Pedia Prof - Oamil

Pediatric Nursing
by: Mabel M. Oamil, BSN, RN, MAN, CHA

Principles of Growth and Development
Interrelated Dimensions:
✓Growth:
✓ An increase in number and size of cells as they divide and synthesize
new proteins
✓ Results in increased size and weight of the whole or any of its parts
✓Development:
✓ A gradual change and expansion
✓ Advancement from a lower to a more advanced stage of complexity
✓ Increased capacity through growth, maturation, and learning
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Interrelated Dimensions:
✓ Maturation
✓ An increase in competence and adaptability
✓ Aging
✓ Used to describe a qualitative change
✓ Functioning at a higher level
✓ Differentiation:
✓ Processes by which early cells and structures are systematically modified and altered to
achieve specific and characteristic physical and chemical properties
✓ Sometimes used to describe the trend mass to specific
✓ Development from simple to complex activities and functioning
Patterns of Growth & Development
✓ Directional
✓ Cephalocaudal
✓ Head-to-tail direction
✓ Proximodistal, or near to far (midline-to-peripheral concept)
✓ Differentiation, from simple to more complex activities and functions
✓ Sequential
✓ Definite, predictable sequence
✓ Crawl, creep, stand, then walk
✓ Babbles, form words, sentences
✓ Scribbling to writing
Patterns of Growth & Development
✓ Developmental Pace
✓ Periods of accelerated growth and decelerated growth in both total body growth and growth
of subsystems
✓ rapid growth before and after birth, gradually levels off during early childhood.
Growth is
relatively slow during middle childhood, markedly increases at the beginning of adolescence,
and levels off in early adulthood
✓ Every child develops at his/her own pace
✓ Differentiation, from simple to more complex activities and functions
✓ Sensitive
✓ Limited times during the process of growth when a human being interacts with a particular
environment at a particular time
✓ Periods termed as critical, sensitive, vulnerable, and optimal – one becomes susceptible to
positive or negative influences
Developmental Age Periods
✓ Prenatal period – conception to birth
✓ Germinal - conception to approximately 2 weeks
✓ Embryonic – 2 to 8 weeks
✓ Fetal – 8 to 40 weeks (birth)
✓ Infancy period – birth to 12 months/1 year
✓ Neonatal – birth to 27 or 28 days
✓ Infancy – 1 month to 12 months
✓ Early Childhood – 1 to 6 years
✓ Toddler – 1 to 3 years
✓ Preschool – 3 to 6 years
✓ Middle Childhood – 6 to 11 or 12 years
✓ School Age – 6 years to 12 years
✓ Later childhood – 11 to 19 years
✓ Prepubertal – 10 to 13 years
✓ Adolescent – 13 years to 20 years
Basic Divisions of Childhood
✓Neonate – first 28 days of life

✓Infancy – 1 month to 1 year
✓Toddler – 1 year to 3 years
✓Preschool – 3 years to 5 years
✓School Age – 6 years to 12 years
✓Adolescent – 13 years to 20 years
Developmental Theorists
✓Freud: psychosexual
✓Erikson: psychosocial
✓Piaget: cognitive development
Freud’s Theory of Psychosexual Development
Erikson’s Stages of Psychosocial Development
Erikson’s Stages of Psychosocial Development
Piaget’s Stages of Cognitive Development
Piaget’s Development of Logical Thinking
Newborn Assessment
✓Apgar score at age 1 minute and 5 minutes
✓Reflects general condition of infant
Sign 0 1 2
HR Absent <100 >100
Resp effort Absent Irreg; slow weak Good; strong cry

cry
Muscle tone Limp Some flexion Well flexed
Response No response Grimace Cry, sneeze
Color Blue, pale Body pink, extrem. Completely pink

blue
Apgar Scoring System
✓A score of <4 – in serious danger, needs resuscitation
✓A score of 4-6 – infant’s condition is guarded, may need clearing
of the airway and supplementary oxygen; moderate difficulty
✓A score of 7-10 – considered good; absence of difficulty adjusting
to extrauterine life
✓At 1 min: <7 – depression of CNS, <4 – severe depression of CNS

✓At 5 mins: >8 – no asphyxia, <7 – high risk for subsequent
dysfunction of CNS, 5-7 – mild asphyxia, 3-4 moderate asphyxia,
0-2 – severe asphyxia
Other Descriptions of Newborn Maturity
✓Term = 36-42 completed weeks gestation

✓Preterm = <36 completed weeks gestation
✓Postterm = >42 completed weeks gestation
General Measurements of Newborns
✓Head circumference – 34cm to 35 cm (13.5 to 14 in)

✓Chest circumference – about 2cm less than the head
circumference
✓Abdominal circumference – 30cm to 33cm
✓Length – 46cm to 54cm
✓Body weight – 2.5kg to 3.4kg.
Vital Signs Measurement in Newborns
✓Temperature: 36.5 to 37.5C

✓Heart rate, apical: 120-160 beats/min WNL
✓Respiratory rate: 30-60 breaths/minute
✓Blood pressure: baseline evaluation of cardiovascular status
Nursing Care of the Pediatric Individual
with a Respiratory Disorder
Common Causes
✓Usually preceded by a viral upper respiratory infection
Fluid and pathogens travel upward from the
✓ nasopharyngeal area, invading the middle ear.
✓ Fluid behind the eardrum has difficulty draining back out
✓ toward the nasopharyngeal area because of the
✓ horizontal positioning of the Eustachian tube.
✓ Pathogens gain access to the Eustachian tube, where
✓ they proliferate and invade the mucosa.
✓ Fever – hyperthermia is possible
✓ Irritability or fussiness
✓ Poor feeding to lack of appetite/ anorexia
✓ Severe pain in the ear caused by pressure of
fluid
✓ Lethargy
✓ Decreased light reflex of tympanic membrane
✓ Red bulging tympanic membrane upon
✓ otoscopy
Note
Ear on the left with clear tympanic membrane
(drum); ear on the R the drum is bulging and
filled with pus
Complications
Hearing Loss
Delayed language development
Behavior Problems
Treatment
✓Treatment has always been directed toward antibiotic
therapy; however, recently medical professionals are allowing
for a period of observation or “watchful waiting” to re-
evaluate
✓Waiting up to 72H for spontaneous resolution is now
recommended in healthy infants
✓When antibiotics are warranted, oral amoxicillin in high
dosage is given
Nursing Care Management
✓Relieving pain
✓Mild analgesics, narcotic analgesics
✓Heat or cool compresses to affected side
✓Numbing eardrops – benzocaine (Auralgan)
✓Facilitating drainage when possible
✓Preventing complications or recurrence
✓Educating the family in care of the child
✓Providing emotional support to the child and family
Myringotomy
Pressure-equalizing tubes
✓A myringotomy – a pin hole opening is made in
the ear drum to allow fluid removal. Air can
now enter the middle ear through the ear drum,
by-passing the Eustachian tube.
✓Insertion of pressure equalizing tubes help
prevents the pin hole from closing over. With
the tubes in place, hearing should be normal
and ear infections should be greatly reduced.
Post-op Teaching
✓Administer ear drops as ordered
✓Avoid water in the ears
✓Use ear plugs in bathtub or when swimming
✓Do not allow to swim in lake water- causes infection
✓Heat to ear
✓Assess motor and language development
✓Teach parents to give all of antibiotics completing the entire
course of antibiotics
✓Return for follow-up
Upper Respiratory Tract Infections
✓Nasopharyngitis
✓Young child: fever, sneezing, vomiting or diarrhea
✓Older child: dryness and irritation of nose/throat, sneezing, aches,
cough
✓Pharyngitis
✓Young child: fever, malaise, anorexia, headaches
✓Older child: fever, headache, dysphagia, abdominal pain
✓Tonsillitis
✓Masses of lymphoid tissue in pairs
✓Often occurs with pharyngitis
✓Characterized by fever, dysphagia, or respiratory problems forcing
breathing to take place through nose
Tonsillitis
Clinical Manifestations
✓Pharyngitis and Tonsillitis
✓ Fever
✓ Persistent or recurrent sore throat
✓ Anorexia
✓ General malaise
✓ Difficulty in swallowing, mouth breather, foul odor breath
✓ Enlarged tonsils, bright red, covered with exudate
✓Adenoiditis
✓ Stertorous breathing - snoring, nasal quality speech
✓ Pain in ear, recurring otitis media
Treatment and Nursing Care
✓Saline gargles
✓Analgesics
✓Throat lozenges or hard candy
✓Cool mist humidifier
✓Hydration with cool liquids
Key to understanding
prevention of URI is
meticulous handwashing
and avoiding exposure
to infected persons
Nurse Alert!
Post-operative Care
✓Providing comfort and minimizing activities or
interventions that precipitate bleeding
✓Maintain airway - Place in prone or side-lying position to avoid
aspiration until fully awake
✓Monitor bleeding, esp. new bleeding
✓Nonaspirin analgesics – avoid administering red colored
medications
✓Ice collar
✓Avoiding p.o. fluids until fully awake --then liquids and soft cool
foods.
Nurse Alert for Post-Op T/A surgery
✓Most obvious sign of early bleeding

is the child’s continuous
swallowing of trickling blood.
✓While the child is sleeping,
note the frequency of swallowing
notify the surgeon immediately
Croup
Epiglottitis
Epiglottitis
Nursing Care
✓Maintain patent airway
✓ Oxygen with humidification
✓ Keep resuscitation equipment at the bedside
✓ Provide mist - Cool mist humidifier or running hot water in closed bathroom
✓ Take out into cool, humid night air
✓Meet fluid and nutritional needs
✓ Cool, noncarbonated, non-acid drinks
✓ Assess for difficulty swallowing – may need IV therapy
✓Keep quiet as possible
✓Never attempt to visualize the epiglottis directly with a tongue
depressor or take a throat culture
Reactive Airway Disease (Asthma)
✓Chronic inflammatory disorder affecting mast cells,

eosinophils, and T lymphocytes
✓Inflammation causes increase in bronchial
hyperresponsiveness to variety of stimuli (dander, dust,
pollen, etc.)
✓Most common chronic disease of childhood; primary
cause of school absences
Asthma Triggers
Medications to treat Asthma
Reliever or Rescue Meds
✓Short acting beta-agonists
✓ albuterol
✓ terbutaline
✓Anticholinergic agents: Atrovent

✓Corticosteroids- prednisone (Prelone), for short term
therapy
Medications to treat Asthma
Preventer / Controller Medications

✓Mast-cell inhibitors (Cromolyn)
✓Inhaled steroids ( Advair, Pulmocort, Azmacort) (always

rinse mouth following administration)
✓Leukotriene modifiers - (Singulair)

High fowlers
position
Humidified
Oxygen via
mask
Pulse
Oxymetry
Emergency situations of asthma
✓Acute episode of reactive disease: bronchioles may close

rapidly, causing severe airway obstruction, anxiety,
restlessness, and fear. Will need to be seen in ER if not
relieved by meds
✓Status asthmaticus: medical emergency with severe

edema, profuse sweating, respiratory failure and death if
untreated. Becomes seriously hypoxic…immediate
intervention needed
✓Factor responsible for manifestations of the disease is
mechanical obstruction caused by increased viscosity of
mucous gland secretions
✓Mucous glands produce a thick protein that accumulates

and dilates them
✓Passages in organs such as the pancreas become

obstructed
✓First manifestation is meconium ileus in newborn

(abdominal distention)
Pathophysiology
✓Respiratory System
✓Chronic changes, due to accumulation and retention of mucus in the
airways, air trapping
✓Cycle of infection > increased mucus > inflammation > further
obstruction
✓Pancreas
✓Mucus inhibits the flow of trypsin, lipase, and amylase to the
duodenum. Thus malabsorption of fats.
Pathophysiology
✓Intestine
✓ Mucus accumulation may lead to bowel obstruction
✓ Meconium ileus happens in 10-15%
✓ Sludging of intestinal contents leads to rectal prolapse, fecal impaction,
bowel obstruction and intussusception
✓ Altered absorption of fat soluble vitamins
✓ Reproductive System
✓ 99% of males sterile due to mucus obstruction; females have decrease
fertility due to thick cervical secretions.
✓Salty taste to child's skin
✓Meconium ileus
✓Abdominal pain or difficulty passing stool or frequent stools and
tenacious mucus (rectal prolapse)
✓Clubbing of the fingers
✓Barrel chest
✓Increased respirations, cyanosis
✓Productive cough
✓Mild diarrhea with malodorous stools, steatorrhea.
✓ Relieve airway obstruction
✓ Chest Physiotherapy at least twice a day to increase sputum
expectoration
✓ Physical exercise important adjunct (swimming)
✓ Administration of mucolytic agents
✓ Prevention and treatment of pulmonary infections

✓ Administer antibiotics
✓Provide optimal nutrition for growth
✓Provide well balanced diet which is high in calories, protein, CHO.
Increase salt in hot weather.
✓Administer fat soluble vitamins in water soluble form
✓Administration of pancreatic enzymes prior to all meals and snacks
✓ Comes in enteric coated capsule – may swallow capsule or open and
sprinkle beads over food
✓ Note color, consistency, frequency of stools because enzyme dosing is
correlated with child’s bowel elimination patterns.
with a Gastrointestinal Disorder
Cleft Lip and Cleft Palate
✓Etiology- Failure of maxillary and median nasal

processes to fuse during embryonic
development
✓Remember the psycho-social implications for

these children and families
Assessment
Treatment
✓Surgical repair:
✓Cleft lip – 6-12 weeks (Wong’s), 2-10 weeks (Pillitteri)
✓Cleft palate – 12-18 mos (Wong’s), 6-18 months (Pillitteri)
✓Reconstruction begins in infancy and can continue
through adulthood.
✓Homecare by the family prior to surgery
✓Two main goals:
✓Maintain nutrition
✓Prevent aspiration
Pre-op Nursing Care
✓May breast feed if has small cleft lip
✓If bottle fed, use compressible bottle, longer nipple,
larger hole in nipple, any other special device for
feeding this infant.
✓Feed slowly in upright position and bubble frequently
✓Keep bulb syringe and suction equipment at bedside
✓Position on side after feeding
Post-Op Care
✓Prevent trauma to suture line
✓Logan’s bow to protect site
✓Do not allow to suck
✓Maintain upper arm restraints
✓Position supine
✓No hard objects in mouth- straws, pacifiers, spoons
✓Do not take temperature orally
✓Prevent crying
✓Reduce Pain
✓Prevent infection (increased risk due to mouth breathing)
Esophageal Atresia/ Tracheoesophageal fistula
✓Failure of the esophagus to totally differentiate –

4-5th wk gestation
✓Both are malformations of ESOPHAGUS
✓Cause is unknown
Assessment
✓3C’s -coughing, choking, cyanosis when feeding
✓Respiratory difficulties
✓Drooling
✓Inability to pass suction catheter, NG @ birth
✓Abdominal distention if fistula present
Management
✓Early diagnosis
✓ Ultra sound
✓ Radiopaque catheter inserted in the esophagus to illuminate defect on
X-ray
✓Surgical repair- thoracotomy
✓ Anastomose ends of esophagus if possible (may need 2 stage
repair)
✓ Ligate fistula
Pre-Op
✓ Maintain airway
✓ Keep NPO- administer IV fluids
✓ Elevate HOB 30 degrees
✓ Suction PRN
✓ Gastrostomy for feedings
✓ Prevent aspiration pneumonia
✓ Suction
✓ HOB 30 degrees
✓ Prophylactic antibiotics
Post-Op
✓Maintain airway
✓Maintain nutrition
✓Prevent trauma
✓Monitor growth and development

Gastroesophageal Reflux Disease
(GERD)
The cardiac/lower esophageal sphincter (AKA LES) and lower

portion of the esophagus are weak, allowing regurgitation of
gastric contents back into the esophagus.
(GERD)
(GERD)
Assessment: Infant
✓Regurgitation almost immediately after each feeding when the
infant is laid down
✓Excessive crying, irritability
✓FTH
✓Risk for:
✓ aspiration (pneumonia)
✓ Apnea
✓ Development of respiratory problems (asthma)
(GERD)
Assessment: Child
✓Heartburn
✓Abdominal pain
✓Cough, recurrent pneumonia
✓Dysphagia
(GERD)
Diagnosis
✓Ph of secretions in esophagus <7.0=acid
✓Barium Swallow and visualization of any esophageal

abnormalities
(GERD)
Management & Nursing Care

✓Nutritional needs
✓Positioning – PRONE (supine worsens GERD)
✓Medications
✓ H2 receptor antaqgonists (-tidine)
✓ Cholinergics – metoclopramide (Reglan)
✓ Proton pump inhibitors – (-prazole)
✓CPR instruction for parents/caregivers
✓Possible Nissen Fundoplication
Diarrhea/Gastroenteritis
Severe
✓A disturbance of the intestinal tract that alters motility and

absorption and accelerates the excretion of intestinal
contents. 3-30 stools/day!!!
✓Most infectious diarrheas in this country are caused by
Rotovirus, but can be c.diff
Severe
✓Increase in peristalsis
✓Large volume stools (loose, watery, green)
✓Increase in frequency of stools with cramps, nausea,
vomiting
✓Urge with small stool present
✓Increased heart & resp. rate, decreased tearing and fever
Severe
Complications
✓Dehydration
✓ Mucus membranes dried, cracked
✓ Decreased elasticity of skin
✓ Depressed fontanels, eyes sunken
✓ Decreased urinary output, dark
✓Metabolic Acidosis
✓ pH <7.35
✓ HCO3 =/<22mEq/L
Severe
Diagnosis
✓Stool culture
causative organism
✓ABG’s to diagnose Metabolic Acidosis

Severe
Treatment & Nursing Care
✓Contact isolation
✓Treat cause
✓Weigh daily
✓Monitor I&O, assess for dehydration
✓Skin care
✓Fluid and electrolyte balance
✓ Oral rehydration
✓ IV rehydration (RL or D5NS)
Appendicitis
✓Inflammation of the lumen of the appendix which

becomes quickly obstructed causing edema,
necrosis and pain.
Appendicitis
✓Pain
✓Vague
✓Periumbilical
✓Rebound tenderness
✓No bowels sounds “silent abdomen”
✓Anorexia with or without vomiting
✓Diarrhea
✓Increased temperature
✓If ruptures/perforates, there is immediate relief of pain
followed by high fever and dehydration
Appendicitis
Diagnosis
✓WBC <15-20,000
✓Rebound tenderness at McBurney’s point
✓Abdominal ultrasound or xray - fecalith

Appendicitis
Management and Nursing Care: Pre-Op

✓NPO, IV
✓Comfort measures, knee chest position
✓Antibiotics
✓Thermal therapy – Ice pack
✓No elimination
✓Patient education for post-op
✓ +/- NG tube
✓ Penrose drain vs open wound bed
Appendicitis
Management and Nursing Care: Pre-Op

✓NPO, IVs
✓Antibiotics
✓Analgesia
✓Patient teaching
✓Wound care
✓Open vs laproscopic
✓No contact sports, PE, lifting until released by surgeon
Pyloric Stenosis
The pylorus muscle which is at the distal end of the

stomach becomes thickened causing constriction of
the pyloric canal between the stomach and the
duodenum and obstruction of the gastric outlet of the
stomach.
Pyloric Stenosis
Pyloric Stenosis
Pyloric Stenosis
✓ Treatment: Surgery Pyloromyotomy
✓Post Operative Care:
✓I & O
✓Feeding
✓Feeding begins with clear liquids containing glucose and
electrolytes. Regime example: 8 hours NPO, 10cc sterile hater
feed X 2. Increase to 15cc X 2, progressing to ½ strength
formula, then full strength formula. Observe and record the
infant’s response to feeding.
✓Position with head elevated
✓Assess Surgical site to prevent infection
✓Patient teaching
Intussuception
Intussuception
Therapeutic Intervention
✓Intussusception
✓Hydrostatic Reduction
✓Surgery
Intussuception
Nursing Care
✓Following Hydrostatic reduction
✓ Clear liquids and diet is advanced gradually
✓ Observe for passage of barium and eventually passage of stool
✓If reduction is not successful Surgery
✓Post-op Care
✓ Stabilize the child
✓ NPO and start IV fluids
✓ NG tube to decompress the bowel
✓ Pain medications
✓ Provide information to the parents
Hirschsprung’s Disease
Congenital disorder of nerve cells in lower colon

Assessment
*
Diagnosis
✓History & Physical
✓Barium enema (X-ray)
✓Rectal biopsy- absence of ganglionic cells in bowel mucosa

Management
✓Surgical intervention
✓Colostomy (temporary)
✓Resection (at 12 to 18 months of age)
Nursing Care
✓Pre-op
✓Cleanse bowel
✓Patient/parent teaching
✓Post-op
✓NPO
✓Vital Signs – never take a rectal temperature
✓Assessment
✓Patient/parent teaching
✓ Colostomy care
✓ Skin care
✓ Nutrition
with a Cardiovascular Disorder
Fetal Circulation Structures
✓Umbilical vein, umbilical arteries

✓Foramen ovale
✓Ductus arteriosus
✓Ductus venosus
Fetal Circulation Structures
Changes at Birth
Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation.

Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA,
for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV,
right ventricle; LV, left ventricle.
Pediatric Indicators of Cardiac Dysfunction
✓Poor feeding
✓Tachypnea, tachycardia
✓Failure to thrive, poor weight gain, activity intolerance
✓Delayed physical growth
✓Developmental delays
✓Positive prenatal history
✓Positive family history of cardiac disease
Two Types of Cardiac Defects
✓Congenital:
✓Anatomic, resulting in abnormal function
✓Acquired:
✓Disease process:
✓ Infection
✓ Autoimmune response
✓ Environmental factors
✓ Familial tendencies
Congenital Heart Disease (CHD)
CAUSES:
✓Chromosomal-genetic: 10%-12%
✓Maternal or environmental: 1%-2%
✓Maternal drug use:
✓ Fetal alcohol syndrome: 50% have CHD
✓Maternal illness:
✓ Rubella in first 7 weeks of pregnancy—50% risk of defects, including
patent ductus arteriosus (PDA) and pulmonary branch stenosis
✓ Cytomegalovirus, toxoplasmosis, other viral illnesses lead to cardiac
defects
✓ IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)
✓Multifactorial: 85%
✓Incidence: 5-8 per 1000 live births

✓About 2-3 of these are symptomatic in first year of life
✓Major cause of death in first year of life (after prematurity)
✓Most common anomaly is ventricular septal defect
✓28% of kids with CHD have another recognized anomaly
Older Classifications
✓Acyanotic:
✓May become cyanotic
✓Cyanotic:
✓May be pink
✓May develop congestive heart failure (CHF)
Newer Classifications
✓Hemodynamic characteristics:
✓Increased pulmonary blood flow
✓Decreased pulmonary blood flow
✓Obstruction of blood flow out of the heart
✓Mixed blood flow
Increased Pulmonary Blood Flow Defects
✓Abnormal connection between two sides of heart

✓Either the septum or the great vessels
✓Increased blood volume on right side of heart
✓Increased pulmonary blood flow
✓Decreased systemic blood flow
✓Atrial septal defect
✓Ventricular septal defect
✓Patent ductus arteriosus
Obstructive Defects
✓Coarctation of the aorta

✓Aortic stenosis
✓Pulmonic stenosis
Decreased Pulmonary Blood Flow Defects
✓Tetralogy of Fallot
✓Tricuspid atresia
Mixed Defects
✓Transposition of great vessels
✓Total anomalous pulmonary venous connection
✓Hypoplastic heart syndrome:
✓Right sided
✓Left sided
✓Impaired myocardial function:
✓ Tachycardia, fatigue, weakness, restlessness, pale, cool extremities,
decreased blood pressure, decreased urinary output
✓Pulmonary congestion:
✓ Tachypnea, dyspnea, respiratory distress, exercise intolerance,
cyanosis
✓Systemic venous congestion:
✓ Peripheral and periorbital edema, weight gain, ascites,
hepatomegaly, neck vein distention
with a Acquired Cardiovascular Disorder
Infectious and Inflammatory
Cardiac Disorders
✓Bacterial endocarditis (BE), infective endocarditis (IE), or
subacute bacterial endocarditis (SBE)
✓Streptococcal
✓Staphylococcal
✓Fungal infections
✓Prophylaxis: 1 hour before procedures (IV) or may use PO
in some cases
✓RF
✓ Inflammatory disease occurs after group A β-hemolytic streptococcal
pharyngitis
✓ Infrequently seen in United States; big problem in Third World
✓ Self-limiting
✓ Affects joints, skin, brain, serous surfaces, and heart
✓RHD
✓ Most common complication of RF
✓ Damage to valves as result of RF
Clinical Manifestations of RF
✓Carditis
✓Polyarthritis
✓Erythema marginatum
✓Subcutaneous nodules
Prevention of RHD
✓Treatment of streptococcal tonsillitis and pharyngitis:
✓Penicillin G IM X 1
✓Penicillin V PO q 10 days
✓Sulfa PO q 10 days
✓Erythromycin (if allergic to above) PO q 10 days
✓Treatment of recurrent RF:
✓Same as above
with a Alterations in Neurologic Function
Neural Tube Defects
(NTDs)
✓Failed closure of neural tube

✓May involve entire length of the neural tube or small portion
✓Incidence:
✓Affects more girls than boys
✓Occurs three times more often in Caucasians than in African
Americans
Neural Tube Defects (NTDs)
Midline defects of osseous

spine with varying degrees
of neural herniations. A,
Normal. B, Spina bifida
occulta. C, Meningocele. D,
Myelomeningocele.
✓Cause:
✓50% or more: folic acid deficiency
✓Other cases: multifactorial
✓Treatment = prevention:
✓Supplementation: folic acid 0.4 mg/day
✓If history of NTD, 4.0 mg/day
✓In 1998 FDA fortified cereal grains with folic acid
✓Begin preconception
Antenatal Diagnosis of NTDs
✓Elevated α-fetoprotein in amniotic fluid—16-18 weeks of

gestation
✓Uterine ultrasound
✓Why do we want to know?
Types of NTDs
✓Two most common types:
✓Anencephaly
✓Spina bifida–myelomeningocele
Anencephaly
✓Absence of cerebral hemispheres
✓Brainstem function may be intact
✓Incompatible with life
✓Few hours to few days
✓Death due to respiratory failure
Spina Bifida
✓Failure of osseous spine to close
✓Two types:
✓Spina bifida occulta
✓ Not visible externally
✓Spina bifida cystica
✓ Visible defect
✓ Saclike protrusion
Spina Bifida Occulta

✓Usually lumbosacral, L5-S1
✓Skin indicators (absent, singly or combination):
✓Sacral dimple
✓Sacral angioma or port wine nevus
✓Sacral tufts of dark hair
✓Sacral lipoma
Spina Bifida Occulta

✓“Tethered cord”:
✓Abnormal adhesion to bony or fixed structure
✓Puts traction on the cord
✓ Altered gait
✓ Bowel and bladder problems
✓ Foot deformities
✓May not be seen in early infancy
Spina Bifida Cystica
✓Visible defect with external saclike protrusion

✓Two types:
✓Meningocele
✓Myelomeningocele
Meningocele
✓Sac contains meninges and spinal fluid but no neural
elements
✓No neurologic deficits
Myelomeningocele
✓Neural tube fails to close
✓May be anywhere along the spinal column
✓ Lumbar and lumbosacral areas most common
✓May be diagnosed prenatally or at birth
✓Sac contains meninges, spinal fluid, and nerves
✓Varying and serious degrees of neurologic deficit
✓Clinically, myelomeningocele term is interchangeable with phrase spina
bifida
Myelomeningocele:
The Sac
✓May be fine membrane
✓ Prone to leakage of cerebrospinal fluid (CSF); easily ruptured
✓May be covered with dura, meninges, or skin
✓ Rapid epithelialization
✓ Location and magnitude of defect determine nature and extent of impairment
✓ If defect below 2nd lumbar vertebra:
✓ Flaccid paralysis of lower extremities
✓ Sensory deficit
✓ Not necessarily uniform on both sides of defect
with a Genitourinary Dysfunction
✓Most are postinfectious:
✓Pneumococcal, streptococcal, or viral
✓May be distinct entity OR
✓May be a manifestation of systemic disorder:
✓Systemic lupus erythematosus (SLE)
✓Sickle cell disease
✓Others
Symptoms
✓Generalized edema due to decreased glomerular filtration

✓Begins with periorbital area
✓Progresses to lower extremities and then to ascites
✓Hypertension due to increased extracellular fluid
✓Oliguria
Symptoms
✓Hematuria
✓Bleeding in upper urinary tract, resulting in smoky urine
✓Proteinuria
✓Increased amount of protein = increased severity of renal
disease
✓A noninfectious renal disease
✓Autoimmune
✓Onset 5-12 days after OTHER type of infection
✓Often group A β-hemolytic streptococci
✓Most common in 6-7 year olds
✓Uncommon in children <2 years old
✓Can occur at any age
Nursing Management
✓Manage edema:
✓ Daily weights (check fluid balance)
✓ Accurate I&O
✓ Daily abdominal girth
✓Nutrition:
✓ Low sodium, low to moderate protein
✓Susceptibility to infections
✓Bed rest is not necessary

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Pediatric Nursing

by: Mabel M. Oamil, BSN, RN, MAN, CHA

✓Neonate – first 28 days of life

HR Absent <100 >100

Resp effort Absent Irreg; slow weak Good; strong cry

Response No response Grimace Cry, sneeze

Color Blue, pale Body pink, extrem. Completely pink

✓At 1 min: <7 – depression of CNS, <4 – severe depression of CNS

✓Term = 36-42 completed weeks gestation

✓Head circumference – 34cm to 35 cm (13.5 to 14 in)

✓Temperature: 36.5 to 37.5C

Delayed language development

Treatment and Nursing Care

Nurse Alert for Post-Op T/A surgery

✓Most obvious sign of early bleeding

✓Chronic inflammatory disorder affecting mast cells,

✓Anticholinergic agents: Atrovent

Preventer / Controller Medications

✓Inhaled steroids ( Advair, Pulmocort, Azmacort) (always

✓Leukotriene modifiers - (Singulair)

Emergency situations of asthma

✓Acute episode of reactive disease: bronchioles may close

✓Status asthmaticus: medical emergency with severe

✓Mucous glands produce a thick protein that accumulates

✓Passages in organs such as the pancreas become

✓First manifestation is meconium ileus in newborn

✓ Prevention and treatment of pulmonary infections

✓Etiology- Failure of maxillary and median nasal

✓Remember the psycho-social implications for

✓Failure of the esophagus to totally differentiate –

✓Monitor growth and development

The cardiac/lower esophageal sphincter (AKA LES) and lower

✓Ph of secretions in esophagus <7.0=acid

✓Barium Swallow and visualization of any esophageal

Management & Nursing Care

✓A disturbance of the intestinal tract that alters motility and

✓ABG’s to diagnose Metabolic Acidosis

✓Inflammation of the lumen of the appendix which

✓Rebound tenderness at McBurney’s point

✓Abdominal ultrasound or xray - fecalith

Management and Nursing Care: Pre-Op

Management and Nursing Care: Pre-Op

The pylorus muscle which is at the distal end of the

Congenital disorder of nerve cells in lower colon

✓History & Physical

✓Barium enema (X-ray)

✓Rectal biopsy- absence of ganglionic cells in bowel mucosa

✓Umbilical vein, umbilical arteries

Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation.

✓Incidence: 5-8 per 1000 live births

✓Abnormal connection between two sides of heart

✓Coarctation of the aorta

✓Failed closure of neural tube

Midline defects of osseous

Antenatal Diagnosis of NTDs

✓Elevated α-fetoprotein in amniotic fluid—16-18 weeks of

Spina Bifida Occulta

Spina Bifida Occulta