Pediatric Nursing Review 2

PEDIATRIC NURSING

Review

ERICKSON’S PSYCHOSOCIAL STAGES OF

DEVELOPMENT

Infancy (0 – 1 year)

Toddler (1 – 3 year)

Preschool (3 – 6 years)

School (6 – 12 years)

Adolescent (12 – 18

years)

Trust vs. Mistrust

Autonomy vs. Shame

and Doubt

Initiative vs. Guilt

Industry vs. Inferiority

Identity vs. Role

Diffusion

PIAGET’S THEORY OF COGNITIVE

DEVELOPMENT

Sensorimotor Reflexes

(0 – 2 years)

Pre-operational/Pre-

conceptual (3 – 5

years)

Reliance on reflexes to

interact with

environment

Increase use of

language; unable to put

self in another’s place;

does not understand

relationship of size,

weight, volume

PIAGET’S THEORY OF COGNITIVE

DEVELOPMENT

Intuitive (5 – 7 years)

Concrete Operations (8

– 13 years)

Magical thinking;

egocentric; tendency to

center attention on one

feature

Inductive reasoning

(specific to general);

conservation-ability to

understand things are

essentially the same

even though its shape

and arrangement are

altered

PIAGET’S THEORY OF COGNITIVE

DEVELOPMENT

Formal Operations (13 –

16 years)

Capable of

introspection,

deductive reasoning;

able to formulate

hypothesis

PHYSICAL ASSESSMENT

By what age should the anterior fontanel be

closed?

a. 2 weeks

b. 6 months

c. 12 months

d. 18 months

d. 18 months diamond shaped

Posterior triangle in 2 months

Tells hydration

Should be sitting up

PHYSICAL ASSESSMENT

Posterior fontanel closed when?

A. 2 weeks

B. 2 months

C. 8 months

D. 12 months

PHYSICAL ASSESSMENT

Respiratory

Are young children thoracic or abdominal breathers?

Chest shape

Respiratory 1st vital signs on kids is what we do!!

Boys are thoracic

Girls stay abdominal

Are young children thoracic or abdominal breathers?

A-p diameter is less than transverse

Chest shape

Infants – shape is round

Children & adolescents – transverse diameter to anteroposteriordiameter changes to 2:1

WEIGHT

Birth weight doubles by 6 months

Birth weight triples by 12 months

IQ

IQ = Mental age/Chronological age x 100

GROSS MOTOR SKILLS

2-3 months

3 months

4 months

5 - 6 months

6 months

6 – 8 months

9 months

12 months

Holds head up

Holds head and chest up when prone

Rolls front to back

Rolls back to front

Holds head steady when sitting

Sits unsupported

Sits pull self 2 standing

Stands (alone & holding on)

FINE MOTOR

Circle by 3 years

Cross by 4

Square by 5

Triangle by 6

Social development

2 month smile

3 month breast milk,

6 month stranger anxiety

9 months waves bye bye

12 months comes when called speaks one word

15 months jargon babbles

18 month copies parents

2 yr. two words

FINE MOTOR

Bring hand together

Look for items dropped

from view

Rake finger food 6

months

Bang toys together – 9

months

Grasp

Transfer object by hand

– 6 months

Use thumb to grasp – 9

months

Nesting 1 object inside

another – 12 months

PEDIATRICS FEEDING AND PLAY

0-1 yo breast milk

4-6 mo iron fortified

6-8 mon yellow veggie

Play

Infants solitary play

Toddler parallel play

Preschool associative

or cooperative play

School-age competitive

play

HEALTH ASSESSMENT

Birth – 3 year old pull

the pinna down and

back

After 3 pull the pinna

up and back

PAIN MANAGEMENT

A 10 year old child has just had an appendectomy which of following tools is appropriate a VAS visual analogue Scale

Faces for at least 3-6 year old!!!

Kindergarten count to 100, know shapes, skip jump walk backward walk a straight line

Waiting for pain management “if you let the pain get too bad, the medication will not work as well” is what a nurse says

Give pain meds around the clock

Reevaluate or evaluate the effectiveness of pain med

EXPLORE

a primary care

provider prescribes 240

mg of Cefuroxme bid

PO for a 3 year with

OM. The medication is

available in a 200mg/5

suspension

How much mLs should

the child receive with

each dose?

Feeding tube

Check placement first

Flush tubing before

and after medication

Dissolve tab in

premeasured amt. of

fluid mea

Push slowly

IMMUNIZATION

Vastus lateralis site for

infants and children less

than 2 years

After 2 year, the ventral

gluteal both of these sites

can accommodate fluid

up to 2 ml

The deltoid site has a

smaller muscle mass and

can only accommodate

up to 1 ml of fluid

because size

PLAY ACTIVITIES & SEPARATION ANXIETY

Birth -3 mo visual &

auditory

3-6 months noisemaking

objects and soft toys

6-9 months teething toys

and social interaction,

stack, build cause they

sitting up

9-12 months push pull,

popcorn popping, large

blocks pull apart

Separation Anxiety

Parents at hospital are

toddler

Begins 9 months and

peaks at 18 months

Isolation washable toys

NUTRITION

Solids introduced to infant doubles his birth weight (5

to 6 months)

Are able to sit up at this age!!!

• First, give iron-fortified cereals.

• Next, give pureed or strained foods one at a time to

assess for food allergies.

• Finally, breast milk/formula should be decreased as

intake of solid foods increase.

NUTRITION

Preterm infants < 37 weeks & < 2,500 g

50-60 kcal/kg/daily parenteral

75 kcal/kg/daily orally

Breast milk

Dentition 6-8 teeth w/in 1st year

NUTRITION

0 – 1 year

4 – 6 months

6 – 8 months

8 to 10 months

After 12 months

Breast milk or formula

Iron-fortified cereal,

such as rice cereal

Yellow vegetables,

fruits

Meat

While milk, eggs,

strawberries, wheat,

corn, fish, and nuts

NUTRITION

Toddlers—1-3 year

Finger food “picky”

3 meals & 2 snacks daily

Small portions—healthy

Limit fruit juice—4-6 oz/day d/t sugar

Preschooler—3-5 years

Certain food for a period of time

3 meals & 2-3 snacks/daily all areas food pyramid

Schooler—5-12 years

Depends on activity

Balanced diet

Likes to be included in meal planning & preparation

Adolescent—12-20 years

Growth spurts

Fast food healthy difficult

2,000—3,000 kcal/daily

PLAY

Infants

Toddler

Preschool

School-age

Solitary Play

Parallel Play

Associative or

Cooperative Play

Competitive Play

INFANT PLAY ACTIVITIES

Birth – 3 months

3 – 6 months

6 – 9 months

9 – 12 months

Visual and auditory

stimuli

Noise-making objects

and soft toys

Teething toys and

social interaction

Large blocks, toys that

pop apart, and push

and pull toys

SEPARATION ANXIETY

Begins at 9 months and peaks at 18 months.

IM MEDICATION ADMINISTRATION

The vastus lateralis site for infants and children < 2

years.

After age 2, the ventral gluteal site can be used.

Both of these sites can accommodate fluid up to 2

ml.

The deltoid site has a smaller muscle mass and can

only accommodate up to 1 ml of fluid.

MEDS ADMINISTRATION

MEDICATION ADMINISTRATION

A primary care provider prescribes 240 mg of

Cefuroxime BID PO for a 3 year old with Otitis

Media. The medication is available in a 200 mg/5

ml suspension. How many mLs should the child

receive with each dose?

5ml x 240 mg = 1200 = 6 mL

200 mg x 1 200

Or

D/A x Q

240/200 x 5 = 6

MEDS ADMINISTRATION

List 3 intervention, with rationales, that a nurse can use to decrease the risk of medication errors when administering medications

Interventions

Have 2nd nurse verify dose calculation

Obtain accurate weight of child

Mix medication with small amounts or liquid or soft foods

Rationale

Adult meds forms may be used requiring calculation of very small doses

Dosages are usually based on weight or BSA

If med is mixed in large amounts of liquid or foods, the child may refuse to finish the dose

PAIN MANAGEMENT

Effectiveness of treatment evaluation

15 min after IV

30 min after IM

30-60 min after Orally & nonpharm. Therapy

Older children can give report

Physiologic changes BP, HR, RR are temporary

changes produced by anxiety associated with pain.

Initially, elevated VS will return to normal despite

persistence of pain

Self report using pain scales is useful in children over 7

year

Children 3-7 can comprehend how to use pain rating

scale—assess their ability & validate w/parents

PAIN MANAGEMENT

FLACC Behaviors 0-2 2-7 months

0/10 10 worst

CHEOPS 4/13 13 worst 1-5 years

FACES Use Drawing 3-older

VAS Scale numbered 7-older or as y/4.5

0-10 point to #

MEDICATION ADMINISTRATION

When administering oral medications to a child with a feeding tube, the nurse knows to:

a. Flush the tubing with NS before and after administration of the medication.

b. Dissolve tablets in a premeasured amount of fluid, measure into a syringe, and give slowly into the side of the mouth to prevent clogging the feeding tube.

c. Push slowly on the plunger of the administration syringe to gently administer the medication through the feeding tube.

d. Check tube placement, administer medication by gravity flow, flush adequately, and clamp tubing.

OTIC ADMNISTRATION

Birth to 3 years – Pull the pinna (auricle) down and

back.

After 3 years – Pull the pinna (auricle) up and back.

PAIN MANAGEMENT

A 10-year-old child has just had an appendectomy

following a ruptured appendix. A nurse is

monitoring the child’s response to antibiotics,

postoperative healing, and pain control Which of

the following tools is most appropriate for assessing

the child’s pain?

a. FLACC (Faces, Legs, Activity, Cry, Consolability

Scale)

b. FACES pain rating scale

c. Children’s Hospital Eastern Ontario Pain Scales

(CHEOPS)

d. Visual Analogue Scale (VAS)

PAIN MANAGEMENT

A nurse suspects that a 15-year-old adolescent is

experiencing pain. The nurse asks if the

adolescent would like her pain medication. The

adolescent tells the nurse that she will wait until the

pain worsens. Which of the following statements by

the nurse is most appropriate in response to the

adolescent’s pain?

a. “If you let the pain get too bad, the medication

will not work as well.”

b. “Just let me know when you are ready.”

c. “You need to take your pain medication now.”

d. “Are you sure you don’t want anything now?”

PAIN MANAGEMENT

Thirty to 60 minutes following the administration of an

oral pain medication to a child, it is important that a

nurse

a. Document the child’s pain on a rating scale.

b. Evaluate the effectiveness of the pain

medication.

c. Assess the child for bowel sounds.

d. Massage the child’s painful area.

HOSPITALIZATION

Infant

Toddler

Preschooler—separation anxiety too

School-age--seeks information for a way of control, sense when not being told the truth, stress related to separation from peers and regular routine

-

Adolescent--aintain composure, embarrassed about losing control, worries about outcome, may not be compliant if it makes them appear different from peer group

Experiences stranger anxiety

Experiences separation anxiety

Harbors fear of bodily harm; fears hospitalization is a punishment will ask for a Band-Aid!!!! They think they did something wrong

Fear loss of control

Body-image disturbance; feelings of isolation from peers

7YEAR OLD IN HOSPITAL APPROPRIATE NEEDS

Answer: provide play

activities that foster a

sense of normal routine

Girl like arts and craft

Boys like things to build

Toddler no small lago’s

because choking

Friction toys not near

oxygen

AGE-RELATED INTERVENTIONS

Infant

Toddler

Preschooler

School Age

Adolescent

Near nursing station, consistent caregivers

Parent to provide regular routine, appropriate choices—autonomy, consistent caregivers

Explain procedures, encourage independence—self care, validate feelings, express feelings, toys to allow for expression, “Do you want your med in a cup or spoon, younger children to handle equipment

Provide factual information, express feelings, maintain normal routine—time for school work, encourage to contact peer group

Factual information, include in planning of care for powerlessness, encourage contact peer group

HOSPITALIZATION

Which of the following nursing interventions is most

appropriate for the needs of a 7-year-old child being

hospitalized for an extended time?

a. Bring security items such as a toy and blanket

b. Provide play activities that foster a sense of

normal routine

c. Limit choices whenever possible

d. Restrict family visiting hours

DEATH AND DYING

Which of the following nursing interventions is the

most appropriate when working with a school-age

child who has a terminal disease?

a. Give factual explanations of the disease,

medications, and procedures

b. Perform all care for the patient

c. Tell the child that everything will be okay

d. Reinforce that being in the hospital is not a

punishment for any thoughts or actions

HYPOXEMIA

Tachypnea

Tachycardia

Restlessness

Pallor of the skin and

mucous membranes

Elevated blood

pressure

Work of breathing

Confusion and stupor

Cyanosis of skin and

mucous membranes

Bradypnea

Bradycardia

Hypotension

Cardiac dysrhythmias

Early Late

BRONCHIAL (POSTURAL) DRAINAGE

Schedule treatments 1 hour before meals or 2

hours after meals to decrease the likelihood of the

child vomiting or aspirating.

Bronchial drainage is more effective if other

respiratory treatments (e.g., bronchodilator

medication and/or nebulizer treatment) are

performed 30 minutes to one hour prior to postural

drainage.]

Give a treatment first if they are getting a treatment

and CPT

SUCTIONING

Suction should take no longer than 5 seconds.

Suction catheters should be one-half the size in

diameter of the child tracheostomy tube.

It is no longer the standard of practice to instill

sterile saline into the tracheostomy tube prior to

suctioning.

HYPOXEMIA

When assessing a child removed from an oxygen tent, a nurse recognizes which of the following signs and symptoms as an early indication of hypoxemia?

a. Nonproductive cough

b. Hypoventilation

c. Nasal flaring

d. Nasal stuffiness

Rationale: signs of hypoxemia early! Nonproductive cough, hypoventilation and nasal stuffiness are signs and symptoms of oxygen toxicity plus sub-sternal pain, N/V/Fat/H/sore throat

OXYGEN TOXICITY

Which of the following is the most appropriate nursing

interventions for a child experiencing oxygen

toxicity?

a. Immediately discontinue oxygen administration

b. Increase humidification of oxygen

c. Use lowest possible flow rate of oxygen

d. Monitor oxygenation with a pulse oximeter

Rationale: interventions include using lowest level

necessary to maintain adequate SaO2 levels. O2

should be discontinued gradually, should be

humidified.

OXYGEN SATURATION

Normal values

Acceptable values

Emergency value

Life-threatening value

95 to 100%

91 to 100%

Less than 86%

Less than 80%

OXYGEN ADMINISTRATION

A child with cystic fibrosis is hospitalized with an

acute episode of pulmonary manifestations. Which

of the following nursing interventions is

contraindicated for this child?

a. Perform chest physiotherapy three times daily

b. Administer oxygen at an increased flow rate

c. Deliver aerosolized medication to open bronchi

d. Teach the child to use a flutter mucus clearance

device

ASTHMA

Manifestations of asthma

Mucosal edema

Bronchoconstriction (from bronchospasm)

Excessive secretion production

Expiratory wheeze

Prolonged expiratory phase

Nonproductive, hacking cough know if having asthma attack you hear

Wheezes can be audible

Appearance may show enlarge chest wall anteroposterior diameter

ASTHMA

Treatment Beta 2 adrenergic agonists are bronchodilators

Albuterol

Salmeterol

Terbutaline

Glucocorticoids Prevent inflammation

Suppress airway mucus production

Promote use of beta2 receptor

Beclomethasone QVAR use low dose, difficulty speaking, hoarseness candidiasis

Prednisone

Pulmicort

Flovent

Leukotriene Antagonist Singulair

Mast cell stabilizer Cromolyn Sodium

Monoclonal Antibodies Xolair

B before C Beta agonist then Corticoid

No CPT during an asthma attack.

ASTHMA

A child is exhibiting suspected clinical manifestations

of asthma. The mother asks the nurse what tests

will be necessary to diagnose her child. Which of

the following diagnostic procedures should the

nurse tell the mother is most accurate for

diagnosing asthma?

a. Arterial blood gases

b. Chest x-ray

c. Pulmonary function tests

d. Allergy tests

ASTHMA

A child experiencing an acute asthma attack presents

to the ED. Which of the following medications

should a nurse prepare to administer to the child as

an intervention for an acute asthma attack?

a. Terbutaline (Brethine)

b. Beclomethasone dipropionate

c. Prednisone

d. Albuterol (Proventil) is expensive Proventil

albuterol is cheaper

INHALED STEROIDS

Side Effects

Difficulty speaking

Hoarseness

Candidiasis

TONSILLITIS

Tonsils filter viruses and bacteria.

Lymph tissue.

Highly vascular.

Tonsillitis caused by group A beta-hemolytic streptococci (GABHS)

Chronically infected tonsils may pose a potential threat to other parts of the body. Some children who have frequent bouts with severe tonsillitis may develop other diseases, such as rheumatic fever and kidney infection.

In younger children d/t immature immune systems

Tonsillectomy pre-op – CBC (anemia & infection)

RN intervention Tonsillitis (symptomatic—viral: rest, fluids, warm salt water gargles, Tylenol or ibuprofen for pain, NPO if surgery!

Tonsillectomy – post-op Side lying position initially with HOB up when fully awake

Nothing sharp in mouth, no straws, no sharp food

Look for frequent swallowing, clearing throat, restlessness, bright red emesis, tachycardia and/or pallor

Provide ice collar and throat moist

Clear liquid, soft, bland foods—no fruit punch

Avoid red colored foods and milk initially

Discourage coughing, throat clearing, and nose blowing

Limit strenuous activity for 2 weeks

Notify MD if bright red bleeding occurs, increase pain, lack of oral intake

TONSILLECTOMY

Discharge—must be able to tolerate oral fluids and soft foods, & void prior

Instructions

Call doctor if difficulty breathing, bright red bleeding, lack of oral intake, increase in pain and/or signs of infection

Not to put anything sharp in mouth

No spicy food or hard, sharp foods like corn chips

Limit strenuous activity and physical play w/no swimming for 2 weeks

Full recovery occurs usually within 10 days – 2 weeks!

RESPIRATORY INFECTIONS

Respiratory infections are less common in infants

from birth to 3 months of age because maternal

antibodies offer protection.

CROUP SYNDROMES

Bacterial Epiglottitis

Medical emergency

Caused by Haemophilus influenzae

Dysphonia, Dysphagia, Drooling

Inspiratory stridor

Sore throat, high fever

Tripod positioning

Racemic epinephrine

Prepare for intubation

Corticosteroids

Antibiotics

DO NOT EXAMINE THE CHILD’S THROAT WITH A

TONGUE BLADE OR TAKE THROAT CULTURES.

CROUP SYNDROMES

Croup or Acute Laryngotracheobronchitis (LTB)

Causative agents: RSV, influenza A and B, and

Mycoplasma pneumoniae

Barky cough

Inspiratory stridor

Low-grade fever

URI

Racemic epinephrine

Corticosteroids

Use of warm or cold mist

Possible need for emergency airway

DO NOT EXAMINE THE THROAT

RSV

Diagnosis of Respiratory Syncytial Virus (RSV) is

accomplished through

a. Collection of a sputum specimen

b. A throat culture

c. Nasal aspiration

d. Obtaining blood for a CBC

RSV

What are nursing interventions that would be

expected for a child hospitalized for pneumonia

caused by RSV?

Antipyretics for fever

O2 w/cool mist for comfort

IV &/or oral fluid therapy

Postural drainage and CPT

RESPIRATORY ILLNESS

Viral infections more common in toddler and

preschooler. Incidence decreases by age 5.

GABHS and Mycoplasma pneumoniae rates

increase after age 5.

RSV more common during winter and spring.

Mycoplasma pneumoniae more common in autumn

and early winter.

CYSTIC FIBROSIS

Hereditary; autosomal recessive trait; both

parents must carry the trait

Dysfunction of exocrine glands, causing glands to

produce thick, tenacious mucus

Thick mucus obstructs respiratory passages; also,

obstructs secretory ducts of the pancreas, liver, and

reproductive organs

Sweat and salivary glands excrete excessive

amounts of sodium and chloride

Bronchiectasis and emphysema may develop with

pulmonary fibrosis (these are two most common the

are sterile too reproductive wise)

CYSTIC FIBROSIS

Diagnostic Tests

Sweat chloride test

Absent pancreatic enzymes

Stool analysis indicating steatorrhea (undigested fat)

and azotorrhea (foul-smelling from protein)

Pulmonary function

Sputum C & S—infection

Abdominal X-ray—detects meconium ileus

CYSTIC FIBROSIS

Interventions

Bronchodilators then CPT (do 1 hour before meals or 2

hours after meals)

Flutter mucus clearance device

Pulmozyme nebulizer to decrease viscosity of mucus

Pancreatic enzymes with meals and snacks

High-caloric, high protein diet

Multiple vitamins, including water-soluble forms, of

vitamins A, D, E, and K

CYSTIC FIBROSIS

All of the following are assessment findings seen in a

child with cystic fibrosis except for:

a. Wheezy respirations

b. Clubbing of fingers and toes

c. Barrel-shaped chest

d. Rapid growth spurts

CHD

Key points

Present @ birth because anatomic abnormalities

Result primarily in HF and hypoxemia

Prevent normal blood flow

Any structural lesion in heart or blood vessel that is

directly proximal to the heart = CHD

Many defects spontaneously close

Diagnosed in 1st yr. of life

CHANGES AT BIRTH

FIG. 25-1 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.

RA

3 mm Hg

72-80%

RV

25/0-5 mm Hg

72-80%

Ao

115/80 mm Hg

95%PA

25/15 mm Hg

72-80%PV

9 mm Hg

95%LA

5-10 mm Hg

95%

LV

120/0-10 mm Hg

95%

ATRIAL SEPTAL DEFECT

Figure 25-1 ASD

VENTRICULAR SEPTAL DEFECT

Figure 25-2 VSD

ATRIOVENTRICULAR CANAL DEFECT

Unn Figure 25-3 Atrioventricular canal defect

PATENT DUCTUS ARTERIOSUS

Figure 25-4 PDA

COARCTATION OF THE AORTA

Figure 25-5 Coarctation of the aorta

COARCTATION

Increased blood pressure in the UE.

Increased saturation in the UE.

Weak or absent pulses in the LE

Nosebleeds

Headaches

Leg pain

Weak or absent LE pulse (indicate decreased CO)

AORTIC STENOSIS

Unn Figure 25-6 Aortic stenosis

PULMONIC STENOSIS

Unn Figure 25-7 Pulmonic stenosis

TETRALOGY OF FALLOT

Unn Figure 25-8 TOF

TOF

Pulmonary Stenosis

VSD

Overriding Aorta

Right ventricular hypertrophy

Polycythemia

Squatting position

Clubbing of fingers

Murmur

Severe dyspnea

Hypercyanotic spells

Acidosis

FTT

Growth retardation

TRICUSPID ATRESIA

Figure 25-9 Tricuspid atresia

TRANSPOSITION OF THE GREAT ARTERIES, OR

TRANSPOSITION OF THE GREAT VESSELS

Figure 25-11 Transposition of great vessels

TOTAL ANOMALOUS PULMONARY VENOUS

CONNECTION

Figure 25-12 Total anomalous

pulmonary venous connection

TRUNCUS ARTERIOSIS

HYPOPLASTIC LEFT-SIDED HEART

SYNDROME

Unn Figure 25-14 Hypoplastic left-sided heart syndrome

IMPLEMENTATION/ASSESSMENT

Palpate peripheral pulses, noting rhythm

irregularities and decreased strength or inequality

Palpate extremities for slow cap refill

Auscultate HR & rhythm,

Assess for bradycardia, tachycardia, or

dysrhythmias, heart sounds, murmurs or extra

sounds

Palpate and percuss abdomen for enlarged liver

and/or spleen

IMPLEMENTATION/ASSESSMENT

Sign & symptoms of HF

Impaired myocardial function

Tachycardia

Diaphoresis

decreased UOP

Fatigue

Pale & cool extremities

Weak peripheral pulses

Cardiomegaly

FTT

Anorexia

IMPLEMENTATION/ASSESSMENT

Sign & Symptoms of Pulmonary Congestion

Tachypnea

Dyspnea

Retractions

Nasal flaring

Exercise intolerance

Stridor

Grunting

Recurrent respiratory infections

IMPLEMENTATION/ASSESSMENT

Sign & symptoms of Systemic Venous Congestion

hepatomegaly

Peripheral edema

Ascites

Neck vein distention (not seen in infants)

Signs & Symptoms of Hypoxemia

Cyanosis

Clubbing

Polycythemia

Squatting

Chest deformities

Hypercyanotic spells (blue or “Tet”) = acute cyanosis and hyperpnea!

IMPLEMENTATION

Improve cardiac function

Administer Digoxin (check K, double check dose with another

RN, apical for one minute)

Afterload reduction

Monitor BP (before & after ACE inhibitors, assess for ↓BP,

monitor electrolytes)

Decrease cardiac demands

Rest, cluster care, minimize crying, etc.

Reduce respiratory distress

↑HOB, O2

Maintain nutritional status

Need ↑calories d/t ↑metabolic demands

Promote fluid loss

Diuretics, I & O, weight, electrolytes, hydration, fluid restriction

Support child/family

MANAGEMENT OF HYPOXEMIA

Children with heart defects can have hypercyanotic

“Tet” spells which can result in severe hypoxemia.

Immediately place the child in the knee-chest

position, attempt to calm the child, and call for help.

CARDIAC CATHETERIZATION

If bleeding occurs at the insertion site after the

cardiac catheterization, the first action the nurse

should implement is to

a. Apply pressure

b. Administer vitamin K

c. Call the surgeon

d. Apply a tighter pressure dressing

DIGOXIN

Administer one hour before or two hours after

feedings.

If the child vomits, do not re-administer the

dose.

If a dose is missed by more than 4 hours, withhold

the dose and do not double the next dose.

Observe for signs of digoxin toxicity:

slow pulse,

decreased appetite,

N/V

EPISTAXIS

Active bleeding from nose

Restlessness & agitation

Have child sit up with head tilted slightly forward to

promote drainage out of nose instead of down the

back of the throat.

Apply pressure to the lower nose.

Cotton or tissue can be packed into the nares that

is bleeding.

Ice across bridge of nose.

If bleeding last longer than 30 min., see medical

care.

LEUKEMIA

Most common cancer of childhood

Bone marrow dysfunction

Causes an increase of immature WBCs (blasts) to

be produced

Deficient RBCs cause anemia

Deficient mature WBCs (neutropenia) increase risk

for infection

Deficient platelets (thrombocytopenia) cause

bruising

Invasion of CNS causes increased ICP

Invasion of bone marrow causes bone bain

LEUKEMIA NURSING INTERVENTIONS

Good oral care. Soft brushes.

Avoid rectal temperatures.

Soft, bland diet.

High fiber diet.

Stool softeners/laxatives as needed.

Weigh daily.

Encourage fluids.

Prepare for hair loss.

LEUKEMIA

Low grade fever

Pallor

Increased bruising and petechiae

Listlessness

Enlarged liver, lymph nodes and joints

Constipation

Headache

N/Anx

Low platelet & RBC

Increased immature WBC

Late manifestations Hematuria

Ulceration in mouth

Enlarged kidneys and testicles

Increased intracranial pressure

IRON DEFICIENCY ANEMIA

Most prevalent nutritional and mineral deficiency in

the US.

Common in ages 6 months to 2 years and in

adolescents 12 to 20 years.

Hgb requires iron. Iron deficiency will result in

decreased Hgb levels

Can decrease oxygen to tissues

Cause growth retardation and developmental

delays.

Whole milk is not a good source of iron.

IRON DEFICIENCY ANEMIA

SOB

Pallor

Fatigue

Brittle fingernails

Systolic murmur

Labs:

CBC

RBC

RETICULOCYTE COUNT

FERRITIN

NURSING INTERVENTIONS

Preterm or LBWI require iron supplements

Breastfeed younger than 4—6 months

Iron-fortified formula

Modify diet—high iron, Vit. C & protein

Allow frequent rest periods

Restrict milk intake in toddlers.

Give only 1 qt. per day

Avoid until after a meal

Don’t carry bottle or cups of milk

NURSING INTERVENTIONS

Restrict milk intake in toddlers.

Give iron 1 hour before or 2 hours after milk or antacid. Give on empty stomach.

Give iron with vitamin C to help increase absorption.

Give with straw to avoid staining teeth. Rinse mouth out with water.

Stools may be tarry.

Increase fluids to prevent constipation.

Dietary sources: dried legumes, nuts, green leafy vegetables, red meat, foods iron fortified

Use Z track for parenteral injection—Don’t massage

BLOOD STUDIES

2 months

6 to 12 years

12 to 18 years

Hbg: 9 to 14 g/dL

Hct: 28 to 42%

Hbg: 11.5 to 15.5 g/dL

Hct: 35 to 45%

Hbg: 13 to 16 g/dL

(male)

Hbg: 12 to 16 g/dL

(female)

Hct: 37 to 49% (male)

Hct: 36 to 46 (female)

Age Hgb/HCT

IRON

A nurse is administering parenteral iron dextran to a

child by the Z-track method. Which of the following

strategies is correct when using the Z-track method

to administer iron?

a. Watch the child carefully for an allergic

reaction after administration.

b. Use the deltoid muscle for administration in

school-age children.

c. Massage the injection site for comfort after

administration.

d. Administer no more than 3 ml of iron into one site

at a time.

SICKLE CELL DISEASE

Autosomal recessive genetic disorder.

Promote REST

OXYGEN

Pain management: Tylenol or ibuprofen, opioids for severe pain.

Warm packs to painful joints.

Maintain fluids.

Blood products/exchange transfusion.

PROM to prevent venous stasis.

Prevent infection—hand washing, prophylactic penicillin

Complications: CVA and Acute Chest Syndrome Seizures, abnormal behavior, slurred speech, change in

vision, vomiting, severe headache

CVA: blood transfusions Q3-4weeks prevention

Chest syn.—chest pain, fever 101.3 F or higher, congested chest, tachycardia, dyspnea, retractions, decreased O2 sat

SICKLE CELL DISEASE

LABS:

Screening

CBC

Sickledex (detects HbS)

HGB electrophoresis (definitive dx)

Diagnostics:

Transcranial Doppler (TCD)

Assess intracranial vascular flow/detects CVA

Annually 2-16 yrs

HEMOPHILIA

X-linked recessive disorder.

Hemophilia A

Deficiency of factor VIII

Classic hemophilia

Accounts for 80% of cases

Hemophilia B

Deficiency of factor IX

Christmas disease

HEMOPHILIA

Labs:

aPTT

Factor specific assays

Platelets

Prothrombin

Whole blood clotting time

Diagnostic:

DNA

NURSING INTERVENTIONS

Avoid rectal temperatures.

Avoid unnecessary skin punctures.

Apply pressure for 5 minutes to injection sites.

Monitor urine, stool, and nasogastric fluid for occult

blood.

Rest and immobilize affected joints (hemarthrosis).

Arthrocentesis!

Elevate and apply ice to affected joints.

Soft toothbrush.

Medic Alert bracelet.

HEMOPHILIA

DDAVP—vasopressin increase factor VIII, not

effective for Hem. B

Factor VII

Corticosteroids

NSAID’s

Complications

Uncontrolled bleeding

Joint deformity—rest, immobilize, elevate, ice, ROM

after bleeding, ideal wt., exercise encourage

HEMOPHILIA

True or False:

Aspirin and ibuprofen are the best choices for pain

relief in a child with hemophilia.

RHEUMATIC FEVER

Inflammatory disease of connective tissue which

can include the connective tissue of the heart,

joints, CNS, and subq tissue.

Rheumatic fever can cause RHD which can result

in cardiac valve damage.

Usually occurs within 2 to 6 weeks following an

untreated upper respiratory infection (GABHS).

RHEUMATIC FEVER

Major Criteria

Carditis

Polyarthritis

Chorea – involuntary muscle movements, muscle

weakness, etc. (this is transitory & will resolve)

Subq nodules

Rash (erythema marginatum) – pink macular rash on

trunk and abdomen (not on face)

Minor Criteria

Fever

Arthralgia

NURSING INTERVENTIONS

Penicillin (erythromycin if child allergic to PCN) Assess for allergic response (hives, rash, anaphylaxis)

Assess for N/V/D

Aspirin for anti-inflammatory effect (rheumatic fever is bacterial and not viral in origin) Bed rest

Assist w/ADL’s if chorea prevent the child from bathing, feeding School work arranged

Chorea is self-limiting

Follow prescribed prophylactic treatment 2 daily doses of 200,000 penicillin

Monthly IM of 1.2 mill units of penicillin

Or Daily PO dose of 1 g of Sulfadiazine

Obtain prophylaxis therapy FOR ALL DENTAL WORK & INVASIVE PROCEDURES

ARRANGE medical follow-up Q5years

Elevated or rising serum antistreptolysin-O (ASO) titre – most reliable

IMMUNIZATIONS

Contraindications

Moderate to severe illness

Allergies (e.g., specific medications, eggs, gelatin, or

any vaccine)

Serious reaction following vaccine administration in the

past

History of seizures or other neurological condition

Immunosuppression (e.g., cancer, HIV, chronic steroid

use)

Blood transfusion, immunoglobulin, or recent TB test

Pregnancy

Vaccination Drug Contraindications Ages

DTap Adacel &

Boostrix.

Encephalopathy, seizures 2, 4, 6 months 15-18 months

Td

Hib allergic reaction latex, gelatin,

thimerosal (mercury)2, 4, 6, 12-15 months

RV rotavirus RotaTeq,

Rotarix

Diarrhea, vomiting, HIV 3 doses: 6 weeks

4-10 wks. apart

2 doses: 6 weeks

then 4 wks.

later

IPV (Poliovirus) Ipol allergic formaldehyde, neomycin,

streptomycin, or polymyxin B2, 4, 6-18 months 4-6 years

MMR Pregnancy, neomycin, gelatin 12-15 months, 4-6 yrs.

Varicella Pregnancy gelatin neomycin 12-15 months, 4-6 yrs.

PCV pregnancy 2, 4, 6, 12-15 months

Hep A pregnancy 12 months

Hep B Baker’s yeast 12 hrs after birth, 1-2 months,

6-8 months

Flu eggs TIV: Annually 6 months LAIV: @ 2 yrs.

nasally

MCV4 Guillain-Barre 11-12 yrs.

HPV2 HPV4 Yeast, pregnancy HPV2: 11-12 yrs (9 minimum)

HPV4: males (9 yrs.)

COMMUNICABLE DISEASES

Varicella (Chickenpox) Varicella-zoster virus VZV

No longer contagious once lesions have crusted over

Contagious 1 day before lesions to 6 days after first lesions appear

Very itchy

Direct contact, droplet, Incubation 2-3 weeks

Rubella (German Measles) Low-grade fever mild rash lasting 2 to 3 days

Rash begins on face, spreading down trunk

Prevent exposure to pregnant women

14-21 day incubation Contagious 7 days b4 to 5 days after rash appears

Measles (Rubeola) High fever

Koplik spots

Rash begins at hairline and spreads down body

Respiratory tract, urine, blood, 1-20 day incubation,

Contagious 4 days b4 to 5 days after rash appears

Pertusis (Whooping Cough) Nighttime cough; may have mucous plug

Droplet Isolation

Direct contact, indirect contact w/contaminated articles

6-20 days incubation, contagious during catarrhal stage b4 onset of paroxysms

Mumps Swollen parotid glands; earache with chewing

Paramyxovirus, contagious immediately b4 & after swelling begins

Saliva of infected person, direct contact, droplet, 14-21 day incubation

Infectious Mononucleosis Restrict activities for 2 to 3 months

OTITIS MEDIA

Lower incidence in breastfed infants.

Hearing difficulties and speech delays if OM becomes a chronic condition.

Myringotomy and placement of tympanoplasty tubes may be indicated for the child with multiple episodes

Tubes usually come out by themselves in 6 to 12 months.

IgA in breast milk—protect against infection

Acetaminophen 10—15 mg/kg Q4

Ibuprofen 10 mg/kg Q6

Amoxicillin is 1st Choice 4 OM Give high dose amoxicillin

80-90 mg/kg/day

Augmentin & azithromycin are 2nd line 10-14 days course

Observe for allergic reaction (rash, difficulty breathing etc.)

Discourage use of Decongestants or Antihistamines

Sit upright

Avoid smoke, people w/viral or bacterial respiratory infections

Up to date immunizations

WILM’S TUMOR (NEPHROBLASTOMA)

Malignancy that occurs in the kidneys or abdomen.

Metastasis is rare.

Avoid preoperative palpation of Wilm’s tumor.

Treatment involves:

Preop chemotherapy or radiation to decrease size of

tumor

Surgical removal of the tumor and affected organs

Chemo from 6 to 15 months.

NEUROBLASTOMA

Malignancy that occurs in the adrenal gland, the

sympathetic chain of the retroperitoneal area, head,

neck, pelvis, or chest.

Presents as asymmetrical, firm, nontender mass

in the abdomen. This mass crosses the midline.

Treatment involves:

Surgical removal of tumor.

Radiation in an emergency to decrease the size of a

tumor that is compressing the spinal cord.

Radiation to decrease the size of the tumors and

palliation for metastasis.

BONE MARROW DEPRESSION RESULTING IN ANEMIA,

NEUTROPENIA, AND/OR THROMBOCYTOPENIA

Monitor blood counts for anemia, neutropenia, & thrombocytopenia.

Monitor VS, low-grade temp. may be sign of infection.

Protect from sources of infection.

Avoid invasive procedures.

Avoid ASA/NSAIDs.

Administer filgrastim (Neupogen) to stimulate WBCproduction.

Administer epoetin alfa (Procrit) to stimulate RBCformation.

Administer interleukin-11 to stimulate PLATELETformation.

Soft toothbrush.

Rest periods.

A CHILD WHO IS 2 DAYS POSTOPERATIVE SURGICAL

REMOVAL OF A WILM’S TUMOR IS SOBBING AND

REPORTING ABDOMINAL PAIN. THE CHILD WAS

MEDICATED 30 MIN. AGO, AND THE NURSE OBSERVES

THAT THE CHILD’S ABDOMINAL GIRTH HAS INCREASED BY

6 CM FROM 2 HR PREVIOUSLY. THE CHILD’S SKIN IS COOL

AND MOIST. WHICH OF THE FOLLOWING ACTIONS SHOULD

THE NURSE TAKE FIRST?

A. ASSESS VITAL SIGNS AND DRESSING

B. PROVIDE DIVERSION FOR 30 MORE MINUTES

TO ALLOW MEDICATION TO TAKE EFFECT

C. REPOSITION THE CHILD INTO THE SEMI-

FOWLER’S POSITION

D. PROVIDE THE CHILD WITH A QUIET

ENVIRONMENT

HIV/AIDS

Viral infection—infects the T-lymphocytes, causing immune dysfunction.

CD4+ T-lymphocyte count determines the level of immuno-suppression.

Pregnant women with HIV are usually given antiviral medications during pregnancy.

Retrovir (Zidovudine)

14 wks. Gestation, thru out, & before onset of labor or C-section

Don’t breastfeed

Give 4 6 wks. After delivery

at least 30 minutes before or 1 hour after a meal

LAB: Enzyme immunoassay (antibody screen)

Confirmed by + Western Blot Testing

HIV/AIDS

Which of the following infections indicates that a child

with AIDS is severely ill?

a. Oral-pharyngeal candidiasis

b. Otitis media

c. Pneumocystis carinii pneumonia (PCP)

d. Herpes simplex virus

BURNS

First Degree

Superficial

Sunburn

Pain

Second Degree

Partial thickness

Extremely painful

Scalds

Third Degree/Fourth Degree

Full-thickness

Nerve endings destroyed = no pain

Lava burn

BURNS

Signs of inhalation injury may include mouth and

nose. Maintain airway.

Stop the burning process.

Flush with water.

Remove clothing.

Cover burn with clean cloth.

Provide warmth.

Obtain tetanus prophylaxis.

Moderate to severe burns: fluid replacement.

Pain management prior to wound care.

Wet dressing prior to removal.

SKIN INFECTIONS

Match the following skin disorders with their cause.

____Impetigo contagiosa A. Fungal infection

____Scabies B. Bacterial infection

____Lyme disease C. Viral infection

____Cold sore, fever blister D. Spirochete

____Ringworm E. Burrowing mite

ECZEMA

Which of the following medications can be used for

children with eczema?

Corticosteroids

Accutane

Peroxide

Antihistamines

Calamine lotion

HOW IS CRADLE CAP TREATED?

GASTROINTESTINAL

Rotavirus is a common cause of diarrhea in young

children.

Metronidazole (Flagyl) is used for the child who is

symptomatic of C. difficile.

Mild dehydration is 5% weight loss in infants.

Moderate dehydration is 10% weight loss in infants.

Severe dehydration is 15% weight loss in infants.

PINWORM (ENTEROBIUS VERNICULARIS)

Parasitic worm whose eggs when inhaled or

swallowed can cause perianal itching.

To assist in diagnosis: transparent tape is placed

over anus of child at night. Remove tape prior to

child awakening, toileting or bathing. Tape sent to

lab.

Wash bed linens and underwear in hot water and

dry in hot clothes dryer daily for several days.

Cleanse toys and child care areas thoroughly to

prevent further spread of disease.

Treat with PinX

ORAL REHYDRATION THERAPY (ORT)

Foods and fluids to avoid:

Fruit juices, carbonated sodas, and gelatin, which are

all high in carbohydrates, low in electrolyte content,

and have a high osmolality.

Caffeine, due to its mild diuretic effect.

Chicken broth or beef broth, which has too much

sodium and not enough carbohydrates.

Bananas, rice, applesauce, and toast (BRAT diet).

This diet carries low nutritional value, high carbohydrate

content, and low electrolytes.

PICA

Pica should be considered in which of the following

children presenting to the health clinic?

a. 7-year-old with nausea and vomiting for the

past 3 days.

b. 4-year-old with history of celiac disease

presenting with anemia and abdominal pain.

c. 2-year-old who is still drinking from a bottle and

presents with anemia.

d. 4-month-old who presents with crying, irritability,

and reddish-colored stools.

GI

Which of the following is the term used to describe

impaired motility of the GI tract?

a. Malrotation

b. Obstruction

c. Abdominal distention

d. Paralytic ileus

HIRSCHSPRUNG

Congenital aganglionic megacolon

Males > Females

Impaired colonization of ganglion distal portion of

GI tract

Internal sphincter fails to relax d/t missing inhibitory

neurotransmitter (NO)

Obstruction d/t preventing evacuation of stool, gas,

liquids

Enterocolitis

Stool accumulates

Absence of peristalsis

HIRSCHSPRUNG

HIRSCHSPRUNG

Diagnostic: rectal biopsy, barium enema

Failure 2 pass meconium w/in 24-48 hours

Refusal 2 feed

Bilious vomiting

Abdominal distention

FTT

Constipation

Ribbon-like foul stools

HIRSCHSPRUNG

Surgical removal aganglionic portion of bowel

1st 2 temporary ostomy proximally

2nd corrective surgery (wt. approx. 9kg)

Soave endorectal pull-through procedure

Ostomy closed 2 time of pull-through

RN INTERVENTIONS

Bonding

Coping

Consent

saline enemas, low fiber, high calorie high protein diets, TPN, oral antibiotics, fluid & electrolytes

Restriction of food & fluid prior 2 anesthesia

Atraumatic drugs administration (PO or existing IV) Versed

Wear loose-fitting gown w/underpants or PJ’s

Depends on Preop goals: hygiene, prep removing jewelry, x-ray, ht. wt., check teeth, NPO, voiding recording last void, allergies, check labs, fall & identification precautions, VS

Postop teachings

Crib ready

IV equipment ready

ABC, O2, IV, malignant hyperthermia immediate postop

Stay @ bedside until gag reflex return

O2 sat.

Suction available

Temp 4 hypothermia apply warm blankets

Baseline VS, LOC & activity

Pain

Check dressing: Bleeding

Foley cath care

Skin color & characteristic

Check bowel sounds, turning requirements

Observe 4 shock, abd. Distention

Assess bladder distention

Observe 4 dehydration

Detect infection

Preop care: Postop care:

FASTING REDUCING PULMONARY ASPIRATION

Ingestion Fasting hours

Clear liquids 2

Breast milk 4

Infant Formula 6

Non-human milk 6

Light meal 6

HIRSCHSPRUNG DISEASE

To confirm the diagnosis of Hirschsprung disease, the

nurse prepares the child for which one of the

following tests?

a. Barium enema

b. Upper GI series

c. Rectal biopsy

d. Esophagoscopy

GI

The passive transfer of gastric contents into the

esophagus is termed:

a. Esophageal Atresia

b. Meckel diverticulum

c. Gastritis

d. Gastroesophageal Reflux

PYLORIC STENOSIS

What are features & assessments of a patient with

this diagnosis?

PYLORIC STENOSIS

Olive-shaped mass in RUQ of abdomen and

possible observation of peristalsis when lying

supine.

Vomiting that occurs 30 to 60 minutes after a

meal and becomes projectile as obstruction

worsens.

Constant hungry.

Weight loss, signs of dehydration.

Diagnosed by ultrasound.

INTUSSUSCEPTION

Al, age 5 months, is suspected of having

intussusception. What clinical manifestations would

he most likely have?

a. Crying during abdominal exam, vomiting,

currant jelly-appearing stools

b. Fever, diarrhea, vomiting, and lowered WBC

c. Weight gain, constipation, and refusal to eat

d. Abdominal distention, periodic pain, hypotension

MECKEL’S DIVERTICULUM

Remnant of a fetal duct, which in most newborns

has resolved completely.

More common in boys.

Most symptoms occur in children less than 2 years,

but may occur in children up to 10 years.

May have abdominal pain, bloody stools without

pain, bright red mucus in infant stools.

Diagnosed using a radionucleotide scan.

CHILD IN A CAST

4 categories of immobilization

Upper—wrist, elbow

Lower—ankle, knee

Spinal & Cervical—spine

Spica cast—hip, knee

CAST

Gauze strips & bandages impregnated

Plaster cast mold closely to body part 10-72 hrs

drying

Synthetic casting dries 5-30 minutes

CAST APPLICATION

Dx: fear of bodily harm, loss of extremity

Use plastic doll or stuffed animal 2 explain procedure

During application—distraction

Bubbles, pets, activities at school

“this will help your arm get better”—futile

Extremities checked for

abrasions, cuts, skin alterations, rings causing

constriction from swelling

Gore-Tex liner under hip spica cast prevents

exposure 2 moisture

CAST APPLICATION

Dry rolls of casting material

Immersed in pail of H20

Wet rolls

Put on in bandage fashion & molded 2 extremity

Plaster cast

Underlying stockinet pulled over rough edges

Secured w/layer of wet plaster below rim (padding)

Petaled protected edges (wn/no stockinet form)

Synthetic casts

Usually don’t require padding on edges

NURSING CONSIDERATIONS

H20 evaporation can take 24-48 hrs

Fiberglass dries w/in minutes

Cast uncovered 2 dry inside out

Turn every 2 hours—help drying of body cast

Regular fan or cool air hair dryer

Heated fans or dryers contraindicated (remain wet beneath or burns)

Wet plaster cast—supported by pillow covered with plastic handled w/palm of hands

Dry plaster of paris cast—hollow sound when tapped

Hot spot felt—infection, report, window made to observe site

Chief concern—extremities may continue 2 swell, circulation compromised, neurovascular complication Body part elevated 2 reduce compromise—increase VR

Edema—casts a bivalve (cut A to P halves held 2gather w/elastic bandage)

Always check NEUROVASCULAR INTEGRITY (6 P’S INCLUDE PRESSURE, SENSATION, MOVEMENT, CIRCULATION, TEMP, EDEMA)

Absorbent diaper under perineal

NURSING CONSIDERATIONS

No alterations 2 car seats

Hip Spica cast—fed infants supine head elevated

w/hips & legs supported on pillow @ the side;

children prone easier from small table

AMPUTATION

Congenital absence

Traumatic loss

Osteosarcoma

Part Reattachment

Rinse limb gently w/NS

Loosely wrap in sterile gauze

Place wrapped limb in watertight bag

Cool bag in ice H20 (no freezing, no packing)

Label name, date, time then transport w/child

AMPUTATION

Goal: surgical amputation or repair focuses on

constructing adequately nourished stump

Smooth, healthy, padded, free of nerve endings

Prosthesis fitting

Subsequent ambulation

With no vascular or neurologic deficit—cast applied

2 stump immediately after procedure & pylon metal

extension & artificial foot attached

NURSING CONSIDERATIONS

Stump shaping postop elastic bandaging figure 8

Figure 8 decreases edema, controls hemorrhage & aids

developing contours 2 bear wt.

Stump elevation during 1st 24 hours

Monitor proper body alignment

Older children/adolescent

Arm exercises, bed pushups, parallel bars 4 prosthesis

training, full ROM above amputation daily several times

Teach stump hygiene—soap & H20 every day, check

skin irritation, breakdown or infection, DRY!

Phantom limb—teach preop, increasing limb pain with

ambulation should be evaluated (4 neuroma)

CONGENITAL CLUBFOOT

Deformity of ankle & foot

Forefoot adduction

Midfoot supination

Hindfoot varus

Ankle equinus

Described by position

CONGENITAL CLUBFOOT

Talipes

Varus—inversion or bending inward

Valgus—eversion or bending outward

Calcaneus—dorsiflexion (toes > heel)

Equinus—plantar flexion (toes < heel)

Most common talipes equinovarus! TEV

Plantar flexion w/bending inward

Unilateral > bilateral

May occur isolated defect

May occur association w/chromosomal aberrations,

orthrogryposis, CP, Spina Bifida

CONGENITAL CLUBFOOT

CONGENITAL CLUBFOOT

Classification

Positional Transitional, mild, postural

Intrauterine crowding

May correct spontaneously

Responds 2 simple stretching & casting

Passive

Serial

Syndromic Teratologic

Associated w/congenital anomalies

Usually require surgical correction high incidence of recurrence

Often resistant 2 treatment

Congenital Idiopathic

“True clubfoot”

Almost always require surgical intervention (d/t bony abnormality)

In otherwise normal child

CONGENITAL CLUBFOOT

CONGENITAL CLUBFOOT

DX: Apparent

Prenatal ultrasound or @ birth

Radiograph 4 bone placement

Therapeutic Management Painless plantigrade & stable foot

3 stages Correction of deformity

Maintenance of correction until normal muscle balance

Follow up observations

Serial casting

Manipulation & casting repeated 4 rapid growth (Denis Brown splint)

Maximum correction w/in 8-12 weeks

Radiograph or ultrasound evaluates bone relationship

Failure of alignment by 3 mons. (surgery) between 6-12 months of age

Foot/feet immobilized 6-12 postop walks after cast removed

Passive exercise

NURSING CONSIDERATION

Same as with cast

Passive exercise

Neurovascular checks

Watch for compartment syndrome

VS

Allow for drying

Skin integrity

Circulation!

Teach importance of regular cast changes

Reinforce & clarify orthopedist’s explanations & instructions

Teach cast care, potential problems, encourage parents 2 facilitate normal development

OB COMPREHENSIVE FOCUSED REVIEW

Day One Review

COMPLICATIONS OF NEWBORN

Complication of newborn: Hypoglyclemia

Risk factors

Assessment Under 40

Get them on breast

poor feeding

Hypothermia

Diaphoresis

Weak shrill cry

Lethargy

Flaccid

Seizures

Irregular respiration

Cyanosis

Labs: plasma glucose less 40 mg/dL

HYPOGLYCEMIA

Obtain blood per heel stick for glucose

Provide frequent oral and gavage feeding

HYPOGLYCEMIA CONTINUES

LGA Greater than 4000 gram

Above 90% tile

Risk factor Post term

Maternal DM

Fetal cardiovascular disorder of transposition

Genetics

Assessment Weight first indication

SQ fat

Signs of hypoxia

Birth trauma

Sluggishness

Hypotonia of muscles

Hypoactivity

Tremors from hypocalcemia

CONT’D

Monitor glucose

Initiate early feeding

Monitor thermoregulation

Identify and treat birth injuries

Surfactant for lung maturity

CIRCUMCISION PAIN MANAGEMENT

NPASS

Give oral Tylenol

BREASTFEEDING

Education

Feed 2-3 hrs 8-12 times in 24 hours

Colostrum day 1-3 provides passive immunity

Educate on the benefits

Reduces the risk of infection

Promotes rapid brain growth d/t large amounts of

lactose

Has water

Protein and nitrogen

ATTACHMENT OF MOTHER-INFANT

Assessment:

Looking at baby

Comparing the baby

Face to face

Smiles

Talks to

Response

Identifies characteristics