PEDIATRIC NURSING

Division

Newborn to Adolescent (up to 18 years) focus on Pediatric diseases Neonate (Newborn) 0-28 days of life that can survive extra-uterine life Infant 29 days-1 year old Toddler 1-3 years old

Conditions in Pediatric Nursing 1. Cardiovascular System Most Dangerous 1st trimester Period of organogenesis Beginning of the development of the baby Hereditary Steroids-cleft lip Rubella Virus caused by German measles it can penetrate the placenta serves as the nutrients, supply Low Birth Weight Heart- first to be developed Brain- folic acid (dizziness) is the first sign the fetus is developing the brain Glucose/Sugar Glucose- hypoglycemia Confirmatory Test for Pregnancy- ultrasound H-mole pregnancy test (+) not confirmatory test Grape sized Positive Signs of Pregnancy Fetal skeleton FHT to know breech presentation Ultrasound Fetal movement

Congenital Heart Defects (intrauterine life) AVA normal 1 vein and 1 artery Blue baby syndrome baby turns blue when starts crying RDS Tetralogy of Fallot bluish baby ACCYANOTIC

PDA- Patent DuctusArteriosus ASD- Artrial Septic Defect VSD- Ventricular Septic Defect COA- Coarctation of the Aorta Poor sucking and swallowing Early indication of heart defect

CYANOTIC TOGA (Transposition of great artery) TOF (Tetralogy of Fallot) For black person, first thing to asses for signs of cyanosis: Buccal mucosa (palate) to first test to determine if the black baby is cyanotic Palms Nail beds(Capillary Refill Test) Other name is Blanch Test Normal: < 3 seconds

Nursing Diagnosis: Ineffective Tissue Perfusion

RISK FACTORS:

1. Familial Tendency (history of disease) - 30% chance of inheriting the disease 2. Mother was exposed to rubella virus
German Measles 3 Cs CNS damage Mental Retardation Congenital Cataract (Blindness) Congenital heart defects

1. Mother > 40 years old Primigravida

Hormonal Imbalances

Estrogen and Progesterone

maintains pregnancy

1. Failure of the heart structure to progress

Septal Defect- when shunts does not close

2 TYPES OF CONGENITAL HEART DEFECT

1. Accyanotic 2. Cyanotic

From Left to Right From Right to Left

Newest Disease by World Health Organization Broken Heart Syndrome tachypnea tachycardia insomnia

ACYANOTIC HEART DEFECTS

1. Ventricular Septal Defect (VSD) Opening between 2 ventricles

Signs and Symptoms

Pathognomonic Sign: Systolic murmur at the lower boarder of sternum by auscultation O2 saturation at the right side of the heart

Cardiac catheterization (Invasive Procedure) in order to determine the location of the defect *before injecting dyes, test for allergy then flush after using toilet

Hypertrophy at the right side of the heart

Nursing Responsibilities: NPO (Nothing per Orem) 6-8o before the procedure
Dye- check for the allergies (Anaphylactic Shock)

CBR (Complete Bed Rest) s BRPs (Bathroom privileges)

Protect the site by applying pressure Assess for the complication Fever sign of infection Absent/Weak palpatory pulse thrombi Poor circulation

2. Atrial Septral Defect (ASD)

Failure of the foramen ovale to close
An ASD is a hole in the wall between the two upper chambers of the heart. This defect usually does not cause any symptoms or problems in a young child. However, over a lifetime there can be harmful effects on the heart and lungs. Many holes can be closed through a one-day procedure in the cardiac catheterization laboratory. If surgery is needed, surgeons usually perform an ASD repair before a child begins school.

Right Side Lying Position

Increase pressure at the left side of the heart

The Foramen Ovale should close w/in 24 hrs after birth up to 3 months up to 1 year

Signs and Symptoms Pathognomonic Sign: Systolic murmur at the upper boarder of sternum O2 saturation at the right side of the heart Hypertrophy at the right side of the heart

Management for ASD and VSD

1. Long-term antibiotics To prevent sub-acute bacterial endocarditis/Infection Inflammation of the endocardium 1. Open heart surgery

3. Patent Ductus Arteriosus (PDA)

Failure of the Ductus Arteriosus to close PDA is a heart problem that is usually noted in the first few weeks or months after birth. It is
characterized by a connection between the aorta and the pulmonary artery which allows oxygenrich (red) blood that should go to the body to recirculate through the lungs

Ductus Arteriosus should close within 24 hours after birth up to 1 month

Signs and Symptoms

Pathognomonic Sign: 1. Continuous machinery like murmur Prominent radial pulse Normal (-) radial pulse PDA - (+) radial pulse Normal (+) Femoral pulse COA - (-) Femoral pulse Hypertrophy at the Right Ventricle

Drug of choice = Indomethacin

Prostaglandin inhibitor that facilitate the closure of the DA

Management
Surgery Ligation of PDA

4. Coarctation of Aorta (COA)

Narrowing/Stenosis of the aorta
Coarctation of the aorta is a malformation of the aorta where the largest blood vessel in the body is narrow or small. Pediatric cardiac surgeons are able to surgically enlarge the narrowed aorta.

Signs and Symptoms

Pathognomonic Sign: Absence of Femoral pulse

Nursing Intervention
Monitor the Blood Pressure in the four extremities REVEAL Increase BP upper extremities Decrease BP lower extremities

PULSE Bounding Pulse Weak /Thready/Palpatory

Drug Of Choice : Digoxin

Digoxin is derived from the leaves of a digitalis plant. Digoxin helps make the heart beat stronger and with a more regular rhythm.

Management
Surgery: Angioplasty

CYANOTIC HEART DEFECTS

Nursing Diagnosis: Ineffective tissue perfusion Decrease Cardiac Output

1. Transposition of the Great Arteries (TOGA)

Aorta arises from Right Ventricle PA arises from Left Ventricle Direction of the blood is from Right Atrium Tricuspid valve Right ventricle Aorta s O2

Signs and Symptoms

Cyanosis -1st cry Pinkish normal Blue -Dangerous -Cyanotic Congenital Defect - Respiratory Distress Syndrome Normal cry -strong -vigorous -lusty O-ha Abnormal cry -cat-like cry (meow cri-du-chat syndrome Deficiency of chromosome # 5 Through DNA testing Legal identification- anklet tag -high pitch shrill cry (Increase Intracranial pressure) CSF has blood brain barrier Hydrocephalus abnormal enlargement the head Polycythemia vera Increase no. of RBCs/Red Blood Cells

Due to consistent a decrease of O2

Plethora

Ruddy skin (redness discoloration due to Polycythemia Vera PV)

Cardiomegaly

Enlargement of the heart due to decrease O2 of the body (viscous blood) that will cause Overfatigue of the Myocardium muscle of the heart

2. Tetralogy of Fallot (TOF)

Boot shape
4 Main Conditions:

1. 2. 3. 4.

Pulmonary artery stenosis Ventricular Septal Defect/VSD Overriding of Aorta Right Ventricular Hypertrophy

Signs and Symptoms

High level of Cyanosis Polycythemia vera Severe Dyspnea Squatting/Knee-chest position Promotes lung expansion Inhibits venous return Relieves from difficulty of breathing Tet-spells or Blue-spells bluish discoloration due to short episodes of hypoxia MR/Mental Retardation(Mild) Decrease O2 brain Syncope (Fainting) Decrease O2 brain 6 minutes without oxygen Irreversible brain damage GR/Growth Retardation Decrease O2- vital organs(systemically) Clubbing of fingers Decrease tissue perfusion X-ray film Boot-shape of the heart

Management:
Positioning

knee chest/squatting

Administer O2 as ordered.
1-3 canula Retrolental fibroplasia / Retinopathy of Prematurity Too much oxygen or Increase O2 (toxicity/overdosage) Blindness

No valsalva maneuver Vasoconstriction Increase beat of the heart *Increase in the stimulation of the Vagus nerve Bradycardia

* Increase workload of the heart DOB Cyanosis Increase the fiber in the diet Propanolol

Antihypertensive drug Decrease Heart Spasm

Surgery BLT ( BlalockTaussig procedure) anastomosis (to put together) of pulmonary artery and subclaian artery thus increase peripheral blood flow Check the skin color, no cyanosis (postoperative)sign if the operation is successful

ACQUIRED HEART DISEASE

RHF (Rheumatic Heart Fever)
Systemic inflammatory disease that affects the brain, heart, joints and Subcutaneous tissues It is caused by microorganisms (M.O) GABHS(Grouo A Beta Hemolytic Streptococcus) 3-5x history of sorethroat/year Tonsillectomy- removal of tonsil Sign if there is blood after tonsillectomy Frequent swallowing Thyroidectomy removal of thyroid Sign if there is blood after thyroidectomy blood in the nape area

Complications Tool Jones Criteria in order to diagnosed the patient with RHF/RHD Major (S/SX)
Poly arthritis Subcutaneous Nodules

RHD (Rheumatic Heart Disease) - destruction of the bicuspid valve

Carditis

Erythema Marginatum

Chorea (St. Vitous Dance)

purposeless movement of the body and the hands

Minor (S/SX) Arthalgia (joint pain) Lower grade fever Increase ASO titer anti- streptolysin =first laboratory test that will confirms the patient manifest tonsillitis or RHF -increase ESR (Erythrocyte sedimentation rate) inflammation -increase creactive protein (CRP)

* Presence of 2 major diagnosis *Presence of 1 major + 2 minor history of sorethroath patient + of RHF

Management:
1.Increase oral Fluid Intake (OFI) 2.CBR- because of joint pain 3.Throat swab exam Doctor/ Physician to determine the culture& sensitivity to determine the bacteria Laryngospasm RA ( Respiratory Arrest) Antibiotic Ampicillin Erythromycin every 6 hrs. ASA (Acetyl Salicylic Acid) Aspirin given after meals (gastric irritation) Overdose of aspirin tinnitus = tingling sensation of the ears Five actions of Aspirin

Analgesics Antipyretics Anti inflammatory Anti platelet Anti thrombotic

MULTI-ORGAN SYSTEM DISORDERS

Kawasaki Disease a.k.a mucutaneous lymphnode syndrome is an autoimmune disease in which the medium-sized blood vessels throughout the body become
inflamed. It is largely seen in children under five years of age. It affects many organ systems, mainly those including the blood vessels, skin,mucous membranes and lymph nodes; however, its rare but most serious effect is on the heartwhere it can cause fatal coronary artery aneurysms in untreated children.

Signs and Symptoms

Bilateral conjunctivitis Strawberry tongue Lymphadenopathy

Polymorphous Rash

Desquamation of the Skin

Vasculitis

Management:
Reverse isolation Aspirin Therapy Immune Globulin IV(DOC) anti- inflammation decrease risk of CAD/Coronary Artery Disease Angina Pectoris chest pain Problem in digestion

II. RESPIRATORY SYSTEM DISORDERS

LOBECTOMY removal of one lobe of the lung PNEUMONECTOMY removal of lung

Normal RR:

30-60 bpm (newborn) shallow irregular respirations periods of apnea <15 seconds >15 seconds RDS/Respiratory Distress Syndrome

1. Asthma Bronchoconstriction - Narrowing of the bronchus Nursing Diagnosis: Ineffective Airway Clearance Ineffective Breathing Pattern

INTRINSIC (Internal Stressors) Stress Type A personality workaholic perfect

Emotions

EXTRINSIC (External stressors or environmental factors) Allergens (dust), pollens, perfumes Drugs(antibiotics) Foods(seafood), chocolates Change of the weather from hot to cold

No skin testing - the immune system of the infant is not yet fully develop 2 to 3 months allergic reactions

Signs and Symptoms

Hacky, non-productive cough SOB/DOB Prolonged expiratory period Expiratory wheezes(Pathognomonic sign) -musical breath sound -bronchoconstriction Itchiness at the base of the neck

DRUGS:

1. Albuterol First line of drug 2. Salbutamol

3. Aminophylline

Indications

Used as a bronchodilator in reversible airway obstruction due to asthma. May be used in cases of Pulmonary edema and pulmonary congestion secondary to heart failure STATUS ASTHMATICUS -recurrent episodes of asthmatic attack Epinephrine Drug of Choice

Indications Adrenalin is used in cases of anaphylactic shock, cardiac arrest, and resistant ventricular fibrillation.

Signs and Symptoms

Absence of wheezes/wheezing sound report immediately to the physician it indicates airway obstructions

Management:
Positioning head elevated, high fowlers, semi fowlers, sitting position Administer O2 as ordered Monitor the V/S especially the RR Monitor Skin color presence of cyanosis

2. RESPIRATORY DISTRESS SYNDROME/RDS

Deficiency of surfactant
Preterm Babies Type II alveolar cells that produce the surfactant 3 Best Explanation why surfactant is important surface tension Promotes lung expansion Prevents lung collapse(atelectasis)

Diagnostic Procedures
Amniocentesis - aspiration of amniotic fluid

Lecthin/Sphingomyelin (L/S) ratio = 2:1 Indicates lung maturity

Shakes test

If bubbles last for sometime ( + )lung maturity If bubbles disappear quickly ( )lung maturity

Signs and Symptoms

Pathognomonic sign: Inspiratory grunting Tachypnea Restlessness Nasal Flaring Sternal Retraction

Management: Positioning head elevated Proper suctioning 5-10 seconds 5-15 seconds To prevent HYPOXIA Corticosteroid Betamethasone

Prevents RDS Promotes surfactant maturation

Bronchodilators

3. Laryngotracheobronchitis (LTB)
inflammation of the Larynx, Trachea, Bronchus Croup presents itself as a severe form of cough. It commonly occurs among children between six
months and five or six years of age.

VIRAL INFECTION 1. Parainfluenza virus 1, 2, 3 2. Respiratory Sincytial Virus(RSV)

Signs and Symptoms

Pathognomonic Sign: Inspiratory Stridor Rooster-like sound due to laryngoconstriction Barking/Croupy Cough seal-barking Labored respirations

Respiratory acidosis

Diagnostic Procedure: Throat swab test

Management: Positioning high fowlers Administer O2 as doctors ordered Bronchodilator

Corticosteroid Prednisone anti inflammation

It is used to treat certain inflammatory diseases (such as moderate allergic reactions) and (at higher doses) some types of cancer, but has many significant adverse effects. It is usually taken orally but can be delivered by intramuscular injection or intravenous injection.

HEMATOLOGICAL SYSTEM DISORDER

Omphlagia bleeding of the umbilical cord umbilical cord Omphalitis infection of the

Hemophilia
Genetically acquired Disease Deficiency of clotting factors X-linked recessive genes Usual carrier: Mother Usually affected: son Rare 1% - Father: carrier Daughter: affected

3 TYPES OF HEMOPHILIA 1. Hemophilia A (80%) most common also known as classic deficiency of the clotting factor # 8 1. Hemophilia B (18%) also known as Christmas Disease deficiency of the clotting factor # 9 1. Hemophilia C (2%) rarest absence of clotting factor # 11

Signs and Symptoms

Hemarthosis Hematuria

Bleeding of the joints Melena

Blood in the Urine Epistaxis Hemorrhages

Black tarry stool

Bleeding of the Nose

Diagnostic procedures
1. Platelet Count Normal value = 150,000 400,000 m3 2. Phrothrombin Time (PT) Normal 3. Partial Thromboplastin Time (PTT) Abnormal N/V PTT of infants < 90 secs

Management:
Provide safety precautionary measures Control the bleeding Closed supervision Avoid direct/contact sports like: Games for them are board games like: Ball games Fencing Tug of war Track n field Chess Domino Scrabble Snakes and adders Monopoly

Avoid invasive procedure (NGT, Foley catheter, etc.) PD 996 under EPI injection is promoted through immunization for children by using a small gauge needle in inserting and then you apply firm pressure for 5-10 minutes after you inject the syringe not exceeding to avoid obstruction of blood flow

 Falls Past Interventions Splint the affected area Immobilized Elevate Current Interventions R - est I - ce C -ompress E -levate

Blood Transfusion Cryoprecipitate - 20-30 minutes Fresh Frozen Plasma (FFP) - 1 hour Note: Be at the bedside of the client for the first 15 mins. Because this is the time you watch out for any allergic reactions and hypertension. If hypertension, itching, fever or plank pain occurs: Stop the transfusion Flush with PNSS(Plain Normal Saline Solution) Notify the physician No aspirin therapy

Sickle Cell Anemia

autosomal recessive gene both the parents are the carrier of the trail also known as painful crisis

Normal RBC

Sickle Cell Anemia

Biconcave disk

Crescent shaped RBC

lifespan of normal RBC 120 days

10-12 days only

Normal RBC Hgb A

Normal RBC is replaced by an abnormal RBC

Abnormal RBC Hgb S

Pathophysiology
Sickle Cell Anemia

O2(dehydration, Infxn, Stress, Vigorous exercise,

altitude environment)

Sickling process

Short lifespan of the RBC Viscosity of the blood circulation

Obstruction of the

10-12 days Max. 20 days

Slow circulation

PS: vaso-occlusive crisis

O2 RBC Anemia

Sickling process

Ischemia

Necrosis

Organ damage

Pain

Complication

Arthritis most common complications

OTHER COMPLICATIONS (LEGHEK)

Liver damage - Destruction of hepatocytes Eyes Retinal detachment Genital - Priapism (painful and continuous erection) that can lead to sterility Heart - Myocardial Infarction Extremities - leg ulceration Kidneys Renal Failure

Management:
Hydration highest possible answer Oxygenation Pain Management Narcotic Analgesia Morphine Blood Transfusion Packed Red Blood Cells - 4 hours Encourage the patient to increase the iron and Folic Acid intake FOLIC ACID promote maturation of RBC

Leukemia
Cancer of WBC (White Blood Cells) Group of malignant disease characterized a rapid proliferation of immature WBCs 2 TYPES: 1. Lympho it affects the Lymphatic System (Immune system) 2. Myelo it affects the bone marrow Bone Marrow Red Erythropoiesis (production of RBC) Yellow Fats

ACUTE LYMPHOCYTIC LEUKEMIA Target children 2-10 years old most common good prognosis ( Undergoes Chemotherapy)

Diagnostic Procedure

1. Peripheral Blood Smear -for Immature WBCs

2. Complete Blood Count - RBC = anemia WBC = leukocytosis WBC = leukopenia

3. Bone Marrow Aspiration Adult - post. Iliac cres Child - Sternum, Infant -Anterior Tibia POST BONE MARROW ASPIRATION BLEEDING

- platelet = thrombocytopenia

S/Sx: Bruises ecchymosis (bluish discoloration Melena Hematuria Gum bleeding

Position the pt. on the affected area to increase pressure

Management:
Provide Neutropenic Precautions Reverse isolation Avoid fresh fruits and fresh flowers(harbor M.O)

Administer Chemotherapy as ordered

Side Effects: Nausea and Vomiting Anorexia Mouth sores Alopecia Low self esteem --- offer a wig or cap

GASTROINTESTINAL SYSTEM DISORDER

MOUTH ESOPHAGUS STOMACH SMALL INTESTINES LARGE INTESTINES RECTUM ANUS

Functions:
To maintain Fluid and Electrolyte balance Process and absorbs nutrients from the metabolism To excrete waste products from the digestive process

Disorders

 Cleft lip Failure of the median maxillary of the nasal process to fuse by 5-8 weeks of pregnancy Most common for Boys Surgery (Cheiloplasty) - repair of the lips

Note: It is done 1-3 months, to save the sucking reflex Rule of 10 Cleft palate Failure of the palate to fuse by 9-12 weeks of pregnancy Most common for Girls Surgery (Palatoplasty) repair of palate Note: It is done 6-8 months, to save the speech 10 weeks old 10 grams of hemoglobin 10 lbs of weight

Signs and Symptoms

Evident at birth During feeding, the milk escapes to the nostrils Risk for aspiration Frequent colic, otitis media, Upper Respiratory Tract Infection

Nursing Management
Provide a soft, large nipple Burp the patient as possible to prevent colic Pre-operative care Provide an emotional support to the mother Positioning - upright position Burp the patient as frequent as possible

Post-operative care Positioning Side lying (post cheiloplasty) to facilitate the drainage of the secretions Prone (post palatoplasty)
Feeding methods Rubber-tipped syringe (post cheiloplasty) Soup spoon, paper cup (post palatoplasty) Note: Avoid straw and fork Apply elbow restraints Decrease the movement of the child Apply Logan Bar To maintain the suture line Wash with strength hydrogen peroxide

Hirschsprungs Disease Congenital Aganglionic Megacolon Aganglionic is the absence of ganglion cells w/c are responsible for peristaltic movement No rhythmic contractions

Signs and Symptoms

Palpable fecal matter Abdominal distention Vomiting bilous it contains fecal matter Halitosis (bad breath) Anorexia Loss of weight Chronic constipation PS: ribbon-like stools

Diagnostic Procedure:
Barium Enema

Ultrasound

Rectal Biopsy

Conclusive test Reveal: Absence of ganglion cells

Management:
Monitor Intake and Output Administer enema as ordered

Intussusception
Invagination or telescoping of one bowel to another portion

Signs and Symptoms

Palpable sausage shaped mass in the abdomen Vomiting bilous mucoid Presence of currant jelly stools Bloody and mucoid Persistent paroxysmal abdominal pain Peritonitis

Surgery
Exploratory Laparotomy

Management
Monitor the Vital Signs Monitor the passage of stools

Hypertropic Pyloric Stenosis

Progressive thickening of the muscle layer of the pylorus that causes narrowing and obstruction

Signs and Symptoms

Palpable olive-shaped mass Upper abdominal distention Projectile vomiting non-bilous mucoid Visible peristaltic waves From Left to right

Diagnostic Procedure:

Ultrasound Abdominal x-ray (upper area) c Barium swallow

Surgery
Pyloromyotomy (Fredet Ramstedt) to loosen the tight muscle

Pre-operative care: Thickened formula (not easily vomitted) Post-operative care:

Maintain clear liquid diet for the patient 24 hours

Nursing Management
Monitor the hydration status of the patient. Monitor the dehydration and metabolic alkalosis Monitor the weight Diet

Bronchiolitis
Inflammation of the fine bronchioles and small bronchi

Signs and Symptoms

Nasal Flaring Intercoastal and Subcostal Retractions on Inspiration Increased Respiratory Rate Mild Fever Wheezing Tachycardia Cyanosis

Diagnosis
Chest Radiograph

Chest radiograph of an infant w/ bronchiolitis Pulse Oximetry

Nursing Management
Antipyretics Hydration Anti RSV Immunoglobulin Humidified Oxygen Nebulized Bronchodilators Epinepherine and anti-inflammatory medications

Provide Adequate Ventilation

Celiac Disease
Is the sensitivity of abnormal immunologic response to protein particularly the gluten factor of protein found in found in grains wheat, rye, oats and barley.

Signs and Symptoms

Steatorrhea Bulky, foul-smelling stools Anorectic Irritable Skinny Spindly extremities Wasted Buttocks

child w/ Celiac Disease

Diagnosis
Serum Analysis of antibodies against gluten (IgA) Endoscopy

Oral Glucose Tolerance Test

Nursing Management
Gluten - free Diet

Maintain Hydration

Systems Plus College Foundation Angeles City

College of Nursing

In Partial Fulfillment Of the Requirements in NCM 102

Pediatric Nursing

Submitted to:

Mr. Arnel Jay Sali, RM, RN, MSN

Submitted by:

Buenafe, Ma. Cresencia S.

BSN Level II