesophageal reflux intervention page 30
 Nephrotic syndrome -The clinical manifestations, Nursing assessment, management page 111
 Urinary tract infection - strategies with a parent to prevent a recurrence of page 35
 Generalized tonic-clonic seizure – Nursing Intervention page 32
 Cerebral palsy – Types; management page 37
 Difference between adults and children fluid and electrolyte imbalances page 40
 Intussusception – Clinical manifestations, Treatment page 41
 Juvenile rheumatoid arthritis – Types page 43
 rheumatic fever – Assessment; management page 44
 levothyroxine (Synthroid) – Side effects, page 47
 Reye’s syndrome parent education page 50
 Neuroblastoma – parent education page 55
 Asthma – Teachings, management, meds 58
 laryngotracheobronchitis ; bronchiolitis - Cool Mist, Treatment page 63
 meningeal irritation, Meningitis; myelomingocele - cerebral spinal fluid; surgery, effects, preop care pg 66
 ventriculoperitoneal shunt - Nursing priority page 74
 Wilm’s Tumor – Nursing assessment, management 74
 Clubfoot – Assessment, treatment for a child with congenital clubfoot/ parental education page 78
 acute lympholitic leukemia – signs and symptoms, Nursing management page 83
 appendicitis , laparoscopic appendectomy - Nursing assessment, management page 87
 Hirschprung’s disease see page 2
 sickle cell crisis – Genetics, management, assessment page 90
 Celiac disease - Nursing assessment, management page 94
 post pyloromyotomy -Nursing assessment, management, parent education page 96
 Erickson growth and development – Preschooler, school-agers, adolescents, Toddlers, infants page 99
 Calculations meds; I&O; Fluid loss calculation page 106
 lead poisoning - Nursing assessment, management, parent education page 109
 Nephrosis – symptoms; steroids effects 111
 Kawasaki’s disease - signs and symptoms, Nursing management page 113
 Hydrocephalus - signs and symptoms page 117
 hip dysplasia - Nursing assessment page 125
 talipes equinovarus - Nursing assessment page 78
1
 pyloric stenosis surgery – parent education; nursing assessment; page 130 acid-base imbalances (Respiratory
acidosis/alkalosis; Metabolic acidosis/ alkalosis page 132
 scoliosis- Nursing assessment, management, parent education page 133
In class jeopardy review page 139

Immunization – Schedule
Hirschrung’s disease - aganglionic area, - Nursing assessment, diagnosis,
manifestations, Hirschsprung’s Disease/Congenital Aganglionosis/Megacolon

A disorder at birth in which inadequate motility causes obstruction of the large
intestines. There is an absence of the autonomic parasympathetic ganglion
cells in the colon that prevents peristalsis in that particular part of the colon
S/S during newborn period
-Failure to pass meconium with 24-36 hrs.
-Refusal to suck
-Abdominal distention
-Bile stained emesis (vomit contains bile)
-Constipation within 1st month of life
2
S/S in infant /toddler
-chronic constipation
-ribbon-like stools & foul-smelling odor
-failure to thrive
-abdominal distention & pain
-vomiting
Older Child (seen less frequently)
-Delayed growth
-Weight loss
-History of abdominal distention
-Constipation alternating with diarrhea
Diagnostic Evaluation
 Rectal exam – rectum empty of stool, tight anal sphincter
 Rectal biopsy – absence of ganglionic cells, this confirms the diagnosis
Therapeutic Management
 Stool softeners & rectal irrigations
 2 step- surgical intervention
a. Temporary colostomy
b. Bowel repair – reanastomose (joining) the normal bowel to anal canal –
(normal bowel function should return shortly after)
Nursing Intervention / Pre-op
 Provide stool-softeners / enemas
 Promote adequate hydration
 Assess bowel function
 Avoid taking temperature rectally
Nursing Intervention/Post-op
 Relieve pain
 Prevent infection & maintain skin integrity
 Assess bowel sounds
 Offer small, frequent feedings – water, gelatin – advancing slowly to a
normal diet for the child’s age
 Prepare the child & parents for procedures & treatments (tell them what
to expect)
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4

Tetrology of Fallot – nursing assessment, interventions
 Congenital Heart diseases –
Tetralogy of Fallot (s/s, effects, meds, management)
FYI-If patient is cyanotic and respiratory rate is 45 during crying, eating, and
having BM you should position patient in knee chest or squatting position to
provide relief to heart by trapping blood in lower extremities because of a
reduced pulmonary blood flow.
Signs and Symptoms
HIPOo Hypertrophy of Right Ventricle
o Intraventricular Septal Defect (Ventricular septal defect)
o Pulmonary overflow tract stenosis (Stenosis of pulmonary artery)
o Overriding of aorta dextro position of Aorta
Effects
o Blue baby/ cyanosis
o Poor growth
o Dyspnea on exertion
Treatment
o O2 therapy
o Medication management- Morphine sulfate (opiod analgesic) monitor for
respiratory depression or propranolol/Inderal (betablocker) monitor for
decrease HR and inability of epinephrine to work because receptor sites
may be blocked to cause vasodilation of blood vessels.
o Blalock-Taussig management-procedure Palliative shunt or complete
repair done as early as newborno FYI if open heart surgery with a patch is done be mindful that child is at
risk for infection especially sub-acute bacterial endocarditis, parents
should notify all providers of all planned invasive procedures prior to 6
months post-op because patch has not epithelialized and carries greater
risk of infection and would require antibiotic therapy prior to invasive
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procedure to reduce risk of SBE. After 6 months these precautions are no
longer necessary.
o FYI- Post cardiac surgery diet teaching would include maintaining low
sodium diet 2-3gms/day.
o Calm child
o Teaching knee chest, squatting) Rationale for s/s; decrease blood flow in
lower extremities to manage anoxic (blue spell) or Tet spell
Erikson stage-Infant 0-1year
Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security FYI – Acyanotic
cardiac defects there are 4: (left to right blood flow) Ventricular Septal Defect,
Patent Ductus Arteriosis, Artioventricular canal, Atrial Septal Defect
=pulmonary hypertension because of the back flow of blood.
FYI – Cyanotic cardiac defects – 5 T’s (right to left blood flow)– Tetralogy of
Fallot, Tricuspid Atresia, Transposition of great arteries, Truncus Ateriosus,
Total anomalous pulmonary venous connection.
Erikson stage – Infant -0-1 year
Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security.
6

Anemia – causes, assessment
 Anemia – cause, sickle cell, management, nutrition
Anemia: Decreased amount of RBC or lowered ability of the blood to carry
Oxygen,that can cause other complications such as fatigue and stress on bodily
organs. If anemia comes on quickly symptoms may include confusion, feeling
like one is going to pass out, and increased thirst.
Causes: Excessive destruction of RBC
o Inadequate production of RBC
o Can result from inherited disorders, nutritional problems such as an iron
or vitamin deficiency
o Infection, some kind of cancer, or exposure to a drug toxin
Signs and symptoms
o Feeling tired/Stress on bodily organs
o Weakness
o Shortness of breath or a poor ability to exercise
o Confusion
o Feeling like one is going to pass out
o Increased thirst (Often they crave ice chips)
SIDS – patient teaching, assessment
Sudden infant death syndrome (SIDS) is characterized as the sudden death of
an infant younger than 1 year of age that remains unexplained even after a
complete autopsy, a death scene investigation, and a thorough review of the
clinical history are conducted.1 SIDS is a diagnosis of exclusion in which the
cause of death cannot be determined and for which no pathognomoic (sign of
a particular sign whose presence means that a particular disease is present
beyond any doubt) features have been identified. The risk of an occurrence is
increased by such factors as a premature birth, exposure in utero or infancy to
tobacco smoke, or prone sleeping.2 However, predicting with certainty which
infants will die from SIDS is still not possible. Despite the decline in SIDS, it
remains the leading cause of postneonatal infant mortality, and despite
greater public compliance with the risk reduction guidelines there is room for
improvement in how effectively and consistently they are disseminated.

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Nursing Management to prevent SIDS
o Back to sleep
o Provide a Safe sleep environment
o Make sure the infant’s head and face remain uncovered during sleep.
o Safe sleep environment (no fluffy bedding or stuffed toys)
o If swaddled; the wrap should come no higher than the infants shoulder; it
should be firm not tight. Use a light weight material like muslin or cotton,
to avoid overheating. If the infant is rolling (from approximately 4
months of age), swaddling is no longer appropriate due to entrapment
risk.
o No smoking around the baby. Smoking remains the most important
modifiable risk factor.
o A close but separate sleep area for the baby
o Possible use of a clean, dry pacifier. Pacifier use has been suggested to
protect against SIDS and is recommended by some authoritative bodies.
However this has not been fully endorsed by all.
o Avoid overheating the baby. Hats should not be worn when sleeping. If
the infant requires more than a singlet, jumpsuit and one blanket for
temperature control; reassess if the infant’s environment.
o Avoid products that claim to reduce the risk of SIDS
o Talk to parents, child care providers, grandparents, babysitters, and
everyone who cares for the baby about SIDS risk.
 Infectious diarrhea – Education, management; Nursing interventions
Infectious diarrhea – Education, management; Nursing interventions
Diarrhea (acute gastroenteritis)
o Is an inflammatory and/or infectious process involving any part or all of
the GI tract
o An increase in the frequency, volume & liquidity of stool.
Nursing interventions
o Hydration Assessment
o Electrolyte management
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o
o
o
o
Assessment of stools
Education of the family
Assessment of anorectal area
Protection from skin breakdown
Management
1. Hydration
o Rehydration therapy with oral rehydration solution (ORT).
o ORT will not decrease the number of episodes or volume of diarrhea
but will restore losses, prevent further dehydration and improve
nutrition.
o Hydration: weight, cap refill, skin turgor mucous membranes, # stools,
vomiting, I&O, eye orbits, fontanels, presence of tears, specific gravity
of urine # wet diapers, color of urine
2. Assessment of stools: consistency, color, amount, odor
3. Education of family: hand washing, ORT management, dietary
management, I&O
4. Condition of the skin, color texture, behavior of the child
5. Protection from breakdown: barrier ointment, change diapers q1h, tepid
water, no harsh cleaning agents, air to buttocks, soft toilet paper.
Education
o ORT----Therapy with an oral electrolyte solution is completed over 4 hrs.
for a total of 50 ml/kg for mild dehydration to 100 ml/kg for moderate
dehydration. This is administered PO. For each additional fluid loss in
stool or emesis an additional 10ml./kg.
o This is the preferred treatment of fluid & electrolyte losses caused by
diarrhea in children 1 month to 5 yrs. with mild to moderate dehydration.
If the child is unable to breast/formula feed or refuses food, therapy with
an oral electrolyte solution is completed over 4 hrs. for a total of 50
ml/kg for mild dehydration to 100 ml/kg for moderate dehydration. This
is administered PO. For each additional fluid loss in stool or emesis an
additional 10ml./kg. for each episode is recommended.
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Medications – Vomiting/Diarrhea---Although there are pediatric dosages
published – due to the lack of convincing evidence none are recommended by
the American Academy of Pediatrics
The BRAT diet (old practice, not used as much anymore) used in some
facilities does not contain enough protein. Soda contains glucose which
increases diarrhea due to the increase in osmotic load. Chicken broth contains
too much sodium.
Cystic Fibrosis - postural drainage - Nursing assessment, diagnosis,
manifestations,  Cystic Fibrosis – Treatment, meds effects, s/s (early, late…);
diagnosis, testing, exacerbation  Cystic Fibrosis – Treatment, meds effects, s/s
(early, late…); diagnosis, testing, exacerbation. Inherited autosomal recessive
disorder of the endocrine gland which means that both parents must carry the
gene for the child to be affected.

o An abnormality of the long arm of chromosome 7, Overall incidence 1:4
o Factor responsible for manifestations of the disease is mechanical
obstruction caused by increased viscosity of mucous gland secretions
o Mucous glands produce a thick protein that accumulates and dilates the
glands
o Passages in organs such as the PANCREAS become obstructed
o First manifestation is meconium ileus in NewBorn
Organ Systems being effected:
o Respiratory: thick mucus, inflammation, wheezing, pneumonia, cough,
CHF in latter stage, fatigue, chronic cough recurrent URI thick sticky
mucus chronic hypoxia barrel chest
o Pancreas: obstructed pancreatic ducts by mucus and pancreatic
enzymes (trypsin, lipase, amylase) to duodenum
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o GI: decrease in absorption of nutrients, fatty stools (steatorrhea), flatus,
usually thin, abdominal distension
o Reproductive: 99% of males are sterile
Symptoms:
o Pancreatic enzymes unable to digest fat, protein and some sugars
o Stool characteristics: Steatorrhea, foul odor
o S/S of malnutrition : emaciated extremities
o Unable to absorb fat soluble vitamins (a,d,e,k)
o Pancreatic enzymes unable to digest fat, protein and some sugars:
Pancreatic enzymes given to replace Creon, Pancrease, and Ultrace
before meals.
o Stool characteristics:
-Steatorrhea, fatty stool foul odor 2-3 times bulkier than normal
-Azotorrhea, protein byproduct- nitrogen in stool
o S/S of malnutrition : emaciated extremities
o Unable to absorb fat soluble vitamins
o Malabsorption syndrome: Malnutrition, protrubent abdomen,
steatorrhea and fat soluble vitamin deficiencies leads to celiac syndrome
referral
o In newborns with CF pancreatic enzyme is missing it leads to abdominal
distention with no passage of meconium within 24 hours /rectal prolapse
from straining is a common finding
o Normal level of sodium in sweat is 20 meq/l in CF >60meq
o Lungs: thick mucus noticed in bronchioles
o Increased secretions r/t staphylococus aureus
o Secondary emphysema r/t overinflated alveoli and thickened mucus
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o Respiratory acidosis– holding on to Co2 or unable to excrete the body’s
production and blood PH drops below 7.35.
o Hypercapnia- is red or flushed skin most often to face.
o Atelactesis r/t blocked bronchioles and reabsorption of air
o Increased respirations, cyanosis
o Productive cough
o clubbing is due to chronic peripheral hypoxia
Diagnostic:
o Positive sweat test (pilocarpine iontophoresis)
o 72 hr. fecal fat determination
o Fasting blood sugar
o Liver function studies
o Sputum culture (to ID infective organisms)
o CXR
o Genetic testing needs to be done if suspicious of CF with negative sweat
test. Some babies with FTT may have the disease.
o Level < 40 for both Na and Cl; patients with CF have > 60 for both Na
and Cl
Treatment:
o Increase calories/protein, pulmonary therapy, chest physiotherapy,
oxygen, free access to salt, postural drainage, breathing exercise, aerosol
therapy, antibiotics vitamins aerosol bronchodilators mucolytic
pancreatic enyzmes, lung transplant.
o Respiratory goal: removal of secretions (chest physiotherapy with Therapy
vest) by vibrations loosen mucus
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o Nutritional goal: inc. weight, enzymes with all food (Creon, Pancrease,
Ultrace) dosage is regulated by evaluation of the stool
Nursing diagnosis: Ineffective airway clearance related to tenacious bronchial
secretions
Nursing Consideration:
o General hygiene
o Care should be given to diaper area
o Frequent changes of position help prevent development of pneumonia
o Child wears light clothing to prevent overheating.
o Infants may be given pre-digested formula Pregestimil and Nutramigen
which is more easily absorbed.
o Teeth may be in poor condition due to dietary deficiencies.
o Increase salt in summer
o Give nebulizer before chest PT.
o Do chest PT 30 mins before or 1 hr after meals to prevent vomiting.
o Give pancreatic enzymes before meals.
o Given high protein, high calorie, and high sodium diet.
Diagnosed by age 2 life expectancy to 60 years
Erikson Stages
o Infant 0-1year Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security
o Toddler 0-3 years Autonomy vs Shame and Doubt- Child learns to be
independent and make decisions for self. Nsg Implication: Provide
opportunity for independent decision making such as choosing own
clothes.
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
o School Age – Industry vs Inferiority - Child learns how to do things well.
Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project.
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o Adolescence – Identity vs Role confusion – Adolescence learn who they
are and what kind of person they will be. Nsg Implication: Provide
opportunity for adolescent to discuss things that are important to him or
her. Offer support and praise for decision making.
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Pavlik harness; Bryant’s traction, Boston brace - Parental education Pavlik
harness: Pavlik harness:
If treatment is instituted early, the success of treatment with a Pavlik
harness is greater than 90%. As the child ages and treatment is delayed,
the prognosis worsens. (See Two views of the Pavlik harness .) In some
cases, a Pavlik harness cannot be used. If the family cannot consistently
and correctly use the harness, another form of treatment should be used.
Two views of the Pavlik harness
These illustrations show an infant in a Pavlik harness. The Pavlik harness
maintains the hip in abduction, with the femoral head in the acetabulum

In the child younger than age 6 months, careful positioning to maintain the
hip in abduction with the head of the femur in the acetabulum is achieved
with a Pavlik harness. This harness is worn at all times except for bathing
until the hips are stable on examination. When the hips are stable, usually
in 1 to 3 weeks, the harness is then used during sleep for 6 additional
weeks.
◯ Newborn to 6 months
Nursing care :
treatment starts as soon as it is diagnosed and depends on the child’s age
and the extent of the dysplasia.
Encourage parents to hold and cuddle the infant/child.
Encourage parents to meet the developmental needs of the infant/child.
Teaching :
Teach the family not to adjust the straps.
15
Teach the family how to place the harness if removal is prescribed.
Teach the family skin care (use an undershirt, knee socks, assess skin, gently
massage skin under straps, avoid lotions and powders, place diaper under the
straps).
Bryant’s Traction:■ Bryant traction or hip spica cast (when adduction
contracture is present)
For the child older than age 6 months, a Pavlik harness can't reliably treat
the dysplasia. These children require a spica cast to hold the hips in a
flexed and abducted position. Traction is commonly used before the
application of the cast to gently stretch out the soft tissues around the hip
that have contracted. Traction is usually used for 2 to 3 weeks before
placement of the cast. Sometimes the traction can be done at home.
Bryant traction
Skin traction
Hips are flexed at a 90° angle with the buttock raised off of the bed
Nursing Actions :
Maintain traction (ropes, boots, pulleys, and weights)
Ensure the client maintains alignment
Perform frequent neurovascular checks
Perform range of motion with the unaffected extremities.
Perform frequent assessment of skin integrity, especially in the diaper area.
Assess for pain control using an age-appropriate pain tool. Intervene as
indicated.
Evaluate hydration status frequently.
Assess elimination status daily.
A temporary setback
When the cast has been applied, it usually remains on for several months
and is removed and reapplied to accommodate growth. It may delay
walking for a few months, but the child usually learns quickly how to walk
when the cast is removed.
Hold and turn
Care for a child in a spica cast is essentially the same as that for a child in
a Pavlik harness. Parents should be encouraged to hold the child as much
as possible. The infant should be turned frequently to prevent skin
breakdown.
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Surgical correction: (DDH) or (CHD)
For the child older than age 18 months, surgical correction is usually
required. Surgery enables the removal of tissues that block reduction and
positioning of the femoral head into the acetabulum under direct
visualization. Occasionally, a bone graft is required.
What to Do
Listen sympathetically to the parents' expressions of anxiety and fear.
Explain possible causes of DDH, and reassure them that early, prompt
treatment will probably result in complete correction.
During the child's first few days in a cast or harness, she may be prone to
irritability due to the unaccustomed restriction of movement. Encourage her
parents to stay with her as much as possible and to calm and reassure her.
Assure parents that the child will adjust to this restriction and return to normal
sleeping, eating, and playing behavior in a few days.
Bryant’s traction
Spica cast
17
Boston brace worn under clothes for scoliosis
18
Bilateral cleft lip – postop Management, preop management
Cleft lip is a vertical opening in the upper lip. Occurs more in boys than girls.
Occurs from teratogenic factors present during 5-8 weeks of interuterine life
such as viral infection, certain seizure medication (Phyentoin), maternal
smoking, maternal binge drinking, hyperthermia, stress, and maternal obesity.
It can also be associated folic acid deficiency. More prevalent in males than
females.
o Congenital anomaly resulting from faulty fusion of the median nasal
process and the lateral maxillary processes.
o Usually unilateral (May or may not be bilateral)
o 1st sign usually formula coming from nose.
o Lip repair 3-6 months
o Palate repair 6-24 months
o May have multiple surgeries and multiple surgeons.

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Multidisiplinary approach
o Maxillofacial surgeon
o EENT-prone to otitis media/frequent URI’s
o Orthodontist-teeth are malpositioned
o Audiologist-hearing loss
o Plastic surgery
o Speech therapy-may have a lisp.
Nursing goal/management
o
o
o
o
Maintain adequate nutrition and intake
Provide emotional support for child and parents.
Prior to surgery use cleft palate nipple.
Post operatively
o IV to po - child should be able to drink out of a cup
o Pain management
o Nothing in mouth(straws)
o Avoid air going into stomach
o Rinse mouth with NS after feeding to prevent infection
o Protect the incision site with elbow/arm restraints ( off 10-15 mins
Q2h and assess for circulation
o supine or side lying position
o
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Comfort measures to reduce inconsolable crying CLEFT Palate - Dx at birth
during initial assessment a congenital fissure or elongated opening in the roof
of mouth, divided or split. Emotional turmoil and negative reactions from
parents
CLEFT LIP congenital anomally reulsting from faulty fusion of the median
nasal process and lateral maxillary processes.
First S/Sx formula coming from the infants nose
 Inability to suck
 Ability to swallow
 More prevalent in males
Surgical intervention usually by 18 - 24 months to minimize speech defects
ERICKSON (1-3y/o) PRESCHOOL AGE
Pre op management assess for problems with feeding, breathing, speech and
parental bonding. Ensure adequate nutrition and prevent Aspiration.
 Semi upright position, breast feeding or use of special feeders.
 Educate parents.
Post of Management.
 Risk for infection (mouth) --N/S rinse after feeding. Meticulous care to
suture site.
 Monitor v/s and for respiratory distress. Pain management.
 IV to p.o. Maintain adequate nutrition.
 Prevent Aspiration
 Protect incision site- elbow restraints, nothing in mouth, reduce crying,
supine or side lying. Watch for excessive air. (other RESTRAINTS . OFF
q2h for 15min. Assess color & circulation.
 Detailed home care instructions to parent.
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Nurs Dx: Risk for Infection, Imbalance nutrition, Knowledge Deficit,
Interrupt Family process
ERICKSON PRESCHOOL
Increased intracranial pressure-interventions; the clinical manifestations,
Nursing assessment, management
Increased Intracranial Pressure- Interventions; clinical manifestations, Nursing
assessment, management
ICP: Increased intracranial pressure can be due to a rise in pressure of the
cerebrospinal fluid. This is the fluid that surrounds the brain and spinal cord.
Increased intracranial pressure in children: Increased intracranial pressure in
children refers to an increased pressure inside a child's brain and skull. CP
stands for Intracranial Pressure and refers to the amount of pressure within the
cranium at any one time. Although ICP fluctuates on a daily basis, if allowed to
increase severely, it will result in long term brain injury and death. Common
causes of a severe raise in ICP includes: traumatic head injuries, drug use
(particularly amphetamines), cerebral infections, and stroke.
Normal Pressures for ICP
o 1.5-6mm/Hg for infants
o 3-7mm/Hg for young children
o 8-15mm/Hg for older children and adults
o Intracranial hypertension is considered ICP>20mm/Hg for more than 5
minutes though lower numbers may be used as perimeters for children
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INTERVENTIONS: - Evacuation of mass lesion
o
o
o
o
o
o
o
o
o
o
Maintain euvolemia ( normal amount of body fluids)
Hyperosmolar therapy
Maintain head midline with HOB at 30 degrees
Maintain normocarbia ( normal arterial carbon dioxide pressure)
Ventriculostomy to drain CSF
Consider mild hyperventilation if refractory intracranial HTN
Maintain normal temperature
Sedation and analgesia
Seizure management prophylaxis
Barbiturate therapy
CLINICAL MANIFESTATIONS: S/S
o Irritability, restlessness, Increased pitched cry/poor feeding, setting sun
sign
o Increase head circumference: Increase greater than 2 cm per month in
first 3 months of life
o Fontanelle changes: Anterior fontanelle tense and bulging, closing late
o Vomiting: Occurring in the absence of nausea on awakening in morning
after nap. Possibly projectile
o Eye changes: Diplopia from pressure on abducens nerves, White of sclera
evident over pupil, limited visual fields, papilledema
o Vital signs changes: Increase Temperature and B/P, decrease Pulse and
respiration
o Pain: In older children Headache often present on awakening and
standing or with straining of stool or holding breath
o Seizure/confusion
NURSING ASSESSMENT:
o -Assess motor and sensory functioning
o Denver Development Screening Test (DDST)
o Assesses child’s developmental milestones and ability to perform age
related tasks
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o
o
o
o
Assess Mental status: LOC, orientation, memory
Cranial nerve function/Motor Function
Reflexes (gag, babinski)
Neurological assessment for complications encompasses an array of
congenital anomalies r/t infection, head trauma that can affect mental or
physical problems. Some may be vague symptoms Parents may report
child having difficulty in walking or “just not being themselves”
o -Balance & coordination/Also Cranial nerve functions/Head
circumference Status of fontanels
o -Final assessment child’s resting posture loss of cell function that affects
motor control
o -Decorticate posturing (mesencephalic region)
o -Decelebrate posturing: Spinal cord compromise brainstem
MANAGEMENT:
o
o
o
o
o
o
o
o
Airway, Breathing, Circulation
Positioning
CSF drainage
Osmotic therapy – Mannitol (reduces cerebral edema)
Ventilation
Temperature regulation
Sedation, analgesia
Neuromuscular blockade – Opiods, benzodiazepines and/ or barbituates
NURSING MANAGEMENT
o
o
o
o
o
o
Identify cause of ICP
Monitor for coughing, vomiting and sneezing
Place child in Semi fowler’s
Dexamethasone (Decadon) as prescribed
Osmotic diuretic- Mannitol
Monitor indwelling catheter to assess kidney function when diuretic are
used
o Monitor IV infusion rapid infusion causes increased ICP
o Advice parents to monitor position of burping because pressure over
jugular vein can cause increased ICP
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SURGICAL MANAGEMENT:
-Evacuation of mass, steroids, fluid, electrolyte and nutrition
SEIZURE PREVENTION & MANAGEMENT:
-Barbiturate therapy


25

Diabetes - type 1 diabetes treatment,
ketoacidosis, Somogyi phenomenon, insulin
administration, Treatment for Diabetes;
effects of different insulin
DM

o
o
o
o
o
o
o
Is a condition that causes high levels of glucose in the blood
An absolute or relative deficiency of insulin
Equally affects boy as well as girls
Results from immunologic damage to the islet cells
Failure of beta cells to produce insulin
High levels of glucose in the blood – problem with islets of langerhans
Glucose is the sugar that is the body’s main source of energy and
of course when glucose levels are elevated health problems begin
o Diabetes is a chronic disease in which the body does not make or properly
use insulin, a hormone that is needed to convert sugar, starches, and other
food into energy by moving glucose from blood into the cells. As a result,
high levels of glucose build up in the blood, and spill into the urine and out
of the body.
o The body loses its main source of fuel and cells are deprived of glucose, a
needed source of energy.
o High blood glucose levels may result in short and long term complications
over time.
Type 1
o The body makes little or no insulin
o Occurs early in life
o In people with type 1 diabetes, the immune system attacks the beta cells,
the insulin--‐producing cells of the pancreas, and destroys them.
o The pancreas can no longer produce insulin, so people with type 1
diabetes need to take insulin daily to live.
o Type 1 diabetes can occur at any age, but the disease develops most
often in children and young adults.
o Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes
in the United States.
26
SIGNS AND SYMPTOMS
o
o
o
o
o
o
o
o
o
o
3 “Polys”, Polyphasia, Polyuria, Polydipsia
Weight loss, irritability
Shortened attention span, fatigue
Hyperglycemia that leads to ketoacidosis
Ketones + glucose in urine
Vomiting, electrolyte imbalance, Kussmal respirations, fruity acetone
breath, drowsiness > coma
The symptoms of type 1 diabetes usually develop over a short period of
time and are abrupt.
They include increased thirst and urination.
Parents complain of children with “bedwetting” enuresis in a child that
was previously toilet trained, constant hunger, weight loss (Because
protein is now being used for energy children have a decrease in growth
and remain underweight, and blurred vision.) Children may also feel very
tired all the time.
If not diagnosed and treated with insulin, the person with type 1 diabetes
will eventually lapse into a life--‐threatening condition known as diabetic
ketoacidosis or DKA.
DIAGNOSIS
Diagnosis: if one of the following criteria is present according to American
Diabetes Association
o Symptoms of diabetes + random glucose test > 200 mg/dl of blood
o A fasting glucose level > 126mg/dl
o A 2 hour plasma glucose > 200mg/dl during a 75g oral glucose tolerance
test
 (GTT) (Difficult for children since they must fast 8 hrs before
ingestion of glucose drink)
o Diagnosis by HbA1c Normal < 6
o Random glucose test normal should be 70--‐110
o Fasting BG >120 mg/dl
o Random BG > 160 mg/dl
27
CLINICAL MANIFESTATIONS
o
o
o
o
o
Enuresis/Polyuria
Polyphagia to anorexia
Fatigue, malaise, headaches
Polydipsia
N/V, abdominal pain, dyspnea
GOALS
o Sustain Health & Promote Growth
o Independence in the management of the
condition
o Multidisciplinary approach to
care
Children can participate
o 7--‐8 yo Records BG results in
book
o 8--‐10yo Performs BG testing
o 12--‐14yo Administers insulin
o 15--‐17yo Adjusts insulin based on BG
Results
INSULIN
o Three injections per day
o Immediate acting with rapid acting before breakfast, rapid acting
before th evening meal and intermediate acting before bed
o Withdraw short--‐acting insulin first when two types
o Store insulin in a cool, dry place
o Can have implantable insulin pump--‐high maintenance
THERAPEUTIC MANAGEMENT
Type 1:
o Insulin replacement or oral medications
o Self blood glucose testing
o Exercise
o Diet
o Monitor for Complications: Infections/Ketoacidosis
28
KETOACIDOSIS Cause: insufficient insulin (failure to
take appropriate dose)
S/S
o Elevated blood glucose level
o Ketosis--‐ Kussmaul respirations , N&V, and abdominal pain
o Dehydration and or electrolyte loss--‐polyuria, polydipsia, flushed dry
skin, decrease LOC, coma
Treatment
o Rapid nursing assessment
o Admit to ICU with continuous cardiac monitoring
o Obtain labs, blood glucose,electrolytes, ABG’s.
o Treat electrolyte inbalance and dehydration with electrolytes (potassium)
o DO NOT administer potassium until serum potassium levels are known.
o Give fluids over 24--‐48hrs to prevent cerebral edema/Low dose IV
insulin to control glucose levels
Somogyi effect and posthypoglycemic hyperglycemia, it is a rebounding high
blood sugar that is a response to low blood sugar.[1] When managing the
blood glucose level with insulin injections, this effect is counter-intuitive to
insulin users who experience high blood sugar in the morning as a result of
an overabundance of insulin at night.
29

Gastroesophageal reflux intervention
Gastroesophageal Reflux (GER)/ Gastroesophageal Reflux Disease
This condition is in response to an immature cardiac sphincter muscle which
results in gastric contents returning to the esophagus. Most common in infants
(outgrows by 18-24 months).
Treatment
Nutritional
o –Small frequent feedings
o –Increase bubbling (q1oz)
o –Thickened formula
o –Older child – no chocolate or caffeine products
o –Solids followed by liquids
Position
o –No infant seats as ↑ gastric pressure
o –If supine position – 60 degree angle
o –Older child – Left side with HOB ↑
Medications
o
Acid Suppression Therapy–1st line medications Histamine 2 Receptor Antagonist (Zantac)-decrease HCL present
o
Proton Pump
Inhibitors (PPI)-–2nd line
medications – Suppress gastric secretions line Nexium, Protonix,
Omeprazole
o
Prokinetics–Accelerate gastric emptying (Reglan)
Diagnosis
o
Upper GI series
o
Extended Esophageal pH Monitoring
o
Endoscopy – allows for biopsy & determination of
the severity of complications
30
Nephrotic syndrome -The clinical manifestations, Nursing assessment,
management Nephrosis see pg 108 of this blueprint. Textbook page 1363.

Urinary tract infection - strategies with a parent to prevent a recurrence of
UTI

CLINICAL MANIFESTATIONS
In a newborn they can get UTI from bacteria in the blood
– Newborn or Infant
o Nonspecific changes in feeding/sleeping/behavior
o Changes in color of urine
o Fever or Hypothermia
o Dysuria
o Poor weight gain
– Children
o Abdominal or suprapubic pain
o Frequency/Urgency
o Dysuria
o New or increased enuresis
o Fever
DIAGNOSIS
o Bacteria-most common is E. Coli (80%). Also, group B strep, Klebsiella
pneumoniae, Proteus species, Enterobacter & Staph
o WBC
o Hematuria
o Nitrites
o The diagnosis of UTI is confirmed by the detection of bacteria in a urine
culture, but urine collection is often difficult in a child, especially infants
and very small children. The most accurate test of bacterial content are
suprapubic aspiration (children less than 2 yrs) and properly performed
bladder catheterization (as long as first few ml of specimen are excluded
from the diagnosis.) The specimen should be taken to the lab ASAP but if
delayed can be refrigerated for up to 24 hrs. Storage will result in the
loss of blood cells & casts
31
TREATMENT
o
o
o
o
o
o
o
o
o
Antibiotic therapy-7-10 days oral (Bactrim, Keflex, Macrodantin)
Hydration
Follow-up urine culture
Radiographic imaging studies for all males & females under 5 years if
more than one documented UTI
Antibiotic therapy is guided by culture & sensitivity test. Common
antiinfective agents include the penicillins, sulfonamides (including
trimethoprim/sulfamethoxazole - Bactrim & Septra), the cephalosporins
(keflex), nitrofurnatoin (macrodantin) and the tetracyclines
PREVENTION
Fluid Intake
o 100 ml. per kg. or approximately 50 ml per lb. of body weight
o Fluid intake of water will help to reduce the concentration and
alkalinity of the urine. Adding foods high in animal proteins also
helps to acidify the urine.
o Increasing of dietary fiber and fluid will help prevent constipation.
Empty bladder
o Prevent constipation
Hygienic habits
o Wipe from front to back
o Cotton underwear
32
Generalized tonic-clonic seizure – Nursing Intervention General Tonic Clonic
seizures:

A seizure is an involuntary contraction of muscle caused by abnormal electrical
brain discharges.
May be idiopathic (without cause) and may also be attributed to infections,
trauma, or tumor growth.
Although a generalized seizure tends to be accompanied by impaired LOC,
sometimes it’s too brief to discern impaired consciousness.
The most common type of pediatric seizure is a generalized tonic-clonic
seizure.
Types of Generalized Seizures:
Tonic-clonic seizures (formerly known as grand mal) begins with a tonic phase
of sustained muscle rigidity, commonly accompanied by pallor, eye deviation,
and incontinence. A clonic phase follows, marked by rhythmic jerking of
extremities. Mental status is impaired during both the seizure and immediate
postictal period.
Tonic seizure involves sustained spasmodic muscle contractions with rigidity.
Clonic seizure involves extremity muscles jerk rhythmically as they alternately
contract and relax.
Absence seizures (formerly known as petit mal) are marked by sudden
transient loss of awareness that typically lasts 10 seconds or less. The facial
expression is blank.
Atonic seizures (formerly known as “drop attacks”) have an abrupt onset and
causes loss of consciousness and muscle tone.
Myoclonic seizures are characterized by jerking of trunk and arm muscles in
conjunction with an abrupt head drop. No loss of consciousness occurs.
33
Risk factors include:
o Brain injury
o Tumors
o Infection
o Fluid & Electrolyte disturbances
o Vascular disorders
o hypoxia
o hypoglycemia
Evaluating a child for seizures
-Anticonvulsant medications aren’t recommended after a first-time febrile
seizure.
-A child who has had two or more unprovoked seizures requires a full work-up,
including an evaluation by a pediatric neurologist, EEG, and magnetic
resonance imaging (MRI).
-An MRI is the best radiologic test for finding subtle abnormalities, such as
focal cortical dysplasia and hippocampal sclerosis.
-However, computed tomography may be done urgently to rule out a brain
tumor or an intracranial hemorrhage.
-Intervening for status epilepticus or seizures lasting more than 5 minutes
Assessment:
o
o
o
o
o
Child’s health history
Familial history
Child’s behavior
Temperature/evidence of infection
TORCH titers
34
Torch
o T-Toxoplasmosis
o O-Other can include: syphyllis, varicella, rubeola, polio, flu, viral
hepatitis, gonorrhea, strep B, candida, chlamydia.
o R- Rubella- viral teratogen
o C- Cytomeglovirus – viral teratogen in the HSV family. It is spread by
droplet. No treatment or cure. Instruct mother to avoid crowds and
careful handwash for prevention.
o H- Herpes virus- c-section if active lesions at delivery time.
Interventions:
For a child with status epilepticus, immediate priorities are airway
management and seizure termination.
-Secure the patient’s airway, breathing, and circulation.
- As needed, give oxygen, support ventilation, and establish I.V. access.
-Drugs such as lorazepam, diazepam, midazolam, phenytoin, or phenobarbital
may stop the seizure activity.
-Do not restraint during seizure
-Clear immediate environment
-DO not place any objects in the mouth
-Pad side rails/suction and administer O2 as needed
Long-term treatment:
-An abnormal EEG or signs and symptoms of neurologic impairment are
indications for treatment. The ultimate goal of drug therapy is to prevent or
control seizures with minimal adverse effects.
-If medications fail to control seizures or cause unacceptable adverse effects,
other treatments are considered.
Other treatments include vagus nerve stimulation (VNS) and a ketogenic diet.
35
-VNS therapy is recommended only for adults or children older than 12. A small
battery is implanted subcutaneously, and electrodes are threaded under the
skin and attached to the vagus nerve. The electrodes send small electrical
pulses along the vagus nerve to the brain to prevent seizures. During a seizure,
a magnet may be swiped over the VNS to shorten the seizure or reduce its
severity.
-Another treatment option is a ketogenic diet, roughly 80% of calories come
from fat; the diet mimics starvation by forcing the child to burn fat calories for
energy. Although it’s unclear how the diet controls seizures, it has been found
to improve seizure control in about one-third of children and eliminate seizures
in another third.
-For severe intractable epilepsy, surgical intervention may be recommended,
such as resection of focal cortical dysplasia, hemispherectomy, or corpus
callosotomy.
36
Cerebral palsy – Types; management Cerebral palsy
Nonprogressive neuromotor disorder resulting from brain damage before,
during and shortly after birth-it is not inherited and prevalent in 2 out of 1,000
live births
causes of cerebral palsy prenatal
-radiation, intrauterine infections, drug usage, metal toxicity, fetal anoxia,
cerebral hemorrhage, chromosomal abnormalities, abrupted placenta,
premature detachmentcauses of cerebral palsy post natal
premature birth, asphyxia sepsis, cerebral hemorrhage, inflammatory diseases
of the brain and head trauma
causes of cerebral palsy perinatal (during birth)
-trauma to child's brain during birth, using forcepscerebral palsy classified by:
Looking at limb paralysis and neuromuscular characteristics
Types:
Spastic type: (may involve both extremities or one side or all four):
Quadriplegia: Paralysis of trunk and all four extremities
Diplegia: Paralysis of corresponding extremities on both sides of body either
arms or legs
Paraplegia: Paralysis of Lower trunk and both lower extremities
Hemiplegia: Paralysis of One side of the body such as right arm and leg
common in mild forms
Monoplegia: Paralysis of Single extremity not common
37
characteristics of spastic in cerebral palsy:
Increased muscle tone, exaggerated stretch reflex, slow effortful jerky
voluntary movementscharacteristics of athetoid cerebral palsy:
Slow writhing involuntary movements when spontaneous or volitional actions
are attempted.
characteristics of ataxic cerebral palsy
Disturbed equilibrium resulting in balance problems, reflexes and muscles
characteristics of rigid cerebral palsy
Simultaneous constant contractions of all muscles painful and tiring
characteristics of mixed cerebral palsy
Combination of more than one type most common is spastic/athetoid typically
there is increase muscle tone and slow movement
most common speech problems in cerebral palsy
Articulatory Problems, Respiratory Problems-difficult time controlling breath
stream
Prosodic Problems
assessment of cerebral palsy
Neuromotor Functions
Motor Development
Mental Development-they may
or may not have mental retardation Speech disorders and intelligibility
38
Prosodic Problems
Voice and Respiratory Problems
Resonance Problemshyper nasality
Oromotor Dysfunction- it will manifest with tongue trusts
tough time eating due to lack of muscle control of the
mouth
Augmentative/Alternative Communication-assess it is important to
help them have a method of expressing themselves
Management of CP
Supportive care, prevent deformities (use braces), Speech therapist (talk
slowly), Pad side rails. These patients may have motorized devices, wheel
chairs, scooters, and specialized walkers. They may also have orthopedic
surgery to help with the spastic deformities and help with the balance and
control. For seizures, use Anti-Anxiety drugs. With CP patients, we must
encourage these as much as possible to promote locomotion and
independence. Baclofen, Dantrolene Sodium & Valium: relax muscle
groups in CP patients, decrease spasticity, these drugs are HEPATOTOXIC.
Children will need periodic liver function tests.
39
Difference between adults and children fluid and electrolyte imbalances
Difference Between Adults and Children Fluid and Electrolyte Imbalances

A. Differences from adult patients
 Full renal function reached at 6-12 months of age
 Children can achieve normal renal function after failure
 Young infants cannot concentrate urine as efficiently as older adults
B. Laboratory Test
 Serum Creatnine- The most useful clinical estimation of glomerular
filtration rate is serum creatnine level, an end product of protein
metabolism in muscle and a substance that is freely filtered by the
glomerulus and secreted by the renal tubular cells. Any significant
renal disease can diminish the glomerular filtration rate. The nurse’s
responsibility is in the collection of a 12 or 24 hr. urine specimen. A
normal urine creatnine is 0.7 to 1.5mg/100ml
 Blood Urea Nitrogen(BUN) – Tests the level of urea in the blood and
is used to assess glomerular function, or how well the kidneys can
clear this from the blood stream. A normal value is 5-20mg/100ml
 Urine Osmolarity – is a more sensitive index than specific gravity. The
deviations are either high or low. Normal newborn 50-600 mOsm/L
and thereafter 50-1400mOsm/L.
C. Childs Average Urine Output in 24 Hours
 6 months – 2yrs = 540-600ml
 2 – 5yrs = 500 -780ml
 5 – 8yrs = 600 – 1200ml
 8 – 14yrs = 1000 – 1500ml
 Over 14yrs = 1500ml
40

Intussusception – Clinical manifestations, Treatment
Intussusception is the telescoping of one portion of the bowel into an
adjacent portion causing obstruction.
Is one portion of the bowel into an adjacent portion causing obstruction?
o Most commonly occurs between 3-12 months
o More often in males and in children with Down’s Syndrome.
Clinical manifestations
o paroxysmal intermittent abdominal pain
o red currant jelly stool
o vomiting
o tender distended abdomen
o right sided sausage shaped mass.
o Children draw up their legs when in severe pain, and may vomit.
41
Complications:
o Fever
o Tachycardia
o hypotension
Interventions
Barium given into rectum as enema, and works as diagnostic and or corrective.
If normal brown stool noted after given barium enema, there is a reduction in
the intussusception. If it does not result with barium enema, or for those who
are too ill for this procedure, laparoscopy is used.
TX.
NG tube to minimize enema, and air enema for diagnostic and corrective.
It can reoccurrence in up to 10% of children; therefore, watch for
reoccurrence.
42
Juvenile rheumatoid arthritis – Types
Juvenile Arthritis - is an Autoimmune disease that affects joints of the body

although it can also affect blood vessels and other connective tissue. Can occur
as early as 6 months and rarely continues after age 19. Peaks 1-3 years and 812 years. It occurs most commonly in girls 9-12.
S/S
o Joint pain and swelling
o fever
o rash
o lymphadenopathy
Management
o Improving mobility by doing ROM, stretching, and hydrotherapy
swimming
o Reduce pain with aspirin, non-steroidal anti-inflammatories, ibuprofen,
steroids, and surgery
o Avoid obesity
43

rheumatic fever – Assessment; management
 Rheumatic fever – Prevention, management, nursing diagnosis
Autoimmune disease that occurs as a reaction to a group A beta hemolytic
streptococcal infection. Inflammation from the immune response leads to
fibrin deposits on the endocardium and valves especially the mitral valve and
major joints. This disorders often follows pharyngitis, tonsillitis, scarlet fever,
“strep throat”, or impetigo (all caused by group A beta-hemolytic strep). If left
untreated or not treated with the appropriate antibiotic, mitral valve
insufficiency can result and may not be diagnosed until later in life (adulthood).
Especially girls may be left with mitral valve insufficiency.
44
S/S of rheumatic fever include
o
o
o
o
o
Systolic murmur upon auscultation of the heart
Chorea (sudden involuntary movement of the limbs)
Macular rash on the trunk
Swollen and tender joints
Subcutaneous nodules on tendon sheaths
Important lab findings
Include a positive ASO titer (antistreptolysin-O)-indicates a history of
streptococcal infection.
Increased ESR (sed rate)
Increased C-reactive protein levels
Treatment
o Consists of bedrest during active phase of illness (course of illness usually
lasts 6-8 weeks)
o Antibiotics appropriate for Group A hemolytic strep (penicillin or
erythromycin if allergic to penicillin). May be a one time dose of Pen G or
Monthly IM injections of Pen G.
o Corticosteriods-careful of Cushing syndrome
o Aspirin/Ibuprofen
o Management of heart failure (Digoxin/diuretics)
o Management of chorea (Phenobarbital/diazepam)
o The prognosis will depend upon how much heart damage has occurred
from the illness.
1. Chorea disappears without any residual effects
2. Speech impairment and poor hand coordination noted due to
inflammation of basal ganglia more in girls than boys/ask child to
count rapidly to assess.
3. Assess child smile change from “Cheschire cat” to grin to flat affect.
45
o Chorea refers to brief, repetitive, jerky, uncontrolled movements caused
by muscle contractions that occur as symptoms of several different
disorders.
o Antistreptolysin O (ASO) titer is a blood test to measure antibodies
against streptolysin O, a substance produced by group A Streptococcus
bacteria.
o ESR stands for erythrocyte sedimentation rate. It is commonly called a
"sed rate." It is a test that indirectly measures how much inflammation is
in the body.
o C-reactive protein (CRP) is produced by the liver and is associated with
inflammation. An elevated C-reactive Protein level is identified with
blood tests.
o Diagnostic test/antibody titer (ASO) and increased ESR C-reactive protein
levels reflects child had recent strep
o Pulse rate shows signs of improvement/Child is on bedrest @ 6-8 weeks
To decrease incidence of Rheumatic fever there should be prompt treatments
of all URI’s.
Acute rheumatic fever develops after infection of the upper respiratory tract
with group A beta-hemolytic streptococci
Rheumatic heart disease refers to the cardiac manifestations of rheumatic
fever and includes pancarditis inflammation of the entire heart (myocarditis,
pericarditis, and endocarditis)
Rheumatic fever appears to be a hypersensitivity reaction to a group A betahemolytic streptococcal infection. The antigens of group A streptococci bind to
receptors in the heart, muscle, brain, and synovial joints, causing an
autoimmune response.
Because of a similarity between the antigens of the streptococcus bacteria and
the antigens of the body's own cells, antibodies may attack healthy body cells
by mistake
46
Affects age 6-15
Erikson Stages
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
o School Age 6-12– Industry vs Inferiority - Child learns how to do things
well. Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project.
o Adolescence 12-18 – Identity vs Role confusion – Adolescence learn who
they are and what kind of person they will be. Nsg Implication: Provide
opportunity for adolescent to discuss things

levothyroxine (Synthroid) – Side effects pg 535
Given for hypothyroidism the underproduction of thyroid hormone. It is
hormone replacement therapy that starts in small doses that are increased
gradually according to blood work results.
Clinical manifestations of hypothyroidism
o Easily fatigued
o Tend to be obese
o Myxedema (dry skin)
o Little tolerance to cold
Adverse reactions related to Levothyroxine use
o
o
o
o
Cardiac dysrhythmia/tachycardia/palpitations/cardiac arrest
Anxiety
Headache
Sleeplessness
47
o
o
o
o
o
o
Loss of hair
Heat intolerance
Menstrual irregularities
Weight loss/diarrhea/nausea/vomiting
Decreased bone density
If titrated too quickly, can then cause hyperthyroidism (S/S of
hyperthyroidism : confusion, disorientation, cerebral embolism, shock,
coma, seizures
Levothyroxine should be avoided if there is a history of MI or hypoadrenal
conditions.
Drug interactions with anticoagulants (increases effect), insulin and oral
hypoglycemic (decreases efficacy), anti-acids, iron, cholestryramine, decreases
effect of digoxin.
Food interactions with fiber. Fiber, soybean flour, walnuts, and cottonseed
meal may decrease absorption of the drug.
Those taking this drug should also take Vitamin D supplement to prevent
Rickets (a disorder that can develop due to lack of vitamin D, calcium or
phosphate).
RICKETS
48
Nursing management
o The drug should be given as a single dose in the am on an empty stomach
30 minutes before breakfast.
o Dosing is usually titrated until thyroid lab levels are therapeutic.
o Monitor for cardiac symptoms.
o Advise patient to notify MD if any adverse reaction is noted.
o Warn patient to avoid discontinuing the medication without consulting
MD.
o Warn to avoid skipping doses.
o Advise patient that this medication is often given lifelong.
o BLACK BOX WARNING: Do not use this medication for treatment of
obesity for weight loss. (Parents and teenagers are doing this. Can
cause death)
o Available in mcg tablets po in mcg.

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










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

49

Reye’s syndrome parent education pg 1448
Reyes syndrome is an acute encephalopathy with accompanying fatty
infiltrations of liver, heart, lungs, pancreas, and skeletal muscles. It occurs in
children 1-18 regardless of either gender. Etiology is unknown but it usually
occurs after a viral infection such as varicella or influenza that have also been
treated with aspirin. If left untreated the condition leads to coma and death.
S/S
o Lethargy
o N/V
o Confusion
o Combativeness
FYI

o Teach parents and children to avoid aspirin use during a viral infection.
o Aspirin alone does not cause Reye’s syndrome. It is noted to be in
combination of a current or recent viral infection alongside aspirin
consumption.
50
FYI Not on blueprint
GI
Purpose of GI tract
o Mechanical breakdown of food
o Ingestion-mastication
o Digestion-starts in mouth with the food being broken down into
small particles and mixed with digestive enzymes in saliva to begin
absorption.
o Absorption – the majority of which occurs in the stomach then small
intestine which consists of duodenum, jejunum, and ileum
FYI: It used to be thought that the stomach was a sterile location because
of the high level of high concentration of hydrochloric acid, it was
believed that no bacteria could survive there but since the discovery of
51
the H. Pylori, a bacteria that is the major cause of peptic ulcers, that
theory was disproven.
o Elimination – the process by which the end products of solid waste is
eliminated via the large intestine, rectum, and anus.
Differences in GI tract of adult vs. child
o Adult’s stomach capacity is 2000-3000ml. A newborn’s stomach capacity
is 10-20ml. Which is why the neonate requires frequent feedings.
o Adult GI tract is fully developed. A neonate’s GI tract is immature and is
almost completely developed by age 2.
o Pediatric enzyme production/secretion is deficient until 4-6 months of
age and have minimal saliva.
o Peristalsis waves in infant is faster and may reverse thus the frequency of
regurgitation.
o Fever increases the rate of peristalsis in infant that why there’s diarrhea
with temperature elevation.
o Large intestine is short with less epithelial lining to absorb water.
o Liver is immature and unable to detoxify efficiently and conjugate
bilirubin.
Minimum output
o Infant/toddler/preschool/young school age -1-2ml/kg/hr.
o School Age – 0.5-1ml/kg/hr.
Esophageal Atresia – (Associated with polyhydramnios)
Esophageal Atresia is the incomplete formation of the esophageal lumen
resulting in the proximal (upper) esophagus forming a “blind pouch” which
then does not connect to any other structure.
Clinical Manifestations
o Respiratory distress immediate period after birth especially with feeding.
o 3 C’s
1. Coughing
2. Choking
3. Cyanosis
52
o Excessive oral secretions-blowing bubbles; excessive drooling
o Sneezing
o Abdominal distention
Diagnostic Evaluation
o Hx of maternal polyhydramnios
o X-ray –catheter (catheter must be firm) inserted to determine where it
goes/if any obstruction
o Bronchoscopy/barium enema- will reveal blind end fistula
o CXR
Medical management main focus to prevent pneumonia
o Surgical repair- ligate fistulas and anastomose the esophagus to the
stomach
o Chest tube is inserted to keep air out of the stomach and fluid out of the
lungs.
o Gastrostomy tube may be inserted to drain fluid by gravity from stomach
to prevent aspiration.
o IV fluids to prevent dehydration.
Nursing actions to prevent aspiration and complications
o
o
o
o
o
o
Keep NPO
Maintain IV therapy for fluids and electrolyte maintenance.
Maintain aspiration precautions and keep upright at 30 degrees
Low intermittent or continuous suction
ABT therapy with broad spectrum antibiotics
Maintain thermoregulation of the child (remember fever brings diarrhea,
which is another form of fluid loss).
o Maintain comfort measures to decrease air swallowing.
Nursing actions is surgery is delayed until 18-24 months
o Provide nutrition by G-Tube
o Provide non-nutritional sucking
Post-op Care
o Preserve the surgical site
53
o Prevent infection
o Prevent aspiration
o Should socialize for eating
Vacterl Syndrome What is VACTERL association?
VACTERL or VATER association is an acronym used to describe a series of
characteristics which have been found to occur together.
V stands for vertebrae, which are the bones of the spinal column.
A stands for imperforate anus or anal atresia, or an anus that does not open to
the outside of the body.
C is added to the acronym to denote cardiac anomalies.
TE stands for tracheoesophageal fistula, which is a persistent connection
between the trachea (the windpipe) and the esophagus (the feeding tube).
R stands for renal or kidney anomalies.
L is often added to stand for limb anomalies (radial agenesis).
Babies who have been diagnosed as having VACTERL association usually have
at least three or more of these individual anomalies. There is a wide range of
manifestation of VACTERL association so that the exact incidence within the
population is not exactly known, but has been estimated to occur in one in
10,000 to 40,000 newborns.
54
Neuroblastoma – parent education Neuroblastoma
A type of cancer that starts in certain very early forms of nerve cells found in
an embryo or fetus. (Neuro refers to nerves, blastoma refers to a cancer that
affects immature or developing cells). Occurs most often in infants and young
children; rarely found in children older than 10 years.

Note: (2nd most common solid tumor of childhood
Exclusive to infants and children
55
Unknown cause-not environmental
Familial form
More common in boys than girls and more common in Caucasian
than African-American children
Peak Dx performed at 22 months, 97% before age 10
80% have metastases to the bone, bone marrow, liver or lung)
Neuroblastomas vary in behavior; some grow and spread slowly while
others are quicker. Sometimes, in very young children, the cancer cells die
for no reason and the tumor goes away on its own. In other cases, the cells
sometimes mature on their own into normal ganglion cells and stop
dividing. This makes the tumor a ganglioneuroma.
S/S of Neuroblastoma
-65% have a primary abdominal mass and a protuberant firm abdomen
-Impaired range of motion, pain and limping, chest tumors, spinal cord
compression leads to inability to walk, impaired bowel and bladder,
drooping eyelids or small pupils
Other symptoms include:
A lump or mass in the abdomen, chest, neck, or pelvis (often found by a parent
when bathing the child)
Skin lesions or nodules under the skin with blue or purple patches
Eyes that bulge out and dark circles under the eyes (if the cancer has spread
behind the eyes)
Changes in the eyes, such as black eyes, a droopy eyelid, a pupil that is
constricted, vision problems, or changes in the color of the iris
Pain in the chest, difficulty breathing, or a persistent cough
Pain in the arms, legs, or other bones
Pain in the back, or weakness, numbness, or paralysis of the legs if the tumor
has spread to the spinal cord
Fever and anemia, which is a low level of red blood cells
Constant diarrhea or high blood pressure caused by hormones released by the
tumor
Rotating movements of the eyes and sudden muscle jerks, likely from immune
system problems caused by the disease
56
Assessment:
 DDST(Denver developmental screen): mental status, LOC, Glascow Coma
Scale
 Increased head circumference, decreased cranial nerve function,
decreased reflexes,
Treatment:
 Surgery (Stage 1 & 2)
 Surgery + Radiation+ chemotherapy (Stage 3&4)
{Depends on presence and extent of metastasis
Staging I-IV=other organs involved, lymph node involvement, unilateral tumor
or crosses midline
Early stage (I-III) surgical excision (Stage I & II=80-90% survival)
Later stage (IV) surgery for tumor debulking for pain control then radiation &
chemotherapy (10-30% survival)
Children diagnosed before 1 have a better prognosis=low dose chemotherapy}
 Most patients with low-risk disease receive surgery alone. Sometimes,
infants with small localized tumor have been successfully watched closely
without any surgery, called observation.
 Patients with intermediate-risk disease receive surgery and
chemotherapy.
Post op -evaluate for bleeding and infection
Before chemotherapy monitor
-Urinalysis/CBC, Chemistry/Uric Acid- UA spec gravity and pH check to see if
urine is dilute enough to do chemo and for renal and hepatic insufficiency
During chemotherapy monitor Side Effects
-Cardiac Function/MUGA Scan - measures ejection fraction percentage of
blood ejected from Left- ventricle w/each heartbeat. Longterm complication is
cardiomyopathy and infertility
-N&V, Diarrhea
-Alopecia, Anemia, Neutropenia, thrombocytopenia
-Mucositis
57
BLACK EYES

Asthma – Teachings, management, meds
Asthma – s/s treatment, meds, effects, patient teaching, disease process,
nebulizer, triggers
o Asthma is an immediate sensitivity type-1 response, is the most common
chronic illness in children. It is a chronic inflammatory disorder affecting
mast cells, eosinophils, and T lymphocytes. It affects small airways,
alveoli. Inflammation causes increase in bronchial hyper-responsiveness
58
to stimuli, allergens such as dander, dust, pollen or atopy (allergic
tendency). It is responsible for many hospital admissions and is the
primary cause of school absences. It tends to start before 5 years of age
and is often diagnosed as frequent occurrences of bronchiolitis rather
than asthma. (See table 40.6 pg. 1166) It may be intermittent with
symptom free periods or chronic with continuous symptoms. It causes
mucosal edema, increased airway irritation, mast cells release substances
that act upon airways, bronchospasm, mucus plugging, increased work of
breathing, gas exchange and tissue oxygenation is diminished.
Signs and symptoms
o Expiratory wheezing may be on inspiration with severe asthma
o Dry cough
o Difficulty exhaling/dyspnea/wheezing (often say they feel an elephant on
their chest.)
o No fever
Triggers
o Environmental allergens (dust, mold, tree pollen, animal dander)
o Food hypersensitivities (food allergies especially to peanut/tree nuts,
milk, egg)
o Extreme temperatures and extreme changes in temperature
o Aspirin/NSAID hypersensitivity
o Cigarette smoke
o Turpentine (chemical in stains and paint) or smog (polluted air)
o Perfumes/strong odors or chemical cleansers
o Feathers
o Stress/Anxiety
o Vigorous exercise/physical activities
Pulmonary Function Studies/Tests
59
PFT is a broad term used for multiple tests that include spirometry and peak
flow meter measure how well the lungs take in and exhale air and how
efficiently they transfer oxygen.
Peak expiratory flow rate monitoring for asthma management.
To use a peak flow meter the patient places the meter mouthpiece in their
mouth and blows out as hard as they can. Zones are assigned to rate their
expiratory compliance.
o Green – 80-100% of personal best – signals all clear and asthma is under
good control
o Yellow – 50-79% of personal best – signals caution: asthma not well
controlled: call MD if child stays in this zone.
o Red – below 50% of personal best – signals a medical alert. Severe airway
narrowing is occurring: short acting bronchodilator/beta 2 agonist
(Albuterol via nebulizer/HFA/respiclick; Brand names ProAir,
Ventolin/Proventil HFA) is indicated.
Therapeutic Management
o Allergen avoidance
o Skin testing to identify allergen
60
o Allergen desensitization or also called hyposensitization. FYI: Allergy
injections are given SQ and more recently SL when symptom control is
inadequate with other treatments. It works by increasing IgG
antibodies to block IgE antibodies from coming in contact with an
allergen. SQ injections are given every 3-10 days for 6-8 months then
monthly for 3-5 years. Anaphylaxis can occur 30 minutes after injection
up to 2 hrs. They are prescribed Epi-pens for emergency use. SL is given
weekly.
o Pharmocologic agents such as inhaled anti-inflammatory corticosteroid
such as Flovent, Asmanex works by reducing swelling/inflammation for
mild persistent asthma. If over 6 years old with chronic asthma, they may
also be treated with leukotriene receptor agonist such as Montelukast
(Singulair). Should not be used for an acute asthma attack.
o Rescue
- short acting beta 2 agonist: bronchodilator: Albuterol which are
Ventolin, Proventil, ProAir HFA and ProAir Respiclick (FYI all non-HFA
inhalers have a milk component and should not be given to those with
milk allergy ie; Serevent diskus, ProAir Respiclick, Flovent Diskus, Advair
Diskus, Asmanex.)
-Anticholinergics
-Mast cell inhibitors- Intal/Cromolyn an inhaled non-steroidal antiinflammatory drug prevents asthma symptoms by blocking the release if
mast cell mediators. Given 30 minutes before exposure to triggers.
Cromolyn is not effective if symptoms have begun.
-Systemic corticosteroids/Prednisone – for short course management.
o Long acting bronchodilator (Serevent/Foradil) at bedtime and inhaled
anti-inflammatory corticosteroid for moderate persistent asthma
symptoms.
o Severe persistent asthma symptoms may be treated with high dose oral
and inhaled corticosteroid daily as well as a long acting bronchodilator at
bedtime.
o Long acting beta2 agonist such as Advair HFA is only indicated for
children inadequately controlled by inhaled anti-inflammatory
o Cough suppressants are contraindicated (As long as children are able to
cough up mucus, they are not in serious danger. When they stop
61
coughing up mucus, thick mucus plugs form that can then lead to
pneumonia, atelectasis, and further acidosis.
o FYI – A spacer may be needed for HFA/MDI medications.
o Prevent dehydration which often occurs rapidly during an asthma attack
because of decreased oral intake and increased insensible loss from
tachypnea. Dehydration is destructive because it may contribute to
increased mucus plugging.
Erikson Stages
o Infant 0-1year Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security
o Toddler 0-3 years Autonomy vs Shame and Doubt- Child learns to be
independent and make decisions for self. Nsg Implication: Provide
opportunity for independent decision making such as choosing own
clothes.
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
o School Age – Industry vs Inferiority - Child learns how to do things well.
Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project.
o Adolescence – Identity vs Role confusion – Adolescence learn who they
are and what kind of person they will be. Nsg Implication: Provide
opportunity for adolescent to discuss things that are important to him or
her. Offer support and praise for decision making.
62
FYI for respiratory
o RSV is most frequent in spring and winter months.
o Resistance may depend on the state of the immune system, malnutrition,
anemia, fatigue, and chilling of the body. Conditions that weaken the
defense of respiratory tract may also include allergies and asthma which
occur more frequently during cold weather.

laryngotracheobronchitis ; bronchiolitis - Cool Mist, Treatment
63
 Croup –Treatment, rationale for treatment, teaching
Croup- called Laryngotrachealbronchitis- Is the broad classification of upper
airway inflammation of the larynx, trachea, and major bronchi. Affects children
3months-3 years up to 8 years old. Slowly/gradual progressive. Attacks at
night. Improved with humidity. Can be treated at home. Resolves
spontaneously. Aggravated with crying. It is viral infection. Causative agent
parainfluenza virus 1, 2, or 3 during fall and winter. May also be caused by
influenza, RSV, rhinovirus, more rare measles and herpes simplex virus.
Signs and symptoms
o Barking cough/harsh
o Mild elevation of temperature
o Viral-Inspiratory stridor
Treatment
o Racemic epi nebulization- is nebulization of epinephrine 1:100 strength
mixed with 2-3ml of saline or 3-5 ml of epinephrine 1:1000.
o Corticosteroids: Oral dexamethasone in a single dose- to decrease airway
inflammation.
o Antibiotics not indicated
o Sedatives are contraindicated because they depress the respiratory
system.
o Budesonide
o Antipyretics: Acetaminophen
o Humidified O2 in mist tent or hood, Sips of fluid
o IVs for more severe cases/ I & O
o Do not elicited child gag reflex
o Comfort child to prevent crying
o Avoid Aspirin
Rationale for treatment
64
o Corticosteroid such as dexamethasone, or racemic epinephrine, given by
nebulizer, Budesonide to reduces inflammation and produces effective
bronchodilation to open the airway.
o Intravenous therapy may be prescribed to keep the child well hydrated.
o Dehydration can occur from rapid respirations. Adequate hydration can
help keep mucus moist. (tb pg 1167)
o Humidified oxygen improves ventilation without drying the mucous
membranes, to reduce hypoxemia. ABGs and pulse oximetry provide
objective evidence of the child’s oxygenation. (Tb pg 1167)
o Maintain accurate intake and output records and test urine specific
gravity to ensure that hydration is adequate.o Antipyretics: Acetaminophen are helpful for pain relief and fever.
o Laryngospasm with total occlusion of the airway can occur when a child’s
gag reflex is elicited or when the child is crying.
o Therefore, do not elicit a gag reflex in any child with a croupy, barking
cough, and provide comfort to prevent crying (textbook pg 1165)
o Antibiotics are not indicated for treating croup, because a virus usually
causes croup, antibiotics are reserved for those rare occasions when
bacterial infections cause croup or become superimposed on the viral
infection
o Sedatives are contraindicated because they depress respirations
o Mist therapy: dissolves sticky or dried mucus in the child's breathing
passages and lubricates the throat and windpipe
o Aspirin is avoided in the treatment of croup and other viral illnesses since
aspirin is suspected as being related to Reye's syndrome (Rare but
serious condition that causes swelling in the liver and brain especially
post viral infection).
Teaching
o Parent to run the shower or hot water tap in a bathroom until the room
fills with steam, then keep the child in this warm, moist environment.
o If this does not relieve symptoms, parents should bring the child to an
emergency department for further evaluation and care.
o Small frequent fluids/avoid dairy products/increase po fluids
o Child should be free from cough before returning to school
65
o Excellent recovery but usually recurs
o Close monitoring of the breathing of a child with croup is important,
especially at night.
Affects ages 1-8
Erikson Stages
o Infant 0-1year Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security
o Toddler 1-3 years Autonomy vs Shame and Doubt- Child learns to be
independent and make decisions for self. Nsg Implication: Provide
opportunity for independent decision making such as choosing own
clothes.
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
o School Age 6-12– Industry vs Inferiority - Child learns how to do things
well. Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project
66
meningeal irritation, Meningitis; myelomingocele - cerebral spinal fluid;
surgery, effects, preop care

Meningitis:
-Most common infectious process involving the central nervous system. Primary or the result of neurosurgery, trauma, systemic infection, sinus or ear
infections.
-3 most common primary organisms=Haemophilus influenzae type B, Neisseria
meningitidis & Streptococcus pneumoniae
 Neonatal meningitis caused by Group B strep and E –coli
67
S&S/ Manifestations:o Kernig’s sign- flex leg @ hip & knee then attempt to extend the knee; + if
pain is felt
o Brudzinski’s sign- lie child flat supine with neck flexed; + if child
experiences pain
o Neonate= poor feeding, vomiting, diarrhea, seizures, tense/bulging
fontanel
o Child= fever, vomiting, irritability, seizures, severe headache,
photophobia, nuchal rigidity, altered level of consciousness, muscle or
joint pain & purpura
o Lumbar puncture of CSF=cloudy, increased pressure, increased protein,
low glucose
o Opisothonus- spasm of the muscles causing backward arching of the
head, neck, and spine.
Complications:Serious complications may result from meningitis, such as hydrocephalus,
learning disabilities, seizure disorders, and deafness.
Diagnosis:Lumbar puncture - determines the presence of organisms in the spinal fluid.
Treatment/Management:o Viral meningitis is treated symptomatically.
o Bacterial meningitis is treated with intravenous fluids and antibiotics are
administered.
o Isolation is necessary until the child has been on antibiotics for 24 hours.
o Decreased environmental stimulation and neurologic checks are
essential.
o Elevate the head of the bed to lessen the increased intracranial pressure
that is caused by edema.
o A corticosteroid such as dexamethasone or osmotic diuretic Mannitol to
reduce ICP and help prevent hearing loss
68
o Child’s immediate family may be placed on antibiotics
Nursing Intervention
o Assess neurologic status and vital signs constantly.
o Determine oxygenation from arterial blood gas values and pulse
oximetry.
o Insert cuffed endotracheal tube (or tracheostomy), and posi-position
patient on mechanical ventilation as prescribed.
o Assess blood pressure (usually monitored using an arterial line) for
incipient shock, which precedes cardiac or respiratory failure.
o Rapid IV fluid replacement may be prescribed, but take care not to
overhydrate patient because of risk of cerebral edema.
o Reduce high fever to decrease load on heart and brain from oxygen
demands.
o Protect the patient from injury secondary to seizure activity or altered
level of consciousness (LOC).
o Monitor daily body weight; serum electrolytes; and urine volume, specific
gravity, and osmolality, especially if syndrome of inappropriate
antidiuretic hormone (SIADH) is suspected.
o Prevent complications associated with immobility, such as pressure
ulcers and pneumonia.
o Institute infection control precautions until 24 hours after initiation of
antibiotic therapy (oral and nasal discharge is considered infectious).
o Inform family about patient’s condition and permit family to see patient
at appropriate intervals.
Management for healthcare workers/ family:{Chemoprophylaxis with antibiotics or anti-virals may be necessary for
healthcare workers, family members, and daycare workers who come in close
contact with meningitis.}
Children meningitis (SPecial Neisseria Has EnteredVirus)
Strep pneuminia
Neisseria meningitis
H.influenza
69
Enterovirus
Diagnosing Meningitis: Don’t
MISS
M eningeal symptoms, e.g. Kernig and Brudzinski
I CP increase
S eptic symptoms, e.g. fever, tachycardia
S pinal fluid changes
K ernig symptom
K nee bending
B ridzinski symtptom
B end the neck
B ack is rigid
B oth legs flex at the hips
70
DDx of Meningitis Causes = BAT:
B acterial
A septic, e.g. viral
TB
MENINGITIS complications :
ABCDE CROSS
A- Ataxia
B- Blindness
C- Cranial nerve palsies
D- Deafness
E- Epilepsy
C- Cerebral herniation
R- Repeated episodes
O- Optic nerve atrophy
S- Stroke
S Spina Bifida
A congenital neural tube defect in which there is incomplete closure usually in
the lower spine of the vertebrae and neural tube during fetal development.
It occurs during the 4th week of gestation. Amniocentesis or ultrasound can
detect the disorder in the fetus.
Folic acid (folate) taken during pregnancy helps to prevent spina bifida (and
other neural-tube defects).
71
The three forms of this disorder are spina bifida occulta, meningocele, and
meningomyelocele:
• Meningocele occurs when one layer of the meninges (the spinal cord
covering) herniates through an opening in the vertebral column. The child with
a meningocele will have a visible sac on the back, but may show no disability;
conversely, he or she may experience muscle weakness, difficulty with bowel
and bladder control, and (rarely) paralysis. Corrective surgery is needed.
Generally, the child leads a normal life after surgery.
• Meningomyelocele or myelomeningocele is the most serious form of spina
bifida. The meninges, cerebral spinal fluid, nerve roots and part of the spinal
cord protrude through an opening. The child has a visible sac on the back. He
or she is usually partially or completely paralyzed, and may have bladder and
bowel control problems. Serious possible complications include meningitis
(inflammation of the meninges covering the spinal cord), encephalitis, and
hydrocephalus (80% of cases develop this). You must handle the defect with
great care to avoid injury to the sac or damage to the spinal cord. Surgery is
necessary to prevent infection and to preserve as much nerve function as
possible. It is often done soon after birth. (Surgery can be done in utero)
Causes:o Genetic
o Maternal folic acid deficiency
Diagnosis:o Sonogram, Amniocentesis, elevated AFP
o Appearance of lesion
o CT scan after delivery
S&S/ Manifestations:o Asymptomatic (depending on level of involvement)
o Visible sac on back
o Paralysis
72
o Spastic paraparesis
o Little or no feeling in their legs, feet, or arms, so they may not be able to
move those parts of the body; dislocation of the hips.
o Bladder or bowel problems, such as leaking urine or having a hard time
passing stools.
o A curve in their spine, such as scoliosis.
o Clubfeet
o Fluid buildup in the brain (hydrocephalus).
o Note: Even when it is treated, this may cause seizures, learning problems,
or vision problems.
Treatment/Management:o Prenatal surgery (at 19-25 weeks gestation- risk for abruption; infection,
uterine rupture)
o Some women may opt for termination of the pregnancy>
o Surgery done immediately after delivery decreases risk for
infection/mortality
o Lifelong management of neurologic/orthopedic and urinary problems
Post-op Teaching:o Prevent infection (keep area free of urine and stool)/Prophylactic abx.
o Observe for S/S of hydrocephalus & Inc. ICP
o Position off suture line (prone or side-lying; reposition and padding for
bony prominence)
o Strict I & O (fluids to flush kidneys)
o Instruct parents on home care (because of absent lower cord, bladder
and bowel non-functional; teach parents to catheterize at home)
o Teach the need for orthopedic follow-up to maximize mobility
o Referral to Community for Resources
Nursing Alert: For some reason, children with spina bifida tend to be
extremely sensitive to latex. Make sure such children do not come in contact
with items such as tourniquets, catheters, rubber bands, gloves, balloons, or
various tubes made of latex. Most medical items now have the latex free labels
73
74


ventriculoperitoneal shunt - Nursing priority
Wilm’s Tumor – Nursing assessment, management pg 1588
WILM’S TUMOR (NEPHROBLASTOMA)
o Malignant neoplasm of the kidney aka Nephroblastoma
o Most common cause of renal cancer in children
o Peak > 3 y/o (6months -4years)
o Boys > girls
o Maybe r/t cryptochordism, hypospadias, aniridia (lack of color in the iris),
cystic kidneys, hemangioma, and talipes disorders.
75
o Probably arise from a malignant cluster of mesoderm cells during
gestation- chromosome 11.
o Tumors are usually encapsulated for extended periods of time, rupture of
capsule  spread (seeding) of tumor into the abdomen.
o Metastasis  lungs
S/S
o Usually asymptomatic
o Firm, non-tender mass palpated that should not be palpated more than
necessary can aid in metastasis.
o Abdominal enlargement and pain
o Periorbital edema with ecchymosis around eyes
o Hematuria, low grade temp
o Anemia r/t decrease erythropoietin productions
o Respiratory involvement, SOB
o HTN r/t increased renin production by the kidneys
DX
o Intravenous pyelogram (IVP)
o Ultrasound
76
o CT scan, MRI
o Surgical removal a.s.a.p. for DX and check for metastasis
TX
Depends of stage of disease and extent of metastasis
Stage I-II
Surgery and close observation
o Tumor is completely excised
o No spillage of tumor and no residual of tumor
Stage III-IV
o Chemo, radiation, surgery after tumor shrink
i. III- Metastasis of tumor in peritoneal cavity
ii. IV- metastasis of tumor in lungs, liver, bones, brain…
iii. V- b/l involvement is present at DX
o Children <1 y/o – good prognosis
o Radiation and chemo
Nursing interventions
o Avoid palpating abdomen because of seeding of cancer cells
77
o Monitor BP for HTN
Pre op
o Child education
o Chemo and radiation
Post op
o Close monitoring of fluids to prevent hypovolemia
o Pain management
o Gentle handling
o Assess daily wts, I&O, urine specific gravity
o Chemo and radiation
o Assess VS for s/s of shock
o Family education
In general Nurse should:
o Assess labs and VS
o Pain management
o Close monitoring of fluid levels
78

Clubfoot – Assessment, treatment for a child with congenital clubfoot/
parental education Club foot is a bone deformity and malposition with soft
tissue contracture. It can be unilateral or bilateral. It affects boys x 2 greater
than girls.
o Exact cause UNKNOWN
o Familial tendency- 1/10 chance that a parent with clubfoot will have an
affected offspring
o Gestational weeks 9-10
S/Sx
Common types of foot malformations
o Talipes varus- inversion of foot
o Talipes valgus- eversion of foot
o Talipes equinus- plantar flexion in which toes are lower than heel
79
o Talipes calcaneous- dorsiflexion in which the toes are higher than the
heel
o Talipes equinovarus- inverted plantar flexion in which the toes are lower
than the heel
Clubfoot categories
o Positional clubfoot (postural)
o Syndromic clubfoot (teratologic)
o Congenital clubfoot (idiopathic)
Positional clubfoot
o Due to intrauterine crowding
o Corrected with stretching and casting
80
Syndromic clubfoot
o Associated with congenital anomalies
o Often more severe and resistant to treatment
Congenital clubfoot
o Child is otherwise normal and healthy
o Wide range of rigidity and prognosis
o Requires surgical intervention due to bone abnormality
Dx:
o Can be detected in utero by ultrasonography
o Readily apparent at birth
81
o Affected foot/feet are smaller
o Empty heel pad
o Transverse plantar crease
o If unilateral, affected limb may be shorter with calf atrophy
Examine hip thoroughly: increased risk of hip dysplasia
Tx: Therapeutic Management of Clubfoot
- Goal: achieve a painless and stable foot
- Treatment often done during newborn period
1. Correction of the deformity
2. Maintenance of the correction until normal muscle balance is gained
3. Follow up observation to avert recurrence
- Casting begun immediately after birth
- Manipulation and casting repeated frequently
- Casted until maximum correction (8-12 weeks)
- X-ray or US done to determine correction- If not corrected after 3 months,
then surgery
82
Surgery for Clubfoot:
- Pin fixation
- Release of tight joints and tendons
- Casting for 2-3 months, foot/feet are immobilized
- Once cast is removed, allowed to walk
- Varus-prevention brace is used to maintain correction
- May require repeated surgeries
Nursing Intervention: Postsurgical/Post Casting
- Strengthen leg muscles, promote ambulation, prom
- Assessment of skin and circulation
83
- Pain management
-Dennis Browne shoe
-Proper Cast Care
-Neurovascular checks q2hrs
- Parent education of treatment, cast care
- Normal development
- Provide emotional support, promote
optimal growth, development, self-image

acute lympholitic leukemia – signs and symptoms, Nursing management
 Leukemia – S/S, management, med effect, testing
Leukemia is a group of disorders usually begins in the bone marrow and result
in high numbers of abnormal white blood cells characterized by the
uncontrolled proliferation of abnormal immature blood cells often called
blasts. Categorized by specific blood cell lineage-lymphoid or myeloid. Most
common cause of childhood cancer. Mostly seen in children <15yrs old. More
84
common in boys. Most common in industrialized countries. Most common
form ALL- Acute lymphocytic Leukemia that has a survival rate of 85%. Age 2-6
peak more whites than blacks. If dx before 2 yrs and after 8yrs prognosis is
poor. AML-most prevalent in late adolescents. More resistant to treatment.
Signs and Symptoms
o
o
o
o
o
o
o
o
o
o
o
o
Swollen lymph nodes
Feeling of fatigue from decrease O2 r/t decrease RBC
Night sweats
Easy bruising causing bluish or recurring nose bleed
Frequent infection
Bone or joint pain
Weight loss
Enlargement of the spleen or liver which can lead to abdominal pain
Abnormal WBC’s
Pale skin (pallor from decrease RBC)
Decreased production of RBC’s
Decreased platelet production if less than 50,000mm monitor for s/s of
bleeding.
Therapeutic Management
o
o
o
o
o
Chemotherapeutic agents to prevent spread of leukemia,
Targeted therapy
Radiation therapy
Stem Cell transplant
For induction to decrease the leukemia cells and to achieve remission:
(1)IV vincristine and L-asparaginase
(2)Oral prednisone
(3)Methotrexate PO,IV,IM intrathecal
(4)Cyclophosphamide PO, IV, IM
o Additional medications: anti-gout agents – allopurinol to control the
severity of hyperuricemia during chemotherapy
85
Nursing Management
o Use good hand washing technique before and after contact with the child
o Assess the child for the side effect of chemotherapy
o Administer an antiemetic 30 minutes before chemotherapy is given; an
antiemetic is commonly continued for up to 1 day after the
chemotherapy has been completed.
o Assess the oral mucosa for pain, ulcers, lesions, stomatitis, and any
effects on changes in eating patterns
o Assess for bleeding from any orifice, check urine and stool for blood;
monitor platelet, WBC, H & H, and neutrophil counts
o Assess for signs of infection
o Provide mouth rinses and a soft toothbrush; apply topical xylocaine as
ordered before eating.
o Provide a nutritionally complete diet and a diet based on the child’s
preferences
o Isolate the child from persons with upper respiratory or other infections
Medication effects: (Don’t know whether she means side effect of meds) :
o
o
o
o
o
o
o
Hair loss
Nausea and vomiting
Mouth sores
Loss of appetite
Tiredness
Easy bruising or bleeding
Increase in chance of infection due to destruction of WBC
Testing:
o Bone Marrow Biopsy
o Chest X’ray
o Lumbar puncture
o Peripheral blood smear
o MRI and CT scan
86
o CBC
o Bone scan
Affects ages up to 15 yrs
Erikson Stages
o Infant 0-1year Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security
o Toddler 1-3 years Autonomy vs Shame and Doubt- Child learns to be
independent and make decisions for self. Nsg Implication: Provide
opportunity for independent decision making such as choosing own
clothes.
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
o School Age 6-12– Industry vs Inferiority - Child learns how to do things
well. Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project.
o Adolescence 12-18– Identity vs Role confusion – Adolescence learn who
they are and what kind of person they will be. Nsg Implication: Provide
opportunity for adolescent to discuss things
appendicitis , laparoscopic appendectomy - Nursing assessment,
management
87
Appendicitis
Inflammation of the appendix, a blind sac connected to the end of the
cecum. This inflammation can lead to perforation, peritonitis & sepsis.
Children with high fiber diets are a lower risk for appendicitis
Most common ER abdominal surgery
The etiology of appendicitis is poorly understood. There is an obstruction
of the lumen of the appendix, most commonly a result of a feclith or
hardened feces.
Laparoscopic appendectomy
Surgical removal of the appendix
Clinical Manifestation/Nursing Assessment
•
•
•
•
•
•
•
•
•
•
Pain –McBurney’s Point
Guarding of abdomen
Low grade temperature
N/V
↑ WBC (15,000-20,000) with ↑ bands or “shift to the left”
Anorexia
Personality changes
Pyuria
↓or absent bowel sounds
Bands or shift to the left = indicative of inflammatory process. To elicit
rebound tenderness: press firmly over part of the abdomen distal to the
area of tenderness & release the pressure suddenly – rebound
tenderness is present if the child feels pain in the original area of
tenderness.
• Pain is most intense at McBurneys point which is located midway
between anterior superior iliac crest and the umbilicus. Rebound
tenderness or Blumberg sign is not a reliable sign and very painful to
88
elicit on a child. This response is found only when the peritoneum
overlying the diseased organ is inflamed.
Mc Burney's Point
Management
Pre-op Nursing Care
–
–
–
–
–
–
–
–
Actions to correct fluid & electrolyte imbalance
Pain Assessment
NPO
IV therapy
Right side-lying or low semi-fowlers
NO HEAT (ice packs to abdomen)
No enemas or laxatives
Quiet play
Post-op Nursing Care
–
–
–
–
–
Assess bowel sounds x 4 quads
N/G tube to decompress stomach
Low semi fowlers or right lying with knees flexed
Pain management
Antibiotic therapy-Ampicillin, gentamycin & clindamycin 7-10 days
89
– N/G tube with intermittent suction is required until gastric motility
returns.
– The wound may be open for drainage, at which point nursing care will
include moist dressing changes and possible wound irrigations with
antibacterial solutions. Pain management requires round the clock
opiods for first 24 hrs.
Hirschprung’s disease – see page 1 of blueprint
90
sickle cell crisis – Genetics, management, assessment
Sickle Cell: Hereditary (normal hemoglobin replaced with Hgb, abnormal)mostly in those of African heritage, although it can affect middle eastern and
Mediterranean decent as well as others. In this condition the hemoglobin
forms long rods when it gives off oxygen stretching red blood cells into
abnormal sickle cell shapes. This leads to premature destruction of RBC
resulting in chronically low levels of hemoglobin. These abnormal RBC can clog
small blood vessels leading to recurring episodes of pain as well as problems
that can affect every other organ system in the body.
o Autosomal recessive disorder – both parents must be carriers of the sickle
cell trait
o If both parents have trait the risk of children is 25%
o Sickling is not found until late infancy from the from the presence of fetal
Hgb
o Spleen is the first organ affected
o Children suffer from splenic sequestration which is life threatening,
because the blood gets trap in the spleen. Any condition that requires the
increase in Oxygen after the transport of Oxygen. Examples Infection,
Trauma & Dehydration, stroke.
o Fever can trigger a crisis, hypoxia, stress but can resume normal shape
with rehydration, reoxygenation.
o Hand foot syndrome also called dactylitis is the painful swelling of hands
and feet and in some infants is the first sign of a sickle cell anemia.
o Children with sickle cell are at greater risk for certain bacterial infections.
It is important to watch for temp 101*F or higher; they should be seen by
MD immediately.
Therapeutic Management:
o Analgesics to control the severe pain during a crisis; Opiods such as
morphine and oxycodone parenterally or via PCP pump
o Antibiotics to treat the existing infection
o Stem cell transplant also called bone marrow transplant is the only
known cure for sickle cell disease. Risk of rejection.
91
Treatment:
o
o
o
o
o
Rest
O2 administration
Fluid and electrolyte replacement
Blood replacement/transfusion
Bone marrow transplant/Stem cell transplant- only known cure for sickle
cell.
o Immunizations to prevent life threatening infections for Pneumonia,
Influenza, and Meningitis.
o Folic acid is given to increase red blood cell production.
o Hydroxyurea is given to help reduce the stickiness of RBC’s and it
decreases the frequency and intensity of pain episode and other
complications such as :
o Acute chest syndrome (leading cause of death in sickle cell disease.
It is caused the lowering level of oxygen in lungs.)
s/s
o
o
o
o
o
o
Fever
Cough
Excruciating pain
Sputum production
Shortness of breath
Low oxygen levels
o Acute Sequestration Crisis - refers to an acute condition of
intrasplenic pooling/trapping of large amounts of blood/red blood
cells
s/s
o Irritability
o Unusual sleepiness
o Looks pale
o Weakness
o Fast heart beat
o Big spleen (splenomegly)
92
o Pain on the left side of abdomen
o Decrease H&H
o Painful
Nursing Management:
o Assess for signs of hypoxia, irritability, restlessness, agitation and
hyperventilation along with increase apical pulse and RR, confusion and
cyanosis
o Monitor input & output, daily weight
o Assess for signs of infection and dehydration (dry mucous membranes
and skin, poor skin turgor, decrease urine output)
o Encourage child to drink fluids every 2 hours. Use 5oz/kg of body weight
as a minimum fluid requirement
o Provide rest periods to decrease oxygen expenditure
o Administer blood products as ordered, assess for a transfusion reaction
o Perform passive range-of-motion exercise every 4 to 6 hrs
o Isolate child from sources of infection; administer antibiotics as ordered
Nutrition: A high–calorie, nutrient–dense diet
o Adequate fluid consumption to maintain hydration:
o Vitamin and mineral supplementation: Blood levels of several vitamins
and minerals are often low in individuals with sickle cell disease,
including vitamin A and carotenoids, vitamin B6, vitamin C, vitamin E,
magnesium, and zinc. This can result in a significant deficiency of
antioxidants, which may increase the risk of disease flare–ups. Studies
indicate that vitamin–mineral supplements of certain nutrients (vitamins
C and E, zinc, and magnesium) or treatment with a combination of high–
dose antioxidants can reduce the percentage of sickled red blood cells.
o Omega–3 fatty acid supplements: Supplementation with omega–3 fatty
acids can improve the membranes of red blood cells and may decrease
flare–ups of the disease.
o Calcium and Vitamin D
o Low fat or fat free milk
o Cheese, green leafy vegetables
o Orange juice & tofu
93
o Dried fruit, nut & nut butters or smoothies
Affects infants and up
Erikson Stages
o Infant 0-1year Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security
o Toddler 1-3 years Autonomy vs Shame and Doubt- Child learns to be
independent and make decisions for self. Nsg Implication: Provide
opportunity for independent decision making such as choosing own
clothes.
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
o School Age 6-12– Industry vs Inferiority - Child learns how to do things
well. Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project.
Adolescence 12-18 – Identity vs Role confusion – Adolescence learn who they
are and what kind of person they will be. Nsg Implication: Provide opportunity
for adolescent to discuss things
94

Celiac disease - Nursing assessment, management
Celiac Disease-is a sensitivity or abnormal immunological response with the
chronic inability to tolerate foods containing gluten. The cause is related to
intestinal villi atrophy which reduces absorption of all nutrients. Gluten free
diet because they are not absorbed. Gluten is a factor of protein includes
barley, wheat, rye, or oats including thickeners cause they are gelatin/proteincontaining items.
Assessment/Clinical Manifestations
o Steatorrhea-fat containing bulky stools
o Foul smelling stool
o Distended abdomen
o FTT- malnutrition with wasting body but blump face
o Monitor H&H for possible anemia
95
Medical Management
o Avoid all gluten-containing foods to reduce risk of GI carcinoma
o Vitamin ADEK replacement, need water soluable forms of vitamin A&D
o Folate and iron replacement to correct any anemia present
o Monitor stools for fat and protein
Celiac crisis is the development of extreme symptoms may develop with an
infection. That will result in the following:
o Watery diarrhea and vomiting
o Electrolyte imbalance and dehydration
o Metabolic acidosis
96

post pyloromyotomy -Nursing assessment, management, parent education
Pyloromyotomy is a surgical procedure in which an incision is made in the
longitudinal and circular muscles of the pylorus. It is used to treat hypertrophic
pyloric stenosis. Hypertrophied muscle is cut along the whole length, till
mucosa bulges out.
Pre OP
o Strict I&O
o Monitor for sign of dehydration
o NPO
o Maintain IVF infusions
Post OP
o Small regular feedings
o Place on right side with HOB elevated high fowlers
o Pain management
o Assess suture line
o Vomiting common in first 48hrs
97
Care of the incision
o The incision (surgical cut) from the operation will be covered by a
dressing called steri-strips. You do not need to do anything to the strips.
Wash your hands before touching or cleaning the incision area.
o A small amount of blood on the strips is common. If the blood seems
fresh (bright red in colour) or if the amount of blood increases, press on
the area with a clean, dry washcloth for 5 to 6 minutes. Then call your
baby's surgeon's office. If the bleeding does not stop, take your baby to a
family doctor or to the emergency department.
o The steri-strips will fall off on their own. If they have not fallen off
already, you can take off the strips 7 to 10 days after your baby's
operation.
Activities
You can allow your baby to do all normal activities once he returns home.
Food and drink
98
o During the first 24 hours after the operation, your baby may still vomit.
This is common. The vomiting is usually due to the side effects of the
pyloric stenosis. It will slowly get better.
o Your baby should be able to eat the breast milk or formula he normally
eats after the operation.
o If your baby has problems eating, call your surgeon's office.
Pain medicine
Your baby can have pain medicine as needed after the first 24 hours. This type
of operation is usually not very painful, so your baby should only need plain
acetaminophen by mouth.
Bathing
You can give your baby a bath 48 hours after the operation.
99

Erickson growth and development – Preschooler, school-agers, adolescents,
Toddlers, infants Growth and development
o Weight double in six months and triple in one year
o Anterior fontanel close at 12-18 months and posterior fontanel
close at 3 months
o Tooth eruption begins at 4-6 months, and then one tooth per
month
3months old
o Social smile
100
o Know primary care givers
o Lift head and chest in prone position
o Rolls side to back
o Neonatal reflexes begins to fade
o Follow objects with eyes
Toys
o Mobile, music box and mirror to stimulate them
o They sleep 10-16 hrs.
o Safety is a primary concern – baby should sleep in a crib with no stuffed
animals, should be sleeping on their back
Six months old
o Apprehensive of stranger
o Roll well
o No head lag
101
o Sits with help
o Use palmer grasp
o Sleep 14hrs. with longer period at night and 2-3 naps
Nine months old
o They have stranger anxiety
o Waves bye bye
o Sits well without assistance
o Know two syllables without meaning
Twelve
o They imitates
o Walk with assistance
o Stands without assistance
o They can have push toys
o Shows jealousy
Managing stress while in hospital
102
o Encourage rooming- parents staying over
o Place near the nursing station
o Need consistent staffing-continuity of care
o Hold for feedings
o Sucking and pacifier
Feeding
o Don’t heat up their food in the microwave
o Don’t prop bottles
o Breast milk maybe refrigerated for 48hrs
o Start them on fruits and vegetables at six month, but don’t give
strawberries
o Start them on meat and eggs at 9month, but no eggs white
Toddler
1-3 yrs
o Autonomy VS shame
103
o Popbelly appearance
o Anterior fontanel closes at 18month
18months milestones
o Separation anxiety
o Walks independently by 15 months
o Drink from a cup
o Scribbles with crayon
24 month milestones
o Negative behavior started : temper tantrums
o Parallel play
o Bowel control
o Kick and jump
Managing temper tantrums in toddler
o Ignore behavior
o Don’t reason with, threaten, promise, or give in
Preschool years 3-5 years
104
o Initiate VS guilt
o Have 20 deciduous teeth
o Completed toilet training
3 years old
o Masturbation is normal
o Manage with diversion
o Able to ride a tricycle
4-5 years
o Magical thinking
o Fear of body mutilation
o Inquisitive
o Use scissors
o Associative play
Preschooler
o Fear of body mutilation
o Give band-aids
105
Managing hospitalization
o Rooming in
o Family pictures
o Phone calls
o Leaving a parent’s belonging behind
o Speaks in complete sentence
o Follow direction
o Car seats until 4 years legally
School age development- 6-12 years
o Industry VS inferiority
o Like same gender friends
o Do collections
o Enjoy schools
o Know how to do cursive writing
o Play board, card, and video games
o Tolerates separation, but prefers parents close by
106
o Explain all procedures
o Fear of pain
Adolescence 12-18 years
o Rebellious behavior
o Peer pressure
o Body image
o Play activity team sports
o Intimates relationships
Hospitalization
o Social isolation
o Body image and non-compliance
Calculations meds; I&O; Fluid loss calculation Calculations of medications,
I&O, Fluid loss calculation

107
Conversions:
 1 teaspoon = 5 mL
 1 tablespoon = 15 mL
 1 ounce = 30 mL
 1 gram (g) = 1000 milligrams (mg)
 1 milligram (mg) = 1000 micrograms (mcg)
108
 1 liter (L) = 1000 milliliters (mL)
 Pounds to kilograms = pounds / 2.2
 Fluid replacement - calculations of fluid requirements
 WONG
 100cc/kg for 1st 10 kg of body wt.
 50cc/kg for 2nd 10 kg of body wt.
 20 cc/kg for remaining body wt. in 24 hr.

daily fluid requirements for a child weighing up to 10kg: 100mL/kg/24
hr.
daily fluid requirements for a child weighing 11-20 kg: 1000mL +
50mL/kg for each kg above 10
daily fluid requirements for a child weighing >20 kg: 1500mL + 20mL/kg
for each kg above 20 kg
calculate urine output: mL/kg/hr.
-Divide the amt. of urine in mLs by
the child's weight in kgs, and then divide by the number of hours that
the urine was from
expected urine output for infants & toddlers (Burn patients too) should
be: >2-3mL/kg/hr.
expected urine output for preschoolers & young children should be >12 mL/kg/hr.
expected urine output for teenagers should be 1mL/kg/hr. or 4080mL/hr.
109
urine output should be at least 1mL/kg/hr.
rule for calculating maintenance fluids for 24 hours:
100/50/20 rule
100mL/kg for the first 10 kg
50mL/kg for the next 10 kg
(so really, 1500 is the base)
20mL/kg for every kg over 20
(divide for 24 for hourly rate)
110
lead poisoning - Nursing assessment, management, parent education LEAD
POISIONING
 Average serum of lead level if 0.6 mcg/dL
 Exposure when ingested contaminated food, water, soil, inhale dust
contaminated with lead, paints on toys and crafts
 Lead interferes with CNS cell function, kidneys, and adversely affects
metabolism of vitamin D and calcium.

Class I
 < 9mcg/dL
 generally asymptomatic although subtle neurological effects may be
present with any exposure
Class IIA & IIB
 IIA- 10-14 mcg/dL
 IIB- 15-19 mcg/dL
 Mild impairment in growth, fine motor skills, and cognition
 Anemia
Class III
 20-44 mcg/dL
 general fatigue and motor impairment
 difficulty concentrating
 paresis or paralysis, tremor
 headache
 diffuse abdominal pain, vomiting, wt. loss, constipation
 anemia
Class IV
 45-69 mcg/dL
 colic (intermittent, severe abd cramps), anorexia, vomiting
 hyperirritability
 increased lethargy
 lead line (blue-black) on gingival tissue
111
Class V
 >70 mcg/dL
 encephalopathy abrupt seizures, changes LOC, coma, death
 ataxia
CHEALATION
 Therapy for lead poisoning which involved the administration of an
agent that binds with lead, decreasing its effects and increasing rate of
excretion.
 Has serious side effects
 Penicillamine
(heavy
metal
toxicity
medication
and
immunosuppressant) is used only when TX with other drugs is not
effective.
NURSING MANAGEMENT
 Screening, education, follow-up
 Educate parents about sources and how to reduce exposure
 Importance of foods high in iron and calcium to counteract losses
112

Nephrosis – symptoms; steroids effects
Nephrotic Syndrome (Nephrosis)- Altered glomerular permeability due to the
fusion of the glomeruli membrane surfaces, causes abnormal loss of protein in
urine.
Occurs in three forms
o Congenital, which occurs as an autosomal recessive disorder is rare
o Secondary, as a progression of glomerulonephritis or in connection with
systemic disease such as sickle cell anemia or systemic lupus
erythematosus;
o
Idiopathic (Primary).
Clinical Manifestations (Four characteristic symptoms)
o Proteinuria- As a result of increased glomerular permeability, protein lost
in urine
o Edema- Low protein in blood causes fluid shift from bloodstream to
interstitial tissue
o Hypoalbuminemia- Results from low protein levels in bloodstream
o Hyperlipidemia- Liver increases Lipoprotein production in blood to try to
compensate for protein loss. Some children have such high lipid levels
that when blood is drawn a circle of white fat is formed at the top of the
specimen in the test tube.
Nursing Assessment
o
o
o
o
o
Periorbital edema (Most noticeable in the morning when they wake up)
Ascites (Fluid collecting in the abdominal cavity)
Scrotal edema in boys
Anorexia or vomiting due to pressure on stomach from Ascites
Difficulty breathing (When ascites becomes more extensive) abdominal
fluid presses on diaphragm and decreases lung expansion.
113
o Laboratory studies- 1+ to 4+ protein; 24-hour total urine can show up to
15g protein(Usually urine contains no protein)
A. Therapeutic Management
o Goal is to reduce proteinuria and edema.
o Treated with course of corticosteroids, such as IV methylpredinisone or
oral predinisone. Initial dose given until dieresis without protein loss is
accomplished; Then dosage is reduced for maintenance and continued
for as long as 1-2 months.
o Parents are instructed to test first urine specimen of the day for protein
with a chemical reagent strip and keep accurate chart showing pattern of
protein loss. Approximately once a week they are asked to collect a 24hours urine so total protein loss can be measured.
o Teach parents corticosteroids suppress immune system, so try and keep
the child infection free during steroid therapy.
o Prednisone causes cushingoid appearance or “Moon face”, extra fat at
the base of the neck and also increased body hair.
o Diuretics not commonly used but in cases where child responds poorly to
prednisone alone, Lasix may be added to reduce edema. Monitor
Potassium levels while children are taking lasix, Can lead to HypoKalemia.
o Children who are prednisone resistant or do not respond to
corticosteroids may be prescribed Cyclophosphamide (Cytoxan),
Cyclosporine (Sandimmune), or Mycophenolate mofetil (CellCept). These
stronger immunosuppresants may be effective in reducing symptoms or
preventing further relapses of the disease. Cyclophosphamide is a
chemotherapy drug. Be certain to inform parents child does NOT have
cancer just because they are taking chemotherapy agent.
114

Kawasaki’s disease - signs and symptoms, Nursing management
 Kawasaki – s/s, management, med effects; teaching
Kawasaki Disease
- This is the # 1 cause of CAD in infants and children
These patients have to follow a cardiologist the rest of their life.
Kawasaki Disease Pathophysiology
It is a febrile multisystem disorder that occurs almost exclusively in children
before puberty. There is an association between having your carpets
professionally cleaned and the development of the disorder in young children
within the household. It most commonly occurs in boys less than 4 years old.
It is an acute systemic vasculitis, it is life threatening and of an unknown cause.
It results in an inflammation of coronary arteries and capillaries. This leads to
damage to the coronary arteries, myocardial ischemia and infarction. Continued scarring of the coronary arteries over time leads to coronary
aneurysms.
The 3 Phases of Kawasaki Disease
These include:
1.) Acute Phase
2.) Sub - Acute Phase
3.) Convalescent Phase
115
Kawasaki Disease: Acute Phase
This phase of Kawasaki Disease begins with the abrupt onset of a high fever
that is unresponsive to antibiotics and antipyretics. The child is very irritable
here, and continues to develop additional diagnostic symptoms, such as:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
High fever that does not respond to antipyretics
Lethargy and irritability
Conjunctivitis
Red cracked lips
Edema
Erythema of the palms, feet
Peeling of the hands and feet
Strawberry Tongue
Cervical Lymphadenopathy
Minor rash on the trunk
Various rashes in the diaper area
Abdominal pain
Diarrhea
Anorexia
Swollen and reddened joints may occur
Kawasaki Disease: Sub-Acute Phase
This phase of Kawasaki Disease begins with the resolution of the fever on its
own approximately 10 days after onset, and lasts until all clinical signs of the
disease disappear. It lasts 11 days. (2-4 weeks)
- This phase is when the child is at the GREATEST RISK for developing a
coronary artery aneurysm and myocardial infarction.
S/S
o
o
o
o
Skin desquamation on palms and soles
Rise in platelet count
Possibly the formation of aneurysm
Elevated ESR and WBC
116
Kawasaki Disease: Convalescent Phase
During this phase of Kawasaki Disease, all clinical signs of the disease have
resolved, 25th day to 40 days but laboratory values have not returned to
normal. These values can take up to 6-8 weeks to return to
normal. Symptoms often confused for Juvenile Rheumatoid Arthritis. (Child
appears normal)
Observable Lab Values for Kawasaki Disease
Acute stage
Elevated WBC
Elevated ESR- erythrocyte sed rate
With this, be concerned with:
o Elevated ESR
o Elevated CRP
o Signs of anemia and thrombocytopenia (check for this)
Kawasaki Disease: Complications
o
o
o
o
o
o
o
These include (Symptoms of a Myocardial Infarction):
Abdominal Pain
Restlessness
Vomiting
Inconsolable Crying
Pallor
Shock
The Goal of Treatment of Kawasaki Disease
This is to decrease myocardial and coronary artery inflammation, and prevent
myocardial infarctions.
117
Medications:
o Ibuprofen and platelet anti-aggregators
o Gammaglobulins IV IgG 2G/kg over 10-12 hours
o Aspirin Regime-Given 80-100mg/kg/day Q6H for 72 hours until fever
drops, then 10mg/kg/day until platelet count drops up to 2 weeks (may
continue for 6-8 weeks) Aspirin is used as an antipyretic and antiagglutination drug. (Aspirin toxicity-H/A, dizziness, disorientation,
increased temperature, hyperventilation, nausea, and tinnitus.)
o Anticoagulants Lovenox and Coumadin (Antidote for Coumadin toxicity is
Vitamin K IM.)
Nursing Interventions for Kawasaki Disease
These include:
o Strict I&O (May need a Foley or Urine Bag)
o Monitor Cardiac Status (tachycardia, gallop, decreased output)
o Check for Infusion reactions (Pain, Rash, Fever, tachycardia, S/S of Shock )
o Monitor Skin integrity
o Check for signs of CHF (decreased urinary output, gallop rhythm,
tachycardia, respiratory distress)
These patients WILL NOT get MMR, MMR-V, Intranasal flu, Oral polio, or
Varicella immunizations (live ones) for 11 months -1 year.
Erikson Stages
o Infant 0-1year Trust vs Mistrust- child learns to love and to be loved.
Nursing Implication: Provide experiences that add to security
o Toddler 0-3 years Autonomy vs Shame and Doubt- Child learns to be
independent and make decisions for self. Nsg Implication: Provide
opportunity for independent decision making such as choosing own
clothes.
o Pre-school 3-5/6- Initiative vs. Guilt –Child learns how to do things basic
problem solving and that doing things is desirable. Nsg Implication:
Provide opportunities for exploring new places or activities. Allow free
form play.
118
o School Age – Industry vs Inferiority - Child learns how to do things well.
Nsg Implications: Provide opportunities such as allowing child to
assemble and complete a short project.
o Adolescence – Identity vs Role confusion – Adolescence learn who they
are and what kind of person they will be. Nsg Implication: Provide
opportunity for adolescent to discuss things
Hydrocephalus - signs and symptoms Hydrocephalus
Congenital
cause
include
Arnold
Chiari
formation
associated
with
myelomeningocele. Can be acquired by meningitis, trauma, or intraventricular
hemorrhage in premature infants
o Increased amount of CSF within the ventricles of the brain
o May be caused by obstruction
of CSF flow or by overproduction or
inadequate reabsorption of CSF
o May result from congenital
malformation or be secondary to injury,
infection, or tumor
S/sx:
o -widening pulse pressure
o -decreased pulse
o -decreased RR
119
Physical findings of ICP in INFANTS
o -bulging fontanels
o -separated sutures
o -scalp veins dilated
o -sun setting eyes
o -increased circumference head
o -Papilledema
o -seizures
o -behavioral Findings of IICP in INFANTS
o –irritable
o -high pitched cry
o -feeding changes
120
Physical findings of IICP in CHILDREN
o -n/v
o –HA
o -vision changes
Behavioral Findings of ICP in CHILDREN
o –restless
o -decreased school performance
o –lethargy
o -memory loss
LATE Physical Findings of IICP
o -vital changes (bradycardia)
o -cheyne-stokes respirations
o -widening pulse pressure
o -pupil changes
o –posturing
121
LATE Behavioral Findings of IICP
o -decreased LOC
o -decreased motor
o -decreased sensory response.
Communicating Hydrocephalus
Occurs when the flow of CSF is blocked after it exits the ventricles. This form is
called communicating because the CSF CAN still flow between the ventricles,
which remain open.
Non-communicating Hydrocephalus-also called "obstructive" hydrocephalus
Occurs when the flow of CSF is BLOCKED along one or more of the narrow
passages connecting the ventricles.
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Decorticate Posture – C- appearing hand flexion
o Involuntary Still Flexion of Arms
o Legs stiffly extended, internally rotated
o Plantar Flexion of the feet
o Due to Damage to Cortico-spinal Tracts
Decerebrate Posture – e-appearing hand flexion
o Results from Damage to the upper brain stem
o Arms abducted and extended
o Wrists pronated, fingers flexed
o Legs stiffly extended with plantar Flexion of the feet.
Dx/Test:
CT and MRI to confirm
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Glasgow Coma Score
-15 is highest score
-8 or lower is a coma
-3 categories (eye/verbal/motor responses)
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Tx:
-Relieve pressure
-treat complications
-long term psychomotor and developmental issues
-provide family support
·Catheter is the threaded under the skin and the distal end positioned in the
peritoneum (common) or the right atrium
·Shunt drains excess CSF from the lateral ventricles; fluid is the absorbed by
the peritoneum or absorbed in the general circulation via the right atrium.
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Nursing Considerations:
Hydrocephalus post-op care
-continue ICP monitoring
-position on unoperated side
-HOB FLAT (regulates CSF to be removed slowly)
-pain management
-assess abdominal status
-strict I&O
-Increased risk for latex allergy
-older children may have balance and coordination difficulty
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hip dysplasia - Nursing assessment
Hip Dysplasia-Developmental Dysplasia of the Hip (DDH). It is the abnormal
development of the hip that develops during fetal life, infancy, or childhood
- 30-50% were born breech
- Cause is UNKNOWN
- Affected by gender, size, birth order, delivery type, intrauterine position, joint
laxity, postnatal positioning, twins and family history
-Relaxin and Estrogen may cause laxity of hip joint and capsule leading to joint
instability
- Diagnosis needs to be made ASAP
- Treatment started before 2 months of age is most successful
Dx/Test:
Ortolani Test
- Baby supine, hips flexed and knees bent
- Place middle fingers over the great trochanter and thumbs on the inner side
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of thigh
- Carry knees to mid-abduction
- Push one leg lateral (out) and pull anterior/ up
- Can you feel femoral head slip forward into acetabulum? Makes a clicking
sound and consider + Ortolani
- Is a relocation maneuver
Barlow Test
- Baby supine, hips flexed and knees bent
- Place middle fingers over the great trochanter and thumbs on the inner side
of thigh
- Carry knees to mid-abduction
- Push down and medial (in)
- Does femoral head slip out and then slip back in when pressure is released?
Something you feel
- Is a dislocation maneuver
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Allis/Galeazzi Test
- Baby supine, hips flexed and knees bent
- Are the knees the same height?
Clinical Manifestations of DDH
- Wide Perineum in Bilateral Location
- Asymmetric thigh and gluteal folds
- Limited abduction
- X-ray not reliable until 4-6 months of age because it cannot see cartilage
- Ultrasound reliable beginning at 4-6 weeks of age because it can see cartilage
Therapeutic Management of DDH
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- Pavlik harness-Worn continuously until the hip is stabilized
-Removal of Harness can cause Dislocation
Sponge Bath the Child
Can place Socks and Clothing over Brace
Assess for skin irritation
AVOID LOTIONS and POWDERS
- Spica cast for older toddler/child 6-18months:
Closed Reduction (Using Weights to keep hips to
hold them in a position for a time to cast)
Open Reduction Surgery
Cast Immobilizations
Abduction Brace
Nursing Care when in Cast:
Proper Cast Care Implementation
Neurovascular Skin Assessment
Skin Integrity
~Petaling
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~Perineal Area Care
Prevent complications of immobility
Promote Growth and Development
Provide family Teaching and Support
Keep Cast Extremely Elevated on Pillows
Avoid Indenting Cast While Wet
Observe Extremities for any evidence of swelling, skin breakdown,
discoloration, capillary refill time or skin barrier breakdown
Check Movement and Sensation of the visible extremities frequently
Follow orders regarding restriction of activities
Restrict Strenuous Activities for the first few days
Pad rough edges when dry (Petaling)
Avoid letting affecting limb hang down for any length of time
Not putting anything inside of the cast
Keep cast Clean and Dry
Assess for proper fit frequently apparent in Newborns
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talipes equinovarus - Nursing assessment – see page 77 of this blueprint
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pyloric stenosis surgery – parent education; nursing assessment; acid-base
imbalances (Respiratory acidosis/
alkalosis; Metabolic acidosis/ alkalosis Pyloric stenosis surgery – parent
education; nursing assessment; acid-base imbalances
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o Surgical intervention is the cure & done as soon as the infant is
metabolically stable
o Laparoscopic treatment
o Fredet-Ramstedt procedure (pylormyotomy) is most commonly
performed
o High risk of infection post-op – abdominal incision is near the diaper
area
Parent Education
o TUCK DIAPER LOW to prevent contamination
o THE SURGICAL PROCEDURE IS THE MUSCLE OF THE PYLOTUS IS SPLIT
DOWN TO THE MUCOSA ALLOWING FOR A LARGER LUMEN Sounds
simple but high or INFECTION
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o NPO
1. Promote adequate hydration
2. Prevent aspiration
o IV fluids REPLACE ANY ELECTROLYTE INBALANCE /Provide pacifier for
sucking Mouth care after vomiting /
o NPO
o IV therapy for restoration of fluid & electrolytes
o PRONE position or HOB elevated
o N/G care
o Record daily weight & monitor I&O
o Provide support to the parents
Nursing Assessment
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A “good” eater
Regurgitation of feeding to PROJECTILE vomiting
Nonbilious emesis- because the obstruction is in front of the bile duct.
Emesis may be blood tinged
Irritability
Upper-abdomen distention
MOVABLE PALPABLE OLIVE SIZED MASS RIGHT OF THE UMBILICUS
Peristaltic waves may move left to right
Failure to Thrive → weight loss
Dehydration → hemoconcentration → ↑ HCT
Decrease # and volume of stools
Check for signs of dehydration & malnutrition
Prone to metabolic Alkalosis
↓ HCL →↑ pH Acid-base Imbalances
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– Prone to metabolic Alkalosis
– ↓ HCL →↑ pH
o
o
o
o
Normal PH of blood -7.35-7.45
Normal PCO2- 35-45mm/Hg- carbon dioxide in arterial blood
Normal HCO3 – 22-26mEq/L – bicarbonate in arterial blood
Normal PO2 – 80-100mm/Hg – oxygen in arterial blood
Metabolic acidosis-results from diarrhea because of a great deal of
sodium lost with stool. This excessive sodium causes the body to
conserve hydrogen ions to keep the total number of positive and
negative ions in serum balance.
o PH <7.35
o Decrease Bicarb (HCO3)<22mEq/L
Metabolic alkalosis-results from vomiting a great deal of hydrochloric
acid is lost in emesis. The loss of chloride ions causes a decrease in
hydrogen ions.
o PH>7.45
o Increase Bicarb (HCO3) >26mEq/L
Respiratory acidosis- results from hyperventilation trapping carbon
dioxide in alveoli. This rapid shallow breathing results in an inability to
expire freely.
o PH<7.35
o PCO2>40mm/Hg
o Increase Bicarb(HCO3)>26mEq/L
Respiratory alkalosis – results from hyperventilation. This rapid deep
breathing resulting in insufficient oxygen confusion and disorientation.
o PH>7.45
o PCO2 <40mm/Hg
o Decrease Bicarb (HCO3)<22mEq/L
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
scoliosis- Nursing assessment, management, parent education
Scoliosis is the lateral curvature of the spine that's apparent on frontal
projection, measures greater than 10 degrees, and is associated with vertebral
rotation
o Right thoracic curve most common
o Classified as nonstructural or functional (flexible spinal curve, with
temporary straightening when the patient leans sideways) or structural
(fixed deformity)
o Types: idiopathic, congenital, or neuromuscular
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Pathophysiology
The vertebrae rotate, forming the convex part of the curve. The rotation
causes rib prominence along the thoracic spine and waistline asymmetry in the
lumbar spine. The severity of spinal deformity dictates the physiological
impairment.
If severe, the rib cage may press against the lungs and heart, interfering with
breathing and cardiac pumping.
Exact cause unknown
Possible explanations:
o Local inflammation and infection
o Neurofibromatosis (Recklinghausen's disease)
1. Neuromuscular scoliosis: may be caused by muscular dystrophy, polio,
cerebral palsy, or spinal muscular atrophy
2. Nonstructural scoliosis: may result from acute disk disease, leg length
discrepancies, paraspinal inflammation, or poor posture
3. Structural scoliosis: during growth spurt in adolescence, 11 to 14yrs for
females and 13 to 16 years for males.
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4. Traumatic scoliosis: may result from vertebral fractures or disk disease
S/sx:
Familial history
Detected during community screening
Hemlines look uneven
Pant legs appear unequal in length
One hip higher than the other
Backache, fatigue, and dyspnea
Debilitating back pain
Severe deformity
With thoracic curve exceeding 60 degrees, possible reduced pulmonary
function
With thoracic curve exceeding 80 degrees, increased risk of cor pulmonale ( an
enlargement of the right side of the heart as a result of disease of the lungs or
pulmonary blood vessels) in middle age.
Disturbed self-image.
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Dx/Test:
Spinal X-ray studies confirm scoliosis and determine the degree of curvature
and flexibility of the spine; they also determine skeletal maturity, predict
remaining bone growth, and differentiate nonstructural from structural
scoliosis.
Tx:
Close observation with radiographic follow-up every 6 to 8 months
Brace (thoracolumbosacral orthosis [TLSO or Boston brace]; cervico-thoracolumbar-sacral orthosis [CTLSO or Milwaukee brace])
Spinal orthoses
Functional strengthening program
Treatment-Activity
Gradually increased activity
No vigorous sports
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prescribed exercise regimen
Swimming, but no diving
Treatment-Surgery
Posterior segmental fixation instrumentation
Posterior spinal fusion with instrumentation and bone grafting
Anterior spinal fusion with solid rods
Nursing Considerations:
Pain level and relief
Respiratory status
Activity/mobility level
Skin integrity (with brace use)
Body image
Sensation, movement, color, and pulses
Postoperative status
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Pt Teaching:
how to inspect the brace daily for fit or breakage
skin care measures, including wearing a cotton shirt under the brace
ways to minimize the appearance of the brace such as wearing bagging
clothing
skin care measures
safe body mechanics
relaxation techniques
strengthening exercises
postoperative activity restrictions, as appropriate
importance of adhering to recommended follow-up care, especially if
observation is the mode of treatment.
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Review
o Diet plan for CHF baby. What is increase caloric intake per ounce.
o Burn victim with chest tightness, the procedure done is an escharotomy.
o Test that evaluates 4 pediatric areas social/personal (socialization), fine
motor function (eye/hand coordination and manipulation of small
objects), language (production of sounds, ability to recognize and
understand and use language), gross motor functions (motor control,
sitting, walking, jumping, and other movements) is called the Denver
Developmental screening tool.
o Nutrition for a burn patient is protein and calorie diet.
o Keep in balance rule of 9’s for children to estimate body surface area
Lund-Browder chart where the body is divided into areas in increments
of based on 9%.
o The most common form of childhood cancer WBC’s ALL-acute
lymphocytic leukemia.
o Cerebral palsy is normal IQ, floppy, rigid limbs, promote socialization.
o The cross-eyed appearance of the eyes after birth is called Strabismus
o Cardiac tamponade is when a large amount of fluid (can be fluid, pus,
clots, blood, or gas) in the pericardial sac resulting in slow or rapid
compression of the heart causing the heart itself not be able to beat.
o Polyuria, polydypsia, polyphasia are the triad of diabetes mellitus.
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Strep/tonsilitis is strep infection risk of developing rheumatic fever.
Epiglotitis, Oropharygnx, Pharynx are parts of the upper airway.
An infant can sit unsupported at this age 8 months.
A preschooler can hop on 1 foot at this age – 4 years old.
A new born weighs 7.5lb at birth at 1 year 10kg/22lbs.
Without treatment children that have Kawasaki ds have 25% chance of
developing which cardiac condition coronary artery aneurysm and MI.
5 P’s of neurovascular pain, pulse, paresthesia, pallor, paralysis.
Besides immunizations what prevents spread of infection.
This viral infection rubella causes it in child from pregnant mother who is
exposed.
Koplik spots on buccal mucosa, fever, very itchy brownish-red spots(rash)
is measles.
Fracture involving the growth plate is an epiphyseal fracture.
Bruising, crepitus are signs of possible fraction.
A preschooler may have fear about arm prior to cast removal that the
arm will be cut off.
Recommendation that all children 1-18 and adults to get an annual flu
vaccine.
HPV vaccine helps prevent cervical cancer in women less than 35 years.
DTaP, IPV, PCV13, Rotovirus,& HIB immunizations given at 2, 4, 6
months.
Priority mgt for a hemophiliac who fell is elevate and immobilize,
pressure and cool compress, administer clotting factor and monitor for
bleeding.
Telescoping of the bowel is intussusception.
Nursing priority for cleft/lip Hydration, nutrition, meeting the infant
sucking needs.
Megacolon and hirshspung disease ganglion cells at the distal bowel
descending colon dies mgt stool softner.
McBurney point to check for appendicitis rebound tenderness right
abdomen.
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