pediatric disorders

MLNG CELESTE,RN, MD 1

Childhood Disorders

Respiratory Disorders


Anatomy and physiology of respiratory tract

• Origin of respiratory system: > arises as an out pouching from the

pharyngeal pouch; this gradually migrates to the thoracic area ( completed by the 3rd fetal month)

> right primary bronchus is slightly larger than the left and form obtuse angle (FB)

> larynx is 1/8 the adult size at birth > trachea is 4cm long in newborn, 1/2 of adult’s


> at birth the bifurcation is located at the 3rd

or 4th thoracic vertebra > at 4 years, it is at the level of T5 > at 12 years, it is located between T5 to T6 > ethmoidal and maxillary sinuses are present

at birth> Frontal and sphenoidal sinuses do not develop

until 6-8 years of age


>after 2 years of age the R bronchus is shorter and more vertical than the left

> change in thoracic breathing begins at 2-3 years of age and is complete at 7

> in infants, the wall of the airway has less cartilage (advantageous in an infant – an infant does not develop bronchospasm- less smooth muscle in the airway), therefore wheezing cannot be a prominent finding


Adult vs Pediatric Airway• Smaller airway diameter 4mm • Distance between structures is shorter• Organisms move faster, usually viral• Infants obligate nose breathers• “Little finger”=trachea size


• Respiratory system is divided into 2 divisions: 1. upper respiratory tract

a. noseb. Para nasal sinusesc. pharynxd. larynxe. epiglottis

2. lower respiratory tracta. bronchib. bronchiolesc. alveoli


• Inspiration : - delivers warm and moistened air to the alveoli

transports O2 across the alveolar membrane to hgb –laden RBC allows CO2 to diffuse from RBC back to alveoli thru expiration , CO2 filled air is discharged to outside


Respiratory center > medulla of the brain receptors:

1. peripheral receptor-aortic arch and carotid arteries( stimulated by

decrease PO2)2. central respiratory receptor- stimulated

by: a. increased PCO2 b. decreased temp.

c. body acidity d. increased BP


Assessment of respiratory illness in children

• Physical assessment: A. cough- a reflex initiated by stimulation of

nerve of respiratory tract mucosa by the presence of dust chemicals, mucus or inflammation- useful procedure to clear excess mucus

paroxysmal cough- refers to series of

expiratory cough after deep expiration( seen in whooping cough, aspiration )


B. rate and depth of respiration:tachypnea > increased RR, 1st indicator

of airway obstruction in young children

C. Retraction> inward drawing of the chestcauses: airway obstruction, stiff lungs

non compliant lung > commonly seen in infant and

newborn because intercostal tissue is weaker and

less developed


• Supraclavicular orSuprasternal retractionSuggests upper airway obstruction

• intercostal retractions suggest lower airway obstruction


D. Restlessness : - when infantS or children have decreased

O2,they become anxious and restless

E. Cyanosis – blue tinge to the skin- becomes apparent when PO2 is <

40mmhg resulting to increased RR


F. Clubbing of fingers:- change in the angle between the

fingernail and nailbed because of increased capillary growth in the fingertips

G. Adventitious sounds:- extra or abnormal breathing sounds- I/E ratio is reversed (bronchial or

tubular breathing)


types of adventitious sounds:1.rhonchi- obstruction at the level of

nose or pharynx2.stridor- obstruction at the level of

larynx(best heard in supine position)

3. wheezing – obstruction is in the lower trachea or bronchioles

(expiration)4.rales –when alveoli are filled with

fluids, fine crackling sounds


H. Chest diameter:- in children with COPD unable toexhale completely air trapped in lung - - alveoli (hyperinflation) ,

produceselongated A-P diameter of the chest ( pigeon chest)


• Laboratory tests:A. blood gas analysis > an invasive method

for determining the effectiveness of ventilation acid-base

status> provides information about

oxygenation of the blood as well as O2 saturation of Hgb


causes of decreased O2 saturation1. pt with respiratory distress (O2 cannot reach the bloodstream)2.Hgb is defective, cannot carry a full complement of O2

PCO2 - measures efficiency of ventilation PCO2 - seen in children who are hyperventilating (breathing deeply) - blowing off to much PCO2

PCO2- seen in children who are hypoventilating (breathing very shallow) - can’t blow off the CO2


CO2 retention( due to obstruction/ or hypoventilation)

partial pressure of CO2 rises and concentration of CO2 in the plasma increases

respiratory acidosis( the body compensates by increased kidney

tubular reabsorption of HCO3 (bicarbonate)

respiratory alkalosis( bicarbonate exceeds the amount of acid in the blood)


in doing ABG- we need arterial blood (reflects how the lungs are oxygenating the blood)

if venous blood : only reflects oxygenation of particular extremity from which blood is drawn

SITES commonly used for ABG:1. temporal artery- young infant2.umbilical artery- newborn3.radial artery- older children

Other sites: (small infant) if impossible to obtain arterial blood directly, heel or finger stick may be used (just warm the area for about 20

minutes)


B. Pulse oximetry - continuous ,non invasive technique for measuring O2 saturation

How to use:1. sensor and photo detectors are

placed around vascular bed2. infrared light is directed through the finger from the sensor to the photo

detector( hgb absorbs light wave differently when bound to O2 )


Advantages: 1. non-invasive 2.continuous monitoring by pulse

oximeter allows you to modify the care

Disadvantages: 1. sensor is small ( needs frequent checking)

2. excess light may distort the reading


ABG values: PH- 7.35-7.45 < 7.35 - acidosis,

> 7.45 - alkalosis

PCO2- 35-45 mmHg < 35 - alveolar hyperventilation and respiratory alkalosis> 45 means ventilatory failure and respiratory acidosis

PO2 – 80-100 mm Hg 60 -80 mmHg - mild hypoxemia

40-60 mmHg - moderate hypoxemia < 40 mmHg - severe hypoxemia


explanation: > ph, pco2 - alkalosis

> ph, pco2 - acidosis

how to know if metabolic or respiratory? >references are ph and HCO3

if ph and HCO3 - both elevated it is metabolic

If ph and HCO3 is - opposite direction (one is increased, the other is decreased) it is respiratory ( SMOR)


C. Nasopharyngeal culture

D. Respiratory syncytial virus nasal washing > pt is placed in supine position and 1-2 ml of sterile saline is dropped with sterile needle-less syringe into one nose, then nose is aspirated using small, sterile bulb syringe

E. Sputum analysis:>rare in children younger than school age


• Diagnostic tests:1. chest X-ray2. bronchography3.pulmonary function test - measures the

forces of inertia, elasticity, and flow resistance

measured by the use of spirometry- device that records the force of air exchange


Therapeutic techniques

Expectorant therapy1.Coughing2.Chest physiotherapy - 3 technique are involved

1. postural drainage2.percussion 3. vibration

3.Mucus clearing devices- by use of flutter device- stainless steel ball inside the device moves when the child breathes out -causing vibration in the lung -helps loosen the mucus


Therapy to improve oxygenation

• O2 administration: via hood, nasal cannula,and O2 mask

• Pharmacologic therapy:1.antihistamine2.decongestant-causes vasoconstriction

leading to shrinkage of mucous membrane - expands breathing

space


3. expectorant- helps raise mucus 4. bronchodilator- used to open lower

airway 5. metered dose inhaler- route of

medication

• Incentive spirometry - device that encourages children to inhale deeply to aerate the lung

• Breathing technique- blowing ball, blowing out with purse lips

• Tracheostomy -opening in the trachea to create an artificial airway to relieve respiratory obstruction

• Endotracheal tube intubation


Disorders of upper respiratory tract

• Choanal atresia• Acute nasopharyingitis• Pharyngitis• Tonsillitis• Epistaxis• Sinusitis


• Laryngitis• Congenital laryngomalacia/tracheomalacia• Croup• Epiglottitis• Aspiration• Bronchial obstruction


Choanal atresia > congenital obstruction of the posterior

nares by an obstructing membrane or bony growth, preventing newborn from drawing air through the nose into the nasopharynx

> either unilateral/bilateral

Dx. Can be assessed by holding the newborn’s mouth closed, then gently compressing

1st nostril, then the other


• Sign: cyanosis• Treatment:1. local piercing of the

obstructing membrane 2. surgical removal of the bony

growth


Acute nasopharyngitis (common colds-coryza)

• Most frequent infectious disease in children• Average of 10-12 colds/ year• Incubation period- 2-3 days• Causes: 1. rhinovirus-most common cause

2.coxsackie virus-most common cause

3.respiratory syncitial virus(major etiologic agent)

4.adenovirus 5. parainfluenza /influenza virus


• Signs and symptoms:1.nasal congestion 2.watery rhinitis3.low grade fever4. mucus membrane is edematous5.cervical lymph nodes may be swollen and

palpable6. body malaise


• Pathophysiology: > initial pathology is submucosal

edema of nasal mucosa by shedding of ciliated epithelial cells (5th day) nasal mucopurulent discharge

> interferon ( plays major role in recovery)


• Treatment: Common colds is self-limiting> supportive care> relief of nasal obstruction- use of

isotonic saline drops and aspiration

> antipyretic or analgesic agents > antitussive is sometime used for

persistent cough


• Nursing diagnosis: parental health-seeking behaviors related to management of child’s cold symptoms


Pharyngitis

> it is an inflammation of mucous membrane of the throat and involves the nasopharynx, uvula and soft palate

> peak incidence occurs between 4 to 7 years of age> either bacteria or viral, occurs as a result of

a chronic allergy


• Viral pharyngitis: > causative agent is virus

signs and symptoms:1. sore throat2. fever3.general malaise

Physical examination:1. enlarged lymph nodes2. erythema on the back of the pharynx


• Treatment:1. antipyretic2. gargle with warm water- school age3. provide liquid foods- (+) difficulty of

swallowing

Nursing diagnosis: > risk for fluid volume deficit


Streptococcal pharyngitis:> caused by group A beta-hemolytic

streptococcus> can lead to cardiac and kidney damage> more severe than viral infection

Signs and symptoms:1. marked erythema of the back of throat and palatine

tonsils2. tonsils are enlarged and (+) white exudates in

the tonsillar crypts3. high grade fever4. difficulty swallowing


- Spread by infected nose or throat mucus through coughing or sneezing

- Dx: throat swab and culture


treatment:1. antibiotics- 10 days course of oral

antibiotics( pen G or clindamycin)

2. high fluid intakes3.relief of pain

Complications:1. Rheumatic fever2. Glomerulonephritis


Retropharyngeal abscess

> limited to young infants> infected lymph nodes that drain the

nasopharynx located behind the posterior pharyngeal wall

Signs and symptoms:1. sore throat2. fever3. enlargement of regional lymph nodes


laboratory findings:leukocytosis- increased WBC count

treatments:1. antibiotics( benzathine pen G. penicillin V2. abscesses resolve on their ownif not - can do incision3.adequate fluid intakes


Tonsillitis > term commonly used to refer to infection and inflammation of palatine tonsils

palatine tonsils- located on both sides of pharynx

Adenitis- refers to infection and inflammation of the adenoids ( pharyngeal) tonsils

Adenoids- located in the nasopharynxTubal tonsils- located at entrance to the eustachian tubeLingual tonsils-located at base of tongue


Signs and symptoms:1. difficulty of swallowing2.fever3.lethargy4.mouth breathing- (posterior

pharyngeal obstruction)

5.difficulty hearing- (Eustachian tube

obstruction)6.halitosis7. sleep apnea


Causes:> child <3 years old-often viral> school age children- group A beta-

hemolytic

Treatment: 1. antipyretic2. analgesics3. antibiotics4. if recurrent onset of tonsillitis - can do tonsillectomy


Tonsillectomy-removal of palatine tonsilsAdenoidectomy- removal of pharyngeal

tonsils-can be done in children having sleep apnea

Indication for tonsillectomy: > chronic tonsillitis (not done if inflamed- because may spread infection)

Nursing diagnosis: pain related to surgical procedure


Epistaxis (nosebleed)

> extremely common in children and usually occurs in trauma > occurs during respiratory illness, after

strenuous activity

Management:1. keep patient in upright position with head tilted slightly forward to minimize the amount of blood pressure in nasal vessels , keep blood moving forward not back to nasopharynx


2. apply pressure to the side of the nose with your fingers

3. keep the child quiet and stop crying because crying increases pressure in the blood vessels of the head and prolonged bleeding4. control of bleeding, can give epinephrine

( 1:1000) to constrict blood vessels5. can put nasal packing for continued pressure


Sinusitis

> rare in children younger than 6 years of age because frontal sinuses do not

develop fully until 6 years of age> occurs as secondary infection in older children

Causes: streptococcal staphylococcal

H- Influenza


signs and symptoms:1. fever2. purulent nasal discharge3. headache4.tenderness over the affected sinus


treatment:1. antipyretic2.analgesic3. antibiotic for specific infection4. nasal spray- Oxymetazoline HCl(afrin) shrinks the edematous mucus membrane and allows infected material

to drain5. warm compress

Complication if untreated: otitis media and osteomyelitis ( involves

facial bone)


Laryngitis

>inflammation of larynx> occurs as complication of pharyngitis

or from excessive use of voice

Management :1.sips of fluid offer relief from annoying tickling

sensation2. rest the voice for at least 24 hrs


Congenital laryngomalacia/tracheomalacia

>means laryngeal structure is weaker than normal and collapses more than usual in inspiration

> produces laryngeal stridor present from birth, intensified when infant is in supine or sucking

Sign and symptoms:1. stridor2.retraction- on inspiration because of

increased effort needed to pull the air into trachea from collapse cartilage ring


management: no routine treatment -instruct parents to feed the child

slowly


Croup ( laryngotracheobronchitis)

> inflammation of the larynx, trachea, and major bronchi

> one of the most frightening diseases of early childhood for both parents and children

> common cause organism is viral infection usually parainfluenza virus


signs and symptoms:1. low grade fever2. barking cough at night3. inspiratory stridor4.retractions

Management:> provide warm, moist environment- as an emergency measure> give corticosteroids (nebulizer)- reduces inflammation and bronchodilation> intravenous hydration

Nursing dx.: Ineffective airway clearance related to edema


Epiglottitis

> inflammation of the epiglottis( flap of tissue that covers the opening to larynx to keep out food and fluids> its an emergency because the swollen epiglottis can’t rise and allow the airway to

open


causes:1. H-Influenza type b2. pneumococci, streptococci - most

common cause3. echovirus4.respiratory syncitial virus

Signs and symptoms:1. begins as mild URTI2. 1 to 2 days (+) severe inspiratory

stridor3. high fever4. hoarseness5. sore throat6. dysphagia


never illicit gag reflex- may cause complete obstruction

Laboratory findings:1. leukocytosis ( 20,000-30,000 mm3)

with the proportion of neutrophils

Management:1. provide warm moist environment2. O2 administration3. antibiotic therapy4. intravenous therapy


Aspiration

> inhalation of foreign objects into the airway> common in infant and toddlers

Management: Heimlich subdiaphragmatic abdominal thrust

( stand behind the child and place a fist just under the child diaphragm)


*if the child is lying on his back at the time of aspiration, stand at the head of the table or bed, place hand under child diaphragm and exert inward and upward thrust*

* for infant, use back thrust to dislodge an aspirated object-turn the infant prone over your arm and administer up to 5

quick back blows forcefully bet. The infants shoulder blades using the heel of the hands*


Bronchial obstruction> obstruction on the bronchus (commonly on

the right)> common in child younger than school-age

Sign and symptoms:1.violent cough2.hemoptysis3.fever4. purulent sputum5.localized wheezing6.dyspnea


Laboratory findings:1.radioopaque finding on chest X-ray2.leukocytosis

Complications:1. pneumothorax2.atelectasis3. lipid pneumonia


management:

1. bronchoscopy –removal of foreign body2. close observation after bronchoscopy,

frequent V/S monitoring3. maintain on NPO after procedure, assess for

gag reflex


Disorders of lower respiratory tract


Influenza > inflammation and infection of the major airway> caused by orthomyxoviruses, influenza type A, B, C

Sign and symptoms:1.cough2. fever3.fatique4.achings pain5.sore throat6. GIT symptoms-diarrhea, vomiting


incubation period: 1-5 days

Management:1. antipyretic2. antiviral drugs( tamiflu)3. influenza vaccine( yearly given)

Complication:1. bronchitis 2. pneumonia


Bronchitis

> inflammation of major bronchi and trachea

> affect preschool and school age

Sign and symptoms:1. fever 2. cough3.nasal congestion


causes:1. influenza virus 2. adenovirus 3. mycoplasma pneumoniae

Course of disease: 1-2 weeksSign and symptoms:

1.fever 2. dry hacking cough 3. on auscultation can hear rhonchi and

rales 4. On chest x-ray finding-diffuse alveolar

` hyperinflation and some marking on hilus of lungs


Management:-1. aim in relieving the respiratory symptoms

2. antipyretic 3. adequate hydration

4. antibiotic therapy


BronchitisViral Bacterial

Etio Rhinovirus,Influenza,RSV, Parainfluenzaadenovirus, paramyxovirus

S. pneumoniae,S. aureus, H. Influenzae, M. Catarrhalis

S/sx Rhinitis, cough, malaise, chills, mild fever, sore throat

higher fever and a more prod cough

Dx ClinicalXray – normal

Elev c-reactive CHON

Course Mild & self-limiting Up to 2 weeksRx supportive empirical; amox-

tetracycline, erythromycin


Bronchiolitis

> inflammation of the fine bronchioles and small bronchi

> common lower respiratory illness in children younger than 2 years of age , peak in 6 mos of age

Causes: 1. adenovirus 2. parainfluenza 3. respiratory syncytial virus


sign and symptoms:1. nasal flaring2.intercostal/subcostal retarction on inspiration3. tachypnea4. mild fever5. expiratory wheezing6. tachycardia7. chest x-ray –pulmonary

infiltrates or collapse of alveoli


Management:1. antipyretic 2. adequate hydration 3. if in respiratory distress can

hospitalized the pt. 4. O2 administration 5. nebulized with

bronchodilatorsnursing diagnosis:

> parental anxiety related to respiratory distress in child


Respiratory syncytial virus > an RNA virus, common cause of

bronchiolitis in young children.> can cause apnea/periodic halt of

respiration> peak in severity between 48 to 72 hrs Sign and Symptoms:

-lethargic, cyanosis, nasal flaring retraction, grunting, rales/ rhonchi Diagnosis: throat or nasal culture


management: therapy is supportive1. O2 administration2.antiviral drugs( ribavirin)3. isolate the patient4. vaccination-RSV-IGIV and

palivizumab


asthma

> an immediate hypersensitivity ( type 1) response, most common illness in

children> condition may be intermittent, symptom-

free period> common seen in children with atopy or tend to be hypersensitivity to allergens


Mechanism of disease:> primarily affect the small airways and involve 3 processes:

1. bronchospasm-happen because of stimulation of PSNS (smooth muscle constriction)2. inflammation bec. of mast cell3. mucus production activation this will release histamine, leukotrienes & prostaglandin


Signs and symptoms:1. dry cough2. expiratory wheezing3. cyanosis4. retractions


Clinical Assessment of Asthma

MILD MOD SEVERE

breathless walking talking at resttalks in sentences Phrases words

Alertness may be agitated

usually agitated

agitated

RR Inc inc >30accessory (-) (+) (+)

wheeze audible audible audible w/o steth

pulse <100 100-120 >120


Intermittent Mild Persistent

ModeratePersistent

Severe Persistent

Am sx < 1x/wk >1x/wk Daily; aff activ

Daily; dec activ

Pm sx </= 2x/mo >/= 2x/mo >1x/wk > 1x/wk

PEFR 80% </= 80% 60-79% <60%

PEFR var < 20% 20-30% 30% >30%


Ndx: • Ineffective breathing pattern r/t

bronchospasm, edema and accumulation of mucus

• Fear r/t sudden onset of Asthma attack• Activity intolerance r/t imbalance between O2

supply and demand• Health seeking behaviors r/t prevention and

treatment for asthma attack


Management• B2 agonists, Theophylline, Steroids, Cromolyn

Na, O2• Orthopneic position• Monitor VS, hydration• Adequate nutrition and non allergenic diet• Environmental modification• Health education


Status Asthmaticus

• Progression of attack unresponsive to therapy• Preceding upper respiratory tract infection,

allergen, cigarette smoke• HR and RR inc, dec breath sounds, cyanosis

Mx: cont B2 agonist and IV steroid, O2, coughing, fluids, monitor I and O, ET


Pneumonia• Inflammation of lung parenchyma

Bacterial and atypical pathogens:NB – GBS, Gr (-) bacilli, chlamydiaChildren – S. pneumoniae, H. Influenzae, M.

catarrhalisAdolescents – S and M Pneumoniae, M. catarrhalisHospital acquired – Pseudomonas, Klebsiella, E.

Coli, Enterobacter sp

Viral Pneumonia - RSV, Parainfluenza, Adenovirus, Influenza


Pathophx: aspiration/hematogenous/inhalation Alveoli inflammation hypoxemia

S/sx: fever, chills, cough, irritability, poor feeding, restlessness, headache, GI sx, tachypnea, use of accessory muscles, decreased BS, crackles, dullness on percussion, chest retractions

Dx: cxr, blood and sputum c/s


UncommonCommonCommonInc RR

Non-toxicVariableToxicToxicity

Low-gradeVariableHighFever

InsidiousVariableAbruptOnset

5-15 yoAnyAnyAgeAtypicalViralBacterialParameter

UncommonCommonCommonInc RR

Non-toxicVariableToxicToxicity

Low-gradeVariableHighFever

InsidiousVariableAbruptOnset

5-15 yoAnyAnyAgeAtypicalViralBacterialParameter


AtypicalViralBacterialPerimeter

UncommonvariablecommonInc WBC

Fine crackles, wheezing

variable(+) consolidationfew crackles

PE

Bullous myringitis, pharyngitis

Mild coryzaMild coryzaAssoc sx

Non prodNon prodProductiveCough

AtypicalViralBacterialPerimeter

UncommonvariablecommonInc WBC

Fine crackles, wheezing

variable(+) consolidationfew crackles

PE

Bullous myringitis, pharyngitis

Mild coryzaMild coryzaAssoc sx

Non prodNon prodProductiveCough


• Nsg Dx:• Ineffective breathing pattern r/t physiologic

effects of Pneumonia• - O2, monitor VS, CPT, encourage

coughing and deep breathing

• Risk for deficient fluid volume r/t diminished oral intake and increased insensible fluid losses sec to diaphoresis, dyspnea and fever

• - weigh and monitor daily, sips of fluid, temp control, monitor I and O


• Activity Intolerance r/t effects of Pneumonia and Tachypnea- rest periods, O2, small frequent feedings, gradual increase in activity, support and contact with family


Tuberculosis

• High incidence in infancy and adolescence

• Primary Complex – based on xray; first encounter of a child w/ TB; Ghon’s tubercle w/ lymphangitis and regional (hilar) lymphadenopathy

• Primary Pulmonary TB – clinical TB• d/t Mycobacterium Tuberculosis

Dx: exposure, s/sx (2 or more), PPD, cxr


Classification of TB

Class I TB exposure – (+) exposureClass II TB infection – (+) exposure and PPDClass III TB disease – active TB or 3 or more of

criteria - Exposure, s/sx, (+) tuberculin test, xray, sputum exam, culture

Class IV TB inactive – (+/-) hx of prev TB, (+/-) hx of prev hx of chemotherapy, (+) xray evidence of healed lesion and (+) PPD


S/sx: fever, weight loss, cough, anorexia, night sweats, painless lymphadenopathy

Tx: SCC Intensive

INH, Rifampicin, PZA x 2 mos

Maintenance INH, Rifampicin x 4 mos


Respiratory Distress Syndrome

• Preterm, infants of diabetic mothers, C/S, hx of asphyxia

S/sx: inc RR, chest retractions, nasal flaring, expiratory grunt, cyanosis, HPN, hypothermia

Dx: ABG, Xray

Mgmt: surfactant replacement, O2, ventilation, supportive care


Decreased surfactant

lungs collapse

Inc pulmonary resistance

blood shunts through F.O. and D.A.

poor lung perfusion and gas exchange

further decrease in surfactant hypoxia

acidosis

Cardiovascular Disorders


Fetal Circulation

• placenta provides the exchange of gas and nutrient

• four shunts in fetal circulation:– Placenta– Ductus venosus– Foramen Ovale – Ductus arteriosus


Special Structures:Foramen OvaleConnects the left and right atriumBypassing fetal lungsObliterated after birth to become fossa ovalisUmbilical VeinBrings oxygenated blood coming from the placenta to the heart and liverBecomes ligamentum teresUmbilical arteriesCarry unoxygenated blood from the fetus to placentaBecome umbilical ligaments after birthDuctus venosusCarry oxygenated blood from umbilical vein to IVCBypassing fetal liverBecomes ligamentum venosum after birthDuctus arteriosus

Carry oxygenated blood from pulmonary artery to aortaBypassing fetal lungs

Becomes ligamentum arteriosum; closes after birth


Fetal Circulation


Fetal circulation: oxygenated blood (placenta)

umbilical vein

liver ductus venosus

inferior vena cava

right atrium

foramen ovale (flap opening in the atrial septum that allow only R-L movement of

blood)


• Continuation: left atrium left ventricle right ventricles

(small amount)

aorta pulmonary arteries ductus

arteriosus supply the body aorta

supply blood to the body


• Continuation: superior vena cava right atrium

right ventricle

pulmonary arteries ( ductus arteriosus)

aorta

supply blood to the body


Common Congenital Heart Defects

• abnormalities that develop before birth• can occur in the heart's chambers, valves

or blood vessels• A baby may be born with only one defect

or several that tend to occur in combination.

• Of the dozens of heart defects, some are mild and may need minimal or no medical treatment even through adulthood, while others are life-threatening, either immediately to the newborn or over time.


1.Acyanotic Heart Disease L R shunt high pressure to low pressure oxygenated to unoxygenated blood

2. Cyanotic Heart Disease R L shunt


Classifications of CHD

1. Defects with increased pulmonary blood flow-ASD, VSD, PDA

2. Defects with decreased pulmonary blood flow- TOF, Tricuspid Atresia

3. Obstructive Defects- COA, Aortic stenosis, Pulmonic stenosis

4. Mixed Oxygenation/ defects-TOGV, Truncus Arteriosus, Hypoplastic left heart syndrome (HLHS)


ACYANOTIC HEART DISEASES


Atrial septal defect• Similar to a ventricular septal defect, this is

a hole that occurs when the septum separating the right and left atria doesn't close properly.

• This allows blood from the left atrium to flow into the right atrium, instead of into the left ventricle and on to the aorta and the rest of the body.

• The defect can cause several complications, including arrhythmias, heart failure, stroke and, in rare cases, pulmonary hypertension.

• Minor cases may cause no symptoms and may not require treatment.

• Larger defects may require surgical closure or cardiac catheterization


1. Atrial Septal Defect

• Opening between atria• females• late childhood/early adulthood• S/sx: cyanosis (CHF), dyspnea,

fatigue, failure to thrive, split S2

• Mx: Antibiotics, surgery 1-3 yo

• Cx: endocarditis, heart failure• Postop: monitor

arrhythmia, administer antibiotics


Ventricular septal defect• Sometimes called a hole in the heart• most common congenital heart defect• occurs when the septum, the muscular wall separating the

right and left ventricles, fails to fully form• The hole allows oxygen-rich blood to leak from the left

ventricle into the right ventricle, instead of moving into the aorta and on to the body.

• Too much blood may flood the lungs.• This defect can lead to heart failure, excessive blood pressure

in the lungs (pulmonary hypertension), infections of the heart (endocarditis), irregular heartbeats (arrhythmias) and delayed growth.

• Small holes may heal on their own or cause no symptoms. Larger holes may require surgical repair by stitching together or covering with a patch.


2. Ventricular Septal Defect• Opening in ventricular

septum• Most common• S/sx: respiratory infections,

failure to thrive, dyspnea, fatigue, pansystolic murmur

• Mx:closes spontaneously otherwise surgery <2 yo failure

• Postop: monitor • Cx:pulmonary HPN,

endocarditis, heart arrhythmia, administer antibiotics


Patent ductus arteriosus• Before birth, a temporary blood vessel called the ductus

arteriosus connects the pulmonary artery and the aorta. • This allows blood to bypass the lungs because oxygen is

delivered to the fetus through the placenta and umbilical cord.

• The temporary vessel normally closes within a few hours or days of birth since the lungs take over.

• If it remains open (patent), some blood that should circulate through the body is misdirected to the lungs.

• This defect can cause heart failure or endocarditis. In infants, it can be closed with medications. In older children and adults, plugs, coils or surgery can be used to close the vessel.


3. Patent Ductus Arteriosus

• Aorta to pulmonary artery• Common in prematurity, high

altitude, maternal rubella• females• S/sx:clubbing, dyspnea,

“machinery murmur” (2nd-3rd ICS)

• Cx:heart failure, endocarditis, pulmonary artery stasis/HPN

• Mx:Indomethacin, surgery


Aortic stenosis• defect that narrows or obstructs

the aortic valve opening, making it difficult for the heart to pump blood into the aorta.

• Mild cases may not have symptoms initially, but they can worsen over time.

• The defect can cause heart enlargement, left-sided heart failure, arrhythmias, endocarditis and fainting.

• Treatment includes surgical repair or replacement of the valve or, in young children, widening through balloon valvuloplasty


Tetralogy of Fallot• This defect is a combination of four (tetralogy)

congenital abnormalities. The four defects typically are ventricular septal defect (VSD), pulmonary stenosis, a misplaced aorta and a thickened right ventricular wall (right ventricular hypertrophy).

• They usually result in an insufficient amount of oxygenated blood reaching the body.

• Complications of tetralogy of Fallot (fuh-LOE) include cyanosis — sometimes called "blue baby syndrome," since the lips, fingers and toes may have a bluish tinge from lack of oxygen — as well as poor eating, inability to tolerate exercise, arrhythmias, delayed growth and development, and stroke.

• Surgical repair of the defects is required early in life.

• Tet spells- irritability, pallor and blackouts or convulsions,


CYANOTIC HEART DISEASE1. Tetralogy of Fallot

• S/sx: cyanosis, clubbing, dyspnea, fatigue, squatting, “Tet spells”, failure to thrive, systolic murmur, polycythemia

• Cx:thromboembolism,CVA• Mx: O2, knee-chest position,

surgery 1-2 yo• Postop:monitor for arrhythmia Blalock Taussig: anastomose

subclavian art. and pulmo art. - avoid BP and venipuncture in

right arm


Transposition of the great vessels/ arteries• With this defect, the positions of the aorta and the

pulmonary artery (the great arteries) are reversed (transposed).

• The aorta arises from the right ventricle instead of the left and the pulmonary artery arises from the left ventricle instead of the right.

• This creates a circulatory pattern that prevents nourishing oxygenated blood from reaching the body.

• This condition would quickly be fatal to a newborn except it's generally accompanied by another defect — commonly a septal defect or patent ductus arteriosus — that does allow oxygen-rich blood to get to the body. Surgical repair is usually necessary shortly after birth.


2. Transposition of the Great Vessels

• Aorta from R ventricle• Pulmonary a. from L

ventricle• Males• S/sx:cyanosis,

murmurs• Mx:PGE for PDA,

Balloon catheter to create ASD, definitive surgery 1 wk-3 mos


3. Total Anomalous Pulmonary Venous Return

• Pulmonary vein drains to SVC or R atrium

• PDA or foramen ovale essential

• S/sx:cyanosis, fatigue

• CX: R heart failure• Mx:PGE, surgery


Coarctation of the aorta• This is a narrowing (coarctation), or constriction, in a

portion of the aorta. • Coarctation forces the heart to pump harder to get

blood through the aorta and on to the rest of the body.• This defect can cause several life-threatening

complications, including severe hypertension, aortic aneurysm, dissection or rupture, endocarditis, brain hemorrhage, stroke, heart failure and premature coronary artery disease.

• Repair is typically recommended before age 10, either by surgically removing the affected portion or widening it through balloon angioplasty and placement of a stent.


Coarctation of the Aorta• Constriction of aorta• males• S/sx: asymptomatic HPN,

irritability, headache, epistaxis, dyspnea, claudication, higher BP in upper extremities, dec femoral and distal pulses,systolic murmur

• Cx:chronic HPN• Mx:surgery 2 yo• Postop: monitor abdominal

pain, antihypertensives


Ndx: Ineffective cardiopulmonary and peripheral tissue

perfusion related to impaired cardiac function • Proper positioning to maintain respiration• Conserve energy to promote rest• Quiet activities and stimulation• Anticipate needs• Administer prescribed drugs


Activity intolerance r/t effects of congenital heart defect and dyspnea

• Rest periods• Adequate nutrition small frequent feedings iron supplementation


Pulmonary stenosis• the flow of blood from the right

ventricle to the pulmonary artery is obstructed by narrowing at the pulmonary valve.

• When there's an obstruction (stenosis), the right ventricle must pump harder to get blood into the pulmonary artery.

• The defect may occur along with other defects, such as thickening of the muscle of the right ventricle immediately below the valve.


• in many cases, pulmonary stenosis is mild and doesn't require treatment. But because it can cause heart failure, arrhythmias or enlargement of the right heart chambers, surgery may be necessary to repair the stenosis or replace the valve.

• Special balloons to widen the valve (balloon valvuloplasty) may also be used.


Truncus arteriosus• This is a defect in which the normally distinct pulmonary

artery and aorta merge into one single great vessel (truncus) arising from the right and left ventricles.

• In addition, there's usually a large ventricular septal defect, essentially turning the right and left ventricles into a single chamber.

• This allows oxygenated and unoxygenated blood to mix. Too much blood may flow to the lungs, flooding them and making it difficult to breathe.

• It can also result in life-threatening pulmonary hypertension.Surgery is needed to close the septal defect with a patch and to separate the pulmonary arteries from the trunk.

• A conduit is placed to connect the right ventricle to the pulmonary artery. Because the conduit doesn't grow with the child, repeat surgery may be necessary over time.


Truncus arteriosus


Hypoplastic left heart syndrome• In this condition, the left side of the heart is

underdeveloped (hypoplastic), including the aorta, aortic valve, left ventricle and mitral valve.

• As a result, the body doesn't receive enough oxygenated blood. In the first few days after a baby is born, the ductus arteriosus remains open (patent), allowing normal circulation, so the baby may seem fine initially.

• But when the ductus arteriosus naturally closes, signs and symptoms begin, including a bluish cast to the skin from lack of oxygen, difficulty breathing and poor feeding. This condition may be accompanied by an atrial septal defect.

• Treatment options for this life-threatening condition are a heart transplant or a multistage surgical procedure done during the first few years of life.


Hypoplastic left heart syndrome


Atrioventricular canal defect• This is a combination of defects, including a

large hole in the center of the heart and a single common valve instead of the separate tricuspid and mitral valves.

• Also called atrioventricular septal defect, this defect is classified by whether it's only partial, involving only the upper chambers of the heart, or complete, in which blood can travel freely among all four chambers of the heart.

• Both forms allow extra blood to circulate to the lungs, causing the heart to enlarge.The condition is often associated with Down syndrome. Infants may also have trouble breathing and not grow well.

• Surgery is often done in infancy to close the hole and reconstruct the valves.


Atrioventricular canal defect


Other Cardiovascular Problems


Kawasaki Disease/Mucocutaneous Lymph Node Syndrome

• Before puberty, peaks 4 yo

• S/sx:spiking fever x 5 days, bilateral conjunctivitis, reddened pharynx, dry lips, strawberry tongue, cervical lymphadenopathy, peripheral edema, erythema and desquammation, truncal rash, arthritis

• Patho: Respi infection immune complex systemic vasculitis aneurysm and MI

• Dx:clinical

• Mx: Salicylates and Immunoglobulins


• Risk for ineffective peripheral tissue perfusion related to inflammation of blood vessels

- Observe for chest pain, color changes, vomiting

• Pain r/t swelling of lymph nodes and inflammation of joints- Comfort measures, administer pain medications


Other Measures:Protect edematous areasRecord intake and outputOffer soft food Administer prescribed medication


Rheumatic Fever• Autoimmune• Grp A Beta hemolytic strep• 6-15 yo, peaks 8 yo• 1-3 wks after untreated infection• Dx: 5 major criteria – polyarthritis,

carditis, subcutaneous nodules, erytHema marginatum, sydenham’s choreaminor – fever, polyarthralgia, hx of RF, inc ESR, antecedent strep infection

• To diagnose, either 2 major or 1 major and 2 minor present

• Cx:mitral valve insufficiency and myocarditis

J. N. E. S.


Mgmt: salicylate, penicillin

Ndx:Risk for noncompliance r/t knowledge deficit

about importance of long term therapy- prevent initial and recurrent attacks

Decreased cardiac output r/t disease process- bed rest, comfort and appropriate activities


Nursing Care• Monitor vital signs• Provide adequate nutrition• Promote safety to prevent chorea related

injuries

Gastrointestinal Disorders


Altered Gastrointestinal Functioning

Acquired and congenital conditions of the GI tract can result in altered GI functioning.

A thorough assessment is necessary for prompt treatment.


Interventions are geared toward:• controlling and correcting the problem• promoting adequate nutrition and

normal function and • preventing complications


Characteristics of the pediatric GI System

• Peristalsis occurs within 2 ½ to 3 hours in the neonate and extends to 3 t0 6 hours in older infants and children.

• The stomach capacity of the neonate is 30 to 60 ml, which gradually increases to 200 to 350 ml by age 12 months and 1,500 ml in the adolescent.


• Up until 4 to 8 weeks, the neonatal abdomen is larger than the chest and the musculature is poorly developed.

• The sucking and extrusion reflexes persist until 3 to 4 months.

• Saliva production begins at age 4 months and aids in the process of digestion.


• Spit-ups are frequent in the neonate because of the immature muscle tone of the lower esophageal sphincter (LES) and the low volume capacity of the stomach.

• Increased myelination of nerves to the anal sphincter allows for physiologic control of bowel function, usually at about age 2.


• The liver’s slow development of glycogen storage capacity makes the infant prone to hypoglycemia.

• From ages 1 to 3, the composition of intestinal flora becomes more adultlike and stomach acidity increases, reducing the number of GI infections.


Diagnostic Tests


Barium or Gastrografin SwallowPrimarily used to examine the esophagusGastrografin and barium facilitate imaging through X-rays, but Gastrografin is less toxic if it escapes from the GI tractNursing Interventions:- Explain the procedure to the child and his parents.- Maintain the child on NPO starting at midnight before

the test.- Tell the child that he must hold still during the X-ray.- After the test, monitor bowel movements for excretion

of barium. Monitor GI function.


Upper GI Imaging

• Upper GI series- Swallowed Barium moves into the esophagus,

stomach, and duodenum to reveal abnormalities.

- Barium outlines stomach walls and delineates ulcer craters and filling defects.


• Small bowel series- An extension of the upper GI series- Visualizes Barium flowing through the small

intestine to the ileocecal valve


NI:- Explain the procedure to the child and his parents.- Tell the child that he must hold still during the X-

ray.- Make sure the lead apron is properly placed

around the genital area.- After the test, monitor bowel movements for

excretion of barium.- Monitor GI function.


Barium Enema• Allows X-ray visualiztion of the colon.NI:- Explain the procedure to the child and his parents.- Usually, the child will follow a liquid diet for 24 hours before

the test.- Bowel preparations are administered before the

examination.- Tell the child that X-rays will be taken on a test table and

that he must hold still.- Cover the genital area with a lead apron during X-ray.


Stool SpecimenExamined for suspected GI bleeding, infection,

or malabsorptionTests include the Guaiac test for occult blood and

microscopic tests for ova, parasites and fat

NI:- Obtain the specimen in the correct container.- Be aware that the specimen may need to be transported

to the laboratory immediately or placed in the refrigerator.


Fiber-optic Testing

• Esophagogastroduodenoscopy – a fiber-optic scope is inserted to allow direct visual inspection of the esophagus, stomach and duodenum

• Proctosigmoidoscopy – the rectum and distal sigmoid colon are inspected directly

• Colonoscopy – the descending, transverse and ascending colon are inspected directly


• NI:- Explain the procedure to the child and his parents.- Obtain written, informed consent.- A mild sedative may be administered before the

examination.- The child may be kept on NPO starting at midnight

before the test.- The child may be placed on a liquid diet for 24 hours

before the examination or require enemas and laxatives until clear.


Endoscopic RetrogradeCholangiopancreatography (ERCP)

Contrast media is injected into the duodenal papilla to allow radiographic examination of the pancreatic ducts and hepatobiliary tree

NI:- Before the procedure:

Explain the procedure to the child and his parents.Obtain written, informed consent.Check the child’s history for allergies to cholinergics and iodine.Administer a sedative and monitor the child for the drug’s effect.


- After the procedure:Monitor the child’s gag reflex (the child remains on NPO status until his gag reflex returns)Protect the child from aspiration of mucus by positioning the child on his side.Monitor the child for urine retention.


GI Intubation

To empty the stomach and intestineTo aid in the diagnosis and treatmentTo decompress obstructed areasTo detect and treat GI bleedingTo administer medications or feedings


NI:Maintain accurate intake and output records- Record the amount, odor and consistency of

gastric drainage every 4 hours.- When irrigating the tube, note the amount of

normal saline solution instilled and aspirated

Check for fluid and electrolyte imbalances.Provide good oral and nasal care. Make sure the

tube is secure but that it isn’t causing pressure on the nostrils.


To support the tube’s weight and prevent its accidental removal, anchor the tube to the child’s clothing.

After removing the tube from a child with GI bleeding, watch out for signs and symptoms of recurrent bleeding.

Maintain a calm and reassuring manner and provide emotional support because many children panic at the sight of the tube.


Cleft Lip and Palate

• failure of fusion of maxillary and median nasal process

• hereditary• unilateral/bilateral• malesMx: surgery – Cheiloplasty;

usually 1-3 mos• Rule of 10’s-10 wks,

10 lbs, Hgb 10 gm


Cleft Palate• midline opening of palate• usually w/ Cleft lip• Female• surgery 6-18 mos - allows

anatomic changes; <1 y/o (ie, formation of palatine arch and tooth buds)


Ndx:• Risk for imbalanced nutrition, less than body

requirements r/t feeding problems• Risk for ineffective airway clearance r/t oral

surgery• Risk for infection during post op period


Nursing CarePreop• Adequate nutrition; sips of fluid btw feeding in upright

position; use rubber tipped syringe; Burp • Prevent ear and upper respiratory tract infection• Address body image and speech concerns• Reassurance to parentsPostop• monitor respiratory distress d/t edema, hemorrhage• Suction mucus and blood gently• dropper feeding 1st 3 weeks; regular feeding after• Anticipate needs and position to prevent tension on sutures

• Position side lying in cleft lip; prone in cleft palate


Tracheoesophageal Fistula

• Communication of the esophagus and trachea• maternal hydramnios and prematurity• S/sx:coughing, choking, cyanosis, dyspnea, excessive

secretion, abdominal distention• Dx: Ba swallow


Ndx:• Risk for imbalanced nutrition, less than body

requirements r/t inability for oral intake• Risk for infection r/t aspiration or seepage of

stomach contents into lungs• Risk for impaired skin integrity r/t gastrostomy

tube insertion site


Nursing carePreop• Suction regularly• Elevate the head• Gastrostomy feeding• hydration• O2Postop1. Observe for respiratory distress2. Proper positioning –avoid hyperextension of neck1. Continue suction2. Prevent wound infection 3. Provide pacifier


Hirschprung’s Disease

• Aganglionic megacolon• Absence of

parasympathetic ganglionic cells in a segment of the colon (usually at the distal end of the large intestine: rectosigmoid colon)

• Lack of innervation to a bowel segment causes a lack of, or alteration in, peristalsis in the affected part

• Male predominance


• CausesFamilial, congenital defectCommonly exists with other congenital anomalies, particularly Down’s syndrome (trisomy 21) and anomalies of the urinary tract

• PathophysiologyAs stool enters the affected part, it remains there until additional stool pushes it through.

• The affected part of the colon dilates; a mechanical obstruction may result.


• ComplicationsSevere ConstipationEnterocolitis – severe diarrhea, Hypovolemic

shock, Death

S/sx:ConstipationRibbonlike stools Failure to pass meconium or stoolabdominal distentionBile stained or fecal vomiting


• Dx: Rectal biopsy provides definitive diagnosis by showing the absence of ganglion cellsBa enema – shows distention of the colon; spasm and a narrowed lumen in the affected bowelAbdominal X-rays show distention of the colon and air-fluid levels; No air is seen in the rectum

• Mx:colostomy, surgery: To decompress the colon, a temporary colostomy or ileostomy may be necessary


Ndx:• Constipation r/t reduced bowel function• Imbalanced nutrition, less than body requirements r/t

reduced bowel function

Nursing CarePreop1. Administer isotonic enemas: Normal saline solution or

mineral oil to evacuate the bowelDaily enemas with 0.9% NaCl Don’t administer tap water.

*Tap/hypotonic water will cause cardiac congestion or cerebral edema

2. Minimal residue diet with vitamin supplementation3. Position semi fowlers to relieve dyspnea from distended

abdomen4. pacifier


After colostomy or Ileostomy1. Monitor fluid intake and output (ileostomy will likely cause

excessive electrolyte loss)2. Keep the area around the stoma clean and dry; use

colostomy or ileostomy appliances to collect drainage3. Monitor for return of bowel sounds to begin diet

Postop1. Observe for abdominal distention2. Small frequent feedings after NGT removal3. Colostomy care

5. Assist parents to cope with children’s feeding problems


Intussusception• 2-6 mos• Invagination of intestine • S/sx:intense abdominal pain,

vomiting, blood in stool “currant jelly”, abdominal distention (sausage shaped mass)

• NECROSIS: fever, tachycardia, rigid abdomen

• Dx:sonogram “coiled spring”• Mx:Ba enema (reduction by

hydrostatic pressure), surgery


Ndx:• Pain r/t abnormal abdominal peristalsis• Risk for deficient fluid volume r/t bowel

obstruction


Nursing Care

1. Provide comfort measures - pacifier for infants

2. NPO

3. Adequate hydration via IV therapy

4. Promote parent-infant bonding


Pyloric Stenosis• Hypertophy/hyperplasia of

pyloric sphincter• Males• S/sx:nonbillous vomiting,

s/sx of of dehydration and wt loss, abdominal distention, “olive” sized mass RUQ, visible peristalsis

• Dx:xray-”string sign”, USG, endoscopy

• Mx: surgery


Ndx:• Risk for deficient fluid volume r/t inability to

retain food• Risk for infection at site of surgical incision r/t

danger of contamination from feces d/t proximity of incision to diaper area


Nursing care• Hydration• Pacifier• may give thickened feedings on upright position then NPO just

before surgery• Monitor I and O, weight, and vomiting

Postop1. dropper feeding 4-6 hrs after surgery 45 min- 1 hr duration; oral

rehydration soln then half strength breastmilk/formula at 24 hr interval

2. Side lying position3. Monitor weight and return of peristalsis

4. Wound care5. Pacifier for oral needs


Diaphragmatic Hernia• Herniation of intestinal

content into the thoracic cavity

• Left side• S/sx:respiratory

difficulty, cyanosis, retractions, (-) breath sounds affected side, scaphoid abdomen

• Cx: pulmonary HPNMx:’E’ surgery


Ndx:Risk for ineffective airway clearance r/t displaced

bowelRisk for imbalanced nutrition, less than body

requirements, r/t NPO status


Nursing CarePreop• Elevate head • Low intermittent suction

Postop1. Semi-fowlers2. Maintain warm, humidified envt – lung fluid drainage3. Suction prn4. Chest pptx5. NPO – prev pressure on diaphragm


Necrotizing Enterocolitis

- Bowel develops necrotic patches, interfere w/ digestion, lead to paralytic ileus, peritonitis and perforation

- D/t ischemia sec shock or hypoxia, infection, immature GIT immune protection

S/sx: abdomen tense and distended, stool (+) for occult blood, > 2 ml gastric residual, bradycardia, apnea

Dx: abdominal xrayMgmt: d/c feeding, IV or TPN, Antibiotic, colostomy,

surgery for perforation


Celiac Disease/Gluten sensitive enteropathy/Celiac sprue

• Characterized by poor food absorption and sensitivity or intolerance to gluten (a protein found in grains : wheat, rye, oats, barley)

• Usually becomes apparent between ages 6-18 months

• Causes:Gluten intoleranceImmunoglobulin deficiency


• PathophysiologyA decrease in the amount and activity of enzymes in the intestinal mucosal cells causes the villi of the proximal small intestine to atrophy and decreases intestinal absorption.

• ComplicationsLymphoma of the small intestine


• S/sx: steatorrhea (fatty stools) because of inability to absorb fatchronic diarrheaanorexiamalnutrition; weight lossfailure to thrivecoagulation difficulty from the malabsorption of fat-soluble vitaminsirritabilityanemic (Fe deficiency)abdominal pain and distention


• CELIAC CRISIS: acute vomiting and diarrhea

• Dx:clinical; IgA antigliadin Ab, gluten free diet

• Mx: gluten free diet, vitamin & Fe supplementation

• NDx: Imbalance nutrition: Less than body requirements r/t impaired absorption


NI:- nutrition counseling Eliminate gluten from the diet:

avoid cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some chocolates

Give the child: corn and rice products, soy and potato flour, breast milk or soy- based formula, and fresh fruits.

Replace vitamins and calories; give small, frequent meals.

Monitor for steatorrhea- its disappearance is a good indicator that the child’s ability to absorb nutrients is improving.

Endocrine Disorders


Cystic Fibrosis• Autosomal recessive• Dysfunction of exocrine glands; inc viscosity of

mucous glands • Affects lungs, pancreas, intestines and sweat

glands• Cystic fibrosis (multiple organ disease; the primary

pathophysiologic mechanism in cystic fibrosis mucus buildup in the lungs and pancreas; steatorrhea; azotorrhea)

• S/sx: GI - meconium ileus, rectal prolapse, steatorrhea, malnutrition, failure to thrive

Respiratory – recurrent infection,cough, dyspnea, clubbing, cyanosis


Sweat Gland – ”salty taste”Other – males infertile, abnormal glucose toleranceDx: history, sweat test (Cl 2-5x the normal),

absence of pancreatic enzymes, immunoreactive trypsinogen in blood and pulmonary involvement

Mx: chest physiotherapy, antibiotics, pancreatic enzymes, vitamins, lung or pancreas transplant


Ndx:• Imbalanced nutrition, less than body

requirements r/t inability to digest fats• Ineffective airway clearance r/t inability to

clear mucus from the respiratory tract


Nursing Care

1. Hi calorie, Hi CHON, moderate fat diet2. Nebulization and physiotherapy3. Frequent Position changes when in bed4. Oral care5. Adequate rest and comfort


Musculoskeletal Disorders


Clubfoot (Talipes)

• Ankle-foot disorders• Types: Varus – inward

rotation Valgus – outward

rotation Calcaneous –

upward rotation or dorsiflexion

Equinas – downward rotation or plantarflexion


• Males

• Unilateral more common

• Talipes Equinovarus (plantar flexion and medial deviation) – 95%

• S/sx: foot cannot be manipulated by passive exercises into correct position

• Mx: cast and splint, surgery then casting and corrective shoes


NDx: Risk for impaired skin integrity r/t corrective devices

Nursing Care• Exercise• Cast and brace care• Skin care• Restraints if necessary• Diversional activities• Health teaching


Congenital Hip Dysplasia

• Imperfect hip development affecting femoral head and acetabulum

• Female• Unilateral more

common• Inc frequency w/

breech deliveryA.A. Lower right legLower right legB.B. asymmetric skin asymmetric skin

foldfold


A. Normal hip

B. subluxated hip

C.Dislocated Hip


S/sx:• limited abduction of affected hip• shortening of leg on affected side

(Galeazzi/Allis sign)• asymmetric thigh and gluteal folds• buttocks on affected side will flatten on prone• pelvis dips on normal side when standing on

affected leg (Trendelenburg)• palpable click (Ortolani’s click)• Mx: maintaining hip in abduction traction and casting


A. Frejka splint

B. Pavlik Harness

C. Hip abduction for subluxation

A. Ortolani’s test

B. Barlow’s Test


NDx: Impaired physical mobility r/t immobilization device

Nursing Care• Maintain proper positioning-keep legs abducted• Adequate nutrition• Diversional activities• Regular exercise• Ensure adequate circulation • Provide comfort• Maintain cast, traction, splint


Neurological Disorders


Brain Tumor

• Second most common form of cancer in children• 1-10 yo, peak 5 yo• Usual location - brainstem or cerebellum• TYPES: Astrocytoma- glial tissue; 5-8 yo Medulloblastoma – cerebellum; 5-10 yo; cause

compression of 4th ventricle; most common Brain stem tumor – support tissue of neural cells;

paralysis of 5th-7th, 9th-10th CN


S/sx: headache, vision changes, vomiting, enlarging head circumference, papilledema, lethargy, ataxia, nystagmus, personality changes, seizures, lethargy, coma

Dx: skull films, bone scan, CT scan, Lumbar puncture, MRI, angiography

Mx: surgery, chemotx


Preop1. Stool softeners2. Dexamethasone3. Dilantin 4. Shave head5. Prepare patient and family psychologically


Postop1. Proper position – low fowler’s2. Anticipate needs3. Saline eye drops as needed4. Monitor VS and NVS5. Regulate IV6. Observe head dressings7. Provide comfort and opportunity for self

expression


Benign Febrile Seizure

• 6 mos - 5 years • fever >/= 38.5C• generalized tonic-clonic • rarely persist > 10 minutes• Postictal stage• 30-40 % recurrence• (+) family history


NURSING CARE

• Turn child to side & allow to drool• Do not restrain• Do not put anything in the mouth• Dec temp• Refer if: sx persist another sx occurs delirious/difficult to rouse after sx


Seizure

• Paroxysmal involuntary disturbance of brain function

Epilepsy: recurrent seizures unrelated to fever or to acute cerebral insult


Generalized Seizures

• Absence Seizures/Petit Mal: - staring spell that lasts a few seconds

- 100x a day - appear as if daydreaming

• Generalized/Grand Mal/Tonic-Clonic 4 stagesProdrome: mood or behavioral changes; precede

attack by hoursAura: immediately before seizure and will localize the

attack to its point of origin within the nervous system


Tonic phase (10 secs)eyes open. Elbows flexed. Arms pronated. Legs extended. Teeth clenched. Pupils dilated. Breath held- cyanosis. Bowel or bladder control may be lost at the end of this phase

Clonic phase (1-2 min)tremor gives way to violent generalized shaking. Eyes roll backwards and forwards. Tongue may be bitten, tachycardia develops. Breathing commences at the end of phase.


• Partial Seizures

Simple partial: with motor and sensory symptomsComplex partial/psychomotor: simple partial developing into a complex seizure, consciousness impaired at onsetPartial seizure with secondary generalization

discharges spread from their point of origin and excite other structures


Mx: Acute Attack• Provide O2• Position properly• Turn head to side• Promote safety • Do not restrain


Prevention• Health teaching• Supervise activities• Antiepileptics Generalized Tonic-Clonic, Focal – Phenobarbital,

Phenytoin Absence – Ethosuximide, Valproate


Erb Duchenne’s Paralysis

• Damage on C5-C6 due to birth trauma• Unilateral• S/sx: shoulder adducted, internally rotated,

elbow extended, forearm pronated and the wrist flexed “waiter’s tip”, (-) moro reflex

• Mx: PT, surgery• Nsg care: advise exercise and frequent follow

up


Cerebral Palsy• Damaged motor function d/t anoxic brain injury

secondary to infection, perinatal asphyxia, metabolic disorder

• Nonprogressive

• TYPES: Spastic Dysphagia – most common; hypertonicity

Athetoid/dyskinetic – worm-like Ataxic – wide based gait w/ repetitive mvmt Mixed


• S/sx: spasticity/rigidity, difficulty feeding, delayed speech and motor devt, mood swings, impulsive, short attention span, irritable

• Dx: Clinical

• Mx: antispastics, antibiotics, surgery, nutrition, prevention of injury, PT

NDx: Risk for injury r/t neuromuscular impairmentSelf care deficit r/t neuromuscular impairment

- ensure safety, assist in ADL, ensure adequate nutrition, assist children achieve maximum potential


Hydrocephalus• Impaired circulation and absorption of CSF 2 TYPES:1. Obstructive/Noncommunicating – w/n

ventricular system2. Nonobstructive/Communicating – obliteration of

SA cisterns or malfunction of arachnoid villi

S/sx: head enlargement, ant fontanel wide and bulging, scalp veins dilated, broad forehead, sclera shows above iris, brisk tendon reflexes, spasticity, irritability, lethargy, poor appetite,

cracked pot sound on percussion


Ndx:

Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure- monitor vs, head circumference, I and O - O2- position flat or head 30 deg- do not lie on operative site


Risk for imbalanced nutrition, less than body requirements, related to increased intracranial pressure- NPO until bowel sounds return- position head w/o flexion- observe for constipation- note how child sucks- IV fluids- obtain daily weight


Spina Bifida• Collective term for all SC disorders

Spina Bifida Occulta – posterior laminae fail to fuse- dimpling, abnormal tufts of hair

Meningocoele - meninges herniate through unformed vertebrae; protrusion covered by a layer of skin- usually occurs in the lumbar region- protrusion is covered by a skin layer or only the clear dura mater


Myelomeningocoele – SC and meninges protrude through the vertebrae defect - absent motor and sensory function - flaccidity, lack of sensation in LE- loss of bowel and bladder control- may be accompanied by hydrocephalus

Dx: sonography


• Risk for infection r/t rupture or bacterial invasion of the neural tube sac- position side lying or prone- keep sac moist - place under radiant warmer- post op – prone until site is healed

• Risk for ineffective cerebral tissue perfusion r/t increased intracranial pressure- measure head circumference- assess for s/sx of inc ICP


• Risk for impaired skin integrity r/t required prone positioning- reposition head every 2 hrs if w/ hydrocephalus- change diapers frequently

• Impaired physical mobility r/t neural tube d/o- passive exercises- may use leg braces, crutches- inspect lower extremities and buttocks for irritation or possible infection

• Risk for impaired elimination r/t neural tube d/o- intermittent catheterization

- surgery


Meningitis

• Inflammation of meninges• Bacterial, Tuberculous, viralS/sx: opisthotonus, neck rigidity, irritability, high

pitched cryDx: Lumbar puncture, Bld C/S, Ct scan, MRINDx: Risk for infection r/t presence of infective

organismTx: Abx


Hematologic Disorders


Iron Deficiency Anemia

Infant’s iron supply 4-6 mosAnemia – 9-24 mos

S/sx: pallor, tachycardia, irritability, Hg < 9 g/dl, susceptible to infection

Mgmt: iron fortified formula, iron rich diet and vitamins

Nsg care: give iron w/ vit c, use w/ dropper at the back of the mouth, expect black stools, provide iron rich food


Hemophilia A• Inherited interference w/ blood coagulation

• Factor VIII

• Sex linked recessive

• S/sx: excessive bleeding NB – apparent Pre-school – accidents/falls School age – bleeding between joints Adolescent – ulcers, hematuria

»Mx:factor 8


NDx: Acute pain r/t bleeding into joints

Nursing Care

• Promote safety• Watch out for bleeding – rest area, ice

compress, elevate body part• Monitor transfusion reaction• Passive ROM• Assist in gaining control of situation


Acute Lymphocytic Leukemia• Uncontrolled proliferation of WBC

• Lymphoblast

• Most frequent CA in children

• 2-16 yo

• Males


S/sx: pallor, low grade fever, lethargy, petechiae, bleeding, vomiting, anorexia, bone pain, painless lymphadenopathy

Dx:WBC variable w/ blasts, low platelet and hematocrit, anemia

BMA > 25% blast cells


Mx: chemotherapy Cx: CNS s/sx, renal failure

NDx: Risk for infection r/t decreased immune function

Activity intolerance r/t reduced oxygen carrying capacity of blood


Nursing Care

• Prevent infection• monitor bleeding and transfusion reactions• Provide comfort and pain alleviation• Health teaching• Emotional and psychological support


Beta Thalassemia

• B chain defect• Heterozygous – Thalassemia minor• Homozygous – Thalassemia major• 4-6 mos oldS/sx: anemiaDx: peripheral blood smearTx: blood transfusion - pRBC


Genitourinary Disorders


Urinary Tract Infection

• Females• E coli• Ascending infection• S/Sx:infants – mimic GI d/o; dysuria, frequency,

hematuria, low grade fever, abdominal pain and bedwetting

• Dx: urine culture suprapubic any amount clean catch > 100,000/ml• Mx: antibiotic hydration


Acute Glomerulonephritis

• Inflammation of glomeruli or kidney• Follows infection with strep10-14 days• 5-10 yo• Males


S/sx:sudden onset of edema and hematuria, proteinuria, hypertension

Dx: urinalysis and 24 hour urine hypoalbuminemia inc ESR, BUN, Crea, antistreptolysin O


Mx: semi fowlers diuretics, antibiotics

O2 antihypertensives

Nsg Care: quiet play activities diet – normal CHON, mod salt restriction, fluid

restriction daily weight and output


Nephrotic Syndrome• Altered glomerular

permeability(autoimmune); inc permeability to albumin

• 3 yo• Males• Minimal change syndrome

S/sx: proteinuria, edema-periorbital area, hypoalbuminemia, hyperlipidemia

Dx:urinalysis and 24 hr CHON, inc ESR


Mx:steroids, immunosupressant

NDx: Risk for decreased fluid volume r/t CHON and fluid loss

Imbalanced nutrition: less than BR r/t CHON and fluid loss

Nsg care: Adequate nutrition, proper diet – dec saltWeigh daily, monitor I and OProtect edematous areasAdminister prescribed drugsHealth teaching


Wilm’s Tumor

• Malignant tumor of the kidney• Associated with other anomalies • 6 mos-5 yo, peaks 3-4 yo• Good prognosis• S/sx:abdominal mass, hematuria, low grade fever,

anemia, wt loss• Dx: CT scan• Mx: Nephrectomy, radiotherapy avoid abdominal palpation


Hypospadia/Epispadia

A. Hypospadia B. Epispadia

C. Hypospadia w/ chordee


CONGENITAL MALFORMATIONS OF THE URINARY TRACT

• Epispadias -Urethral opening on the dorsal surface of the penis

• Surgical correction


• Hypospadias-Male urethral opening on the ventral surface of penis, or female urethral opening in vagina

• Surgical reconstruction


Hypospadia - common - chordee - fibrous band

Mx: surgery

Nsg care: Post op – pain relief assist parents in coping


Cryptorchidism

• Failure of one or both testes to descend

• Descend up to 6 weeks at birth

• May be d/t dec testosterone

• S/sx:right testis more common

• Mx:chorionic gonadotrophin hormone

Orchiopexy 1 yo


Other Diseases


Atopic Dermatitis

• 2 mos-3 yo• R/t food allergyS/sx: papular and vesicular

skin eruptions w/ erythema, pruritus, dry,flaky scales upon healing

Mx: reduce allergen, topical steroids

NDx: Impaired skin integrity r/t eczematous lesion

Nsg care: Reduce allergen Prevent skin dryness and

pruritus


Otitis Media• Inflammation of the middle ear• 6-36 mos, 4-6 yo• S. Pneumoniae, H. Influenzae, M. Catarrhalis• Follows URTIS/sx:pain in affected ear, fever Cx:hearing impairmentMx: antibiotics, analgesics, antipyreticsNDx: Acute pain r/t inflammatory process

- provide comfort, reinforce completion of antibiotic, offer liquids and finger food (prevent pain when chewing)


Inguinal Hernia

• Protrusion of a bowel through the inguinal ring

• males• S/sx:painless lump in the

groin • Cx:bowel strangulation• Mx:surgery <1 yo • Post op Nursing care:

wound care assess circulation

in the leg


diarrhea• Viral – Rotavirus, Adenovirus• Bacterial – Shigella, Salmonella, Cholera• Protozoan – Amoeba

• TYPES:• Mild: fever, irritable, 2-10 episodes/day, dry

mucous membranes, tachycardia• - 2.5-5% wt loss• Mx: oral rehydration


Severe: fever, tachycardia, tachypnea, pale and cool skin, apprehensive/lethargic, obvious s/sx of dehydration, UO scanty, several episodes of loose stools

-5-15% wt loss

• Cx:dehydration• Mx:fluid and electrolyte replacement• Dx:Stool exam and culture Electrolyte determination

NDx: deficient fluid volume r/t fluid losses in stools- promote hydration and comfort, Record I and O


Protein Energy MalnutritionMarasmus• Low calorie, low CHON• 0-2 yo• (-) edema• “all skin and bone”• (+) growth retardation• Apathetic, quiet• Good appetite• Infrequent skin/hair

changes• Anemia uncommon


KwashiorkorLow CHON1-3 yo(+) edemaWasting variableGrowth retardation variableIrritable, moaningPoor appetite(+) skin and hair changes(+) anemia


PoisoningUsually 2-3 yoSoap, cosmetics, detergents, drugsMales>females – childrenFemales>males – adolescent

Mx:1. Determine age & wt, type of poison swallowed,

time of ingestion, route of poisoning, amt ingested, present condition of child


2.Use syrup of ipecac to induce vomiting except: caustic, corrosive, hydrocarbon, px is comatose3. Activated charcoal then syrup of ipecac4. Monitor VS5.refer to hospital/poison control center


POISONINGAcetylsalicilic acid (Aspirin)S/sx:nausea, vomiting, fever, profuse sweating,

flushing, hyperthermia, hyperventilation, convulsions, coma

Mx:stabilize airway and breathingFluid and electrolyte replacementActivated charcoalAlkalinization of urinehemodialysis


BurnsAssessment

A airway - check nose, face and neck (priority) singed and sooty hair of the nose, give high flow 02B breathingC circulation - if there is no breathing and circulation start CPRD check for disability and manage accordinglyE expose or determine extent of injury


Kinds of Burn:Flame – gasoline, kerosene, petroleumChemical – acid or alkaliElectrical – most fatalRadiation – sunlight

< 1 yo – scaldingPre school – reaches up a stove, spills coffeeOlder children – flame burns


TBSAParkland Formula (4ml x TBSA x BWkg)

1st 8H give ½, 2nd 8H give ¼ and for the 3rd 8H give the last part)


0-1 yo 1-4 yo 5-9 yo 10-14 yo

15 yo

Head 19 17 13 11 9Neck 2 2 2 2 2Ant trunk 13 13 13 13 13Post trunk 13 13 13 13 13r. Buttock 2.5 2.5 2.5 2.5 2.5L buttock 2.5 2.5 2.5 2.5 2.5Genitalia 1 1 1 1 1r. Upper arm

4 4 4 4 4

l. Upper arm

4 4 4 4 4


0-1 yo 1-4 yo 5-9 yo 10-14 yo 15 yor. Lower arm 3 3 3 3 3

l. Lower arm 3 3 3 3 3

r. Hand 2.5 2.5 2.5 2.5 2.5

l. Hand 2.5 2.5 2.5 2.5 2.5r. Thigh 5.5 6.5 8 8.5 9l. thigh 5.5 6.5 8 8.5 9r. Leg 5 5 5.5 6 6.5

l. leg 5 5 5.5 6 6.5

r. Foot 3.5 3.5 3.5 3.5 3.5l. foot 3.5 3.5 3.5 3.5 3.5


Classification1st degree – partial thickness (painful,

no blisters, erythematous); epidermis2nd degree – deep partial thickness

(painless, with blister, blanch); epidermis and dermis

3rd degree – full thickness (painless, leathery, whitish/charred)

4th degree – bones and visceral organs are affected


Hospitalization recommended- Total burns > 10% of BSA or > 2% FTB

*halved if < 2 yrs old- Hands, feet, face or genitalia involved- Inhalation injury- Associated injuries present- Burn is inflicted- Infected burn- Prior medical illness- comatose


Management:- 1st 24 hrs - D5LR- 8-24 hrs post burn - colloid- Give TIG or TAT and TT- Prophylactic antibiotic- Sterile dressing for wound

Small minor burns – dressings, soap and waterMore extensive burns – antibacterial

cream/ointment, thick/thin dressings and cleansing bath


Down’s Syndrome

Trisomy 21Maternal age >35 yo, paternal age >55Features:nose is broad and flat, eyelids have an

extra fold of tissue at the inner canthus, palpebral fissure slants upwards, white specks in iris, tongue protrudes, back of the head is flat, neck is short, extra fat pad, low set ears, poor muscle tone, short thick fingers, simian crease, cognitively challenged


Poor immune functionCongenital heart diseasesCataractALL occurs 20x more

Mx: early education and play opportunities prevention of infection counseling and support


Child Abuse• Non accidental injury

inflicted by an adult• Physical, emotional,

sexual• Children grow up to be

abusers themselves and are violent

• Nsg Resp: treat injury, report to DSWD, NGO, Bantay Bata


Substance Abuse

• Use of chemicals• Improve mental state• Induce euphoria• Peer pressure• Feel more confident• Adolescent rebellion


TYPES OF ABUSED SUBSTANCES

Tobacco - sign of maturity

Alcohol - most frequent - no stigma

Amphetamines – sense of well being, alertness, self esteem and wt loss



Anabolic steroids – improves athletic ability

Marijuana – stress reliever bec gives a sense of well being, altered sensory perception



Hallucinogens – distortions in vision, smell or hearing

Opiates – physiologic craving

Cocaine – inc VS, dec appetite, cardiovascular arrest, euphoria,

excitement, hallucinations


ASSESSMENT OF SUBSTANCE ABUSE

• Failure to complete homework• Poor reasoning ability• Decreased school attendance• Frequent mood swings• Deteriorating physical appearance• Recent change in peer group• Negative perception of parents


Nursing Intervention

• Caution against drug abuse• Provide counseling• refer to rehab facilities


Thank you!

pediatric disorders

Documents

blood mlng celeste

alveoli mlng celeste

rr mlng celeste

aspiration mlng celeste

outside mlng celeste

adults mlng celeste

years of age mlng celeste

increased bp mlng celeste