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7/30/2019 Overview of Child Health
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Overview of Child Health Nursing
Child Health Nursing
Focuses on protecting children from illness and injury Assists children to obtain optimal levels of wellness
Primary roles of the Pediatric Nurse
Care provider Educator Advocate
Pediatric Health Statistics
Infant Mortalityo Number of deaths per 1000 live births during 1styear of life.o Infant mortality rate is an indicator of how healthy the nation is.o This rate is used to compare national health care to previous
years and to other countries.o There has been a great decrease in the number of deaths over
the past century. In 1997, 6.9 per 100 live births.
Childhood Mortality
For children older than one year, death rates have always been lessthan those for infants.
In later adolescence, there is a sharp rise in deaths.
Injuries; the leading killer in childhood
Injuries cause more death and disabilities in children than anydiseases.
Some examples include:o Motor vehicle accidents are the leading cause of death in
children over 1 year of age.o Majority of deaths are due to no use of seatbelts.
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Drowning is 2nd leading cause of death in boys 1-14; both sexes 15-24years old. Drowning is the 3rd leading cause of death for girls 1-14.
Burns are the 2nd leading cause of death from injury in girls and the 3rd
in boys from 1-14 years old.
Childhood Morbidity (Illness)
An illness or injury that limits activity, requires medical attention orhospitalization, or results in a chronic condition.
Examples:o Congenital heart defectso Asthmao Cerebral Palsyo Cystic Fibrosis
Concerned with helping to decrease these statistics as children miss
school and other activities when ill.
Advanced Practice roles for nurses in Child health nursing
Family nurse practitioner Neonatal nurse practitioner Pediatric nurse practitioner Nurse midwife
Growth and Development
Growth : used to show an increase inphysical size or a significantchange.
Includes:o Heighto Weighto Head circumference
Development : Used to denote an increase in skill or ability to finction. Measured by:
o Observing child do specific taskso Parents description of childs abilityo Using standardized testing (Denver II screening test)
Principles of Growth and development
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G & D is a continuous process from birth to deatho Rate of growth varies at different times
G & D proceeds in an orderly mannero Growth from smaller to largero Development: from sitting to crawling to walking
Different children pass through the predictable stages at different rates All body systems do not develop at the same time. CNS, Cardiac develops quickly. Lungs are typically the last to develop.
Development is Cephalicaudal, which is the 3rd principle of G & D. Headto toe.
Development goes fromproximal to distal, which is the 4th
principle.
Example: Development proceeds from gross to refined. A child cannot learn tasks until the nervous system is ready. Neonatal reflexes must be lost before development can proceed.
Factors that influence growth and development
Genetics Gender Health Intelligence
Temperament
Inborn in all of us A way of reacting to the world around us
Reaction Patterns:
Activity levelo Level of activity differs widely among children
Rhythmicityo Have a regular rhythm is physiologic terms
Approach
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o Childs response to a new situation Adaptability
o Is the child able to adapt to new situations? Intensity of reaction Distractibility Attention span and persistence Mood quality
Categories of temperament
The Easy Childo Easy to care for if they have predictable rhythmicity, approach
and easily adapt to new situations, have a mild to moderateintensity of reaction, and an overall positive mood quality.
o 40-50% of children fall into this category
The Difficult childo Children are difficult if irregular in habits, have negative mood
quality, and withdraw from new situationso 10% of children fit this image.
Slow to warm up childo Describes children who are overall fairly inactive, respond only
mildly, adapt slowly to new situations, and have a generalnegative mood.
o 15% of children display this pattern.
Other factors that impact growth and development
Environment Socioeconomic level Parent-child relationship Position of birth in the family Health Nutrition As a child normally develops somewhat predictably in growth and
physical development, he also matures emotionally, intellectually, andspiritually along certain paths.
Review:
Eriksons theory of Psychosocial development Piagets theory of cognitive development Kohlbergs theory of Moral development
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Assessment of the Child
Basic Principles
Know norms; child vs. adult A & P variations are farthest from adult norms at birth
o Most of these variations mature quickly in the first yearo By 5-7 years of age, body is that of a Small adult; however, a
child is not a miniature adult and should not be treated as such. As a child normally develops somewhat predictably in growth and
physical development, he also matures emotionally, intellectually, andspiritually along certain paths.
Try to see the childs world and body through his/her mind. If you do
this, you will connect with the child.
Approach to exam
Always think of where the child is developmentally. Approach must be individualized Usually the child will be frightened and anxious. May lack verbal skills
to express fear or ask for information. Use both hands on child when possible comforting touch.
o Place left hand on shoulder while auscultating the heart.o Move unhesitatingly, firmly, and gracefully.o Talk pleasantly and reassuringly.
Instructions to the child:o Use a directive voiceo Have specific instructionso Do not ask, but instead tell a child
Example: Say Roll over on your belly rather than Willyou roll over on your belly?
Physical Exam
Can take place almost anywhereo On parents lapo On the flooro Examiners lap
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Conducting the exam
Perform the least distressing procedures first and the most distressinglast.
o Heart and lungs; have the child lie down.o Abdomen, throat, and ears (throat and ears are the worst)o Genitalia and rectum
Physical exam technique
Inspectiono Observe before you touch
Auscultationo Use diaphragm of stethoscope for high pitched sounds (bowel
sounds)
o Use bell of stethoscope to help localize sounds for infant Palpation
o Use pads of fingers to determine tenderness and pulsationso Use palmar surface of fingers to determine masses and organ
enlargemento Observe reaction to palpation rather than to ask if it hurts (dont
suggest that it does) Percussion
o A more advanced technique usually done by physicians andadvanced practice nurses.
The general survey
Vital signs General appearance Mental status Body measurements
Vital signs
Temperatureo Body temperature in infants is less constant than in adultso Use ax/tympanic for children less than 4 years of ageo Values are the same as in adults
Axillary: hold childs arm firmly Tympanic:
o Less than 3 years of age
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Insert gently into ear Pull down on ear
o Over 3 years of age Pull up on ear
Rectal temperatureo Most hospitals are done only with doctors order, or there is a
standing order.o Lubricate tip wello Insert 1 inch
Pulseo Apical is besto May use femoral arteries, brachial arterieso Radials only in older children (at least 2 years old)
Respirationso The younger the child, the more abdominal breathingo Observe the abdomen instead of the chest in infants and small
childreno
May need to auscultate the chest or put the stethoscope in frontof the mouth and nose. Oxygen saturations Blood pressure
o Wide enough to over 75% of the upper armo Narrow cuff elevates reading, wide cuff lowers readingo In infants less than 1 year:
Thigh BP = arm BPo Older than 1 year:
Systolic in thigh is 10-40 mm Hg higher than in arm Diastolic is same in thigh and arm
o If BP in thigh is less than in arm:
Cardiac anomaly or decreased circulation to extremities Be sure to use correct size cuff Use the same extremities, the same size cuff, and same
position whenever possible when trending values for anindividual patient.
o Diastolic BP Diastolic pressure reaches about 55 mm Hg at one
year of age Gradually increases to 70 throughout childhood
o The most common cause of hypertension in children are: Anxiety (increases BP in children) Renal disease (78%)
Coarctation of the aorta (2%)
General appearance
To form a general impression of childs health and well-being To pin-point specific areas that may require more detailed assessment
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Initial observations
Degree of illness or wellness Mood State of nutrition Speech, cry, facial expression, posture Apparent chronological and emotional age Respiratory pattern Parent and child interaction
Parent and child interaction
Amount of separation tolerated
Displays of affection Response to discipline Look for signs of:
o Anxious parentso Disengaged parentso Stressed familieso Possible abusive parents (no separation anxiety when removed
from parent, or over-affectionate)
Child cries or clings to parent
Ignore the child temporarily Engage the parents in conversation, then place a small game, toy, or
your stethoscope within reach of the child while continuing yourdiscussion
Mental status
Is the child alert?
Able to respond to questions easily? Assess appropriateness of behavior Assess memory
Assessing Growth/Body measurements
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Height, weight, head circumferenceimportant indicators of growth Measured and plotted on standard growth charts These charts are used to determine if the baby/childs growth is falling
within the accepted percentile for age
Length
Birth to 36 monthso Fully extend the body by:
Holding the head midline Grasping the knees together gently Pushing down on the knees until the legs are fully
extended and flat against the table.o Hold pencil at right angle to the table and mark the head and
toes (which are pointed toward the ceiling)
Height
Childs back is to the wall, with heels, buttocks, and back of theshoulders touching the wall and the medial melleoli touching ifpossible.
Check for bending of the knees, slumping of the shoulders, or raisingthe heels of the feet
Weight
Birth to 36 months, weigh nude Older children with panties and light gown Balance (or zero) scale prior to weighing
Head circumference
Measure at greatest circumference Slightly above the eyebrows and pinna of the ears
o Around the occipital prominence at the back of the skullo Compare to 36 months
Denver Developmental
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The standard for measuring the attainment of developmentalmilestones throughout infancy and childhood.
Designed for birth to 6 years Includes screening for:
o Personal social skillso Fine motor adaptiveo Languageo Gross motor
Denver screening for articulation and eyes
Example of DDST for One year of age:
Personal/Socialo Drink from a cup, imitate activities, play ball with examiner,
indicate wants, play pat-a-cake
Fine motor/adaptiveo Scribbles, puts block in cup
Languageo Dada/Mama specific, one word
Gross motoro Stands alone
More on DDST:
Only a measure of developmental attainmentnot a measure ofintelligence
Not a highly specific testo Most normal children score as normal
Not very sensitiveo Many children with mild developmental delays also score normal
Only a screening test Other more sophisticated tests are available if delay is suspected even
when DDST is normal.
Heart Murmurs
50% of all children develop an innocent heart murmur at some pointduring childhood. It is usually not something to be overly concernedabout unless there are other symptoms. Must be determines if murmuris normal; therefore always report when one is heard.
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Abdomen
Protuberant abdomen is typical in most children until adolescence. If child is ticklish on palpation, hold his/her hand over yours to reduce
apprehension and increase relaxation of the abdominal musculature.
Neuromuscular
If possible, watch the child standing upright. Have them walk, stoop,and touch their toes
Checking for scoliosis.
More tidbits:
Always think of childs development when assessing Know the BP and pulse variations When there is an abnormal finding ALWAYS gather more data Weight is a huge concern for children. Many medications are weight
dependent. The Denver Developmental is not very precise; its more of a screening
tool As it says, the Denver Developmental is only developmentalnot a
cognitive or an IQ test. For breath sounds:
o Encourage the child to blow out your light, in your pen light or
flashlight. This will almost always produce full inspiration.
Care for the Hospitalized child
General communication guidelines
Pay attention to infants and younger children through play or byoccasionally directing questions or remarks to them.
Include older children as active participants. With children of all ages, the nonverbal components of the message
conveys the most. Communicate at the childs level
o Developmentally and physically
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Communication Guidelines
Allow children time to feel comfortable Avoid sudden or rapid movements, extended eye contact, or other
gestures that may be seen as threatening. Talk to the parent if the child is initially shy Communicate through puppets, dolls, or stuffed animals before
questioning a young child directly. Give older children the opportunity to talk without the parents present Speak in a quiet, unhurried, and confident voice. Speak clearly, be specific, and use simple words and short sentences. Be honest with children Offer a choice only when one exists. Allow them to express their concerns and fears Use a variety of communication techniques; if one technique doesnt
work, try another.
Infant
One month to one year old Eriksons developmental task: Trust vs. Mistrust
o Task: Attachment to the mothero Resolution of crisis: Trust in persons; faith and hope about the
environment and future.o Unsuccessful resolution of crisis: General difficulties relating to
persons effectively; suspicion; trust-fear conflict, fear of thefuture.
Infant: communication
Forms first social relationships Communicates needs and feelings through nonverbal behaviors and
vocalizationso Smile and coo when contento
Cry when distressedhunger, pain, body restraint, loneliness Respond to adults nonverbal behaviors
o Become quiet when cuddled, patted, or receive other forms ofgentle, physical contact.
o Get comfort from the sound of voiceusually respond to anygentle firm handling until they reach the age of stranger anxiety(5-8 months).
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Infant: Stressors of Hospitalization
Separation anxiety Stranger anxiety Painful, invasive procedures Immobilization
Separation Anxiety
Occurs as early as 4 months old; infants face shows disapproval asprimary caregiver walks away.
Three stages of separation anxiety:o Protest
Cries loudly; rejects attempt to be comforted by anyonebut the caregiver
o Despair Crying stops and depression is evident Much less active Uninterested in food or play Withdraws from others
o Detachment (denial) Shows increased interests in surroundings Interacts with strangers or familiar caregivers Forms new but superficial relationships Appears happy Detachment usually occurs after prolonged separation
from parents; rarely seem in hospitalized children.
Behaviors represent a superficial adjustment to loss. Interventions for separation anxiety:
o Encourage parents to room-in with infanto Involve parents in childs care whenever possibleo Keep parent in infants line of visiono If parent is unable to be with infant, place familiar object with
infant (stuffed toy, etc.)o Support sibling and grandparent visitation
Stranger anxiety
Occurs as early as 5 months Usually peaks at 8 months Behaviors exhibited by infant:
o Crieso Screamso Searches for parent with eyeso Clings to parent
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o Avoids and rejects contact with strangers Interventions for stranger anxiety:
o Holding out hands and asking the child to come will usuallynot work. If infant must be handled, better to pick up firmlywithout gestures.
o Observe position in which parents hold infant and imitate this.o Hold infants where they can see their parentso Are usually more at ease upright than horizontal.
Fear of proceduresinterventions
During procedure, use sensorysoothing measures (Stroking skin,talking softly, giving pacifier)
Cuddle and hug after stressful procedure or encourage parent to do soif present.
Older infants may associate objects, places, or persons with priorpainful experiences and will cry and resist at the sight of them
o Keep frightful objects out of viewo Perform painful procedures in separate room, not in crib,o Use non-intrusive procedures whenever possible.
Immobilization
Infants explore life through activity and mobility. If taken away:o Feel helplesso May have difficulty with language skillso May have problems mastering developmental taskso Problems with motor skillso Immobility impacts development.
Immobilization interventions:o Play therapyo Transport infant outside of room by wagon of by carryingo Spend time interacting with infanto Encourage caregivers to do the same
Toddler
Ages one to three years old Eriksons developmental task:Autonomy vs. shame and doubt.
o Task: Gaining some basic control over self and environmento Resolution of Crisis: Sense of self-control and adequacy; will
power
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o Unsuccessful resolution of crisis: Independence-fear conflict;severe feelings of self-doubt.
Developing a sense of autonomy He wants to make choices and like the word No! Is egocentric Focus communication on toddler
o Toddler not interested in the experiences of others
Stressors of hospitalization
Separation anxiety Loss of control Painful, invasive procedures Bodily injury Fear of dark
Separation anxiety
Verbally attack stranger (Go away!) May physically attack stranger (kicks, bites, hits) Tries to escape to find parent Tries to physically force parent to stay (clings) May have temper tantrums or refuse care Behaviors may last from hours to days
Separation anxietyinterventions
Childs reaction to separationo Toddler might ignore parent.
Other strategies are same as for infant. Feels more secure with familiar item Allow them to touch and examine articles that will come into contact
with them Be direct and concrete
They interpret words literally.
Loss of control
Very threatening to the toddler Many hospital situations decrease amount of control a child feels
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Loss of control occurs due to:o Restriction or limitation of movemento Altered routines and rituals
Eating Toileting Sleeping Bathing Play
o When routines are disrupted, problems can occur in these areas Interventions
o Promote freedom of movement Encourage parent-child contact Transport in carriage, wheelchair, carts, etc. Maintain childs routine Encourage as much independence as possible (allow child
to wear clothes from home, etc.)
Bodily Injury/Invasive procedures
Concept of body very poor Intrusive procedures (examining ears) create much anxiety React with intense emotional upset and physical resistance Interventions:
o Tell child its ok to yell, cry, or do whatever is needed duringprocedure
o Explain procedure in relation to childs senseso Ignore temper tantrumso Use distraction techniques (Sing song with a child)
Fear of the dark
Keep night light on in room at all times Encourage parents to room-in with child
Preschool
3-6 years of age Eriksons developmental task: Initiative vs. Guilt
o Task: Becoming purposeful and directiveo Resolution of Crisis: ability to initiate ones own activities; sense
of purpose.o Unsuccessful resolution of crisis: aggression-fear conflict; sense
of inadequacy or guilt
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Developing a sense of initiative Preschooler is:
o Egocentrico Has increased language skillso Concept of time and frustration tolerance is limitedo Illness and hospitalization may be viewed aspunishment
Fears of hospitalization
Separation anxiety and fear of abandonment Loss of control Bodily injury Painful, invasive procedures Fears of the dark, ghosts, monsters
Separation anxiety- preschooler
Tolerate separation better than toddlers; may develop substitute trustin other significant adults
However, they may show other behaviors:o Refuse to eato Have difficulty sleepingo Cry quietly for parentso Constantly ask when parent will be visitingo May express anger
Interventions:o Have parents bring in familiar articles from homepictures/radioo If child has attachment to special item, have it brought ino Same strategies for toddlers
Loss of control
Egocentric and magical thinking; perception of actual events are morefrightening
o Typical fantasy: Illness is a punishment for their misdeeds Purely verbal instructions do not help them, have them practice on doll
or toy.
Bodily injury
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Differentiate poorly between themselves and outside world. Fear of mutilation Take things literally Stick for blood Fear if when given a shot, when needle is removed, their insides will
leak everywhere (put a band aid in place).
Interventions:
Point out on drawing, doll, or child where procedure is performed Emphasize that no other body part will be involved Use non-intrusive procedures when possible Apply adhesive bandage over puncture site Encourage parental presence Allow child to wear underpants with gown Explain unfamiliar situations, especially noise or lights
Involve child in care whenever possible (hold equipment, removedressing)
Praise child for helping and attempting to cooperate Never shame child for lack of cooperation
School age child
6-12 years old
Eriksons developmental task: Industry vs. Inferiorityo Task: developing social, physical, and school skillso Resolution of Crisis: competence, ability to learn and worko Unsuccessful resolution of crisis: Sense of inferiority; difficulty
learning and working Developing a sense of industry and concrete thought Has increased language skill
o Interest in acquiring knowledgeo Improved concept of timeo Increased self-controlo Developing relationships with peers; peers are very important at
this stage.
Usually will want explanations and reasons for why things are beingdone Want to know more about procedures, activities, and objects Have a greater concern for privacy and body integrity Usually easier to communicate with than previous age groups
o Concrete thinkers; no abstract thought
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Stressors of hospitalization
Separation anxiety Loss of control Bodily injury Painful, invasive procedures Fear ofdeath
Separation anxiety
Younger school age children miss their parents more than olderchildren
Middle/late react more to separation from peers and usual activitieso May feel lonely, bored, isolated, depressed due to separation,
not the illness.
o May try to be brave and strong.o May be irritable with parents
Interventionso Make environment as home-like as possible
Continue school lessons Have friends visit or call on phone Decorate walls with cards
Bodily injury
Less concerned with pain, more concerned about disability or death Take very active interest in their health Request facts
Invasive procedures
Want to know about a procedure (will it hurt? Whats it for?) Tolerate intrusive procedures well By age 9 or 10 should less fright to pain
Adolescent
Ages 12-20 years
Eriksons developmental task: Identity vs. Role confusion
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o Task: developing sense of identityo Resolution of Crisis: sense of personal identityo Unsuccessful resolution of crisis: confusion about who one is;
identity submerged in relationships or group memberships Developing a sense of identity and abstract thought Fluctuate between child and adult thinking and behavior
o Need to express their feelings, for some this comes easily, forothers it does not.
o Major sources of concern for this age group are attitudes andfeelings toward sex, substance abuse, relationships withparents, peer-group acceptance, and developing a sense ofidentity.
Stressors of hospitalization
Loss of control Altered body image, disfigurement
o Do not want to look different Separation from peer group Loss of control
o Anything that interferes with sense of independenceo Patient role fosters dependencyo May withdraw, be uncooperative, angry, frustrated.
Altered body imageo Very relevant at this stageo Any change that makes them different from peers is seen as a
major tragedyo Insecure with their bodies due to the many changeso May react with know it all attitude (but may be afraid, deep
down)o Privacy is very importantmay need to give them some time
alone.
Cystic Fibrosis
Epidemiology
Affects approximately 30,000 children and adults in the US today or 1in 2500 live births
Occurs most commonly in whites, rarely in blacks and Asians
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More than 10 million Americans (1 in 31 or 3.3%) are symptom freecarriers of the defective CF gene
Survival
In 1955, few children with CF lived to attend elementary school. Today,the median age of survival is 32 years.
In this decade, many CF survive into their 40s.
Etiology
An inherited (genetic) disease CF is an autosomal-recessive disease (this means an individual must
inherit 2 defective CF genes, one from each parent) The defective gene in CF occurs in Chromosome 7 The gene causes the dysfunction of the exocrine glands
What are exocrine glands?
Glands that secrete things such as:o Lungso Pancreaso Sweat glandso Salivary glandso Digestive glands
Pathophysiology
CF causes the body to produce an abnormally thick, sticky mucuswhich:
o Clogs the lungs and leads to life-threatening lung infections;o Obstructs the pancreas, preventing enzymes from reaching the
intestine to help break down and digest food Primary symptoms:
o Thick, sticky mucuso Salty taste on skin
Marked electrolyte changes in sweat glandso Chloride in sweat is 2-5X above normal
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Lung involvement
Thick tenacious mucus polls in the bronchial tree and obstructsbronchioles
Results in:o Bronchiectasis : Chronic dilation of the bronchi. Involves a
chronic cough that produces mucopurulent sputum. Over timeresults in destruction of the bronchial walls.
o Pneumonia : Staph Aureus, pseudomonas, and H. Influenzae Symptoms over time include:
o Clubbing of fingers Clubbing is related to lack of tissue perfusion
Symptoms over time:
Easily fatigued Physical growth stunted Chest may become enlarged from over inflation of alveoli because air
cannot be pushed past the thick mucus on expiration (barrel chested) Increased carbon dioxide in blood (hypercapnia and/or chronic
acidosis)
Pancreas involvement
Thick secretions mix with pancreatic enzymes and block the pancreatic
duct. Therefore:
o Essential pancreatic enzymes cannot flow into the duodenum toaid with digestion (lipase, trypsin, and amylase)
o Fats, proteins, and some sugars cannot be digestedareexcreted in stools:
o Stools (The 4 Fs in CF) Frothy (bulky/large) Foul smelling (comparable to a cats stool) Fat containing greasy Steatorrhea Floaters
Clogged ducts causes back pressure on the acinar cells (they make theenzymes)
The cell lining of pancreas is damaged Over time the acinar cells atrophy and no longer produce the enzymes
Symptoms related to Pancreatic Involvement
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Protuberant abdomen because bulk of stool is setting in the intestines Signs of malnutritiononly benefit from 50% of food taken in Fat soluble vitamins are not absorbed A, D, E, K In infants, thick, sticky stools (meconium) which may cause intestinal
obstructiono One of the first signs of CF in infants
Sweat gland involvement
The structure of the sweat glands is not changed, however: Level of chloride to sodium in the perspiration is increased 2 5 times
above normal Some parents report they knew their newborn had the disease because
when they kissed their child they could taste such strong salt in theirperspiration
How is CF diagnosed?
By the history (cough, stool, abdomen, hx. of pneumonia) The abnormal concentration of chloride in sweat The absence of pancreatic enzymes in duodenum (can be tested
through NG tube) Pulmonary involvement
Common complaints that bring these patient to the doctor
Newborn that loses 5-10% of weight after birth but does not gain itback
Feeding problemskids are always hungry because of their poordigestive function
Frequent respiratory infections Cough
Diagnostic tests
A sweat test is a test for the chloride content of sweat Infants may not be tested until 6-8 weeks of age. (they dont sweat a
great deal)o Normal concentration of Chloride in sweat is 20 mEq/Lo A level of 50-60 mEq/L suggests CFtest is repeated
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o A level >60 mEq/L = CF Duodenal analysis of secretions for detection of pancreatic enzymes Stool analysis: for fat content (although appearance may be enough) Pulmonary testingchest x-rays or PFTs
Therapeutic management
Maintain respiratory functiono Keep bronchial secretions as moist as possible to facilitate
drainage: Moistened oxygen: Oxygen is supplied to children by
mask, prongs, ventilators, or neubulizers, and rarely bytent
Aerosol therapy- 3-4 times/day via neubulizer to provideantibiotics and bronchodilators
o Never give cough syrups or codeine Aggressive chest physiotherapy- usually needed 3-4 times a day Activity- need frequent position changes, especially when in bed. Helps
facilitate drainage of various lobes, as well as prevent skin breakdown. Respiratory hygiene: frequent mouth care, toothbrushing and good-
tasting mouthwash. Need frequent check-ups and current immunizations/vaccines Adequate rest and comfort
o Dyspnea can lead to exhaustiono Need periods of rest during the day:
Rest period before meals so not too tired to eat Rest periods before chest physiotherapy
Promote optimal nutritiono Pancreatic enzyme supplements with meals and snacks
Pancreatic enzyme: Cotazym or pancrease Comes in large capsule which can be opened and
dissolved in a tsp. of food Children usually begin to gain weight, and stools decrease
in size and foul odor.o High calorie, high protein, moderate fat dieto Multivitamins and E, others when deficient.
During hot months, extra salt may be added to food to replace thatwhich is lost through perspiration
Keep room temp at 72 degrees and have water available at all times.
Parents need to supervise kids playing outdoors to preventoverheating.
Keep well hydrated all of the time!
Complications
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Infertility in males related to blocking of vas deferens from tenaciousseminal fluid
Infertility in females related to tenacious cervical secretions that blocksperm penetration
Rectal prolapse in infants from straining to pass hard stool. Loss ofblood supply to prolapsed rectal mucosa can occur if not replaced
promptly and properly. Hypercapnia/respiratory acidosis from inability to adequately exhale
carbon dioxide Exhaustion, slow growth patterns Skin irritation in diaper area from stool that is irritating due to acidic
nature of stools Socialization and peer acceptance difficulties Cor Pulmonale (right sided heart failure) from increased respiratory
resistance Anemia and bruising Frequent respiratory infections and compromised immunity
Portal hypertension related to obstruction of bile ducts
area of biliaryfibrosis biliary cirrhosis Pneumothorax related to rupture of pulmonary blebs
Parental involvement
Parents assume a great deal of responsibility when taking care of a CFchild.
o Need to encourage a balance of work, the child, and the rest ofthe family
o Encourage involvement of support groupo Requires extensive involvement of the discharge planner
Nursing Diagnoses
Ineffective airway clearance r/t thick mucus in the lungs Ineffective breathing pattern r/t thick tracheobronchial secretions and
airway obstruction High risk for infection r/t presence of mucus secretions conductive to
bacterial growth Altered nutrition: Less than body requirements r/t inability to digest
nutrients Fear/Anxiety (parent or child) r/t prognosis and effect of illness on
growth and development Knowledge Deficit (parent or child)
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Summary
CF is an inherited genetic disorder Causes the exocrine glands to produce thick secretions Primary body organs involved are lungs and pancreas. Prone to respiratory infections r/t mucus. Digestion problems r/tpancreatic enzymes. Treatment centers around control and management. No cure for the
disease.
Eriksons Stages
Infant
One month to one year old Eriksons developmental task: Trust vs. Mistrust
o Task: Attachment to the mothero Resolution of crisis: Trust in persons; faith and hope about the
environment and future.o Unsuccessful resolution of crisis: General difficulties relating to
persons effectively; suspicion; trust-fear conflict, fear of thefuture.
o Developmental tasks: Learning to eat solid foods
Toddler
Ages one to three years old Eriksons developmental task:Autonomy vs. shame and doubt.
o Task: Gaining some basic control over self and environmento Resolution of Crisis: Sense of self-control and adequacy; will
powero Unsuccessful resolution of crisis: Independence-fear conflict;
severe feelings of self-doubt.o Developmental tasks:
Learning to walk Learning to use fine muscles Toilet training Learning to communicate
Preschool
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3-6 years of age Eriksons developmental task: Initiative vs. Guilt
o Task: Becoming purposeful and directiveo Resolution of Crisis: ability to initiate ones own activities; sense
of purpose.o Unsuccessful resolution of crisis: aggression-fear conflict; sense
of inadequacy or guilto Developmental tasks:
Independence of self-care Learning sexual role identity Forming reality concepts Internalizing concepts of right and wrong Learning to identify with family members and others.
School age child
6-12 years old
Eriksons developmental task: Industry vs. Inferiorityo Task: developing social, physical, and school skillso Resolution of Crisis: competence, ability to learn and worko Unsuccessful resolution of crisis: Sense of inferiority; difficulty
learning and workingo Developmental tasks:
Acquiring game skills Learning to relate positively with peers Building a wholesome self-concept
Refining communication skills
Adolescent
Ages 12-20 years
Eriksons developmental task: Identity vs. Role confusiono Task: developing sense of identityo Resolution of Crisis: sense of personal identityo
Unsuccessful resolution of crisis: confusion about who one is;identity submerged in relationships or group membershipso Developmental tasks:
Forming peer relationships Responding to an appropriate sexual role Attaining emotional independence Achieving a sense of economic independence
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Cardiac defects in children
Alteration in Fluid-gas transport
Cardiac Defects in children:
Divided into two major groups:o Congenital cardiac defectso Acquired heart disease
Congenital Heart Disease
Anatomic abnormality present at birth; the heart has not developed asit should in utero.
Thus, the heart is unable to adjust to life outside of mom Results in abnormal cardiac function
Acquired Cardiac disease
Abnormalities that occur after birtho Can occur by selfo Can occur with other congenital heart defectso Example; Rheumatic disease is the 2nd largest cause of cardiac
problems in children over 5)
Both congenital and acquired heart disorders can lead to heartfailure
Assessment of cardiac function
Historyo History of heart disease in the familyo Contact with known teratogens, such as rubella during
pregnancyo Presence of chromosomal abnormalities (Downs)
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o Poor weight gain and/or feeding behavioro Exercise intolerance and/or fatigue during feedso Sweating during feedingo Frequent respiratory infectionso Respiratory difficulties, such as tachypnea, dyspnea, and
shortness of breath.o Recent streptococcal infection (may lead to valve damage)
Physical examo Begins with observation of general appearance, then the
specificso Use general assessment techniques but look specifically for the
following:o Inspection:
Nutritional state: failure to thrive or poor weight gain Skin color: cyanosis and pallor Chest deformities- enlarged heart Unusual pulsations of neck veins seen in some patients
Respiratory pattern- tachypnea, dyspnea, presense ofexpiratory grunt Clubbing of fingers (now rarely seen in children d/t
advances in surgical techniques)o Palpation
Quality and symmetry of pulseso Auscultation
Heart rate and rhythm Presence of murmurs
o Height and weighto Position of comfort
Remember, squatting/fetal positions are often
comfortable for a child with a CHD. Tests of cardiac function
o Electrocardiography Records electricitygenerated by the beating heart Painless but scary, child must be still
o Exercise stress test Monitoring of heart rate, BP, ECG, and oxygen
consumption at rest and during exercise on a tread mill orbicycle
o Chest x-ray Shows accurate picture of heart size and contour; size of
the heart chambers
Used more as a screening toolo Echocardiography
Ultrasound (high frequency sound waves produce animage of heart structures)
The primary diagnostic test for heart disease.
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Cardiac catherization
Radiopaque catheter is inserted through peripheral blood vessel intoheart
o Contrast material is injected and films taken (calledangiography)
Reasons for performing:o Diagnose specific heart diseaseo Measure pressures and O2 satso Visualize heart structureso Determine blood flow patterns
Preparation for Cardiac cath
Although done frequently, there are some risks. Typical reactions
include:o Acute hemorrhage from entry site (usually femoral artery)o Low grade fever (reaction to contrast media)o Nauseao Vomitingo Loss of pulse in the catheterized extremityo Transient dysrhythmias (d/t ventricular irritability)
Done on an outpatient basis NPO for 2-4 hours before Older children should see the cath lab before procedure Accurate height and weight (for medications) Most children are sedated to decrease anxiety
Post catheterization care
Are usually on a cardiac monitor and pulse oximeter for the first fewhours of recovery.
Know the baseline pulse/BP before the procedure to compare Most important nursing responsibility is observation of the following for
signs of complications:o Pulses, especially below the catheterization site, for equality and
symmetry (pulse just distal to site may be weaker for the firstfew hours but gradually increase in strength.
Observations of:
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Temperature and color of the affected extremity. Coolness or blanchingmay indicate arterial obstruction.
Vital signs are taken every 15 minutes. Special emphasis on heart rate.Must take for one full minute.
Assess blood pressure, especially for hypotension.o Hypotension could indicate:
Hemorrhage Too much medication Dehydration
Dressing, for evidence of bleeding. Fluid intake, both IV and oral, to ensure adequate hydration.
o Remember sensible and insensible fluid loss (breathing tooquick!).
Hypoglycemia, especially in infants.
Interventions
Child must keep extremity straight 4-6 hours after venouscatheterization and 6-8 hours for arterial cath.
Childs diet can be resumed as soon as tolerating sips of clear liquid Keep site clean and dry Encourage child to void.
Congenital heart disease
Incidence: 4-10 per 1000 live births The major cause of death in the first year of life
o Other than prematurity/low birth weight More than 35 well recognized defects Statistics improving due to more surgeries/treatments that help
prevent death.
Etiology
Not known in 90% of cases Factors associated:
o Maternal rubella during pregnancyo Maternal alcoholismo Maternal age over 40o Maternal insulin-dependent diabetes
More likely to have other defects such as Down syndrome.
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Circulatory changes at birth
In order to understand the pathophysiology of cardiac defects, it isimportant to understand fetal circulation and the changes that occur atbirth.
Review of prenatal circulation- 3 essential structures
Ductus venosus (DV): opening between umbilical vein and inferior venacava.
o The ductus venosus is a vessel that allows blood to bypass thefetus's liver. It carries blood with oxygen and nutrients from theumbilical cord straight to the right side (right atrium) of the
fetus's heart. The ductus venosus closes shortly after birth,when the umbilical cord is cut and blood flowing between themother and fetus stops.
Foramen ovale: opening between the right and left atriumbypassesfetal lungs.
o The foramen ovale is an opening in the wall that separates theupper right and left heart chambers (atria). This opening allowsblood to flow to the left side of the heart without going to thelungs. Before birth, the foramen ovale is kept open by thepressure of blood that passes through it. When the baby takesthe first breath, blood begins to flow through the lungs, and theforamen ovale closes
Ductus arteriosis (DA): Opening between pulmonary artery anddescending aorta; allows fetal blood to bypass the lungs.
o There is still very little blood getting into the fetal lungsjustenough to help it grow in utero, even though they are collapseduntil birth.
Purpose of these structures
Allow most of blood to bypass the liver and lungs.
Fetal circulation
Oxygenated blood from placenta to ductus venosus inferior vena
cava right atrium. Blood then shunts over to the left atrium through the foramen ovale.
Then over to the left ventricle aorta head/extremities.
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The unoxygenated blood returns to the right atrium via the superior
vena cava flows into the right ventricle exits thought thepulmonary artery (which is connected to the aorta).
Most of this blood shunts through the ductus arteriosis into descendingaorta, and back into the placenta.
Birth changes
Infant cries, lungs expand Ductus arteriosis closes as resistance decreases though the pulmonary
vasculature (infants now need to use their own lungs) Clamping cord causes ductus venosus to clot (infant needs to use own
liver)
Venous return from lungs causes increase in left atrium pressure. Increased left atrium pressure causes left to right blood flow through
patent foramen ovale (which is a bad thingwe no longer want tobypass the lungs)
The foramen ovale is a one way valve so it closes permanently.
Birth changes, summary
Ductus venosuso Clots to form ligamentus teres
Foramen ovaleo Closes to form interatrial septum
Ductus arteriosiso Closes to form ligamentum arteriosus
Altered hemodynamics
Important to remember pressure gradients as blood will always flow (orshunt) from an area of higher to lower pressure.
Heart defects cause a change in the direction of this normal flow ofblood; create symptoms, especially those associated with congestiveheart failure.
Congenital heart defects
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Usual causeheart structure fails to progress beyond earlier Was once classified as Cyanotic and Acyanotic New classifications below
Classification of Congenital heart disease
Increase in pulmonary blood flow Decrease in pulmonary blood flow Obstruction to blood flow from ventricles Mixed blood flow
Defects with increased pulmonary blood flow
Ventricular septal defecto Hole between the ventricles
Atrial septal defecto Hole between the atrias
Patent Ductus Arteriosis (PDA)o Allows blood to flow from higher pressure aorta to the lower
pressure pulmonary artery, causing a left to right shunt. Atrialventricular septal defect
o Most likely to be a low artrial and a high ventricular defect.
More blood to the lungs than needed. These defects allow blood to flow from area of higher pressure (left
side of the heart), to area of lower pressure (right side of the heart). This creates increased blood volume on the right side of the heart
which increases pulmonary blood flow. Usually results in CHF.
o Pulmonary hypertension and cor pulmonae are frequentdisorders associated with this.
Defects causing Decreased pulmonary blood flow
Tetralogy of the Falloto Pulmonic Stenosis: Narrowing of the pulmonary artery or valveo Ventricular septal defect
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o Overriding of the aorta: position of the aorta is not correct. Bloodmay be shunted from both ventricles.
o Hypertrophy of the right ventricle Clinical symptoms:
O2 sats below 80% Clubbing of fingers and toes Polycythemia (increased hct) Anoxia aeb: dizziness & convulsions Squatting Stunted growth
Tricupsid Atresiao Extremely serious.o Tricupsid valve is completely closed.o No blood flow from the right atrium to the right ventricleo Blood passes through patent foramen ovale into the left atrium
and through a ventricular septal defect to the right ventricle andout to the lungs.
Defects causing obstruction to blood flow from ventricles
Coarctation of the aortao A segment of the aorta is too narrow, near the insertion of the
ductus arterious.o High blood pressure developso Left ventricle is enlargedo Oxygenated blood to the body is reduced.
Pulmonary stenosiso Narrowing of the pulmonary artery or pulmonary valve just distal
(under/below) to the valve.o Eventually causes right ventricular enlargement (hypertrophy)
Aortic stenosiso Narrowing of the aortic valveo Prevents blood from passing freely from left ventricle unto aorta.o Causes left ventricular hypertrophy from increased pressure in
the left ventricle.
Mixed blood flow
Cardiac anomalies that involve the mixing of blood from thepulmonaryand systemic circulation in the heart chambers.
Results in deoxygenation of systemic blood flow. Cyanosis is not always visible.
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Mixed blood flow involves:
Transpositions of the Great Arterieso Aorta arises from the right ventricle instead of the lefto Pulmonary artery arises from the left ventricleo Blood enters the heart from the vena cava.
o Goes to the right atrium to the right ventricle then goes outthe aorta to the body completely deoxygenated.
o Very incompatible with lifeo Surgery indicated
Total Anomalous Pulmonary Venous Returno Pulmonary veins return to the right atrium or the superior vena
cava instead of to the left atrium as they normally would. (Theoxygenated blood keeps going back into the lungs)
o Blood must be shunted across a patent foramen ovale or ductusarteriosus in order to reach the systemic circulation.
Truncus Arteriosus
o One major artery or trunk arises from the left and rightventricles in place of a separate aorta and pulmonary artery.
o Usually accompanied by a VSD.o Restructure common trunk to create two separate vessels (2
separate trunks) Hypoplastic left heart syndrome
o Left ventricle of the heart is non-functional.o Unable to effectively pump blood into the systemic circulation.o Right ventricle enlarges as it tries to do all of the work.o Transplant or the 3 Staged Norwood procedures performed.
Two principle clinical consequences of defects
Heart failure Hypoxemia
Heart Failure
Results when myocardium of heart cannot circulate and pump enough
blood to supply oxygen and nutrients to body cells Blood pools in the heart or in pulmonary or venous systems To increase cardiac output, the heart compensates in several ways:
o Muscle fibers lengthen, causing ventricles to increase andhandle more blood with each stroke (ventricular hypertrophy).
o Heart rate can also increase Eventually the heart can no longer compensateblood pools, unable to
be pushed forward effectively.
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First signs of CHF
Tachycardia, at rest and on slight exertion Tachypnea Scalp sweating, especially in infants Fatigue and irritability Sudden weight gain Respiratory distress
Implementation in CHF
Reduce workload of the heart:o Decrease extra fluid (diuretics)
o Strengthen cardiac function (digoxin)o Decrease afterload with vasodilators
Afterload is the amount of force needed for left ventricleto push blood through the body.
Decrease cardiac demandso Allow for uninterrupted sleep periodso Small frequent feedings or gavage
The more food in the stomach, the more cardiac work it isto digest.
Reduce respiratory distresso Count respirations carefullyo Humidified O2o Semi or high Fowlers
Hypoxemia
Color is not a great indicator SaO2 of 80-85%-- Saturation of Oxygen (arterial blood/Hemoglobin) Polycythemia (increase of the RBCs d/t chronically low oxygen
saturations) Clubbing
Squatting to increase venous return Hypercyanotic spells
Surgical intervention
Early intervention prior to hypoxic episodes preferred
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Mortality rates vary from 2% to 25% Surgery should be done in major centers
Alteration in Nutrition and Elimination
Overview of function of GI system
Responsible for taking in and processing nutrients for all parts of thebody.
Any problems can quickly affect other systems of the body In children, can affect overall health, growth, and development
Overview of nutrition
Infantso First 6 months can live off of breast milk or commercially
prepared formula with iron addedo May need to have Fluoride added if not already in the water.
Cows milk is not recommended until 1 year of age d/t allergies First year is one of rapid growth
o High proteino High calories
A little about obesityo A baby who is overweight by the age of one will usually struggle
with weight as an adult.
Introducing solid foods
5-6 months: iron-fortified infant cereal mixed with breast milk, orangejuice, or formula.
7 months: vegetables 8 months: fruit 9 months: meat 10 months: egg yolk
Toddler Nutrition
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Appetite is usually smaller than infant because they are growing at aless rapid rate
Tend to play with their food Want to feed themselves. Do not want to be fed. May also choose the same foods over and over.
Preschooler and Nutrition
Still not very big eaters at this age Parents should attempt to make meal times a pleasant experience for
children.
School age children and nutrition
Good appetites Should begin the day with breakfast Usually hungry after school
Adolescents and nutrition
Growing so fast that they may always feel hungry May tend to eat faddish foods or those not very nutritious. May rebel against a parents wishes for them to eat good food This is a time when binging and unhealthy dieting may occur (even
with athletes) Tend to not eat enough iron, calcium, and zinc
Physiological differences: Adults vs. Children
Internal distribution of watero Fluid is a greater fraction of their total body weight as compared
to adults
Infants: 75-80% TBW 2 years: 60% TBW Amounts stay approximately the same through later
childhood and adult lifeo Body water is also distributed differently in infants than older
children. Infants have more interstitial fluids
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Extracellular fluid compartment in infants includes 35-45% body water
Insensible water losso Loss of fluid through lungs and skino Insensible water losses per unit of body weight are higher for an
infant and younger child than an adult. Total body surface is largerin infants/children
Body surface is the percentage of skin compared tototal body weight.
Infants have more skin for their size. The more skin,the more fluid loss through skin
Infants and children have rapid respiratory rate andmetabolic rate
o All of these factors contribute to greater fluid loss throughevaporation.
o In addition, treatments or other conditions may increase fluidoutput
Activity, fever, diarrhea, vomiting Kidney function
o During the first 2 years, kidneys are not mature Do not excrete waste products efficiently Difficulty concentrating or diluting urine Sodium regulation mechanisms are not mature
o Nurses want to make sure that kidneys are working beforeadding potassium to I.V. fluids.
Other imbalanceso Children are also more readily susceptible to imbalances in:
Serum glucose Calcium
Potassium
Glucose
Infants and children haveo Higher glucose needs due to high metabolic rateo Low glycogen storeso Hypoglycemia a threat under periods of stress
Calcium
Infants and children have:o Regulation of calcium less exact in infant than in older child or
adulto When stressed, more growth hormone (GH) is secreted
GH increases result in increased calcium deposits in bone
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Infant unable to keep up with these increased demands Hypocalcemia results.
Potassium
Potassium concentration easily affected by decreased intake orintestinal illnesses (diarrhea)
Decreased K can lead to cardiac arrhythmias K must fall below 3 mEq/L before symptoms show
Critical!
Any condition that interferes with normal water and
electrolyte intake or causes excessive losses will produce amore rapid depletion of fluid and electrolyte stores in theinfant and child than it will in the adult.
Example:
Adults, when they do not eat for a day due to GI upset, and whosekidneys are normal, will have 14% less body fluid by the end of the day
Infants who do not eat for a day, and whose kidney function is normal,will be 40% short of fluid by the end of the day!
Urine output norms
Infants: 2-3ml/kg/hr Toddlers/preschoolers 2ml/kg/hr School age: 1-2ml/kg/hr Adolescents: 0.5-1ml/kg/hr
Physical assessment
Skino Color indicates the state of perfusiono As extracellular fluid volume decreases (as with dehydration),
peripheral circulation decreases.o Note the following:
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Warmth Skin color: from pink to pale as peripheral circulation
decreases (cyanosis is a late sign) Hands will get cold before core temperature Cap refill increases
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o Weight The single most important variable to follow in
planning treatment of fluid imbalanceso Intake and output
Record all intake Output usually a decrease in urine output and an
increase in specific gravity (the higher the specificgravity, the more dehydrated the person is).
Every hour is documentedo Output
Weigh diapers 1 gm = 1 ml document all stools, vomiting, wound drainage,
perspirationo Behavioral assessment
Changes seen with fluid volume deficit usually include: Anorexia Drawn, flaccid expressions Decreased levels of activity Increased seeking of comfort and attention
Diarrhea
Increase in stool frequency and content of water Caused by abnormal intestinal water and electrolyte transport More water in the intestines
Acute diarrhea
Major cause of infant mortality in developing countries Most cases caused by infectious agents, viral or bacterial, and
parasites Chronic diarrhea is more likely related to malabsorption or
inflammatory cause
Infectious causes of acute diarrhea
Viruseso Rotavirus is responsible for 50% of hospital admissions for
dehydration and diarrhea Also a nosocomial infection
Bacteriao Salmonella
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o Campylobacter (ingested by contaminated food)o Clostridium difficile (C-Diff)
Food poisoning
Staphylococcus Clostridium perfringens Clostridium botulinum
Parasites
Giardia lamblia Cryptosporidium
Etiology
Spread by contaminated food or water Also from person to person More common in crowded conditions, such as day care centers and
schools Infants immune system plays a role (the younger the infant, the less
developed the immune system).
Assessment of mild diarrhea
Fever of 101-102 degrees F may be present Anorexia Irritable Appear unwell Episodes of diarrhea consist of 2-10 stools per day Mucous membranes are dry Pulse rapid
Skin feels warm Skin turgor is not yet decreased at this time Urine output usually normal Skin color is pale
Therapeutic management of mild diarrhea
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Is not serious at this stagechildren can be treated at home Rest the GI tract for at least one hour; then offer water or oral
hydration solutions such as pedialye.o Approximately 1 tablespoon every 15 minutes x 4o Then 2 tablespoons every hour x 4o If retained, give small sips of fluid; avoid giving large amounts of
fluid. Give in small doseso Do not give OTC drugs such as Imodium or Kaopectate
because theyre too strong for little tummieso Depended on developmental age of child; instruct on good
handwashing technique.
Severe diarrhea
May result from mild or may appear on its own
Temp: 103-104F Pulse and respirations are weak and rapid Skin is pale and cool Infants may appear apprehensive, listless, lethargic (appears as a
hypovolemic state) Obvious signs of dehydration
o Depressed fontanelo Poor skin turgoro Sunken eyes
Bowel movement every few minutes Stool is liquid green, may be mixed with mucus and blood (because the
intestines are inflamed and irritated) Stool may be passed with explosive force Urine output scanty and concentrated Lab findings:
o Increased hematocrit, hemoglobin, serum protein levelso Falsely high because the percentage is low
Loss of 2.5-5% of body weight- mild dehydration Severe diarrhea can cause of loss of 5-15% of body weight quickly Any infant who has lost more than 10% if body weight requires
immediate treatment
Therapeutic measures
Assessment of the fluid and electrolyte imbalance Rehydration Maintenance of fluid therapy Reintroduction of adequate diet Antimicrobial agents if necessary
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Nursing considerations: assessment
Observe general appearance and behavior Assess for dehydration
o Decreased urine outputo Decrease in weighto Dry mucous membraneso Poor skin turgoro Sunken fontanel in infant
More severe dehydrationo Increase in pulseo Increase in respirationso Decreased blood pressureo Prolonged cap refill timeo All signs of impending hypovolemic shock
o Also assess for septic shock
Nursing goals
Urine output is more than 1ml/kg/hr Bowel movements are formed and fewer than 4 per day Stool tests negative Blood pH more than 7 (to prevent metabolic acidosis) Specific gravity < 1.030
Malabsorption syndromes
Celiac Disease Short bowel syndrome
Celiac Disease
Sensitivity or immunological response to the gluten factor of protein When gluten is ingested, a autoimmune response destroys part of the
small intestine mucosal Body is unable to properly digest food and absorb nutrients, especially
fats As a result, these children develop:
o Steatorrhea (bulky, foul-smelling, fatty stools)o Deficiency of fat-soluble vitamins (A, D, E, K)
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o Protuberant abdomeno Rickets (disease in bone formation) due to a loss of vitamin Do Hypoprothrombinemia may occur due to loss of vitamin K (need
Vitamin K to make prothrombin in the liver)o May also have iron deficiency anemia and low albumin (blood
carrier molecule that helps maintain blood volume and blood
pressure) levels.
Assessment of Celiac disease:
These children may be anorexic and irritable A typical celiac baby:
o Would be fit and well until after the ingestion of gluten-containing solids (usually between 6 and 18 months of age)
o Then the baby would develop pale, bulky, offensive smelling
stools (steatorrhea), become miserable and lethargic They gradually fall behind other children in their age in height and
weight Appear skinny with spindly extremities and wasted buttocks Face, however, may be plump and well-appearing
Diagnosis of Celiac disease:
History Clinical symptoms Serum analysis of antibodies against gluten Biopsy of intestinal mucosa (too determine degree of inflammation) Stool may be collected for fat content analysis Children are also put on a gluten-free diet and observedresponse to
this diet is usually very dramatic Continue children on a gluten-free diet for life Need to take water-soluble forms of vitamins A and D May also need to take iron and folate to correct anemia
Gluten is not found in rice or corn.
Celiac crisis:
Can occur when any child with celiac disease develops an infection Usually experiences acute vomiting and diarrhea
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o Cause electrolyte and fluid imbalances
Short Bowel syndrome and its causes
A decrease in the amount ofabsorptive surface Caused by congenital malformations such as gastroschisis (infant born
with some or all of intestinal contents outside of body; loses absorptivesurface), or intestinal atresia.
May be seen in children with intestinal ischemia due to malroation(twisting of intestines), intussusception (the slipping of one part of anintestine into another part just below it; ensheathed), and volvulus(infection which makes bowel obsolete).
Occasionally seen in patients with chronic irritable bowel disease (IBD). Necrotizing entercolitis in preemies (tissue death in bowels due to
colonization/infection and/or inflammatory changes).
Care of the infant/child with Short bowel syndrome:
Parenteral nutrition Enteric feedings if tolerated Monitor for vitamin and mineral deficiencies
Mortality-related complications of SBS
Sepsis Liver and biliary tract infections associated with TPN-causes cholestasis
o Seen in children under 4 years of ageo Leads to liver failure
Obstructive disorders
Hypertrophic pyloric stenosis
Intussusception
Pyloric stenosis
Pyloric sphincter is the opening between the lower portion of thestomach and the beginning portion of the intestine (duodenum).
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If there is hypertrophy (increase in size) or hyperplasia (excessiveproliferation of normal cells in normal tissue) of the muscle surroundingthe sphincter, there will be problems with the stomach emptyingcalled pyloric stenosis.
At 4-6 weeks of age, infants begin to vomit with feeds Vomiting grows increasingly forceful until it is projectile; can project up
to 3-4 feet (this is the most common symptom) Occurs most frequently in first born white males
o 1:150 maleso 1:750 females
Cause is unknown, but is probably inherited Vomitus usually smells sour (because of increased gastric acid)
Diagnosis of pyloric stenosis
Made primarily from history When the parent says their infant is vomiting, we need to find out:
o What is the duration, intensity, frequency, description of vomituso Is the infant ill in any other way?o Many infants show signs of dehydration at the time of diagnosis.
A definite diagnosis is made by watching the infant drink; there isusually an olive-sized mass in the right upper quadrant which becomesmore prominent with drinking the water (seen on the outside of thebody).
May also confirm with ultrasound
Therapeutic management of pyloric stenosis
Surgical correction: pyloromyotomyo Muscle of pylorus is split allowing for a larger lumeno Is usually done laparoscophyo Prognosis is excellent
Nursing care postoperatively for pyloric stenosis:
Feedings usually begun 4-6 hours post-op with 1 tsp (5 ml) of 5%glucose in saline hourly by bottle for four feeds
If no vomiting, 2 tablespoons given hourly for the next four feeds Next, half-strength formula is given every 4 hours By 24 to 48 hours, infants are taking their full formula diet or being
breastfed. Usually discharged after 48 hours. Do not give more fluid than ordered; risks for breaking open the newly
operated areas.
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IV fluids decreased as oral amount increases Infants need to be bubbled/burped well after each feeding to decrease
swelling; we dont want air or gas to be in tummies Lay them on their side, preferably right side, to aid the flow of
fluid through the pylorus via gravity Monitor daily weights Usually no vomiting occurs after the surgery. If it does, report
immediately! Feeding regimen may need to be adjusted. Some infants experience diarrhea due to the rapid functioning of
pyloric sphincter Elevate the head of the bed Monitor intake and output carefully; weigh all diapers
Nursing care for the pyloric sphincter incision
Care of the operative site:o Observe for any drainage or signs of inflammationo Care of incision as dictated by hospital policyo Keep diaper folded low to prevent contamination of incisiono Change diapers frequently
Intussusception
Invagination of one portion of the intestine to another (telescoping is agood synonym for it)
Generally occurs at 6-12 months Typically idiopathic in patients under 12 months May be related to another disorder in patients over 12 months.
Treatment of intussusception:
Surgery Reduction by fluid/air/barium (done in radiology)
Motility disorders
Hirschsprungs disease (once known as Congenital Aganglionicmegacolon)
GERD (low esophageal and gastric mobility)
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Hirschsprungs Disease (Congenital Aganglionic megacolon)
Absence of ganglionic innervation to a portion of the bowel Peristalsis does not occur in non-innervated bowel areas Patients have chronic constipation or ribbon-like stools
Treatment of Hirschsprungs disease
Surgery to remove the agangilionic colon segment May be done in 2 stages, with a temporary colostomy for 6-8 months
to allow bowel to rest.
Meckels Diverticulum
In embryonic life, the intestine is attached for the umbilicus by a duct This duct becomes a ligament near term In 2-3% of infants, this duct remains open as a pouch off of the ileum
Problems associated with Meckels diverticulum
Some gastric mucosa (which secretes acidic fluids) may be displaced This may allow acidic, irritating secretions to flow into the intestine This irritates the bowel, leading to ulceration and bleeding Appendicitis symptoms Can serve as a lead point causing intussusception (from weakened
area) A fibrous band extending from the diverticulum to the umbilicus can
act as a constricting band around the bowel
Treatment of Meckels diverticulum
The diverticulum (pouch) is surgically resected.
Structural defects
Cleft lip and palate
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Esophageal atresia Tracheoesophageal fistula
Cleft lip and palate
Cleft lip occurs when there is a failure of the fusion of the maxillary andmedian nasal processes.
Cleft palate occurs when there is a failure of the fusion of the palatalprocess (roof of the mouth)
Associated Nursing Diagnoses for Cleft lip and palate
Risk for fluid volume deficit
Risk for altered nutrition; less than body requirements Risk for aspiration
Treatment for cleft lip and palate
Special nipples before surgery and while recovering Cleft lip surgery is usually done between birth and 10 months of age Cleft palate repairs are done at 18-24 months, so that anatomic
changes in the palate contour are complete. Recovery is usually excellent Remember, these are typically stages surgeries
Tracheoesophageal Fistula and Esophageal atresia
Failure of the esophagus to develop normally, will end in a blind pouchor connect directly into the trachea instead of being a discretepassage.
These defects may occur separately or in combination About half of the infants with TEF or EA also have associated
anomalies, especially congenital heart disease and anorectalmalformations.
Clinical manifestations of TEF and EA
Excessive salivation (drooling)
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A newborn with drooling that is accompanied with choking, coughing,and sneezing, especially when fed.
Fluid returns through the nose and mouth Infant becomes cyanotic and may stop breathing Most are corrected with one surgery or two or more staged surgeries.
Alteration in Activity and Mobility
Why study this topic?
Quest for mastery at every stage of development is related tomobility.
Infant:
Speech, language, and overall development require sensorimotoractivity.
Toddler
Explore and imitate behaviors, a must for autonomy.
Preschooler
To express initiative, requires vigorous activity.
School-age
Strongly influenced by physical achievement and competition
Adolescent
Relies on mobility to achieve independence.
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Effects of Immobility:
Affects all body systems in some way. Major physical consequences that impact children are:
o Significant loss of muscle strength, endurance, and muscle mass(atrophy)
o Bone demineralization leading to osteoporosiso Loss of joint mobility and contractures.
Other effects:o Metabolism
Decreased metabolic rateo Cardiovascular system
Pooling of blood in extremities Postural hypotension Blood clots
Dependent edemao Respiratory system
Decreased chest expansion Can lead to increased secretions,pneumonia
o GI system Constipation
o Urinary system Difficulty voiding UTIs (d/t retention and urinary stasis)
o Integumentary Decreased circulation and increased pressure can lead to
ulcers.
o Behavioral changes in Immobilized children: Restlessness Lack of concentration Depression Regression Egocentrism Decreased communication Feel isolated May become angry, aggressive or quiet and passive
Effects of Immobility and the family:
Financial strain Siblings may feel ignored Guilt Caregiver becomes worn out
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Common Musculoskeletal problems
Traumatic injuryo Soft tissue injuries to the muscles, ligaments, and tendons are
common in children.o In young children they occur from mishaps during play.o For older children and adolescents, they occur during sports.
Soft Tissue Injuries
Contusions (bruise)o Damage to soft tissue, subcutaneous structures, and muscleso Injured area is ecchymotic (black and blue discoloration) due to
blood leaking into tissues; swollen and painful. Cannot tell how long ago injury occurred by the bruise.
o Immediate treatment is application of cold.
Sprainso Occur when trauma to a joint is so severe that a ligament is
partially or completely torn or stretched. Usually involvesdamage to blood vessels, muscles, tendons, and nerves.
o Child may describe a snap, pop, or tearing.
Therapeutic management of soft tissue injuries
The first 6-12 hours is the most critical for almost all soft tissueinjuries.
Basic principles include RICE or ICESo R.I.C.E.: Rest, ice, compression, elevationo I.C.E.S.: Ice, compression, elevation, support
Ice immediately; do not apply for more than 30 minuteso Reverse effects: vasodilation occurs
Elevate the extremity above heart level. Torn ligaments, especially those in the knee, are usually made
immobile with a cast or splint for 3-4 weeks. Passive leg exercises, gradually increased to active leg exercises,
begun as soon as sufficient healing has occurred.
Fractures
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Common injury at any age but more likely to occur in children andolder adults
Usually due to traumatic incidents at home, school, in a motor vehicle,or associated with recreational activities
Rarely occur in infants unless there is an underlying hematologydisorder
Toddlers- be suspicious of fractures at various stages of healing School-age childrenusually due to bicycle-automobile or skateboard
injuries Adolescents: bikes, motorcycles, sports
Common Fracture sites:
Forearm: falling on the outstretched hand. Clavicle fractures are common
Hip fractures are rare Auto/pedestrianfrom 4 to 7 years of age
o Triad of injury: Level of the bumper, fractured femur Hood of the automobile, injury to childs truck Contralateral (Originating in or affecting the opposite side
of the body) head injury due to impact
Types of fractures in children
Bends : Deformity without breaking (think of a young, green stick thatwont break, but it bends)
Buckle fractures : Compression of the porous bone, raised or buldgingprojection at site. (not broken all the way through)
Greenstick fracture : incomplete fracture, bone is angulated beyondlimits of bend.
Complete fracture : Divides bone fragments
Complete fractures
Transverse : straight up and downo Crosswise, at right angles to the long axis of the boneo Oblique : Slanting but straight, between a horizontal and
perpendicular direction (diagonal).o Spiral: slanting and circular, twisting along the bone shafto Comminuted : broken into pieces (crushed).
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Fractures, continued
Closed or simple Open or compound (protruding through the skin)
Growth plate or Epiphseal injuries
Weakest part of long bones Frequent site of damage Fracture may be through degenerating cartilage cells, without damage
to growth Other fractures of the epiphysis may cause growth problems such as
shortening of the limb
Associated problems with fractures in general
Muscles contract and spasm Bones are pulled out of alignment Severe hemorrhage in tissues, especially with femur fractures Vascular injuries
o Femur fracture may cause injury to sciatic nerveo Bone marrow is high vascularized
5 Ps of Ischemia
Pain Pallor Pulselessness Paresthesia Paralysis
Nursing actions for fractures
Support the injured limb; splint, DO NOT MOVE OR STRAIGHTEN OUTTHE BONE.
Ask the child to point to where it hurts Ask the child to wiggle fingers or toes Check distal pulses Get historical information from someone who witnessed the injury if
possible.
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Diagnostic Evaluation
History may be lacking!o Young children cannot tello Older children may not tell the truth in fear of repercussions
Radiography is the most useful tool
Therapeutic management of fractures
Reduction : regain alignment and length; setting bone. Immobilization : retains alignment and length Restore function Prevent further injury
Bone healing and remodeling
Rapid in childreno Due to thickened periosteum (the fibrous membrane that forms
the covering of bones).o Generous blood supply from bone marrow
New bone cells are formed in immense numbers almost immediatelyafter the injuryimmediate treatment is detrimental
Examples of healing times for femoral shaft in different age groups:o Neonatal period: 2-3 weekso Early childhood: 4 weekso Later childhood: 6-8 weekso Adolescents: 8-12 weekso The general rule of thumb is that the younger the child is; the
quicker the bones heal.
Delays in healing
Gaps between fragments delays or prevent healing Prompt healing with end-to-end apposition (two normally contiguous
parts)o Though, may cause bony overgrowth and greater length of
extremity Angulated deformity may remodel in young children. Careful reduction
and follow-up to prevent permanent disability.
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Fracture complications
Circulatory impairment Nerve compression syndromes Non-union Pulmonary emboli (fat, blood, and air)
Circulatory impairmentvery important
Absence of pulse, discoloration, swelling, pain Report immediatelyto practitioner Take steps to improve circulation (take action!)
o Loosen ace wrap
Most common lawsuits against nurses
Compartment syndrome
Typically caused by blunt trauma Pressure rises within this space with tight dressings or casts,
hemorrhage, trauma, burns, and injury Most common symptoms
o First sign: Pain out of proportion to injuryo Second sign: Tenseness on palpationo Third sign: motor weakness
Non-union fractures
Failure of bone fragments to unite Failure to unite due to any of the following:
o Separation of bone fragments at fracture siteo Hematoma (swelling of comprising a mass of extravasated
blood, usually clotted, caused by a break in a blood vessel)
o Extra tissue between bone fragmentso Necrosis of bone tissues or infectiono Interruption of blood supply
Bone grafting may be required
Pulmonary Emboli
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Blood, air, or fat (fat tends to occur faster) May not occur for 6-8 weeks after injury Fat emboli, first 24 hours usually in adolescents Signs and symptoms:
o Dyspneao Chest paino Onset of sudden pain
Nursing interventionso First: Elevate the heado Second: Administer oxygeno Notify physician immediately
Cast care
Risk for altered peripheral tissue perfusion related to pressure from
cast Expected outcomes:
o No pain or numbness in extremityo Distal nail beds blanches and refills in less than 3 secondso Pedal pulses palpableo Area surrounding case is warm and pink
Interventions:o Keep extremity elevatedo Check circulation every 15 minutes during the first hour, every
hour for 24 hours, then every 4 hours thereaftero Assess for numbness or tingling (children under 6 or 7 may not
be able to express this)o Edema that does not improve with elevation should be reportedo Assess for the 5 Psif any of these symptoms are present,
requires immediate attention! Can lead to permanent paralysis of extremity.
Risk for impaired tissue integrity related to pressure from casto Edges of cast are usually covered by a fold of stockineto If no stockinet, adhesive tape strips are applied to prevent skin
irritation (petaling)o If the cast is surrounding the genital area, or there is any chance
of cast coming into contact with stool or urine, need to coverwith plastic. Prevention is very important as once urine haspenetrated a cast, there is no way to remove it.
Can clean cast with a damp cloth when soiled with food Knowledge deficit related to cast care
o Instruct parents/child on how to care for casto Instruct on 5 Ps
Casting complications
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Continued swelling could cause cast to become a tourniquet.o This is why we wait a day or two to cast
Parents should receive verbal and written instructions Teach neuro/circulation checks to parents (5 Ps) Document parents response to teaching. Always have parents re-
demonstrate
Cast removal
Most casts in place to 6-8 weeks Removed with electric cast cutter Skin usually looks macerated and dirty, a good bath will remove dirt.
o Atrophy will resolve in its own Once healing takes place, the extremity is as strong as beforebut
children will usually favor the extremity. Allow them to regain full use
on their own time schedule.
Scoliosis
Lateral (sideways) curvature of the spine May involve all or only a portion of the spinal column Functional scoliosis (in response to another condition)
o Occurs as a compensatory mechanismo Usually due to unequal leg lengthso Created a pelvic tilt that is C-shapedo Must correct the initial problem
A lift placed in one shoe Remind the child to maintain good posture (walking with
book on head 3 x daily for 10 minutes) Sit-ups and push-ups are good exercises
Structural scoliosis Permanent curvature of the spine with damage to the vertebrae Spine has an S-shaped appearance
Usually there is a family history 5x more common in girls than boys Usually peaks between 8-15 years (school age) Diagnosis is made on physical exam by having the child bend forward X-rays confirm diagnosis Therapeutic management:
o If spinal curve is less than 20 degrees, no therapy except closeobservation until the child reaches 18 years of age)
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o If greater than 20 degrees, may use braces, traction, surgery, orcombination.
Nursing care of the immobilized child: Goals and interventions
Goal One : Increase physical mobility related to mechanical restrictions,physical disability
o Transport child by gurney, stroller, wagon, bed, WC from room toplay room, lobby, or other area as allowed
o Change position of bed in roomo Out of bed in chair, wagon, etc. as allowed
Goal Two : Assist child to maintain optimal autonomyo Provide mobilizing devices (crutches, WC)o Assist with acquiring specialized equipmento Instruct in use of equipment
Encourage activities that require mobilization Allow as much freedom as possible and encourage normal activities Encourage child to participate in own care Allow child to make choices
High Risk for Impaired Skin integrity
Goal: Maintain skin integrityo Place child on pressure-reducing mattresso Change position frequently, unless contraindicatedo Protect pressure points with proper positioning and cushioningo Inspect skin surfaces for signs of breakdowno Eliminate mechanical factures that cause frictiono Good skin careo Gently massage skin area until contraindicated
High risk for injury
Child will experience no physical injury
o Teach correct use of devices (child and parent)o Assist with moving and/or ambulatingo Remove hazards from environmento Modify environment as neededo Keep call button within reacho Keep siderails up at all timeso Help child use bathroom or commode if possible
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o Implement safety measures appropriate to childsdevelopmental stage
o Diversional activities
Muscular Dystrophies
The largest group of muscle disorders of childhood
Three types:
Congenital myotonic dystrophyo Begins in uteroo Newborn may already have significant myotonia (muscle
weakness)o Usually die before one year of age due to respiratory failure
Assessory muscles for respiration fail
Facioscapulohumeral Muscular dystrophy
Begins after 10 years of age Facial weakness is the predominant symptom Very slow progression of symptoms Less disability than the other types Normal lifespan is possible.
Pseudohypertrophic Muscular Dystrophy/ Duchennes Disease
Most common form of MD Symptoms usually appear by age 3 years
Occurs only in boys Late in meeting motor milestones Muscle weakness gradually becomes more pronounced Usually wheelchair-dependent by adolescence Heart and respiratory failure may occur by early adulthood
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Cerebral Palsy
Cerebral Palsy
A group of non-progressive disorders of upper motor neuronimpairment that result in motor dysfunction.
Can happen before, during, or after birth Occurs 2:1000 births Most common permanent disability of childhood
Incidence and Causes of CP
Most frequently associated with brain anoxia that leads to cell
destructiono Symptoms can range from very mild to quite severe, depending
on the extent of brain damage Also can be caused by:
o Kernicterus (a form of jaundice from hyerbilirubinemia; stainingof the brain with bilirubin)
o Meningitis (viral is the most common) Occurs most frequently in very low weight infants (born prematurely),
or those small for their age.o Their lungs haven