Infant spring 12 without graphics

NUR 2310 Pediatric Nursing
Concepts

ANDREA STORRIE,MSN, CPNP

GROWTH AND DEVELOPMENT

Unit 1
Developmental influences on child
health promotion

One hundred years from now
it will not matter
What kind of car I drove.
What kind of house I lived in.
How much money I had
in my bank account.
Nor what my clothes looked like.
But the world may be
a little better
Because I was important in the life of a child.

CHILDREN’S HEALTH
A CHANGING PARADIGM
• Sixty years ago leading causes of death
were infections and catastrophic disease
• Today’s leading causes are complications of low birth
weight, congenital anomalies and injury
• Antibiotics, immunizations and cancer advances
changed the paradigm
• How do pediatric nurses function now and how will the
future change pediatric nsg.?

GROWTH AND DEVELOPMENT

GROWTH

– Increase in the size and number of cells resulting in
increased size and/or weight of a part
– Quantitative change

GROWTH AND
DEVELOPMENT

DEVELOPMENT

• Gradual change and expansion progressing from lower
to advanced complexity. The emerging and expanding
of individual capacities

• Qualitative change

G & D CONTINUED
MATURATION
– An increase in competence and adaptability
DIFFERENTIATION
– Process by which early cell structures are
systemically modified to achieve specific
properties.
– A development from simple to more complex
activities and functions.
– All four of these processes are interrelated
simultaneously.
– None occur without the other.

BASIC ASSUMPTIONS ABOUT CHILD
DEVELOPMENT
• Development is orderly
• Development has direction
• Development is complex
• Each child is unique
• Development necessitates practice
• Development requires a role model

BASIC ASSUMPTIONS CON’T
• Development requires energy to be expended
• Children develop through conflict and adaptation
• Development goes through cycles
• Development has sensitive periods

DEVELOPMENTAL INFLUENCES
PATTERNS OF GROWTH & DEVELOPMENT:
DIRECTIONAL TRENDS

– CEPHALOCAUDAL
– PROXIMODISTAL (NEAR TO FAR)
– DIFFERENTIATION
– GENERAL (MASS) TO SPECIFIC

FACTORS INFLUENCING GROWTH AND
DEVELOPMENT
• Heredity • Disease
• Neuroendocrine • Environmental
factors hazards
• Nutrition • Stress
• Interpersonal • Mass media
relationships – AAP
• Socioeconomic
factors

ERIKSON’S STAGES OF PERSONALITY
DEVELOPMENT

• Involves a specific conflict or developmental task
• Infant - Trust vs. Mistrust
• Toddler - Autonomy vs. Shame and Doubt
• Preschooler - Initiative vs. Guilt
• Schoolager - Industry vs. Inferiority
• Adolescent - Identity vs. Role Confusion
• Adulthood- Intimacy vs. Isolation

Piaget’s Stages of Cognitive Development
• Sensorimotor (Birth to 2 years)
progress from reflex to sense of cause and effect
• Preoperational (2 to 7 years)
egocentric - thinking is concrete and tangible
• Concrete operational (7 to 11 years)
increasingly logical and coherent - develop conservation
• Formal operations (11 to adulthood)
think abstractly - adaptable and flexible

FREUD - PSYCHOSEXUAL DEVELOPMENT
• Oral stage - birth to one year
• Anal stage - one to three years
• Phallic stage - three to six years
• Latency period - six to twelve years
• Genital period - age twelve and over
DURING CHILDHOOD, CERTAIN REGIONS OF THE BODY ASSUME A PROMINENT
PSYCHOLOGIC SIGNIFICANCE WHICH SHIFTS FROM ONE PART OF THE BODY TO
ANOTHER

PLAY

• Universal medium for learning

• Children learn what no one
else can teach them

• Play is the work of children

http://www.brightcove.tv/title.jsp
?title=894297564&channel=82
5544798

CLASSIFICATION OF PLAY

Practice play
referred to as functional
or sensorimotor play

Symbolic play

Games

SOCIAL ASPECTS OF PLAY

• Solitary play
• Onlooker play
• Parallel play
• Associative play
• Cooperative play

FUNCTIONS OF PLAY
• Physical development
• Cognitive development
• Emotional
development
• Social development
• Moral development
• Therapeutic value

Anticipatory Guidance

• Parents need to know how to a provide safe
environment for their child
• Need to know what to expect before it happens
• Based on child's developmental level
• Awareness of the child’s changing capabilities allows
the parents to be more alert and reactive to safety
hazards the child is likely to encounter

SAFETY PRECAUTIONS WITH INFANT TOYS
• Select toys that are smooth and rounded and made of
wood or plastic
• Plastic toys should be made of tough and resilient
material
• Avoid fuzzy and furry stuffed animals
• Inspect toys for small removable parts
• Check toys for toxic paint
• Supervise infants if playing with paper, string, or cloth

PEDIATRIC UNIT SAFETY PRECAUTIONS
• Baby proof room
• Provide only age appropriate toys
• Remove all medical equipment except when used for treatments
• Cords out of reach
• Outlets covered
• Crib rails up to highest adjustment
• Maintain physical contact if infant or toddler is on an unguarded
surface such as a scale or treatment table
• NEVER LEAVE UNATTENDED NEAR WATER !

CHILDREN’S RESPONSE TO HOSPITALIZATION

• Separation Anxiety:
– Protest: crying, screaming, wrongly
viewed as misbehavior
– Despair: decreased activity or withdrawal,
often viewed as a good thing or “settling in”
– Denial or detachment: starts to play & form
other attachments, resigned not content

CHILDREN’S RESPONSE CON’T

• Fear of the unknown
• Fear of pain or mutilation
• Loss of control
• Anger
• Guilt
• Regression

PARENTAL STRESSORS

• Fear of the unknown
• New environment
• Separation from child
• Guilt
• Financial burden
• Fear that child will suffer or even die
• Fatigue
• work, care of other children, distance to hospital

COMMUNICATING WITH CHILDREN

• Allow time to feel comfortable
• Avoid rapid advance or other threatening
gestures
• Talk with parent if child is initially shy
• Communicate through transition objects such as
dolls or puppets
• Assume an eye level position

COMMUNICATION CON’T.

– Speak in a quiet, unhurried, confident tone of voice
– Speak clearly, be specific, and use simple words and short
sentences
– State directions and suggestions positively
– Offer a choice only if one exists
– Be honest
– Allow time to express concerns and fears
– Give older child the chance to talk without parents present

GUIDELINES FOR ADMISSION
• Introductions
• Orient child and family
• Apply identification
• Explain hospital rules
• Perform nursing admission history
• Take baseline vital signs & obtain specimens
• Support child and parents as necessary

HEALTH HISTORY
• Immunizations current?
• Well Child Care?
• Sick Care only?
• Who is the provider?
• What routines are normal for the child?
– Bedtime ritual? Read a story? Rock?

IMMUNIZATIONS

http://www.cdc.gov/vaccines/recs/schedules/child
-schedule.htm#printable

http://www.cdc.gov/vaccines/pubs/pinkbook/pink
-chapters.htm

http://www.flshots.com/

ASSESSMENT GUIDELINES
• Perform in an appropriate, nonthreatening area
• Provide time for play & getting acquainted
• Observe for readiness to cooperate
• Avoid prolonged explanations about procedures
• Involve child and parent in exam process
• Use a firm, direct approach
• Proceed with exam in an organized sequence
• Reassure child throughout exam & use praise
• Discuss findings with the family

Pediatric Assessment
• Toddlers are the most challenging to examine
– Sequence is flexible
• What are some differences of a pediatric assessment
vs. the assessment of an adult?
• Lymph nodes are often palpable in healthy infants and
children up to 12 years or age (cervical, axillary,
inguinal, and occipital areas)

PLAGIOCEPHALY (POSITIONAL)

• Misshapen head
• Back of head is flattened due to constantly being
placed in supine position
• Infants need belly time
• Treatment
– DOC band
– Need to be worn 23 hours a day
– Frequent adjustments

PERFORMING A PEDIATRIC PROCEDURE
Before the procedure
– Offer ways to cope with pain or discomfort
– Use developmentally appropriate words
– Give choices when possible
– Be sure consent form is signed
– Always wash hands thoroughly

PERFORMING A PEDIATRIC
PROCEDURE
During the procedure
Talk to the child if he/she desires
Keep the child informed of progress
Tell the child when the ”worst is over”

PED PROCEDURES CON’T
After the procedure
– Praise the child for attempting to cooperate
– Provide an opportunity to vent feelings
– Reunite the child with parents
– Reward the child in an age-appropriate way
– Record the process and it’s outcomes

MEDICATION ADMINISTRATION

“8” rights
– Patient, Order, med., dose, time, route, documentation, &
attitude

– Oral medications
– Intramuscular administration
– Vastus lateralis
– Intravenous administration
– NG, OG, or Gastrostomy administration
– Rectal Administration

ADDITIONAL PROCEDURES WITH VARIATIONS

• Measurement of I & O
• Parenteral fluid therapy
• Inhalation therapy
• Chest physiotherapy
• Postural drainage
• Gavage or gastrostomy feeding
• Ostomies

BIOLOGICAL DEVELOPMENT
• GAINS 5-7 OUNCES WEEKLY FOR 1ST 5-6 MO.

• DOUBLES BIRTH WEIGHT BY 6 MO.

• TRIPLES BIRTH WEIGHT BY 12 MO

• BIRTH LENGTH INCREASES 50% BY 12 MO.

• HEAD SIZE INCREASES 33% BY 12 MO.

BIOLOGICAL DEVELOPMENT
• BRAIN INCREASES IN WEIGHT BY 2 ½ TIMES
• ORGAN SYSTEMS BEGIN TO MATURE
• GROWTH CHARTS ARE MOST ACCURATE ASSESSMENT
OF CHILD’S GROWTH

Infant spring 12 without graphics

GROSS MOTOR MILESTONES
• HEAD CONTROL ESTABLISHED @ 4-6 MONTHS
• TURNS ABD. TO BACK @ 4-5 MONTHS
• TURNS BACK TO ABD. @ 6-7 MONTHS
• SITS WITHOUT SUPPORT @ 8-9 MO.
• CRAWLS AND PULLS UP @ 8-9 MO.
• STANDS ALONE @ 10-12 MO.
• WALKS W/ ONE HAND HELD 10-12 M
• WALKS INDEPENDENTLY 12-15 MO.

FINE MOTOR MILESTONES
• 1 MONTH - HANDS FISTED – PALMAR GRASP
• 3 MONTHS - CAN HOLD RATTLE
• 4-5 MONTHS – BEGINS REACHING & GRASPING WITH
PALMS
• 6-7 MONTHS – PICKS UP OBJECT WELL -TRANSFERS
OBJECTS FROM HAND TO HAND

FINE MOTOR MILESTONES
• 8-9 MONTHS - PINCER GRASP DEVELOPS,
REACHES FOR TOYS, RAKES FOR OBJECTS
• 10-12 MONTHS – RELEASES CUBE INTO CUP
AFTER DEMO. – PINCER GRASP COMPLETE
– FEED SELF WITH SPOON

SOCIAL MILESTONES
• SMILES RESPONSIVELY TO STIMULI @ 6-8 weeks.
• SHOWS FEAR AND ANGER @ 4-8 MO.
• SMILES AT SELF IN MIRROR @ 6-7 MO
– PLAYS PEEK- A -BOO

SOCIAL MILESTONES

• STRANGER ANXIETY HEIGHTENS @ 6-8 MO.
• QUIETS SELF AND QUIETED BY MUSIC @ 10-12
MO.
• HAS MOOD CHANGES @ 10-12 MO.

LANGUAGE MILESTONES

• RESPONDS TO SOUNDS @ BIRTH
• COOS, BABBLES- 3 MOS
• BABBLING COMMON @ 4-5 MONTHS
• MAKES VOWEL SOUNDS “ee, ah, ooh”- 4-5
months

LANGUAGE MILESTONES
• BELLY LAUGHS & TALKS TO TOYS 6-7 MO.
• First few words have meaning- 8-9 mos “mama, dada”
– Understands simple demands- “wave bye bye”
– Comprehends –”No,no”

• 10 -12 months says “mama or dada”
• By 1 year recognizes objects by names

• CAN SAY 3-5 WORDS WITH MEANING BY 1 YEAR
– Knows own name
– Enjoys jabbering

PSYCHOSOCIAL DEVELOPMENT-ERIKSON

• TRUST VS. MISTRUST – THE BASIC DEVELOPMENTAL TASK OF
INFANCY
– TRUST OF SELF, OTHERS , AND THE WORLD

– TRUST DEVELOPS WHEN INFANT’S NEEDS ARE CONSISTENTLY
MET

– IF NEEDS NOT CONSISTENTLY MET MISTRUST OF WORLD
DEVELOPS

COGNITIVE DEVELOPMENT
PIAGET
• SENSORIMOTOR
– INITIALLY RELATES TO WORLD THROUGH REFLEXES
– Realize others besides themselves control the environment
– Object permanence by 9 months
• One of the key tasks of this stage
• Seen in the development of separation anxiety

COGNITIVE DEVELOPMENT
PIAGET
– FOUR STAGES DURING INFANCY
• USE OF REFLEXES
– Sucking, rooting, grasping
• PRIMARY CIRCULAR RESPONSE (1-4 months)
– Replacement of reflexive behaviors with voluntary acts
• SECONDARY CIRCULAR RESPONSE
-Continuation of primary lasts until 8 months
- Primary circular reactions are repeated and prolonged for the response that
results

• COORDINATION OF SECONDARY SCHEMAS
– Use previous behavioral achievements primarily as the foundation for adding
new intellectual skills
– Object permanence

Development of Body Image
• Parallels sensorimotor development
• As physical needs are met they feel comfort and satisfaction with
their body
• Messages convey by caregivers reinforce these feelings
• Object permanence is basic to development of self image
• By the end of the first year they realize they are distinct from
their parents
– At the same time is increased interest in their image
– Smile at themselves in the mirror

IMMUNIZATIONS REQUIRED FIRST 6 MONTHS

• DTaP SERIES
• HEPATITIS B SERIES
• POLIO SERIES
• STREP PNUEMOCOCCUS SERIES (Prevnar)
• H. INFLUENZA B- HIB SERIES
• Rotavirus vaccine

IMMUNIZATIONS REQUIRED@ 12-15 MONTHS

• BOOSTERS
– DTAP
– PNUEMOCOCCUS
– HIB
• MMR
• VARICELLA

INFANT NUTRITION
• HUMAN MILK MOST DESIRABLE COMPLETE DIET FOR THE FIRST 6 MONTHS

• BREAST MILK OR FORMULA UNTIL 12 MONTHS

• IRON SUPPLEMENTS @ 4-6MO FOR BREAST FED BABIES
D/T DEPLETED IRON STORES

• FORMULA BABIES MAY HAVE ENOUGH FROM DIET

• NO BOTTLES IN MICROWAVE TO HEAT

• NO SOLIDS UNTIL 4-6 MONTHS

– EARLY EXPOSURE TO SOLIDS CAN PRODUCE ALLERGIES
– EXTRUSION REFLEX IS STRONG IN YOUNG INFANTS

ADDITION OF SOLID FOODS
• IRON FORTIFIED RICE CEREAL USUALLY FIRST

• FRUIT JUICES CAN BE ADDED AFTER 6 MONTHS

• STRAINED VEGETABLES USUALLY NEXT

• FOLLOWED BY STRAINED FRUITS, THEN MEATS

• EGGS, COW’S MILK, AND CITRUS ARE THE MOST COMMON
INFANT ALLERGENS. DELAY INTRODUCTION UNTIL INFANT
12 MONTHS OLD

INTRODUCING SOLID FOODS TO INFANTS

• INTRODUCE WHEN INFANT IS HUNGRY
• BEGIN BY PUSHING FOOD TO BACK OF TONGUE BECAUSE OF
EXTRUSION REFLEX
• USE A SMALL SPOON WITH A STRAIGHT HANDLE
• BEGIN WITH 1-2 TEASPOONS OF FOOD, INCREASE GRADUALLY
• INTRODUCE FOODS ONE AT A TIME WITH 4-7 DAYS BETWEEN
ADDING NEW FOODS

• AS AMOUNT OF SOLID FOOD INCREASES, DECREASE
AMOUNT OF FORMULA TO PREVENT OVERFEEDING

• DO NOT INTRODUCE FOODS BY MIXING WITH FORMULA IN
THE BOTTLE

• EARLY FEEDING EXPERIENCES ARE SLOPPY

• CHILDREN CAN’T BE PRESSURED INTO EATING NEATLY UNTIL
THEY HAVE MANIPULATIVE SKILLS

PLAY
• SOLITARY OR ONE-SIDED PLAY
• OVER THE YEAR BECOMES MORE SOPHISTICATED AND
INTERDEPENDENT
• SENSORY STIMULATION IS VERY IMPORTANT
• INFANTS NEED TO BE PLAYED WITH, NOT MERELY
ALLOWED TO PLAY

CLEFT LIP & CLEFT PALATE
• MULTIFACTOR ETIOLOGY
• TENDS TO RUN IN FAMILIES
• ENVIRONMENTAL TERATOGENS MAY PLAY A ROLE
• CHROMOSOMAL ANOMALIES OFTEN HAVE CLEFTS AS A FEATURE
• MATERNAL SMOKING IN 1ST TRIMESTER ASSOCIATED WITH 10 % OF CASES
• APPEARS MOST OFTEN IN ASIAN AND NATIVE AMERICAN INFANTS - LEAST IN
AFRICAN-AMERICAN
• Maternal intake of folic acid may prevent (NIH, 2007)

• PATHOPHYSIOLOGY- FAILURE OF THE MAXILLARY AND PREMAXILLARY
PROCESSES TO MEET AND FUSE. NOTHING IS MISSING, ALL THE PIECES ARE
THERE.

• CAN BE INCOMPLETE OR COMPLETE

• CLEFT PALATE CAN BE MISSED. FULL VISUALIZATION AND PALPATION OF THE
PALATE NEEDED DURING NEWBORN EXAMINATIONS

• CLEFT LIP CAN BE UNILATERAL OR BILATERAL
– EXTENT OF CLEFT AND NASAL DEFORMITY IS VARIABLE

• SURGICAL TREATMENT
– CLEFT LIP REPAIRED BY AGE 3 TO 6 MO
– CLEFT PALATE REPAIRED AT 6-24 MO.
• MULTIDISCIPLINARY TEAM APPROACH D/T PROBLEMS
WITH SPEECH, ORTHODONTIA AND EARS/SINUSES

• NURSING CARE- CLEFT LIP REPAIR
– PREOP- DEAL WITH FEEDING PROBLEMS
– ENCOURAGE PARENT/INFANT BONDING
– Z-PLASTY REPAIR OF LIP MINIMIZES NOTCHING
– POST OP- PREVENT INFANT CRYING, CLEAN SUTURE LINE,
MAINTAIN SUPINE POSITIONING, MAINTAIN ELBOW
RESTRAINTS AND LIP BOW (LOGAN BOW)

Mosby items and derived items ©
73 of 60
2006 by Mosby, Inc.


• NURSING CARE- CLEFT PALATE REPAIR
– PERFORMED BEFORE FAULTY SPEECH HABITS OCCUR
– PREOP- DEAL WITH FEEDING PROBLEMS
– POST OP- PREVENT INFANT CRYING, ASSESS FOR PAIN, PREVENT
CHILD FROM INSERTING HARD OR POINTED OBJECTS IN MOUTH
AND AVOID HARD FOODS
– NEED TO MONITOR RESPIRATORY STATUS CLOSELY
– OBSERVE FEEDING ONCE RESUMED- I & O
• Liquids to soft diet within 48 hours

ESOPHAGEAL ATRESIA WITH
TRACHEAL-ESOPHAGEAL FISTULA

• PATHOPHYSIOLOGY:
• FAILURE OF THE ESOPHAGUS TO FORM AS A CONTINUOUS
PASSAGE
• THE PROXIMAL SEGMENT TERMINATES INTO A BLIND
POUCH
• THE DISTAL SEGMENT IS CONNECTED TO THE TRACHEA OR
THE PRIMARY BRONCHUS BY A SHORT FISTULA

78 of 60
2006 by Mosby, Inc.

CLINICAL MANIFESTATIONS

– EXCESSIVE SALIVATION AND DROOLING
– THE THREE “C’s”= COUGH, CHOKING AND CYANOSIS
– APNEA
– RESPIRATORY DISTRESS WITH FEEDS
– ABDOMINAL DISTENTION


• THERAPEUTIC MANAGEMENT
– PREVENTION OF ASPIRATION AND PNEUMONIA
• NPO AND IV FLUIDS
• “POUCH TUBE” TO REMOVE SECRETIONS
• ELEVATE HEAD
• GASTROSTOMY TO DRAIN STOMACH CONTENTS
(decompression)
- SURGICAL CORRECTION


• NURSING CARE – PREOP
– IF SUSPECTED MAKE INFANT NPO
– ELEVATE HEAD
– CLEAR SECRETIONS WITH CONTINUOUS SUCTION
– OXYGEN FOR RESPIRATORY DISTRESS


• NURSING CARE- POST OP
– MAINTAIN GASTROSTOMY TUBE
– If a staged repair- care of cervical esphagostomy
– SLOW RETURN OF ORAL FEEDS
– DISCHARGE AFTER ORAL FEEDINGS RESUMED AND
G-TUBE REMOVED

DIAPHRAGMATIC HERNIA
• FAILURE OF DIAPHRAGM TO CLOSE PRENATALLY
ALLOWING ABDOMINAL ORGANS TO BE
DISPLACED INTO THE ABDOMEN

• DEFECT ON IS USUALLY ON THE LEFT SIDE. BOWEL
ENTERS THE CHEST CAVITY AND PUSHES HEART TO THE
RIGHT. IMPEDES GROWTH OF THE LUNG
• AFTER BIRTH THE BOWEL FILLS WITH AIR WHICH
FURTHER COMPROMISES BREATHING AND
CIRCULATION

• CLINICAL MANIFESTATIONS
– HEART SOUNDS LOUDER ON THE RIGHT
– SCAPHOID ABDOMEN
– BOWEL SOUNDS IN CHEST
– INCREASING RESPIRATORY DISTRESS
• STABILIZATION PRE-OP
– RESUSCITATED WITH ET TUBE NOT MASK
– ELEVATE HEAD OF BED
– AFFECTED SIDE DOWN
– NPO AND GASTRIC DECOMPRESSION (NG TUBE)

HYDROCEPHALUS
• IMBALANCE BETWEEN PRODUCTION AND ABSORPTION OF CSF
CAUSING ACCUMULATION IN VENTRICLES
– Communicating
– Noncommunicating
• FOUND EARLY ON WELL EXAMS BY SERIALLY MEASURING AND
GRAPHING HEAD CIRCUMFERENCES
• VERY OFTEN ASSOCIATED WITH MYELOMENINGOCELE

HYDROCEPHALUS
• EARLY PHYSICAL SIGNS
– BULGING FONTANELS
– DILATED SCALP VEINS
– SEPARATED SUTURE LINES
• LATE PHYSICAL SIGNS
– SETTING SUN SIGN- SCLERA VISIBLE ABOVE IRIS
– SHRILL HIGH PITCHED CRY DUE TO ICP
– OPISTHOTONOS

HYDROCEPHALUS
• VENTRICULAR-PERITONEAL SHUNT USUALLY NEEDED (VP shunt)
• Infection is greatest hazard
• Monitor closely for signs of infection and ICP
• Pain management
• Educate parents on signs of infection and increases ICP
• Teach parents how to change dressing

NEURAL TUBE DEFECTS
• SPINAL BIFIDA OCCULTA
– DEFECT PRESENT IN VERTEBRA
– NO SAC PRESENT
– NO OBVIOUS DEFICITS BUT “SOFT” SIGNS MAY BE
PRESENT

Spina Bifida Cystica
• Meningocele
• Sac contains meninges and spinal fluid but no
neural elements
• Not associated with neurological defect

Spinal Bifida Cystica
• Myelomeningocele
• Sac contains meninges, spinal fluid, and nerves
• Manifestations relate to degree of defect, which
is determined by the level of the lesion

NEURAL TUBE DEFECTS
• CAN BE DETECTED BY ULTRASOUND
• CAN BE DETECTED BY AFP
• INITIAL CARE
– PREVENTION OF INFECTION
– NEUROLOGIC ASSESSMENT
– DEALING WITH IMPACT ON FAMILY

NEURAL TUBE DEFECTS
• MULTIDISCIPLINARY APPROACH
– NEUROLOGICAL AND NEUROSURGICAL EVALUATION
– ORTHOPEDIC EVALUATION
– GENITOURINARY EVALUATION
– GASTROINTESTINAL (BOWEL CONTROL)
EVALUATION

Nursing Considerations
• After birth:
– Prone positioning
– Radiant warmer to maintain temp without clothing
– Application of moist, nonadherent sterile dressing
over sac
– Prevent infection

• Post op care same as any surgical procedure
• Latex allergy precautions
• Family support
• Education

DEVELOPMENTAL DYPLASIA OF THE HIP

• HIP JOINT INSTABILITY
• MULTIFACTORAL ETIOLOGY
• FRANK BREECH PRESENTATION HAS HIGH
ASSOCIATION WITH D.D.H.

• DIAGNOSTIC EVALUATION
– POSITIVE BARLOW OR ORTOLANI MANEUVERS
DURING ASSESSMENTS
– RESTRICTED ABDUCTION
– ASYMMETRICAL SKIN FOLDS ON POSTERIOR THIGHS
– APPARENT FEMUR SHORTENING
– DDH

• THERAPEUTIC MANAGEMENT
– “DOUBLE DIAPER”
– PAVLIK HARNESS
– HIP SPICA CAST
• AVOID INDENTING WET CAST WITH FINGERS. USE FLATS
OF HANDS
• DO NOT PULL ON ABDUCTION BAR
• PROTECT CAST FROM SOILING

CLUB FOOT
• FOOT TWISTED OUT OF THE NORMAL POSITION
• EXACT CAUSE NOT KNOWN
• UNILATERAL CLUB FOOT IS MORE COMMON
• IF MILD TREATED WITH EXERCISES
• IF MORE INVOLVED SERIAL CASTING IS PERFORMED
• IF MAXIMUM CORRECTION IS NOT ACHIEVED 3-6 MO., SURGERY
FOLLOWS
• LONG-TERM FOLLOW UP INDICATED

CLUB FOOT
• Serial casting is begun immediately
• Correction usually takes 8 to 12 weeks
• Severe case or cases in which casting does not correct
deformity require surgery
– Done between 4 months and 1 year of age

Care of child with a cast
• Assessments
– Circulation
– Sensation
– Movement
• Interventions
– Elevate limb
– Avoid indenting the cast while it is drying
– Parent education

IRON DEFICIENCY ANEMIA
 ANEMIA CAUSED BY INADEQUATE SUPPLY OF DIETARY IRON

 MATERNAL IRON STORES ADEQUATE FOR 4-6 MONTHS (FULL-
TERM) AND 2-3 MONTHS (PREEMIE)

 TREATMENT
 IRON FORTIFIED FORMULA
 ORAL IRON SUPPLEMENT
 VITAMIN C
 DECREASE WHOLE MILK AND ADD Iron Fortified CEREALS,
VEGETABLES, AND MEATS

IRON DEFICIENCY ANEMIA
 ANEMIA CAUSED BY INADEQUATE SUPPLY OF DIETARY
IRON

 MATERNAL IRON STORES ADEQUATE FOR 4-6 MONTHS
(FULL-TERM) AND 2-3 MONTHS (PREEMIE)

 TREATMENT
 IRON FORTIFIED FORMULA
 ORAL IRON SUPPLEMENT
 VITAMIN C
 DECREASE WHOLE MILK AND ADD Iron Fortified
CEREALS, VEGETABLES, AND MEATS

Fe Deficiency Lab Values
• RBC- low

• Hgb/HCT- low

• MCV/MCH- low- microcytic anemia

• Ferritin levels (iron storage) low

Anemia: Lab Evaluation

– Normal Peripheral Smear • Iron Deficiency Anemia

• ATOPIC DERMATITIS ATOPIC DERMATITIS
ECZEMA / IS PROBABLY GENETICALLY
DETERMINED WITH CONTRIBUTING FACTORS
• A PRURITIC ECZEMA ASSOCIATED WITH DRY SKIN,
ALLERGY, AND EMOTIONAL STRESS WHICH STARTS IN
INFANCY & MAY CLEAR BY 2-3 YRS.
• AFFECTS 9-12% OF YOUNG CHILDREN

ECZEMA/ATOPIC DERMATITIS
 THERAPEUTIC MANAGEMENT

 MOISTURIZE SKIN
 REDUCE INFLAMMATION (TOPICAL OR ORAL
STEROIDS)
 RELIEVE ITCH (MEDS AND LUBRICATION)
 PREVENT SECONDARY INFECTION
 REMOVE IRRITANTS AND ALLERGENS
 IDENTIFY AND AVOID POTENTIAL FOOD
TRIGGERS

ECZEMA/ATOPIC DERMATITIS
• TREATMENT METHODS
– AVOID ENVIRONMENTAL TRIGGERS SUCH AS
OVERHEATING, SOAPS, WOOL, ETC.
– ORAL ANTIHISTAMINES (Atarax, Benadryl,
Claritin)
– INFREQUENT TEPID BATHING, WET
COMPRESSES, OCCLUSIVE CREAMS AND
COOL COMPRESSES
– LOW POTENCY ANTI-INFLAMMATORY
CREAMS (Elocon, Cutivate)

FAILURE TO THRIVE (FTT)
• PERSISTENT DEVIATION FROM NORMAL
GROWTH CURVE (GROWTH < 5TH
PERCENTILE)

• ORGANIC FTT- THERE IS A PHYSICAL
PATHOLOGICAL PROCESS PRESENT. THE FTT
MAY OR MAY NOT BE CORRECTABLE
DEPENDING ON THE UNDERLYING CAUSE.

• NON-ORGANIC FTT
– CAUSES
• DISTURBED PARENT-CHILD RELATIONSHIP
• POVERTY
• HEALTH BELIEFS
• INADEQUATE NUTRITIONAL KNOWLEDGE
• FAMILY STRESS

• MIXED FTT
– Combination of organic and inorganic etiologies


CLINICAL MANIFESTATIONS

• GROWTH FAILURE
• DEVELOPMENT DELAY
• APATHY
• POOR EYE CONTACT/RADAR GAZE
• STIFF POSTURE
• NO FEAR OF STRANGERS


• MANAGEMENT

– Reversal of malnutrition
– Treat any underlying medical conditions
– Multidisciplinary approach


• Accurate assessment of initial weight and
height
• Record of all food intake and eating
behaviors
• Assessment of parent child relationship

SUDDEN INFANT DEATH SYNDROME (SIDS)
• UNEXPLAINED DEATH AFTER POST MORTEM
EVALUATION OF A CHILD LESS THAN 1 YR. OLD

• EPISODES HAVE DECREASED 40% SINCE THE “BACK TO
SLEEP” CAMPAIGN

• INCIDENCE NOW 0.6 IN 1000 LIVE BIRTHS

• PEAK AGE 2-4 MONTHS

• 95% OF DEATHS OCCUR BY 6 MONTHS

SUDDEN INFANT DEATH SYNDROME - SIDS

• MANY THEORIES BUT NO KNOWN ETIOLOGY

• SLEEP APNEA NOT THE CAUSE OF SIDS

• MONITORING OF SUBSEQUENT SIBLINGS NOT
RECOMMENDED - 99% CHANCE OTHER
INFANTS WILL NOT DIE OF SIDS

Risk factors
• Infants born weighing less than 3.5 pounds.
• Infants exposed to cocaine, heroin, or
methadone during the pregnancy.
• Infants who have had an apparent life-
threatening event.

Reducing the risks
 Supine position only
 No more side lying (AAP, 2005)

 No blankets, soft, bedding, bumpers, toys etc in the crib

 Do not over clothe the infant

 Pacifiers use at time of sleep (controversial)

 No co-sleeping

SUDDEN INFANT DEATH SYNDROME - SIDS
 CARE OF FAMILY AFTER SIDS EVENT

 COMFORT FAMILY AND ALLOW OPPORTUNITY TO SAY
GOODBYE

 PROVIDE WRITTEN MATERIAL

 ARRANGE FOR F/U HOME VISIT WHEN FAMILY IS READY

 REFER TO SIDS SUPPORT GROUP

Cystic Fibrosis
 Pathophysiology:

 Increased viscosity of mucous gland secretions

 Elevation of sweat electrolytes (NA)

 Mechanical obstruction as a result of thick secretions

 Small passages in organs become obstructed (lungs and pancreas)
 Meconium ileus
 Pancreatic fibrosis

CYSTIC FIBROSIS
• AUTOSOMAL RECESSIVE

• MULTISYSTEM DISEASE
– RESPIRATORY SYSTEM
– DIGESTIVE SYSTEM
– INTEGUMENTARY SYSTEM
– REPRODUCTIVE SYSTEM

CYSTIC FIBROSIS

 DIAGNOSIS
 FAMILY HISTORY

 ABSENT PANCREATIC ENZYMES
 INCREASE SWEAT CHLORIDE - >60 mEq/L
 CHRONIC PULMONARY INVOLVEMENT

 THERAPEUTIC MANAGEMENT
 PREVENT/MINIMIZE PULMONARY COMPLICATIONS
 ENSURE ADEQUATE NUTRITION
 ASSIST CHILD/FAMILY TO ADAPT TO ILLNESS

CYSTIC FIBROSIS
• PULMONARY CARE
– CLEAR AIRWAY (CHEST PT, FLUTTER
DEVICE, PERCUSSION VEST)
– THIN MUCUS THROUGH NEBULIZED MEDS
(PULMOZYME)
– INHALED BRONCHODILATORS
– PROMPT ANTIBIOTIC TREATMENT OF
INFECTIONS
– DAILY PHYSICAL EXERCISE

CYSTIC FIBROSIS
• GASTROINTESTINAL CARE

– PANCREATIC ENZYMES-IF CAN NOT SWALLOW
PILLS MAY BE MIXED WITH A LITTLE FOOD

– HIGH PROTEIN, HIGH CARB, HIGH CALORIE DIET

– VITAMINS A,D,E AND K, IN WATER SOLUBLE FORM

Cystic Fibrosis Related Diabetes
• Shares features of Type I and Type II

• Unique an distinct form that requires special
management

• Average age of onset is 18- 21 years of age

GASTORENTERITIS
• CAUSES ARE VIRAL, BACTERIAL, METABOLIC
AND PARASITIC

• MOST PEDIATRIC CASES ARE VIRAL

• EVEN VIRAL GASTROENTERITIS CAN KILL A
CHILD THROUGH DEHYDRATION

• Approximately 400 children aged 1 month to 4
years die annually as a result of volume depletion

GASTORENTERITIS
• DEHYDRATION AND KIDS

– ASSOCIATED WITH METABOLIC ACIDOSIS

– KIDS HAVE A GREATER EXTRA CELLULAR
FLUID TO INTRACELLULAR FLUID RATIO
THAN ADULTS WHICH RESULTS IN GREATER
AND MORE RAPID LOSS OF FLUID

– CHILDREN EXPERIENCE GREATER
INSENSIBLE WATER LOSS

WATER BALANCE DIFFERENCES
Infants and young children have a greater need for water

More vulnerable to alterations in fluid and electrolyte balance

Greater I & O relative to size

Higher basal metabolic rate

Greater production of metabolic waste

Immature kidney function

EXTRACELLULAR FLUID
COMPARTMENT

Constitutes more than half total body water at
birth

 Has greater ECF until about age 2

 Greater and more rapid water loss
during this age

WATER LOSS
 2/3 of insensible water loss is through skin

 1/3 through respiratory tract

 Insensible fluid loss is increased by heat, humidity,
temperature and respiratory rate

 Infants and toddlers tend to be more highly febrile

Dehydration
• Sodium is the main solute in the ECF

• When ECF volume is reduced in acute
dehydration, total body sodium is almost
always reduced, regardless of serum values

Types of Dehydration

Isotonic
Hypotonic (hyponatremic)
Hypertonic (hypernatremic, hyperosmotic)

 ISOTONIC DEHYDRATION
 Primary form of dehydration in children
 Water and salt are lost in equal amounts
 Major loss is from ECF
 Reduction in plasma volume, circulating volume,
 Shock is greatest threat to life
 Child will display characteristic symptoms of hypovolemic
shock
 Serum sodium remains normal (130-150 meq/L)

Lab Values
K+ normal to low

NA initially normal but then may be low

BUN and Creatinine – High

CO2- low (indicator of severity of
dehydration)

Signs and Symptoms
of Dehydration
 Fewer wet diapers than usual
 No tears when crying; inside of mouth dry and sticky
 Irritability, high-pitched cry
 Difficulty in awakening
 Increased respiratory rate or difficulty breathing
 Sunken fontanel, sunken eyes with dark circles
 Abnormal skin color, temperature, or dryness
 Slow cap refill
 Decreased turgor

GASTORENTERITIS
 ORAL REHYDRATION THERAPY MAY AVOID
HOSPITALIZATION

 CHOICE OF IV FLUID REPLACEMENT IS
BASED ON THE CHILD’S TYPE OF
DEHYDRATION (ISOTONIC, HYPOTONIC OR
HYPERTONIC).

 MAKE SURE THE CHILD IS VOIDING BEFORE
ADDING K+ TO ANY IV FLUID.

Concept of Oral Rehydration

• Rehydration solution of 75 to 90 mEq of
Na+ per liter
• Give 40 to 50 ml/kg over first 4 hours
• Maintain hydration with solution of 40
to 60 mEq Na+ per liter
• Daily volume of maintenance hydration
150 ml/kg/day
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Prevention of Diarrhea

• Most diarrhea is spread by the fecal-oral route
• Teach personal hygiene
• Clean water supply/protect from contamination
• Careful food preparation
• Handwashing

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PYLORIC STENOSIS
 PYLORUS MUSCLE INCREASES IN SIZE AND MASS

 OBSTRUCTS FOOD FROM LEAVING THE STOMACH

 IF UNTREATED DEATH FROM DEHYDRATION AND
ELECTROLYTE IMBALANCES

 REQUIRES SURGICAL CORRECTION
(PYLOROMYOTOMY)

PYLORIC STENOSIS

 CLINICAL MANIFESTATIONS

– VOMITING BEGINS BETWEEN 1 TO 10 WEEKS OF AGE
– VOMITING BECOMES PROJECTILE
– PALPABLE PYLORIC MASS (OLIVE SHAPED)
– VISIBLE GASTRIC PERISTALTIC WAVES
– IRRITABLE AND HUNGRY INFANT

 DIAGNOSTIC PROCEDURES

– ULTRASOUND
– BARIUM SWALLOW

PYLORIC STENOSIS
 NURSING CARE
– PREOP MANAGE FLUIDS &
ELECTROLYTES
• DECOMPRESSION OF STOMACH BY NG TUBE
• IV FLUIDS AND ELECTROLYTES
– MAY HAVE K, Na, & Cl DEPLETION

– POST OP - MONITOR FEEDINGS
• CLEAR LIQUIDS 4-6 HR. AFTER SURGERY
• STEP WISE PROGRESSION TO FULL FORMULA OR BREAST
MILK OVER 48 HOUR PERIOD

INTUSSUSCEPTION
 TELESCOPING OF INTESTINE USUALLY AT THE
ILEOCECAL VALVE

– Terminal ileum telescopes into the ascending colon

 OCCURS BETWEEN AGES OF 3 MONTHS AND 5 YEARS
- HALF IN INFANTS UNDER 1 YEAR

 SYMPTOMS DEVELOP BECAUSE BLOOD SUPPLY TO
COLON IS COMPROMISED

INTUSSUSCEPTION
 CLINICAL MANIFESTATIONS

 WAVES OF COLICKY SEVERE PAIN
 VOMITING
 CURRANT JELLY STOOLS
 LETHARGY (LATE IN COURSE)
 COMPLICATIONS

 ISCHEMIA
 PERFORATION AND PERITONITIS
 SHOCK

Intussusception

BARIUM ENEMA IS PRIMARILY DONE AS A DIAGNOSTIC
PROCEDURE

THE BARIUM ENEMA MAY REDUCE THE OBSTRUCTION BY
HYDROSTATIC PRESSURE.

NONOPERATIVE REDUCTION SUCCESSFUL IN 80-90% OF CASES

BARIUM ENEMA IS NOT DONE IF SIGNS OF SHOCK OR
PERFORATION ARE PRESENT

Clinical Manifestations
of Hirschsprung
• Cogenital aganglionic megacolon
• Aganglionic segment usually includes the
rectum and proximal colon
• Accumulation of stool with distention
• Failure of internal anal sphincter to relax
• Enterocolitis may occur
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Therapeutic Management

• Surgery
• Two stages
– Temporary ostomy
– Second stage—“pull-through”
procedure

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Vesicoureteral Reflux -VUR
• Retrograde of urine into ureters
– Reservoir for bacteria

• Primary – congential abnormal insertion of the
ureters into the bladder

• Secondary – due to an acquired condition

Complications
• Associated with recurring kidney infections
– Pyelonephritis – high fever, vomiting, chills

– Can cause renal scarring in children
• Can occur with the first episode of febrile UTI

Management
• Prevent bacteria from entering the kidney
– Low dose antibiotic therapy
– Urine culture every 2-3 months and prn fever
– Many will outgrow
– Annual cystourethrogram
– Surgery if significant anatomic abnormality , UTI’S,
non compliance with meds, VUR after puberty
especially in females

Prognosis
• Usually excellent with prompt treatment at time
of diagnosis

• Early diagnosis essential to prevent long term
complications

Nursing education
• Wipe from front to back

• Observe frequently for signs of pain, difficulty
voiding

Short Bowel Syndrome (SBS)
• A malabsorptive disorder
• Results from decreased mucosal surface area,
usually as result of small bowel resection
• Therapeutic management
• Nursing considerations

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