Child Health Nursing, 3E Jane W. Ball Solution Manual.pdf (22)

Provide students with medication calculation problems for pediatric emergency drugs.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Arrange for students to have a clinical experience working with a nurse anesthetist who administers sedation for children having minor medical procedures.

•

Have students examine the contents of a pediatric “emergency cart.” Allow the students to practice with the equipment, including the Ambu bag, AED, and suction.

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CHAPTER 22 DISEASES IMMUNIZATIONS AND COMMUNICABLE Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Storing Vaccines During a Disaster Case Study:Immunization Education Plan for a Reluctant Parent; Consequences of Vaccines Shortages Care Plan:Immunization Schedule for a 4-Year-Old; Immunization Schedule for an Infant Media Links:Vaccines; Respiratory Diseases Media Link Applications Videos and Animations:Process of Inflammation Pediatric Dosage Calculations Image Library Table 22–1 Vaccine Safety Information Box 22–1 Infection Control Methods

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LEARNING OUTCOME 1 Compare the vulnerability of children and adults to communicable diseases.

CONCEPTS FOR LECTURE 1. Children are at increased risk of infectious disease because their immune system is not yet fully developed and there are many diseases to which they have not developed antibodies.

2. Communicable diseases have a significant negative impact on the child, the family, and the healthcare system through financial cost, use of healthcare resources, and missed work and school.

3. Preventable infectious diseases are a significant threat to public health. Goals of Healthy People 2020 include elimination of rubella, congenital rubella syndrome, diphtheria, Haemophilus influenzae type B, measles, mumps, polio, and tetanus. In addition, they hope to reduce the incidence of pertussis, hepatitis B, varicella, foodborne pathogens, and pneumococcal and HIV infections.

POWERPOINT LECTURE SLIDES Children Are at Increased Risk for Communicable Disease • Definition—illness passed by direct or indirect contact •

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Risk factors °

Immature immune system

°

Limited prior exposure to communicable diseases

•

°

Poor hygiene behaviors

°

Poor health and immunodeficiency increase risk

Impact of communicable disease °

Child

°

Family

°

Healthcare system

SUGGESTIONS FOR CLASSROOM ACTIVITIES Before class, have students visit the Healthy People 2020 website and find information in the progress report on immunizations and infectious disease. Allow time at the beginning of class for students to meet in groups of two or three and share their findings.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students visit the public health department and observe care of patients in the immunization clinic. Have students note the percentage of patients being seen who are current versus behind on their immunizations.

LEARNING OUTCOME 2 Propose strategies to control the spread of infection in healthcare and community settings.

CONCEPTS FOR LECTURE 1. Children are at risk for infectious disease as a result of poor hygiene.

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2. Nurses play an important role in prevention of the spread of infectious disease.

3. Hand washing, use of standard precautions, avoiding exposure to infected individuals, and decreasing or eliminating pathogens are all strategies that may be used to control the spread of infection.

3. Disease surveillance is necessary to optimize management of communicable disease.

POWERPOINT LECTURE SLIDES Common Routes of Infection Transmission in Children •

Fecal–oral

•

Respiratory

Prevention of the Spread of Infectious Disease •

Hand washing

•

Standard precautions (Box 22–1)

•

Avoid exposure to infected individuals

•

Promote immunizations

•

Decrease/eliminate pathogens

Disease Surveillance • Definition—monitoring patterns of disease occurrence •

Outcomes of disease surveillance °

..

Development of public health programs

°

Scientific advances

°

Reduction or elimination of many infectious and communicable diseases

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students in small groups to research the efforts of national/international healthcare organizations to control/eliminate diseases such as polio, measles, rubella, and HIV. Ask students to compare efforts of this country and developing nations in eliminating diseases. Have them include cultural influences that have been detrimental to preventative measures in developing countries.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students spend time with the infection control nurse in a children’s hospital. Ask them to note risk factors in children who have contracted a common communicable disease.

LEARNING OUTCOME 3 Examine the role that vaccines play in reduction and elimination of communicable diseases.

CONCEPTS FOR LECTURE 1. Vaccines have a significant impact on the morbidity and mortality of children.

2. For optimal health, children require an ongoing program of immunizations.

POWERPOINT LECTURE SLIDES Communicable Disease Incidence Prior to 1950 •

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Polio

•

Rubella

• Measles •

Diphtheria

•

Haemophilus influenzae type B

•

Pertussis

Mechanism of Action of Immunizations •

Active immunity o

Antibody production stimulated by vaccine antigens without causing clinical disease

•

Passive immunity o

Antibodies produced in another host (human or animal) given when child needs antibodies faster than the body can make them

o

Includes immune globulins

o Note—does not confer lasting immunity; child will need vaccine in future

SUGGESTIONS FOR CLASSROOM ACTIVITIES In class, have students divide into small groups and develop a pamphlet that could be used in a clinic to educate parents on the importance of immunizations for children.

SUGGESTIONS FOR CLINICAL ACTIVITIES ..

Schedule students to spend time with a school nurse to review student records, noting immunization compliance and follow-up of noncompliance.

LEARNING OUTCOME 4 Plan the nursing care for children of all ages needing immunizations.

CONCEPTS FOR LECTURE 1. Many children who receive an immunization will experience a negative local or systemic response.

2. If an immunization results in a serious reaction, the Vaccine Injury Compensation Program should be contacted.

3. Several health agencies collaborate yearly to develop immunization schedules. These schedules direct the timing of recommended immunizations administration.

4. Cooperation between parents, healthcare providers, schools, and insurance/managed care organizations results in optimal compliance with immunization schedules.

5. While rare, there are some contraindications to vaccine administration.

6. Informed consent is required before administration of vaccines. Parents must be given a copy of the Vaccine Information Statement when the vaccine is given.

7. Minimizing pain and anxiety during the vaccine administration increases future immunization compliance.

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POWERPOINT LECTURE SLIDES Common Local and Systemic Reactions to Immunizations • Contraindications to Vaccine Administration o

History of anaphylactic reaction to the vaccine or one of its components

o

Moderate to severe acute illness

o

For specific vaccines, pregnancy or allergy to some components

Immunization schedules •

Agencies involved in development: FDA, CDC, ACIP

•

Purpose

•

o

Recommend schedules for immunizations

o

Ensure infants and children are fully immunized

Annual revision o

Reflect new vaccines and information

Barriers to Immunization Compliance

..

•

Economic factors

•

Limited access to health care

•

Lack of convenient primary care

•

Parental knowledge deficit

•

Religious/cultural prohibitions

Strategies for Increasing the Rate of Immunization Compliance •

Required compliance by insurance/managed care organizations

•

Chart audits

•

Administration of immunizations at healthcare visits, hospitalizations, and schools °

Vaccines can be administered when children have a mild illness

°

Give combinations of vaccines at the same visit

•

Provide parents with information

•

Legal issues °

Informed consent must be obtained before immunization administration

°

Required documentation – Date of administration – Vaccine given – Manufacturer – Lot number and expiration date of vaccine – Site and route of administration – Name, title, and address of person administering vaccine

°

A record of the administration should be given to the patient’s parent

Implement Strategies to Minimize Pain During the Administration •

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Provide local anesthetic

•

Give child as much control as possible

•

Be honest with the child

•

Provide sucrose drink and pacifier if appropriate

•

Use age-appropriate distraction techniques

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide students into pairs. Let them role-play situations where parents are hesitant to allow their child to be immunized. One student can play the role of the parent, the other the role of the nurse.

SUGGESTIONS FOR CLINICAL ACTIVITIES Divide students into groups of two to four. Arrange for them to present information about immunizations to parents at clinics, childcare centers, and other settings where parents of small children gather.

LEARNING OUTCOME 5 Design a plan to maintain the potency of vaccines.

CONCEPTS FOR LECTURE 1. A major nursing role in management of communicable disease is to ensure the vaccine administrated was effective.

2. Nurses should check for damaged vials, syringes, tampered packaging, or exposure to temperature that damages vaccine potency.

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3. Package inserts give information on the proper storage of vaccines.

4. Temperature logs need to be maintained and measures taken to promote consistency of temperature in refrigerators and freezers.

5. Facilities should have an emergency plan for safe storage of vaccines in the event of power outages or natural disasters.

POWERPOINT LECTURE SLIDES Potency of Vaccines • Vaccine storage—exposure to different temperatures may result in damage to vaccine potency •

Nursing role: o

Check for damaged or expired vaccines

o

Store vaccines according to manufacturer guidelines

o

Maintain consistency of temperature, temperature log

o

Ensure emergency power source

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide students into groups and assign groups to review the package inserts of commonly given pediatric vaccines. Student groups can make a list of manufacturer recommendations for storage and report back to the class.

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SUGGESTIONS FOR CLINICAL ACTIVITIES Have students visit clinical sites that routinely give pediatric vaccinations to gather information on each facility’s plan to maintain potency of vaccines given. Students should evaluate each plan’s effectiveness and make suggestions for improvement.

LEARNING OUTCOME 6 Differentiate between common communicable diseases and vector-borne diseases.

CONCEPTS FOR LECTURE 1. Communicable diseases differ in their epidemiology, transmission, and incubation period.

Information about the specifics of each disease is needed by the nurse to plan appropriate care.

2. Communicable diseases can be recognized by clinical signs and symptoms as well as diagnostic tests. Therapies include antipyretics, antibiotics, and antiviral medications.

3. Vector-borne diseases are transmitted by biting insects or animals. Microorganisms spread and multiply, initiating an inflammatory response. Antimicrobials prevent growth or destroy microorganisms.

POWERPOINT LECTURE SLIDES Communicable Disease • Clinical manifestations o

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Nonspecific symptoms

o

Fever (most common)

o

Fatigue

o

Malaise

o Weakness o

Aches

o

Decreased appetite

o

Nausea/vomiting diarrhea

Communicable Disease Diagnostic Tests •

Diagnostic tests o

Cultures: – Bacterial – Viral – Fungal

•

Clinical Therapy o

Antipyretics

o

Antibiotics

o

Antiviral medications

Vector-Borne Illnesses • Transmitted by biting insects or animals

..

•

Microorganisms spread and multiply, initiating inflammatory response

•

Antimicrobials prevent growth or destroy microorganisms

SUGGESTIONS FOR CLASSROOM ACTIVITIES Use the information in Table 22–5 to make a matching game of diseases to their clinical manifestations, clinical therapy, and nursing management. Divide students into groups of four to five to play the game. The game can be played in class or left in a learning lab for students to play after class.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students visit childcare centers or elementary schools to gather information about communicable disease surveillance and policies regarding school attendance after diagnosis of a communicable disease. Have students evaluate the effectiveness/accuracy of these policies.

LEARNING OUTCOME 7 Describe the medical and nursing management of common communicable diseases.

CONCEPTS FOR LECTURE 1. Factors such as age and other illnesses and congenital anomalies increase the risk of the development of complications and sepsis. Nurses should have an increased level of surveillance with these patients.

2. Because children with a communicable disease are usually cared for at home, parents require education related to symptom management, when to call the healthcare provider, and limiting spread of infection. ..

POWERPOINT LECTURE SLIDES Nursing Care Related to Communicable and Vector-Borne Diseases •

•

Assess for and treat general symptoms °

Pain

°

Fever

°

Altered nutritional status

°

Dehydration

°

Toxic appearance

Limit the spread of infection °

Isolate from other children

°

Clean shared items

° Maintain a high level of suspicion when numerous individuals with similar signs and symptoms are seen •

Educate parents °

Symptom management

°

Limiting spread of infection

° When to consult the healthcare provider SUGGESTIONS FOR CLASSROOM ACTIVITIES Choose several communicable diseases and assign small student groups to review the Centers for Disease Control and Prevention website for information on management of specific health ..

threats.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to a pediatric primary care clinic where they are likely to see children with communicable diseases. Have them prepare a plan of care that will be helpful to the parents as they care for their child at home. If possible, arrange for students to visit the child in his or her home in 24 to 48 hours to discuss progression of the child’s illness, management of symptoms, and so forth.

LEARNING OUTCOME 8 Create a parent education session that includes important considerations in administering acetaminophen and ibuprofen to infants and children with a fever.

CONCEPTS FOR LECTURE 1. Nursing care for treatment of fever includes administering antipyretics, removing unnecessary clothing, and careful continued monitoring of the child’s temperature. Identify clear fluids the child prefers to drink, and encourage the intake of extra fluids.

2. Either acetaminophen or ibuprofen may be used to treat a child’s fever, but not both. They should also not be used alternately, because this may increase the child’s risk for renal tubular toxicity. The safest course is to use only one antipyretic at the correct dose and administration interval.

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POWERPOINT LECTURE SLIDES Fever Management •

Treatment includes: °

Administering antipyretics

°

Removing unnecessary clothing

° Monitoring temperature ° •

Encouraging extra fluids

Parent education °

Administer only one antipyretic

°

Correct dose

°

Correct administration intervals

• Acetaminophen °

10 to 15 mg/kg/dose every 4 to 6 hours not to exceed 5 doses in 24 hours (daily maximum for children 12 and older is 4 g)

•

Ibuprofen °

4 to 10 mg/kg/dose every 6 to 8 hours, not to exceed 40 mg/kg daily

SUGGESTIONS FOR CLASSROOM ACTIVITIES Create short scenarios with children of various ages and weights, and have students calculate appropriate dosages and intervals of acetaminophen and ibuprofen.

SUGGESTIONS FOR CLINICAL ACTIVITIES ..

Assign students to a pediatric primary care clinic where they are likely to see children with communicable diseases. Have them prepare a plan of care that will be helpful to the parents as they care for their child at home. If possible, arrange for students to visit the child in his or her home in 24 to 48 hours to discuss progression of the child’s illness, management of symptoms, and so forth.

LEARNING OUTCOME 9 Analyze the pathophysiology of sepsis to guide the nursing assessment of infants and children with this disorder.

CONCEPTS FOR LECTURE 1. Sepsis is a systemic inflammatory response syndrome in the presence of infection. Common causative microorganisms include Group B streptococcus. E. coli, Haemophilus influenza, and staphylococcus.

2. Infants (perinatal through first year of life) are at increased risk for sepsis.

3. Conditions that increase the risk for sepsis include low birth weight, multiple invasive procedures, chronic conditions, burns, invasive catheters, a compromised immune system, and long-term antibiotic use.

4. The consequences of sepsis can be severe and include impeded blood flow, which reduces delivery of oxygen and nutrients throughout the body; leaking capillaries, peripheral edema, and fluid accumulation in the lungs; and vasodilation and constriction resulting in hypoxia and organ dysfunction.

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5. Clinical manifestations vary by age. In newborns, manifestations may be nonspecific, such as feeding problems, vomiting, and diarrhea. Nonspecific respiratory disease or apnea may also signal sepsis, as may hypothermia.

6. Early signs in children include fever or hypothermia; tachycardia or tachypnea; bounding pulses; warm extremities; and altered responsiveness. Late signs in children include hypotension; prolonged capillary refill time; mottled, cool extremities; weak pulses; progressive mental changes; decreasing urine output; and fever or hypothermia.

7. Clinical therapy of children with sepsis focuses on organ preservation and typically includes oxygen administration; aggressive fluid resuscitation; vasopressor medications; antibiotics; cardiovascular monitoring; and temperature regulation.

POWERPOINT LECTURE SLIDES Sepsis

..

•

Systemic inflammatory response syndrome in the presence of infection

•

Infants (perinatal through first year) at high risk

•

Low birth weight, multiple invasive procedures increase infant risk

•

Risk for older infants and children increases in the presence of: o

Chronic conditions

o

Burns

o

Invasice catheters

o

Compromised immuse system

o

Long-term antibiotic use

• Common causative microorganisms o

Group B streptococcus

o

E. coli

o

Haemophilus influenza

o

Staphylococcus

Pathophysiology of Sepsis •

Pathophysiology of sepsis leads to: °

Impeded blood flow, reduced delivery of oxygen and nutrients

°

Leaking capillaries, peripheral edema, fluid accumulation in lungs

°

Vasodilation and constriction resulting in hypoxia and organ dysfunction

Clinical Manifestations of Sepsis •

Newborns o Nonspecific—feeding problems, vomiting, diarrhea o

Hypothermia

o

Nonspecific respiratory disease or apnea

•

Early signs in children o

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Fever or hypothermia

o

Tachycardia, tachypnea

o

Bounding pulses

o Warm extremities o

•

Altered responsiveness Late signs in children

o

Hypotension

o

Prolonged capillary refill time

o

Mottled cool extremities

o Weak pulses o

Progressive mental changes

o

Decreasing urine output

o

Fever or hypothermia

Nursing Care for Children with Sepsis •

..

Clinical therapy focuses on organ preservation o

Oxygen

o

Aggressive fluid resuscitation

o

Vasopressor medications

o

Antibiotics

o

Cardiovascular monitoring

o

•

Assessment o

Vital signs and temperature

o

Intake and output, weight

o

Perfusion, capillary refill time

o

Laboratory tests

o

Change in condition

•

•

..

Temperature regulation

Diagnosis o

Ineffective Thermoregulation

o

Interrupted Breastfeeding

o

Ineffective Protection

o

Deficient Fluid Volume

o

Impaired Gas Exchange

o

Interrupted Family Processes

Planning and implementation o

Administer medications as ordered

o

Monitor for side effects

o

Monitor IV fluid administration carefully

o

Provide support to the parents

o

Discharge planning and parent education

SUGGESTIONS FOR CLASSROOM ACTIVITIES Create short scenarios with children of various ages and backgrounds who have sepsis; have students discuss how to provide support for the parents and family.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to a pediatric hospital setting. Have them observe nurses assessing intake and output and weights. In postconference, discuss students’ observations and the role that these assessments play in promoting care in a child with sepsis.

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CHAPTER 23 −BASE BALANCE LECTROLYTE, AND ACID ALTERATIONS IN FLUID, E Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Formula Preparation Case Study:Dehydration and Fluid Calculation Care Plan:Infant Feeding Media Links:Chemistry Analysis; Acid−Base Tutorial Media Link Applications Videos and Animations:Acid−Base Balance Pediatric Dosage Calculations Image Library Figure 23–4 The major body fluid compartments at various ages.

Figure 23–5 The newborn and infant have a high percentage of body weight composed of water, especially extracellular fluid, which is lost from the body easily.

Figure 23–8 Assessing skin turgor takes skill and practice.

Figure 23–13 With normal capillary dynamics, fluid moves out of the compartment by the force of hydrostatic pressure in the blood vessel and is pulled out by interstitial osmotic pressure.

Table 23-1 Electrolyte Concentrations in Body Fluid Compartments

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Table 23-6 Common Intravenous Solutions, Uses, and Components Table 23-14 Summary of Clinical Assessment of Electrolyte Imbalances Table 23-15 Normal Blood pH and Gases Table 23-16 Causes of Respiratory Acidosis Table 23-17 Laboratory Values in Acid–Base Imbalance Box 23-1 Health Conditions Contributing to Fluid Imbalance Box 23-2 Oral Rehydration and Maintenance Fluids for Mild and Moderate Dehydration Box 23-3 Calculation of Intravenous Fluid Needs Box 23-6 Acid–Base Imbalances

LEARNING OUTCOME 1 Describe normal fluid and electrolyte status for children at various ages.

CONCEPTS FOR LECTURE 1. Body fluid is located in several different compartments. The concentration of body water varies with age. Newborns have the highest percent of body water for weight, and percent body water decreases with age.

2. Intracellular fluid is located inside the cells; extracellular fluid consists of intravascular and interstitial fluid.

3. Body fluid is body water with solutes dissolved in it. Some of the solutes are electrolytes such as sodium (Na+), potassium (K+), calcium (Ca++), magnesium (Mg++), chloride (Cl–), and inorganic phosphorus (Pi). The concentration of the electrolytes differs depending on the

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compartment in which each is located.

4. Fluid and electrolyte shifts occur between compartments in response to metabolic changes in the body’s attempt to maintain homeostasis.

POWERPOINT LECTURE SLIDES Body Fluid Is Body Water with Solutes: Concentration Differs Between the Compartments •

Na+

•

K+

•

Ca++

• Mg++ •

Cl-

•

Pi

Body Fluid •

Intracellular fluid: two-thirds of body water

•

Extracellular fluid: one-third of body water o

Intravascular

o

Interstitial (Figure 23–4)

• Between compartments •

Response to body changes

• Attempt to maintain homeostasis

Fluid Moves by: • Filtration: movement between intravascular and interstitial compartments

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• Osmosis: movement into and out of cells Electrolytes Move by: • Diffusion: movement from greater to lesser concentration •

Active transport: o

Requires metabolic energy

o

Effective against concentration gradient

o

Can move from lesser to greater concentration (Table 23–1)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign the various developmental groups to the students. Have groups of students prepare information on children in that age group. Include normal fluid−electrolyte status for each age group.

SUGGESTIONS FOR CLINICAL ACTIVITIES Include fluid and electrolyte status in the basic assessment of the clinical patient. Check relevant lab values. Compare clinical findings to norms.

LEARNING OUTCOME 2 Identify regulatory mechanisms for fluid and electrolyte balance.

CONCEPTS FOR LECTURE 1. When fluid status is compromised, a number of body mechanisms are activated. Several of these mechanisms occur in the kidneys. The kidneys conserve water and needed electrolytes while excreting waste products and drug metabolites. Children under 2 years have immature kidneys and are unable to conserve or excrete water and solutes effectively. ..

2. The body continuously attempts to compensate for fluid and electrolyte imbalance by shifting fluid and electrolytes from one compartment to another.

3. Extracellular fluid excess or extracellular volume overload in children causes edema. Edema changes the dynamic of the filtration process for blood between the capillaries and the interstitial compartment.

POWERPOINT LECTURE SLIDES Regulatory Mechanisms • Cellular membrane o

Active and passive transport

•

Kidneys

•

Lungs

•

Liver

Body Fluid •

Body water percentage for weight varies with age

•

Newborns have highest percentage of water

•

Percentage decreases with increasing age

Fluid Differences of Children

..

•

Larger proportional weight of brain and skin

•

Larger extracellular fluid percentage

•

Kidneys cannot fully conserve fluid and electrolytes until child is 2 years old o

Greater daily fluid need

o

Newborn: four to five times greater daily water need/kg

o

•

10% sodium excretion ability (Figure 23–5)

Kidney o

Conservation of water and electrolytes

o

Under age 2 unable; kidneys immature

• Shifts of fluid and electrolytes o

From one compartment to another

• Edema o

Changes in filtration process of blood

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign the students to work in groups to develop a flow sheet for the regulatory mechanisms of the body in regard to fluid−electrolyte balance.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students assess the regulatory mechanisms and determine if the child is compensating for fluid−electrolyte problems.

LEARNING OUTCOME 3 Interpret threats to fluid and electrolyte balance in children.

CONCEPTS FOR LECTURE 1. The most common causes for fluid−electrolyte imbalance in children are vomiting, diarrhea, nasogastric suction, hemorrhage, and burns. Vomiting and diarrhea can be so severe that children may die from dehydration.

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2. Newborns and preterm infants are at increased risk for imbalances due to their high percent- age of body water content. With the increased body surface area (BSA) and increased insen- sible water loss, infants are at higher risk for dehydration and imbalances.

3. Nurses must work to maintain fluid balance during times of illness with children. With elevated body temperature and increased respiratory function, illness in a child may result in significant loss and imbalance.

4. Exercise- and heat-related illnesses increase the speed with which dehydration can occur.

5. Multiple factors can be attributed to the increased risk of childhood fluid and electrolyte differences. Health promotion and prevention are key to maintaining appropriate fluid and electrolyte balance.

POWERPOINT LECTURE SLIDES Most Common Causes of Fluid−Electrolyte Imbalance • Extracellular fluid-volume deficit: dehydration • Interstitial fluid-volume excess: edema • Extracellular fluid-volume excess Dehydration •

Isotonic

•

Hypotonic

•

Hypertonic

• Children can have severe complications from dehydration: death can occur Premature and Newborns •

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Increased percent body water

•

Increased percent BSA

• At greater risk for dehydration/imbalances Increased Risk for Dehydration or Imbalances with Mild Illness (Box 23–1) • Increased demand with insensible water loss

•

o

Increased respiratory rate

o

Increased metabolic demands

Increased risk with heat-related illness

• Multiple factors affect fluid−electrolyte imbalance • Key is health promotion and prevention SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups. Assign each group one of the common causes of fluid−electrolyte disturbances in children. Have each group present the clinical manifestations and the disturbances that would occur for the given causes.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students determine if the presenting problems of selected patients manifest in correlation with the identified fluid−electrolyte disturbance.

LEARNING OUTCOME 4 Analyze assessment findings to recognize fluid−electrolyte problems and acid–base imbalance in children.

CONCEPTS FOR LECTURE

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1. Clinical manifestations vary depending on the severity of the fluid−electrolyte or acid–base imbalance.

2. Signs specific to dehydration relate to the degree of body weight lost. The range is mild to moderate to severe. To determine the severity, the percentage of weight loss must be calculated. Skin turgor is a basic assessment tool that can be used quickly to determine the next assessment step. The infant’s urine output should be assessed to monitor for both dehydration and edema.

3. Children may also suffer from fluid-volume excess, presenting with edema. Assess skin turgor, urine output, and signs of fluid-volume overload. Monitor heart and lung sounds for excess pulmonary overload.

4. Electrolyte differences will manifest based on the individual electrolyte imbalance. Clinical manifestations also vary based on the electrolyte being high or low. a.

Sodium imbalances: Hypernatremia manifests with increased thirst, low

urine output, decreased level of consciousness, confusion, lethargy, possible seizure activity; hyponatremia manifests with decreased level of consciousness, anorexia, headache, muscle weakness, decreased deep tendon reflexes, lethargy, confusion, or coma. b.

Potassium imbalances: Hyperkalemia manifests as muscle dysfunction,

hyperactivity of gastrointestinal smooth muscle, intestinal cramping and diarrhea, and possible dysfunction of cardiac muscle and cardiac arrhythmia; hypokalemia manifests as decreased gastrointestinal smooth muscle activity, constipation, weak and unresponsive skeletal muscles, possible cardiac arrhythmia, polyuria, and fa-

..

tigue. Other electrolytes to consider are calcium and magnesium.

5. Acid–base balance is necessary for proper function of cells within the body. Acidemia refers to a decreased blood pH; alkalemia is an increased blood pH. The lungs and kidneys play vital roles in maintaining acid–base balance within the body. The assessment findings will differ based on etiology of acid–base imbalance—either respiratory or metabolic. Manifestations of respiratory acidosis are confusion, lethargy, headache, increased intracranial pressure, or coma. Respiratory alkalosis presents as a child with neuromuscular irritability and paresthesias in the extremities and around the mouth, muscle cramping and carpal or pedal spasm, and dizzy or confused state. Metabolic acidosis most often manifests by attempts of the body to compensate with increased respiratory rate and depth and, if severe, may demonstrate peripheral vascular resistance and cardiac arrhythmia. Metabolic alkalosis manifests with a decrease in respiratory rate and depth; increased neuromuscular irritability, cramping, paresthesias, tetany, seizures, and excitation may all occur.

POWERPOINT LECTURE SLIDES Fluid−Electrolyte Imbalance: Dehydration (Figure 23–13) • Mild • Moderate • Severe • Fluid−volume excess o

Assessment findings

• Weight gain • Skin turgor (Figure 23–8) • Edema

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• Urine output • Normal urinary output = 0.5 to 1 mL/kg/hr for children, 2 mL/kg/hr for infants Normal Fluids and Electrolytes • Fluid balance: homeostasis of body fluids and electrolytes •

Electrolytes: cations and anions

•

Extracellular and intracellular balance needed o

Sodium: ECF > ICF

o

Potassium: ECF < ICF

• Balance required for normal cell function •

Cations

•

Anions

Electrolyte Imbalances (Table 23–14) • Clinical manifestations •

Based on individual electrolytes o

Sodium

o

Potassium

o

Calcium

o

Magnesium

Acid−Base Imbalances (Table 23–15; Table 23–17; Box 23–6) • Clinical manifestations

..

•

Based on type of imbalance

•

Respiratory acidosis (Table 23–16)

•

Respiratory alkalosis

•

Metabolic acidosis

•

Metabolic alkalosis

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students, either individually or in groups, a case study. Given the pertinent data of the case study, assign the students the task of determining the correct imbalance.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students perform a complete assessment and review any assessment on patients with imbalances. Assign arterial blood gases to students in pre- or postconference and discuss correlation of ABG with clinical presentation and assessment findings.

LEARNING OUTCOME 5 Integrate assessment information to plan appropriate interventions for children experiencing fluid−electrolyte problems and acid–base imbalance.

CONCEPTS FOR LECTURE 1. Fluid−electrolyte imbalance interventions are based on degree of severity. Clinical therapies for dehydration include oral rehydration or intravenous fluids. The type and amount of fluid will be based on degree of severity. Fluid needs should be calculated and monitored so the child does not become fluid overloaded. Once the dehydration is controlled, the etiology for the dehydration should be addressed. Clinical management for fluid overload should address the cause and focus on prevention of complications from edema.

2. Treatment for electrolyte imbalances should be based on reversal of the imbalance and man-

..

agement of the cause. Ensure patient safety and prevention of further imbalance. Discharge teaching and home care/follow-up should be considered.

3. Management of acid–base imbalances should be to identify those children at risk for an imbalance and educate the caregivers to prevent when possible. Acute care should focus on returning the child to the appropriate acid–base balance and treatment of the etiology.

POWERPOINT LECTURE SLIDES Acid−Base Imbalance (Box 23–3; Box 23–2; Table 23–6) • Interventions based on etiology • Education on prevention Treatment of Etiology of Imbalance • Ensure patient safety • Prevention of recurrence • Discharge teaching • Home care and follow-up SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students, individually or in groups, case studies of patients with fluid and/or electrolyte imbalances. Have the students develop care plans that include goals/outcomes, interventions, and rationales based on assessment of the case studies.

SUGGESTIONS FOR CLINICAL ACTIVITIES Review hospital policy for care of children with imbalances. Discuss ways interventions may be completed to have the best possible outcome in a child with anf imbalance.

..

CHAPTER 24 EAR, NOSE, AND THROAT FUNCTION ALTERATIONS IN ,EYE Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Plan a Vision-Screening Program Case Study:Otitis Media Media Links:Vision Impairment Resources; Hearing Impairment Resources Media Link Applications Videos and Animations:Middle Ear Dynamics; Ear (3D); Eye (3D); Ear Abnormalities; Ear Anatomy; Otitis Media; Nursing in Action: Child with a Sore Throat; Nursing in Action: Ophthalmic, Otic, and Nasal Medication Administration

Pediatric Dosage Calculations Image Library Figure 24–2 Of the three anatomic differences in the eustachian tube between adults and small children (shorter, wider, more horizontal), which do you think could cause more problems for the child and why?

Figure 24–3 Acute conjunctivitis.

Figure 24–4 In hyperopia, light rays focus behind the retina, making it difficult to focus on ob-

..

jects at close range.

Figure 24–7 Acute otitis media is characterized by abrupt onset, pain, middle ear effusion, and inflammation.

Figure 24–8 Otitis media with effusion is noted on otoscopy by fluid line or air bubbles.

Table 24–4 Assessment Questions for Identifying Visual Disturbances in Children Table 24–5 Healthy People 2020 Objectives Related to Vision in Children Table 24–13 Communication Techniques for Children Who Are Hearing Impaired Table 24–14 Healthy People 2020 Objectives Related to Hearing in Children BOX 24–6 Cochlear Implants

LEARNING OUTCOME 1 Identify anatomy and physiology, as well as pediatric differences in the eyes, ears, nose, and throat of children and adolescents.

CONCEPTS FOR LECTURE 1. The eye is a complex structure composed of the eyeball and its supporting structures. A series of six muscles allows the eye to move in all planes and maintain the shape of the eyeball. These muscles are innervated by oculomotor, trochlear, and abducens nerves (CN III, VI, VI).

2. The outermost layer of the eyes is the sclera, while the innermost posterior section of the

..

eye is the retina. Visual images are transmitted to the retina via the pupil and lens. The pupil regulates the light that enters the eye while the lens focuses light on the retina. Light images from the lens are processed by the inner layer of the retina. The rods in the inner layer of the retina perceive dim and peripheral vision while the cones perceive bright and color vision.

Once the image is processed by the inner layer of the retina, the outer neural layer of the retina transports the image to the brain via the optic nerve (CN II).

3. Visual acuity in neonates ranges between 20/100 and 20/400 because the lens is more spherical and cannot accommodate to both near and far objects. By the age of 7, most children have a visual acuity of 20/20. Transient nystagmus and esotropia (turning inward of the eye) are commonly noted in newborns because the rectus muscle is not fully functional. The eyes should be aligned and movement coordinated by 3 months of age. Eye color changes during the first 6 months of life, and the eyeball continues to grow until the third year of life.

4. The ear is responsible for hearing and equilibrium. Sound waves are directed to the middle and inner ear by the auricle, external canal, and tympanic membranes. The middle ear lies behind the tympanic membrane and contains the three bones necessary for sound vibrations and the eustachian tube. Middle-ear pressure is controlled by the eustachian tube. The inner ear contains the vestibule, semicircular canals, and the cochlea. The vestibule and semicircular canals are responsible for the sense of equilibrium, while the cochlea contains the sensory hair cells that active the acoustic nerve (CN VIII).

5. The eustachian tube is proportionately shorter, wider, and more horizontal in infants than in older children and adults, placing the younger child at risk for an ear infection. Auditory nerve function is mature at 5 months of age.

..

6. Mucous membranes line the nose, throat, and mouth. These membranes help to maintain hygiene and protect the body from infectious agents. Taste buds and the salivary apparatus can be found in the mouth. The nasal passages contain the external nostrils, the sinuses, and the throat. Coordinated swallowing, the gag reflex, and the senses of smell and taste are the responsibility of the olfactory, facial, glossopharyngeal, and vagus nerves (CN I, VII, IX, X).

7. Infants are primarily nasal breathers until 6 months of age. Edema and nasal drainage can interfere with the infant’s ability to breathe and feed. Although tonsils vary in size during childhood, they are normally large in school-age children. Taste discrimination increases during childhood. By 6 months of age, the first tooth has emerged, and by 2 years of age all of the primary teeth are present. Secondary teeth erupt during the school-age years.

POWERPOINT LECTURE SLIDES Eye Anatomy •

Eyeball

• Extraocular muscles o

•

Sclera

•

Pupil

•

Lens

•

Retina o

..

Cranial nerves 3, 6, 7

Inner layer

o

-

Rods

-

Cones

Outer layer -

Optic nerve (CN II)

Ear Anatomy •

External ear o

Auricle

o

External canal

o

Tympanic membrane

• Middle ear o

Incus

o Malleus o Stapes o Eustachian tube •

Inner ear o

..

Bony labyrinth -

Vestibule

-

Semicircular canals

-

Cochlea (organ of Corti)

Anatomy of the Nose, Throat, and Mouth • Mucous membranes •

Salivary apparatus

•

Taste buds

•

Nasal passages o

External nostrils

o

Sinuses

o

Pharynx (throat)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Review basic assessment of eyes, ears, nose, throat, and mouth. Have students identify how the assessment findings differ between adults and children.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Assign the students to a clinical site (well-child clinic, dental clinic) that provides pediatric eye and/or dental screenings.

•

Ask students in preconference to assess their pediatric patient’s auditory and vision capabilities and dental status (number of primary or secondary teeth, dental hygiene practices).

Have students report their findings in postconference.

..

LEARNING OUTCOME 2 Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

CONCEPTS FOR LECTURE 1. Abnormalities of the eye include infection disorders and visual disorders. Conjunctivitis of the eye has multiple etiologies: bacterial, viral, chemical, and allergic. Nurses should have familiarity with the normal eye. Periorbital cellulitis is an infection of the eyelid and surrounding tissues that is usually caused by bacteria and most often seen in school-age children. Visual disorders of the eye include hyperopia, myopia, astigmatism, strabismus, amblyopia, cataracts, glaucoma, and retinoblastoma. Color blindness is an inherited disorder that presents most often in males. Retinopathy of prematurity (ROP) occurs when immature blood vessels constrict and become necrotic and is related to premature births and injury of the retina. ROP can be treated but may not be fully resolved.

2. Disorders of the ear include otitis media, otitis externa, and hearing impairment. Otitis media can be associated with viral or bacterial infections. Children are more prone to middle-ear infections due to the width, length, and position of the eustachian tube. Frequent middle-ear infections or chronic effusion in the middle ear can lead to hearing impairment. Children may also be born or develop hearing impairment from other external etiologies.

3. A variety of disorders affect the nose, throat, and mouth. Epistaxis, or nosebleed, is common in school-age children. Nasopharyngitis, or the common cold, affects the nasal and throat passages. Pharyngitis is a bacterial or viral infection of the throat area that can affect the tonsils. Sinusitis affects the inner connections continuous with the nasal and respiratory tracts.

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4. Mouth and dental emergencies occur in children, often related to sporting activities. Children may also develop mouth ulcers, often associated with specific medications or diseases.

POWERPOINT LECTURE SLIDES Disorders of Eye (Figure 24–3) •

Infectious disorders °

Conjunctivitis -

Chemical

-

Bacterial

-

Viral

-

Allergic

•

Periorbital cellulitis

•

Visual disorders °

Disorders of refraction -

Hyperopia (Figure 24–4)

-

Myopia

-

Astigmatism

° Muscular or anatomic abnormalities

..

-

Strabismus

-

Amblyopia

-

Cataracts

-

Glaucoma

-

Retinoblastoma

°

Color blindness

°

Retinopathy of prematurity (ROP)

o

Visual impairment

o

Injuries of the eye

Disorders of Ear (Figure 24–2) •

Otitis media

•

Otitis externa

•

Hearing impairment

•

Injuries of the ear

Disorders of Nose and Throat •

Epistaxis

•

Nasopharyngitis

• Sinusitis •

Pharyngitis

•

Tonsillitis and Adenoiditis

Disorders of Mouth

..

• Mouth ulcers •

Mouth and dental emergencies

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign each group an ear, eye, mouth, or dentition disorder. Ask the group to present the definition, etiology and pathophysiology, clinical manifestations, diagnostic tests, and nursing management for the disorder/abnormality.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Arrange for students to observe at a pediatric clinic/office that specializes in eye or ear/nose/throat medical care.

•

Review basic assessment of eyes, ears, nose, throat, and mouth. Have students identify how the assessment findings would differ between adults and children.

LEARNING OUTCOME 3 Plan for screening programs and identification of children with vision and hearing abnormalities.

CONCEPTS FOR LECTURE 1. As children grow, their vision improves and should be 20/20 by the age of 7 years. Most children undergo a visual acuity screening test during well-child checks as soon as they can cooperate. Once children have reached school age, they are screened every 2 to 3 years. Simple questionnaires may be used to identify children who need further screening or assessment. If a child does not pass a visual screening, refer the child to a healthcare provider for ..

follow-up. Infants and young children should be examined for the presence of the red reflex.

2. Hearing screens may start after birth prior to discharge from the hospital. Many states have enacted laws requiring newborns to be screened after birth. Universal screening of all infants is recommended before 1 month of age. Caregivers should be educated to observe the child for language milestones and response to noise. Children who have clinical presentation suggestive of hearing loss or chronic ear infections/middle-ear effusion may need specific testing to rule out a hearing deficit.

POWERPOINT LECTURE SLIDES Vision Screening •

20/20 by age 6 or 7 (visual acuity)

•

Screening starts at well-child exams when cooperative (screening timing and frequency)

•

•

Screening tools o

Questionnaire available for use (Table 24–4)

o

Cover–uncover test

o

Red reflex exam using ophthalmoscope

Follow-up referral for failure of screening

Hearing Screening •

Infant in hospital o

..

Screening timing and frequency

o

Many states mandate

•

Observation for cues to hearing

•

Clinical manifestations

• Screen for communication development at each well-child visit Risk Factors •

Chronic ear infections

•

Chronic fluid/effusion

•

Follow-up needed for hearing deficit

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign the students to work in pairs. Ask the pairs to develop specific ways to perform screening on children of various ages. Ask the students to seek information on which facilities provide visual and hearing screening to children within the community. Locate community resources that may be utilized.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Assign the students to work in pairs. Ask the pairs to perform vision and hearing screening on their partner. Have the students identify any vision or hearing deficits and discuss how performing screenings on children would differ and ways to interact with children to gain cooperation for the screening process.

•

Assign the students to a clinical rotation that provides screenings, such as a local school or free health clinic. The students may participate in the screenings for a day.

..

LEARNING OUTCOME 4 Integrate evidence-based research to plan comprehensive nursing care for children with vision or hearing impairments.

CONCEPTS FOR LECTURE 1. Visual impairment should be identified and treated promptly. Clinical therapy will vary depending on the type of visual impairment. Children with strabismus or amblyopia may be treated with occlusion or vision therapy and compensatory lenses. Other options are available for treatment based on the severity of the disease state.

2. Compensatory lenses are prescribed for many visual disorders, particularly refractive disorders. Nursing care should be focused on careful eye examination and ruling out other abnormalities with the light reflex test, cover–uncover test, and visual acuity test.

3. For a child with significant visual impairments, planning should be done in collaboration with the caregiver to encourage use of all senses, promote socialization, and provide community and emotional support.

4. Therapy for a hearing deficit will be based on the degree of deficit and functioning of the child. If hearing loss is permanent, a multidisciplinary team including a pediatrician, audiologist, otolaryngologist, speech-language pathologist, nurse, teacher, and social worker should assist the child and family to adapt to the disability.

..

5. For a child with a significant hearing impairment, planning should be done in collaboration with the caregiver to facilitate the child’s ability to receive and send the spoken word or in- formation, meet the child’s educational needs, and provide emotional support.

POWERPOINT LECTURE SLIDES Visual Impairment •

Therapy dependent on type °

Refractive disorders -

°

•

Compensatory lenses

Strabismus and amblyopia -

Occlusion therapy or vision therapy

-

Compensatory lenses

Nursing care °

Eye examination -

Light reflex test

-

Cover−uncover test

-

Visual acuity test

Hearing Impairment

..

•

Therapy considerations

•

Follow-up needed for permanent loss

• Multidisciplinary team

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students develop care plans for each type of visual and hearing impairment. The assignment may be done in groups or individually. If completed in group format, the students may present and discuss how each of the disorders requires slight changes in the care plan.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign the students to observe for a day in the ophthalmology clinic or an ENT clinic.

LEARNING OUTCOME 5 Apply current recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

CONCEPTS FOR LECTURE 1. Care for abnormalities of the eyes includes use of antibiotic eye medication for bacterial conjunctivitis, specifically fluoroquinolones when possible. Provide supportive care for viral and allergic conjunctivitis. Periorbital cellulitis requires treatment with oral or intravenous antibiotics. Other eye disorders may require occlusion therapy, compensatory lenses, surgery, or vision therapy. Treatment is tailored to the disorder. The nurse should refer families to the care of an eye specialist for in-depth diagnosis and a treatment plan.

2. Disorders of the ear require visual exam of the ear, canal, and tympanic membrane. Diagno-

..

sis of otitis media is treated with oral antibiotic therapy if not improving within 3 days of onset. Children with recurrent infections may be referred for tympanostomy tube placement by an ENT. Otitis externa is treated with antibiotic eardrops. Education on potential causes and ways to reduce the incidence of acute otitis media and otitis externa should be provided by the nurse.

3. A child with significant sensorineural hearing loss or who is deaf may be a candidate for a cochlear implant. Other methods may be utilized to communicate with children who are hearing impaired, such as lip reading, sign language, cueing, and finger spelling. Children with a conductive loss may have hearing aids.

4. Recommendations for management of nasopharyngitis, pharyngitis, tonsillitis, and sinusitis should be focused on supportive care and alleviation of the associated symptoms. Antibiotic therapy is not indicated unless there is a known bacterial cause or confirmation. A tonsillectomy is often recommended when children have recurrent throat infections, chronic tonsillitis, or obstructive sleep apnea.

5. Mouth ulcers are treated symptomatically and encouragement should be given to keep the mouth clean until healed. Dental emergencies should be managed on an individual basis. The mouth is highly vascular and may bleed with small injuries. Depending on the severity, emergency medical treatment may be indicated or an emergency dental visit if possible.

POWERPOINT LECTURE SLIDES Abnormalities of Eyes •

Conjunctivitis °

..

Bacterial

°

Viral and allergic -

•

Supportive care

Periorbital cellulitis °

•

Antibiotic eye drops

Oral or intravenous antibiotics

Other disorders ° Multiple types of treatments based on etiology

°

-

Occlusion therapy

-

Compensatory lenses

-

Surgery

-

Vision therapy

Refer to eye specialist

Abnormalities of Ears •

•

Otitis media (Figures 24–7 and 24–8) °

Antibiotic usage

°

Supportive care

Recurrent otitis media or effusion °

•

..

ENT referral for possible tympanostomy tube placement

Otitis externa

° •

Antibiotic ear drops

Hearing loss o

Sensorineural -

o

Cochlear implant (Box 24–6)

Conductive -

Hearing aids

-

Communication devices (Table 24–13)

Abnormalities of Nose and Throat •

Collaborative care includes antibiotics if bacterial in etiology °

Nasopharyngitis

°

Pharyngitis

°

Tonsillitis

°

-

Tonsillectomy

-

Criteria for surgery

Sinusitis

Abnormalities of Mouth • Mouth ulcers ° •

..

Treat symptomatically

Dental emergencies

°

Treat based on severity of injury

SUGGESTIONS FOR CLASSROOM ACTIVITIES Using the groups assigned in Learning Outcome 2, have the groups continue the care plan to include the most current treatment recommendations.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students explore the current trends in the local area for treatment of abnormalities, and compare the area trends for treatment with the recommended published guidelines.

LEARNING OUTCOME 6 Prioritize preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

CONCEPTS FOR LECTURE 1. When eye abnormalities are found on screening, the nurse refers families to the care of an eye specialist. Nurses who provide screening should follow the Healthy People 2020 objectives for vision related to guidelines for evaluation of screening programs. A primary intervention is prevention education. Nurses should make attempts to prevent ROP in premature infants by checking ventilation equipment functioning and oxygen saturation levels. Education and encouragement to use protective eyewear in situations that place vision at risk is appropriate. Sports-related injuries and activities and working with chemicals or tools are examples.

..

2. Protection for the ear should include education related to the Healthy People 2020 objectives for hearing in children. Prevention should focus on hearing screening at appropriate intervals, reducing the incidence of otitis media, increasing access to care for persons who have hearing impairments, increasing frequency of routine hearing assessments, and reducing noiseinduced hearing loss in children and adolescents.

3. Prevention and treatment of nose, throat, and mouth abnormalities should address the need to prevent the spread of communicable diseases such as nasopharyngitis and tonsillitis. Home care such as humidification and proper use of over-the-counter medications should be discussed with caregivers. Injury prevention and care for dental emergencies such as tooth avulsion is integrated into the care plan and education for caregivers.

POWERPOINT LECTURE SLIDES Eye Abnormalities •

Referral to eye specialist

•

Screening based on Healthy People 2020 guidelines (Table 24–5)

•

Primary intervention is prevention °

ROP interventions and prevention strategies

•

Protective eyewear

Ear Abnormalities •

..

Prevention screening o

Healthy People 2020 hearing objectives (Table 24-14)

o

Screening

• Prevention focus o

Decrease otitis media

o

Increase access to care

o

Increase frequency of hearing screens

o

Reduce noise-induced hearing loss

Nose, Throat, and Mouth Abnormalities •

Prevention measures

• Education to prevent communicable diseases • Home care for common communicable diseases •

Injury prevention

•

Dental emergencies °

Tooth avulsion

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students discuss the Healthy People 2020 objectives and ways that nurses may support the objectives for vision and hearing. Develop specific interventions and preventions to meet the ob- jectives.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign the students to interview caregivers who seek home remedies or alternative therapies that may be used in the child’s home.

..

CHAPTER 25 ALTERATIONS INRESPIRATORY FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Teaching Plan for Dust Mite Control; Using a Matrix as an Educational Approach to Asthma Care Plan:The Child with Cystic Fibrosis Media Links:Asthma Resources; Cystic Fibrosis Resources and Support Media Link Applications Videos and Animations:Carbon Dioxide Transport; Gas Exchange in the Lungs; Child Receiving Intubation; Nasal/Oral Suctioning; Pulse Oximetry and Oxygen Delivery Systems: Nasal Cannula; Cardiorespiratory Monitor; Tracheostomy Care; Pediatric Respiratory Emergency Management; Asthma; Alternative Asthma Treatments and Passive Smoke Exposure; Cystic Fibrosis Pediatric Dosage Calculations

Image Library Figure 25–1 It is easy to see that a child’s airway is smaller and less developed than an adult’s airway, but why is this important?

..

Figure 25–2 In children, the trachea is shorter and the angle of the right bronchus at bifurcation is more acute than in the adult.

Figure 25–3 The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm.

Figure 25–4 The chest wall is flexible in infants and young children because the chest muscles are immature and the ribs are cartilaginous.

Figure 25–5 An aspirated screw is clearly visible in the child’s left mainstem bronchus on this chest radiograph.

Figure 25–7 A ventilation-perfusion mismatch can occur when an infant or child has an abnormal distribution of ventilation or perfusion.

Figure 25–18 GUIDELINES FOR A CHILD WITH A RESPIRATORY Digital clubbing.

Table 25–1 Assessment Condition Table 25–4 Summary of Acute Infectious Upper Airway Disorders Table 25–9 Assessing Peak Expiratory Flow Rate (PEFR) Box 25–1 Guidelines for Increasing the Accuracy of Pulse Oximetry Readings Clinical Manifestations: Respiratory Failure and Imminent Respiratory Arrest Partnering with Families: Using a Peak Expiratory Flow Meter

..

LEARNING OUTCOME 1 Describe unique characteristics of the pediatric respiratory system’s anatomy and physiology and apply that information to the care of children with respiratory conditions.

CONCEPTS FOR LECTURE 1. A child’s respiratory tract continues to grow and change until about 12 years of age.

2. A child’s trachea is shorter and smaller in diameter than an adult’s trachea. The diameter does not begin to increase in size until approximately 5 years of age.

3. Airway resistance is increased in children.

4. The lower airway continues to proliferate, with the number of alveoli increasing and continuing to develop until puberty.

5. Children under the age of 6 years are dependent on the diaphragm for respirations.

POWERPOINT LECTURE SLIDES Pediatric vs. Adult Respiratory System Anatomy and Physiology

..

•

Anatomy of airway

•

Comparison of airway structures (Figure 25–1)

•

Upper airway differences °

Airway diameter (Figure 25–3)

°

Position of trachea (Figure 25–2)

•

°

Position of right mainstem bronchus

°

Airway resistance

Lower airway differences °

•

Diaphragm use for respirations °

•

Growth of alveoli

Use of accessory muscles

Immaturity of respiratory system

SUGGESTIONS FOR CLASSROOM ACTIVITIES Discuss the model picture of the child versus the adult airway, paying special attention to the differences and the impact the changes have on the respiratory system.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have clinical models, an adult and a child, present to perform respiratory assessments on the two varying age groups. Identify how the assessment varies based on size of the child.

LEARNING OUTCOME 2 Contrast respiratory conditions and injuries that can cause respiratory distress in infants and children.

CONCEPTS FOR LECTURE

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1. Airway obstruction occurs with blockage of the air passages in the respiratory tract; air exchange is slowed or stopped and respiratory distress occurs.

2. Foreign-body aspiration is a common cause of respiratory distress (Figure 25–5).

3. Acute respiratory distress syndrome (ARDS) occurs from several conditions and results in hypoxemia, hypercapnia, and eventual hypoxia.

4. Several examples of conditions causing ARDS are sepsis, pneumonia, meconium aspiration, gastric content aspiration, smoke inhalation, and near drowning.

5. Apnea, the cessation of respiration for longer than 20 seconds, may be the first sign of respiratory dysfunction in the neonate. Apnea may be central, obstructive, or mixed.

6. Two types of apnea occur during infancy: apnea of prematurity and apparent life-threatening events. Apnea of prematurity is often associated with immature respiratory control. An apparent life-threatening event (ALTE) is defined as a frightening episode of apnea accompanied by a skin color change.

7. Sudden infant death syndrome (SIDS) is the sudden death during sleep of an infant under 1 year of age that remains unexplained after a thorough investigation. It occurs most frequently in infants between 2 and 4 months of age. Parent education is essential to decreasing a child’s risk for SIDS. POWERPOINT LECTURE SLIDES Respiratory Conditions and Injuries

..

•

Airway obstruction

•

Blockage of airway passages by different causes

° •

Foreign-body aspiration (Figure 25–5)

Acute respiratory distress syndrome (ARDS) (Figure 25–7)

• Multiple factors may cause ARDS °

Sepsis

°

Pneumonia

° Meconium aspiration °

Gastric content aspiration

°

Smoke inhalation

°

Near drowning

Apnea in Infants and Children •

Cessation of respirations for longer than 20 seconds

•

Obstructive apnea

•

Central apnea

• Mixed apnea • Apnea of prematurity •

Apparent life-threatening events

Apnea Monitors • Polysomnography Sudden Infant Death Syndrome

..

• The sudden death during sleep of an infant under 1 year of age that remains unexplained after a thorough investigation •

Most SIDS deaths occur in infants between 2 and 4 months of age

•

Parent education related to prevention o

Back to Sleep

o

Avoid loose bedding, toys, pillows

o

Discourage co-sleeping

o

Use of pacifier during sleep

o

Smoking increases risk

SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Review basic CPR for obstruction and breathing difficulties. Discuss teaching for parents of toddlers about aspiration of foreign bodies, and develop a plan for teaching how to determine if an object is the correct size for a child using the toilet paper holder method.

•

In small groups have students develop teaching plans for parents on SIDS prevention. Have groups develop a teaching plan for one of the following: o

A married couple who both work who will be hiring a nanny

o

A single mother who will be enrolling her baby in a home child care

o

A small group of parents whose babies have just been born and are being readied for discharge

o

A large group of parents who are taking parenting classes at a local agency

SUGGESTIONS FOR CLINICAL ACTIVITIES

..

Spend the day in an acute care unit assisting with the care of children who have presented with acute respiratory conditions.

LEARNING OUTCOME 3 Distinguish between mild, moderate, and severe respiratory distress, and plan the appropriate nursing care for each level of respiratory distress severity.

CONCEPTS FOR LECTURE 1. Visual assessment is the first step for evaluation of respiratory status.

2. Complete a full respiratory assessment utilizing the guidelines for a child in respiratory distress (Table 25–1).

3. Clinical manifestation of respiratory distress for a child may include dyspnea, tachypnea, nasal flaring, and retractions (Figure 25–4).

4. The depth and location of retractions are associated with the severity of respiratory distress.

5. Negative pressure created by the movement of the diaphragm to draw in air is increased and the chest wall is pulled inward, causing the retractions. Intercostal retractions are seen in mild respiratory distress. As the distress increases to moderate, the child will have substernal and subcostal retractions. In severe distress, retractions occur in the supraclavicular and suprasternal areas along with use of accessory muscles.

6. Assessment of the child should include quality of respirations, quality of pulse, color, cough, behavior change, and signs of dehydration to assist in determining the level of severity.

7. Nursing care should be focused on determining the cause and alleviating it if possible, such ..

as with a foreign body. Maintain adequate airway, breathing, and circulation. Provide supplemental oxygen as needed and supportive care.

8. Diagnostic tests to determine oxygen saturation include pulse oximetry readings and arterial blood gases.

9. Radiograph findings may indicate the cause of respiratory problems, such as with epiglottis, meconium aspiration syndrome, or pneumonia.

10. Pulmonary function studies may be completed, such as forced vital capacity (FVC), peak expiratory flow rate (PEFR), and forced expiratory volume in 1 second (FEV1), for chronic respiratory conditions.

POWERPOINT LECTURE SLIDES Full Respiratory Assessment (Table 25–1) Clinical Manifestations of Respiratory Distress •

Dyspnea

•

Tachypnea

•

Grunting

•

Nasal flaring

•

Retractions (Figure 25–4)

Assessment of Respiratory Status

..

•

Quality of pulse

•

Quality of respirations

•

Color

•

Cough

•

Behavior changes

•

Signs of dehydration

Nursing Care (Respiratory Failure and Imminent Respiratory Arrest) • ABC—airway, breathing, circulation •

Determine if cause can be alleviated °

•

Foreign body

Supportive care °

Supplemental oxygen

Pulmonary Function for Chronic Conditions •

Force vital capacity (FVC)

•

Peak expiratory flow rate (PEFR) (Partnering with Families)

•

Forced expiratory volume in 1 second (FEVI)

SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Use pictures to demonstrate the various clinical presentations for respiratory distress.

•

Demonstrate respiratory assessment. Demonstrate the use of peak flow meters and have students determine the functional status of a case study patient based on results using the green, yellow, red zone chart.

..

SUGGESTIONS FOR CLINICAL ACTIVITIES If a student has a child patient with noted clinical manifestations of respiratory distress, have the other students observe if possible and discuss the severity based on presentation.

LEARNING OUTCOME 4 Assess the child’s respiratory status and analyze the need for oxygen supplementation.

CONCEPTS FOR LECTURE 1. Diagnostic tests to determine oxygen saturation include pulse oximetry and arterial blood gases.

2. Pulse oximetry provides a transcutaneous estimate of the hemoglobin saturated by oxygen (SpO2), and it is expressed as the percentage of hemoglobin capable of transporting oxygen.

Pulse oximetry helps to assess oxygenation, but not ventilation, and it helps determine when an arterial blood gas is needed.

3. Arterial blood gases assist in the interpretation of acidosis and alkalosis that must be considered simultaneously with assessment of oxygenation status. Hypercarbia in the presence of acidosis is a sign of respiratory failure. Hypoxemia unresponsive to supplemental oxygen is also a sign of respiratory failure.

4. Supplemental oxygen is indicated when the child’s SPO2 level is less than 92%. Children receiving supplemental oxygen are monitored with pulse oximetry and arterial blood gases.

Humidified oxygen may be needed.

..

POWERPOINT LECTURE SLIDES Diagnostic Tests to Determine Oxygen Saturation •

Pulse oximetry (Box 25–1)

•

Arterial blood gases

Supplemental Oxygen • Indicated when SPO2 level < 92% • Monitor with pulse oximetry and blood gases • Humidified oxygen may be needed SUGGESTIONS FOR CLASSROOM ACTIVITIES Using a mannequin, demonstrate and practice use of a pulse oximeter.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students observe use of a pulse oximeter and review arterial blood gas reports on children as appropriate as well as nursing interventions that were provided relevant to assessment data and/or the use of supplemental oxygen. Discuss students’ findings in postconference.

LEARNING OUTCOME 5 Differentiate between the signs and symptoms of a child with an upper airway and lower airway respiratory condition.

CONCEPTS FOR LECTURE

..

1. Respiratory disorders that involve the upper airway include croup syndromes, laryngotracheobronchitis, epiglottitis, and bacterial tracheitis. Upper airway disorders are characterized by inflammation and swelling of the pharynx and surrounding tissues. Clinical manifestations vary according to severity.

2. Upper airway disorders may be viral or bacterial in etiology. Some may be life threatening if not treated promptly. Epiglottitis is the most life threatening, progressing within hours; it may progress to a completely obstructed airway.

3. Lower airway disorders include neonatal respiratory distress syndrome, meconium aspiration syndrome, transient tachypnea of the newborn, bronchitis, bronchiolitis and respiratory syncytial syndrome, pneumonia, and tuberculosis.

4. Common clinical manifestations of lower respiratory disorders in infants include nasal flaring, retractions, grunting, irritability, and tachypnea.

5. Other signs/symptoms of lower airway disorders include crackles, wheezing, labored breathing, dyspnea, cyanosis, and coughing (bronchitis, pneumonia, tuberculosis).

POWERPOINT LECTURE SLIDES Upper Airway Disorders •

Croup syndromes

•

Laryngotracheobronchitis

•

Epiglottitis

•

Bacterial tracheitis

• Characterized by inflammation and swelling of pharynx, surrounding tissues

..

• Clinical manifestations vary according to severity (Table 25–4) Lower Airway Disorders •

Neonatal respiratory distress syndrome

• Meconium aspiration syndrome •

Transient tachypnea of the newborn

•

Bronchitis

•

Bronchiolitis and respiratory syncytial virus

• Pneumonia •

Tuberculosis

• Common clinical manifestations—infants o

Nasal flaring

o

Retractions

o

Grunting

o

Irritability

o

Tachypnea

o

Crackles

o

Labored breathing, dyspnea

o Wheezing o

..

Cyanosis (with increased severity)

o

Cough (bronchitis, pneumonia, tuberculosis)

• Respiratory distress uncommon with TB SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students into groups and have each group present information on a specific upper or lower airway disorder. Have groups develop one general care plan for all upper airway disorders or all lower airway disorders and then determine if each group’s specific disorder would have any variance from a basic upper airway disorder or lower airway disorder care plan.

SUGGESTIONS FOR CLINICAL ACTIVITIES Make clinical assignments to include care of children with upper airway disorders or lower airway disorders when appropriate.

LEARNING OUTCOME 6 Create a nursing care plan for a child with a common acute respiratory condition.

CONCEPTS FOR LECTURE 1. Determine the baseline respiratory function for the child and set goals to return to baseline.

Provide support as needed to maintain appropriate oxygenation. Continue to reevaluate to determine appropriate pulmonary therapies until the child has returned to baseline status.

2. Children have increased need for calories and fluid during acute illness. Encourage fluid and nutrition intake to meet increased metabolic demands and insensible water losses.

3. Children and family members often have anxiety and fear during periods of illness. Anxiety

..

can often increase oxygen needs, having a negative impact on respiratory status.

4. Assessment of teaching needs for parents and children should be completed to determine educational interventions. Discharge planning and/or home care teaching may include needs for home therapies until resolution of the acute phase. Teaching should include the possibility that all symptoms may not resolve for weeks.

POWERPOINT LECTURE SLIDES Respiratory Assessment •

Determine baseline status of child

•

Provide pulmonary therapies as needed

• Maintain oxygenation Increased Metabolic Activity •

Increased need for calories/nutrition

•

Increased need for fluid

Anxiety and Fear Common •

Psychosocial support for parent

•

Psychosocial support for child

Discharge Planning

..

•

Education about duration of illness

•

Need for follow-up

• When to seek emergency care Home-Care Planning •

Education of parents/child about home therapies

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students into groups and have each group present information on a specific acute respiratory disorder during the next class period. Have students develop one general care plan for all acute disorders and then determine if each group’s specific disorder would have any variance from a basic acute respiratory illness care plan.

SUGGESTIONS FOR CLINICAL ACTIVITIES Make clinical assignments to include care of children with acute respiratory conditions when appropriate.

LEARNING OUTCOME 7 Plan the nursing care for a child with a chronic respiratory condition.

CONCEPTS FOR LECTURE 1. The general basis for a care plan based on chronic respiratory issues will be the same: oxygenation, nutrition, treatment management, activity intolerance, and social issues. Details of the care plan will vary based on the individual disease process. The initial step in any care plan is the basic nursing assessment and collaboration with the family.

..

2. The most important nursing-related issue for planning is oxygenation. The condition should be managed so the child has proper oxygenation of tissues. The frequency and severity of the periods of hypoxia determine the extent of lung damage and resulting work load required for compensation.

3. Growth and development issues are extremely important with any long-term chronic condition. Any child has to continually grow both physically and developmentally. The child has increased demands for nutrition to maintain the increased workload for respiratory issues, as well as trying to maintain enough to continue the proper growth pattern. Children with cystic fibrosis have even greater difficulty with nutrition and require specific interventions to maintain proper intake for growth and development. The child should be allowed to interact and play at an age-appropriate level rather than be restricted. The developmental aspect should be included in the plan as well.

4. Social isolation may be a concern with these children. The family and child should be encouraged to participate in developmentally appropriate activities, as appropriate. Peer interaction and having “normal” social interactions will foster better emotional outcomes for the child and family.

5. Treatment management must be coordinated with healthcare providers and the family. The family should have input into daily routines and schedules to help develop a plan of care with medication and treatments that would be more likely to be followed. Family input into planning and timing of treatments increases the likelihood of compliance with plans.

4. Children with chronic conditions may require use of home apnea monitors. The child may have had a polysomnography to determine the severity of a sleep disturbance such as obstructive sleep apnea. ..

POWERPOINT LECTURE SLIDES Chronic Lung Diseases • Asthma • Bronchopulmonary dysplasia •

Cystic fibrosis

Nursing Considerations for Chronic Respiratory Conditions •

Oxygenation

•

Activity intolerance

•

Fluid and nutrition

•

Growth and development

•

Treatment management

•

Social interactions

•

Psychosocial support

Oxygenation • Most important consideration

•

..

°

Assess and reassess

°

Hypoxia leads to chronic changes (Figure 25–18)

°

Permanent changes in body systems

Activity intolerance

•

Stress and coping

• Fluid management as necessary Growth and Development •

Nutritional concerns °

•

Need increased calories to meet body requirements

Developmental °

Appropriate activities and interactions

Social Interactions •

Lack of peers for some

•

Decreased activity tolerance

•

Decreased age activities

Treatment Management •

Family collaboration required °

Plan around family, if possible

• Family education o

Prevention of exacerbations

o When to call healthcare provider, 911 o

Medication administration

SUGGESTIONS FOR CLASSROOM ACTIVITIES

..

Ask a respiratory therapist or pulmonary specialist to attend class and discuss how to develop plans of care for chronic conditions. Ask a parent or caregiver for a child with a chronic condition to speak in class about long-term plans for the child and family.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Have students interview a family with a child with a chronic respiratory condition. Have students seek information on plans of care for the child and family, based on collaboration with a healthcare provider.

•

Have students spend a day in a pulmonary unit or in a pulmonary clinic assisting with the care of children who have chronic respiratory conditions.

LEARNING OUTCOME 8 Demonstrate the nursing assessment for a child with an acute lung injury.

CONCEPTS FOR LECTURE 1. Airway compromise after an unintentional injury can cause death if not managed quickly and effectively. Children are vulnerable to changes in respiratory function after injury because the small size of their airway makes it vulnerable to obstruction. The airway may be obstructed by the tongue or small amounts of blood, mucus, or foreign debris or swelling in the respiratory tract or adjacent neck tissue, leading to hypoxia and respiratory failure. If the child’s neck is flexed or hyperextended, the soft laryngeal cartilage may compress and obstruct the airway.

..

2. Common categories of acute lung injury include smoke inhalation, blunt chest trauma, pulmonary contusion, and pneumothorax. Clinical manifestations vary based on the injury.

Nursing care focuses on airway management.

3. Severity of smoke inhalation injuries depend on the type of material burned and the degree to which the child was exposed. Nursing assessment includes vital signs, pulse oximetry, auscultation, and assessment of level of consciousness and behavioral changes that could indicate increasing hypoxia.

4. Blunt chest trauma may result in pulmonary contusion or pneumothorax. Assess for dyspnea, wheezing, crackles, decreased breath sounds, level of consciousness, vital signs, and cyanosis, which is a late sign of respiratory distress.

POWERPOINT LECTURE SLIDES Assessing Acute Lung Injury • Smoke inhalation o

Vital signs

o

Pulse oximetry

o

Auscultation

o

Level of consciousness

o

Behavioral changes

• Blunt chest trauma o

Observation -

..

Dyspnea, wheezes, crackles

o

-

Decreased breath sounds

-

Hemoptysis

-

Transient temperature elevation

-

Level of consciousness

-

Agitation, lethargy

Careful monitoring -

Inspect thorax

-

Cyanosis is a late sign of respiratory distress

• Pneumothorax o

Airway management

o

Monitoring lung inflation

o

Careful monitoring of vital signs and respiratory function

o

Monitor chest tube, related complications

SUGGESTIONS FOR CLASSROOM ACTIVITIES Ask a nurse from the local hospital’s pediatric intensive care unit to come discuss care of children with acute lung injuries, focusing on nursing care.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students spend a day in a hospital setting assisting with the care of children who have acute lung injuries.

..

..

CHAPTER 26 ALTERATIONS IN CARDIOVASCULAR FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Ethical Dilemma; Teaching Plan—Healthy Heart Curricula; Teaching Plan— Infective Endocarditis Prophylaxis Case Study:Newborn After Congenital Heart Surgery Care Plan:Pediatric Heart Transplant Media Links:Heart Disease Resources and Support Media Link Applications Videos and Animations:Anatomy of the Heart; Asthma; Blood Flow Within the Heart; Blood Pressure: Systole and Diastole; Carbon Dioxide Transport; Congenital Heart Disease; Gas Exchange in the Lungs; Pediatric Cardiovascular Emergency Management; Physiology of Hypovolemic Shock

Pediatric Dosage Calculations Image Library Figure 26–1 Anatomy of the heart, direction of blood flow, and normal pressure gradients and oxygen saturation levels in the heart chambers and great arteries.

..

Figure 26–4 The arrows indicate the flow of blood through the heart while the color indicates the level of oxygen saturation in the blood.

Figure 26–15 This child has returned for one of her frequent follow-up visits to assess her cardiac status after treatment for Kawasaki syndrome.

Figure 26–17 If hemorrhage reduces the circulating blood volume sufficiently then vasoconstriction occurs, shifting blood to larger blood vessels that maintain the perfusion of vital organs.

Table 26–1 Hemodynamics of the Normal Heart Table 26–2 Comparison of Fetal and Neonatal Circulation Table 26–7 Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects That Increase Pulmonary Blood Flow Table 26–8 Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects With Decreased Pulmonary Blood Flow Table 26–10 Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects That Obstruct the Systemic Blood Flow Table 26–11 Congenital Heart Defects That Cause Congestive Heart Failure in the First Months of Life

..

LEARNING OUTCOME 1 Explain the transition from fetal to pulmonary circulation.

CONCEPTS FOR LECTURE 1. Review anatomy of the heart, including atria, ventricles, vena cava, pulmonary artery and vein, and aorta. The child’s heart is proportionately larger in relation to body size than an adult’s. The cardiovascular system changes as the child grows and develops, with blood pressure reaching adult levels by puberty.

2. The work of the heart is to deliver blood to the body organs, tissues, and pulmonary system.

The heart delivers blood to the pulmonary system from the body in an unoxygenated state and is oxygenated in the pulmonary system. Once it is oxygen rich, the blood returns to the heart and is forced into the systemic circulation system. This is known as the hemodynamics of the heart.

3. The transition from fetal to pulmonary circulation occurs within just a few hours after birth.

The first breath expands the lungs, and blood that previously passed through the ductus arteriosus begins flowing to the lungs.

4. Pressure gradients change within the heart. Increased pulmonary blood flow and decreased pulmonary vascular resistance results.

5. Pressure in the left atrium increases as increased blood flow returns from the lungs through the pulmonary veins. Systemic vascular resistance increases and right atrial pressure falls.

6. Increased pressure in the left atrium stimulates closure of the foramen ovale.

..

7. The ductus arteriosus, responding to higher oxygen saturation, closes; permanent closure occurs by 10 to 21 days of life. The heart has transitioned from fetal to pulmonary circulation.

POWERPOINT LECTURE SLIDES Hemodynamics of Heart (Circulatory System) •

Heart pumps blood °

Pulmonary system – Receives oxygen

°

Return to heart

°

To systemic system – Provides oxygen to organs and tissues – Depletes oxygen stores

°

Return to heart

Transition From Fetal to Pulmonary Circulation (Table 26–2; Figure 26–4) •

Occurs within few hours after birth

•

Completes at approximately days 10 to 21 with permanent closure of ductus arteriosus

•

..

Hemodynamics change °

Increased pulmonary blood flow

°

Decreased pulmonary vascular resistance

°

Left atrium increased blood flow

– From lungs through pulmonary veins °

Right atrial pressure falls

°

Increased pressure in left atrium – Stimulates closure of foramen ovale

°

Higher oxygen saturation than fetal circulation – Stimulates closure of ductus arteriosus

SUGGESTIONS FOR CLASSROOM ACTIVITIES • Have students make models of the heart with the fetal circulation and pulmonary circulation.

•

Maintain the models to use through the rest of the chapter.

SUGGESTIONS FOR CLINICAL ACTIVITIES Review the Neonatal Resuscitation Program by the American Academy of Pediatrics.

LEARNING OUTCOME 2 Describe the anatomy and physiology of the cardiovascular system, focusing on the flow of blood and action of the heart valves.

CONCEPTS FOR LECTURE

..

1. The heart is the pump that circulates the blood through the systemic and pulmonary systems.

Blood flows to the lungs for oxygen and carbon dioxide exchange. The oxygen-saturated blood then returns to the heart to be pumped out to the systemic circulation to oxygenate the tissues.

2. Cardiac functioning and interactions of the pressure gradients are important in the ability of the heart to function and provide the needed cardiac output for the body.

3. The infant’s cardiovascular system is proportionately larger in relation to body size than that of an adult. As the pulmonary resistance drops, the right ventricular muscle reduces in size.

4. During infancy, the muscle fibers of the heart are less developed, resulting in limited functional capacity. As the child’s heart grows and develops, the systolic blood pressure rises, reaching adult levels by puberty.

POWERPOINT LECTURE SLIDES Anatomy of Heart •

Atria

•

Ventricles

•

Vena cava

• Pulmonary artery and vein Normal Hemodynamics of Heart

..

•

Cardiac function

•

Pressure gradients (Figure 26–1, Table 26–1)

Heart Size •

Proportionately larger in children

Cardiovascular System Growth •

Continues until puberty

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students label a schematic of the heart with infant and adult pressures.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students observe in the cardiac catheterization lab.

LEARNING OUTCOME 3 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, and obstructed systemic blood flow.

CONCEPTS FOR LECTURE 1. Increased pulmonary circulation occurs with defects that result in blood being increased to the pulmonary system. The increased blood flow results in congestion in the pulmonary system and decreased blood flow to the systemic system. Due to the increased blood flow, the child may develop tachypnea, tachycardia, murmur, congestive heart failure, and other problems.

2. Decreased pulmonary circulation occurs with defects that increase the blood in the systemic circulation or limit blood flow to the pulmonary circulation. The manifestations are cyanosis, hypercyanotic spells, poor weight gain, and polycythemia.

..

3. Defects obstructing systemic blood flow occur with defects that obstruct outflow from the left side of the heart. This results in a higher pressure in the left ventricle, increased afterload, and decreased cardiac output. This can also cause backflow into the pulmonary system, causing increased pulmonary blood flow.

POWERPOINT LECTURE SLIDES Increased Pulmonary Blood Flow •

Defects that cause increased blood flow (Table 26–7)

•

Common manifestations °

Tachypnea

°

Tachycardia

°

Congestive heart failure

Decreased Pulmonary Blood Flow •

Defects that cause decreased blood flow (Table 26–8)

•

Common manifestations °

Cyanosis

°

Hypercyanotic spells

°

Poor weight gain

°

Polycythemia

°

Tricuspid atresia

Obstructed Systemic Blood Flow

..

•

Defects that cause (Table 26–10)

•

Common manifestations °

Diminished pulses

°

Pale color

°

Delayed capillary refill

°

Decreased urinary output

°

Signs of congestive heart failure

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students to use the models of the heart they made, as suggested in Learning Outcome 1.

Ask the students to demonstrate, using the models, the functions of the cardiovascular system and associated problems related to both increased and decreased pulmonary circulation.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students, as schedules permit, to spend time in a cardiac care clinic or cardiac area of the hospital.

LEARNING OUTCOME 4 Create a nursing care plan for the child with a congenital heart defect cared for at home prior to corrective surgery.

CONCEPTS FOR LECTURE 1. Education of the family and other caregivers regarding the congenital cardiac defect and treatment plan must be completed in a family-centered session for optimal planning and out-

..

comes for the child.

2. Assessment and careful monitoring for the worsening condition are priorities in home care.

3. Intake should meet the metabolic needs without excess fluid volume. The child should have appropriate weight gain and growth.

4. Intake and output should be balanced to prevent fluid volume overload and prevent complications from excess fluid. Skin integrity must be assessed for potential breakdown areas due to edema to help prevent infection.

5. Family focus is education to manage illness at home by medication administration, and other therapeutic interventions to prevent complications from heart disease. Family interactions and potential family adjustment issues should be addressed.

POWERPOINT LECTURE SLIDES Nursing Assessment Prior to Surgery • Physiologic Assessment • Psychosocial Assessment Education of Family

..

•

Family-centered plan

•

Home care and planning

•

Assessment for complications

•

Assessment for worsening condition

•

Oxygenation requirements

• Metabolic and nutritional needs •

Fluid-volume balance

•

Skin integrity

•

Management of illness

•

Medications

•

Other therapeutic interventions

•

Prevention of complications

•

Family interactions

•

Family adjustment and issues

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students one topic from the potential care plan and have them develop an in-depth care plan for a child, with emphasis on education for the family and prevention of complications.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Assign students to home health rotations for heart patients.

•

Have students attend a support group or seek support groups online for parents/caregivers of children with heart defects.

LEARNING OUTCOME 5 Plan the nursing care for the child undergoing open heart surgery.

..

CONCEPTS FOR LECTURE 1. Critical care management following the surgery until the child is stable depends on the type and complexity of surgery.

2. Hospital management focuses on postoperative pain management around the clock. Pain management includes use of medications as well as nonmedicated interventions.

3. Rest and promotion of respiratory function should be encouraged.

4. Management of fluid and nutrition should be addressed. The child should be encouraged to return to oral intake as appropriate, but fluid volume should continue in a balanced manner to prevent fluid-volume overload.

5. Activity should be encouraged in a gradual manner to avoid tiring of the patient.

6. Discharge planning and home care includes teaching parents about new care that will be required. The long-term planning needs, such as for antibiotics, should be discussed, as well as other issues as concerns arise.

POWERPOINT LECTURE SLIDES Nursing Assessment at the Time of Surgery •

Presence or risk of acute illness

•

Behavioral patterns

•

Cardiac function

•

Respiratory function

• Weight

..

•

Fluid status

Postoperative Care of Heart Surgery •

Immediate care °

Intensive care unit until stable – One or more days

• Monitoring and assessment via lab values and physical examination o

Cardiac function

o

Respiratory function

o

Fluid intake and output

o

Chest or mediastinal tube drainage

o

Pain

Care Following Transfer to General Nursing Unit • Assessment focuses on signs of complications • Cardiac and respiratory monitoring • Return to oral fluids and nutrition as permitted •

Gradual activity increase

• Family education •

Discharge planning

SUGGESTIONS FOR CLASSROOM ACTIVITIES

..

Have students develop one aspect of the care plan in an in-depth format. Compare how the presurgery heart defect care plan differs from the postoperative heart defect care plan.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to a cardiac unit or cardiac care clinic or procedure area.

LEARNING OUTCOME 6 Recognize the signs and symptoms of congestive heart failure in an infant and a child.

CONCEPTS FOR LECTURE 1. Congestive heart failure (CHF) is a disorder of circulation in which cardiac output is inadequate to support the body’s circulatory and metabolic needs. The etiology has various origins.

2. Clinical manifestations may vary depending on the stage of the disease and etiology. Subtle signs such as poor feeding, lack of weight gain, irritability, and frequent infections can be early indicators of CHF. Assessment should be completed in a careful, thorough manner to include respiratory, pulse, blood pressure, color, heart, fluid status, activity, behavior, and other general concerns. As the disease progresses, the manifestations become more severe with pulmonary and systemic manifestations. Tachypnea, crackles, retractions, cough, dyspnea, and tiring easily develop. Hepatomegaly, ascites, periorbital edema, peripheral edema, and weight gain from fluid retention are systemic manifestations that may be more evident on assessment when CHF reaches an advanced stage.

..

3. Nursing care should be focused on careful assessment of the child and family, promoting oxygenation and cardiovascular functioning, safely administering medications, fostering growth and development, and helping the family plan to care for the child at home.

POWERPOINT LECTURE SLIDES Congestive Heart Failure (CHF) •

Etiology

Assessment of CHF •

Respiratory

•

Pulse

•

Blood pressure

•

Color

•

Heart

•

Fluid status

•

Activity

•

Behavior

•

General

Clinical Manifestations—Initial Signs

..

•

Subtle, may not be immediately recognized

•

Infants

o

Tire easily, irritability

o Weight loss or lack of weight gain

•

o

Diaphoresis

o

Frequent respiratory infections

Older children °

Exercise intolerance

o

Dyspnea

o

Abdominal pain or distention

o

Peripheral edema

o

Changes in skin color

Clinical Manifestations—Later Signs •

•

Infants o

Tachypnea, tachycardia

o

Pallor or cyanosis

o

Nasal flaring, grunting, retractions

o

Cough or crackles

o

S3 gallop

Older children o

..

Anorexia

o

Cough, wheezing, crackles,

o

Fluid volume excess

o

Jugular vein distention

Nursing Management of CHF •

Assessment of child and family

•

Promote oxygenation

•

Cardiovascular function

•

Administration of medications

•

Growth and development

•

Family planning

•

Family education for home care

SUGGESTIONS FOR CLASSROOM ACTIVITIES Develop a Jeopardy-type game to determine the signs, symptoms, and assessment findings associated with CHF. SUGGESTIONS FOR CLINICAL ACTIVITIES Role-play in the clinical setting the education of parents on providing digoxin administration to a child.

LEARNING OUTCOME 7 Differentiate between heart diseases that are acquired during childhood and congenital heart de-

..

fects.

CONCEPTS FOR LECTURE 1. Congenital heart disease is a heart defect due to formation; the child is born with the congenital heart defect—it is not related to an external source or cause. Management for congenital heart disease involves symptomatology and, if possible, surgical treatment for correction.

2. Acquired heart diseases are defects that occur following an infection, bacterial or viral, that cause damage to and problems with the circulatory system.

3. Acquired heart diseases are infective endocarditis, rheumatic fever, and Kawasaki syndrome.

4. Cardiomyopathy is a serious disorder of the heart’s muscle that affects the ventricular systolic function, diastolic function, or both. In 66% of cases, there is no known cause; other etiologies can have a genetic association. Cardiac transplant is the treatment of choice.

5. Cardiac dysrhythmias can be congenital or acquired. Dysrhythmias must be recognized because they can cause decreased cardiac output and congestive failure. Serious dysrhythmias can result in sudden death.

6. Hypertension in children can be related to increased incidence of obesity, diet, and sedentary lifestyles and is a significant risk factor for heart disease and stroke during adulthood.

POWERPOINT LECTURE SLIDES Congenital Heart Disease • Definition—born with defect Acquired Heart Disease

..

• Definition—defect related to illness °

Infective endocarditis

°

Rheumatic fever

°

Kawasaki disease (Figure 26–14)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students to work in groups and present each of the acquired heart disease illnesses. Have each group present the disease, etiology, care, long-term plan, and follow-up required for a specific illness. Also include the type of cardiac disease that can occur along with the potential severity.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to review case studies of acquired heart disease in the clinical setting.

LEARNING OUTCOME 8 Distinguish between the pathophysiology of hypovolemic shock, distributive shock, and cardiogenic shock.

CONCEPTS FOR LECTURE 1. Hypovolemic shock is an acute, complex state of circulatory dysfunction resulting in failure to deliver sufficient oxygen and other nutrients to meet cell and tissue demands.

2. The etiology of hypovolemic shock is varied and can result from conditions such as hemorrhage and dehydration.

..

3. Distributive shock is classified as neurogenic, anaphylaxis, or sepsis.

4. Cardiogenic shock occurs when myocardial function is impaired and cardiac output and perfusion are inadequate.

5. Clinical manifestations of shock vary from system to system and the degree of shock and compensation status of the body.

6. Nursing management is focused on assessment to detect early onset of shock and interventions initiated prior to blood pressure falling.

POWERPOINT LECTURE SLIDES Hypovolemic Shock (Figure 26–15) • Definition—acute complex state of circulatory dysfunction •

Results in failure to deliver sufficient oxygen to meet demands

Hypovolemic Shock—Etiology •

Hemorrhage following significant injury or surgery

•

Plasma loss due to burns, nephrotic syndrome, or sepsis

•

Fluid and electrolyte loss associated with dehydration, diabetic ketoacidosis, diabetes insipidus

Distributive Shock • Abnormal distribution of blood volume • Usually results from decrease in systemic vascular resistance and maldistribution of blood flow to extremities

..

• Child attempts to compensate by increasing cardiac output to maintain blood pressure Distributive Shock—Etiology • Neurogenic—vasodilation occurs with loss of vasomotor tone o

Spinal cord injury, various medications

•

Anaphylaxis with vasodilation

•

Sepsis resulting from one of various organisms

Cardiogenic Shock •

Impairment of myocardial function that interferes with the heart’s ability to maintain adequate cardiac output and tissue perfusion

Cardiogenic Shock—Etiology •

Severe obstructive congenital heart disease such as hypoplastic left heart syndrome

•

Cardiomyopathy

• Myocarditis

•

Severe electrolyte or acid–base imbalance

SUGGESTIONS FOR CLASSROOM ACTIVITIES Using the schematic from Leaning Outcome 2, diagram pressures in the heart when a child is in a state of hypovolemic shock.

SUGGESTIONS FOR CLINICAL ACTIVITIES

..

Have the students observe children diagnosed with shock in an ICU.

..

CHAPTER 27 ALTERATIONS IN IMMUNE FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Adolescent in Screening for HIV Case Study:Postexposure Management of Needlestick Injuries Media Links:Lupus Support; Allergies and Asthma; Pediatric HIV Resources Media Link Applications Videos and Animations:HIV Infection Pediatric Dosage Calculations Image Library Figure 27–1 The primary response encompasses a cascade of events that involve humoral and cellular immunity.

Table 27–1 Cells and Tissues of the Immune System Table 27–4 Diagnostic Procedures and Laboratory Tests for the Immune System Table 27–5 Laboratory Findings for Selected Congenital Immunity Disorders Table 27–10 Mobility Issues for the Child and Adolescent with Juvenile Arthritis Table 27–11 Types of Hypersensitivity Reactions

..

Box 27–6 Measures to Protect Against Latex Allergy

LEARNING OUTCOME 1 Describe the structure and function of the immune system.

CONCEPTS FOR LECTURE 1. The function of the immune system is to recognize any foreign substances within the body— to distinguish “nonself” from “self” and eliminate foreign invaders.

2. The immune system is comprised of many different types of antibodies and produces other types of cells.

3. The immune system produces antibodies that work against the antigens.

4. The primary immune response occurs once an antigen invades the body and antibodies are reactive to specific antigens; the primary response occurs within 3 days of exposure.

5. Once the antigen has been encountered, the secondary immune response occurs after each subsequent exposure.

POWERPOINT LECTURE SLIDES Immune System •

Function

• Makeup of immune system (Table 27–1) • ..

Antibodies

° •

Definition

Antigen °

Definition

•

Primary immune response (Figure 27–1)

•

Secondary immune response

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students draw the primary immune response and review how this relates to a child exposed to a common cold.

SUGGESTIONS FOR CLINICAL ACTIVITIES Discuss clinical care of patients exposed to new viruses and bacteria and explain why newborns are more at risk for admission and treatment than older children.

LEARNING OUTCOME 2 Apply knowledge of the immune system to the care of children with immunologic disorders.

CONCEPTS FOR LECTURE 1. Infants and children have differing amounts of some immunoglobulins. IgG is the only immunoglobulin that crosses the placenta; as a result, a newborn’s levels are similar to those of the mother’s. IgM levels are low at birth, rise markedly at 1 week of age, and continue to increase until adult levels are reached at about 1 year of age.

IgA and IgE are not present at birth. Manufacture of these immunoglobulins begins by 2 weeks of age; however, normal values are not achieved until 6 to 7 years of age.

Children have lower ..

amounts of immunoglobulins, which explains why they become ill so easily.

2. In contrast, cell-mediated immunity achieves full function early in life.

3. Newborns have somewhat lower numbers of NK cells than older children and adults, which decreases their ability to respond to certain antigens.

4. Nurses play an important role in preventing infections in newborns and promptly identifying infections in children of all ages. Nurses also act to help prevent development, progression, or exacerbation of disorders. Diagnostic and laboratory tests can be used to confirm the presence of immunologic disorders.

POWERPOINT LECTURE SLIDES Pediatric Differences •

Differing amounts of some immunoglobulins

• Cell-mediated immunity achieves full function early • Newborns have lower numbers of NK cells Nursing Role • Assessment •

Diagnostic Tests

•

Prevention

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students discuss the role immunoglobulins play in immune function and the increased risk

..

children have for illness.

SUGGESTIONS FOR CLINICAL ACTIVITIES Discuss clinical care of patients experiencing immunologic disorders. What is the potential impact of treatment for immunologic disorder on family functioning? What resources are available?

LEARNING OUTCOME 3 Explain the differences between primary and secondary immune deficiency.

CONCEPTS FOR LECTURE 1. Children with congenital immune deficiency, or primary immune deficiency, are born with a failure of humoral antibody formation (B-cell disorder), a deficient cellular immune system (T-cell disorder), or a combination of both defects. In congenital disorders, the immune deficiency is not caused by another condition.

2. Immunodeficiency may also be acquired, as in HIV infection. Acquired immune deficiency is also called secondary immune deficiency.

3. In B-cell disorders, immunoglobulins may be present in inadequate numbers or nearly absent. X-linked agammaglobulinemia, selective IgA deficiency, and common variable immunodeficiency are examples of such disorders. Because newborns are protected from infection by maternal antibodies in the first months after birth, symptoms of B-cell disorders usually become apparent after 3 months of age once the infant loses maternal antibodies.

..

4. T-cell disorders are characterized by inadequate numbers of T lymphocytes or absence of T-cell functions. Isolated T-cell disorders are rare, are usually accompanied by a Bcell disorder, and may be associated with congenital abnormalities (as in DiGeorge syn- drome) or of unknown cause.

5. Severe combined immunodeficiency disease (SCID), the most severe form of primary immune deficiency, is a congenital condition characterized by absence of both humoral and cellular immunity that is manifested by lack of appropriately functioning T cells and B cells.

POWERPOINT LECTURE SLIDES Immunodeficiency (Table 25–4) •

Immunodeficiency o

•

•

Decreased responsiveness of the immune system

Primary immune deficiency o

B-cell disorder, or

o

T-cell disorder, or

o

A combination of both

Secondary immune deficiency °

Acquired immune deficiency

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups and assign each group to discuss assessment of either a primary or

..

secondary immune deficiency disorder. With what aspects of the assessment do they feel most comfortable? Why? With which aspects of assessment are they least comfortable? What concerns do they have about caring for a child with this disorder? Where would they go to obtain the information or skills necessary to care for a child with this disorder?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students observe nursing care for a child with an immune deficiency disorder. In postconference, discuss what aspects of nursing care they thought were effective or helpful. What would they have done differently and why?

LEARNING OUTCOME 4 Summarize infection control measures needed for children with an immunodeficiency.

CONCEPTS FOR LECTURE 1. Nursing care is focused on preventing the spread of infection.

2. Frequent and thorough hand washing is essential. Standard precautions are always maintained and transmission-based precautions are established when required.

3. Sterile aseptic technique should be followed for all invasive lines/equipment.

4. Avoid contact with infectious individuals and advise caution when discussing use of vaccines for the child or another member of the family.

5. Skin integrity and nutrition/fluids should be encouraged to provide supportive care in avoid-

..

ance of decreased body functions.

POWERPOINT LECTURE SLIDES Nursing Care of Child with an Immunodeficiency •

Prevent spread of infection

•

Hand washing

•

Standard precautions °

Transmission-based precautions

•

Sterile aseptic technique

•

Avoid contact with infectious individuals

•

Vaccine administration caution °

For child and family members

• Maintain skin integrity •

Encourage adequate fluid and nutrition

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups and assign each group one of the nursing considerations for care of a child with an immunodeficiency. Have the groups discuss how nurses can assist and what can be done, with specific suggestions to decrease the risk of infection.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students practice standard precautions and transmission precautions. Make the students re-

..

sponsible for themselves and peers for management of proper precautions.

LEARNING OUTCOME 5 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV) infection.

CONCEPTS FOR LECTURE 1. Collaborate with the family to plan care for the child. The child’s chronologic and developmental age must be taken into consideration. Medical management should focus on further prevention of the spread of HIV. 2. The medication regimen should be determined by the healthcare provider and the child’s parents or caregivers. Provide education regarding side effects and information as needed to reinforce the importance of the medication regimen.

3. Plans for promoting general health, growth, and development are important. Included in general health should be a need to reduce the child’s exposure to infectious organisms.

4. Emotional support for the parents and child should be included in planned activities.

Support groups within the local area for caregivers and child should be identified.

5. Community support and advisement on the confidentiality of HIV status should be reinforced.

POWERPOINT LECTURE SLIDES Collaborate with the Family of a Child with Human Immunodeficiency Virus (HIV) (Table 27–4) ..

•

Plan care °

Age and developmentally appropriate

• Medication regimen

•

°

Education on importance of regimen

°

Education on side effects

Promotion of general health °

•

•

Avoid infectious individuals

Promotion of growth and development °

Proper food

°

Proper atmosphere, toys, friends

Emotional support °

Caregiver

°

Child – Support groups

•

Community support °

Confidentiality

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign student groups an age category and a case of a child who is HIV positive, and include parent information. Have the groups develop a plan of care based on the age of the child and the

..

status of parent involvement.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students, if possible, to spend a day with an infection control nurse or HIV nurse in the HIV clinic.

LEARNING OUTCOME 6 Contrast immune deficiency diseases and autoimmune diseases.

CONCEPTS FOR LECTURE 1. An immune deficiency is characterized by decreased responsiveness of the immune system.

2. An autoimmune disease is a condition in which the body directs the immune system response against itself, resulting in tissue injury caused by a probable immunologic reaction with the host’s own tissues. Structural or functional changes can occur.

3. Autoimmune disorders can be systemic or organ specific.

POWERPOINT LECTURE SLIDES Immune Deficiency Diseases vs. Autoimmune Diseases •

Immune deficiency o

..

Decreased responsiveness of the immune system

•

Autoimmune disorder o

Condition in which the body directs immune response against itself

o

Tissue injury caused by probable immunologic reaction with host’s own tissues

o

Structural or functional changes occur

Autoimmune Disorders •

•

Systemic o

Systemic lupus erythematosus

o

Juvenile arthritis

Organ specific o

Type 1 diabetes

o

Thyroiditis

SUGGESTIONS FOR CLASSROOM ACTIVITIES Engage class in active discussion on the etiologies of different immune deficiency disorders and autoimmune disorders. What implications do these have for nursing care?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students visit local schools and discuss with the school nurse how students with immune deficiency disorders and autoimmune disorders ensure that their conditions are managed at school. Do all students have action plans? Do they have individual health plans or other modifications? What factors make students with these disorders more successful in school?

..

LEARNING OUTCOME 7 Plan nursing care for a child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis.

CONCEPTS FOR LECTURE 1. Nursing management for a child with lupus should focus on avoiding triggers and management of the long-term chronic disease.

2. Maintain fluid balance; children with lupus often have renal involvement, and renal dysfunction assessment should be evaluated on a regular basis.

3. Promote adequate nutrition with a diet based on the child’s needs. Be aware of the potential for renal involvement and the associated need to change the diet.

4. Promote skin integrity. A rash present on the mucous membranes can cause weakening of the tissues, placing the child at increased risk for infection. Practice good hygiene and use sunscreen.

5. Promote rest and comfort. Painful exacerbation may occur and necessitate appropriate pain management. Encourage frequent rest to avoid fatigue.

6. Provide emotional support and encourage community activities and support groups.

7. Nursing management for the child with juvenile arthritis is focused on pain relief, maintaining joint mobility, preventing deformities, and promoting self-care and development.

8. Improvements in mobility occur with the use of physical therapy. The nurse should encourage the child to perform activities of daily living. The child may fatigue more easily, and rest

..

periods may be needed.

9. The nurse should promote a well-balanced diet, because children with decreased mobility have reduced metabolic needs.

10. Encourage hydration to reduce the risk of constipation associated with immobility.

11. The child may be taking aspirin and corticosteroids, and can experience gastric distress. Administration of these products with milk or food will lessen the gastric irritation.

POWERPOINT LECTURE SLIDES Nursing Management of Systemic Lupus Erythematosus •

Avoid triggers

•

Long-term planning for chronic illness

• Maintain fluid balance •

Promote adequate and appropriate nutrition

•

Promote skin integrity

•

Promote rest and comfort

•

Emotional support

•

Community activities and support groups

Nursing Management of Juvenile Arthritis •

Pain relief

• Maintain joint mobility

..

•

Prevent deformities

•

Promote self-care

•

Well-balanced diet

•

Hydration

•

Medication management (Table 27–10)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Engage the class in active discussion on how to avoid triggers and specific interventions to provide appropriate nursing management for a child with systemic lupus erythematosus.

SUGGESTIONS FOR CLINICAL ACTIVITIES Attend a local support group, clinic, or active web chat for children with systemic lupus erythematosus or juvenile arthritis.

LEARNING OUTCOME 8 Describe exposure prevention measures for the child with latex allergy.

CONCEPTS FOR LECTURE 1. Latex allergies are becoming increasingly common. Many healthcare products contain latex, such as gloves, drains, catheters, and intravenous ports.

2. Children at risk for latex allergy should receive allergy testing for latex.

3. Assessment based on a latex allergy questionnaire should be completed.

..

4. Nursing care should include avoidance of exposure to latex for children with latex allergy or those at high risk for latex allergy.

5. Alternative products should be used in care for the child. Latex-free products should be available and must be used.

6. The child should wear a medical alert identification bracelet and have an epinephrine kit available at home and at school.

7. Individuals who provide care for the child should be educated on the signs of a hypersensitivity reaction and be prepared to provide care as needed.

POWERPOINT LECTURE SLIDES Latex Allergy •

Increasingly common

•

Children at risk for allergy

•

Testing for latex allergy

•

Latex allergy questionnaire

Nursing Care for Child with Latex Allergy •

Avoidance of latex exposure (Box 27–6)

•

Alternative products

• Medical alert ID bracelet •

..

Epinephrine kit at home and school

•

Education of caregivers related to hypersensitivity reactions °

Preparation to provide care

SUGGESTIONS FOR CLASSROOM ACTIVITIES Bring into class items used in the hospital setting. Have the students determine if the product contains latex, and if so, ask students to seek alternative products.

SUGGESTIONS FOR CLINICAL ACTIVITIES Within the clinical unit, assign students to determine the hospital protocol for children with a latex allergy. Locate the latex-free cart and/or latex-free products.

LEARNING OUTCOME 9 Apply nursing interventions and prevention measures for the child experiencing hypersensitivity reactions.

CONCEPTS FOR LECTURE 1. Hypersensitivity reactions are responsible for allergic reactions in children.

2. Hypersensitivity reactions have been classified into four categories based on the type of reaction.

3. Type I reactions are immediate reactions that occur within seconds to minutes of exposure to the antigen. Symptoms can range in presentation but may include anaphylaxis in some indi-

..

viduals.

4. Type II reactions are immediate, within 15 to 30 minutes after exposure to the antigen.

Symptoms vary but may include dyspnea or fever.

5. Type III reactions are similar to type II reactions but may peak up to 6 hours after exposure.

6. Type IV reactions are the most common, are delayed up to several hours, and require 24 to 72 hours to fully develop. This type of reaction has variable presentation and is not limited to one tissue type.

7. Management should focus on history and assessment to determine education for prevention.

The child may require an intradermal skin test for allergies.

8. During an allergic reaction, care should be focused on treatment of symptoms and alleviation of anxiety. Children who are prone to type I or II reactions may require an EpiPen. 9. A child who is experiencing anaphylaxis should be considered an emergency and in a lifethreatening situation.

POWERPOINT LECTURE SLIDES Hypersensitivity Reactions in Children (Table 27–11) •

Type I °

•

..

Definition

Type II

° •

Definition

Type III °

•

Definition

Type IV °

Definition

Nursing Management •

History

•

Assessment °

Type I and Type II carry EpiPen

Nursing Management During Hypersensitivity Reaction •

Treatment of symptoms

•

Alleviate anxiety

•

Child with anaphylaxis °

Emergency situation

Reducing Risk for Hypersensitivity Reaction •

•

..

Reduce exposure to triggers o

Home

o

School

Use medications as prescribed

•

Desensitization (allergy shots) if necessary

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign groups each of the types of hypersensitivity reactions and have each group present a case study of a patient who is experiencing the hypersensitivity reaction. The presentation should in- clude possible causes, symptoms, presentation of the child, immediate care required, long-term care required, and follow-up required.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to spend a day in an allergy clinic or office. The students may observe different types of testing and education for specific allergies. The students could provide a detailed case report of a patient observed that day.

..

CHAPTER 28 ALTERATIONS INHEMATOLOGIC FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Stem Cell Transplantation Case Study:An Adolescent in Sickle Cell Crisis Care Plan:A School-Age Child with Hemophilia Media Links:Sickle Cell Resources and Support Media Link Applications Videos and Animations:Circulatory System; Blood Cells; Animation: Sickle Cell Anemia; Sickle Cell Anemia; Nursing in Action: Blood Transfusion Pediatric Dosage Calculations Image Library Figure 28–1 Types of blood cells.

Figure 28–4 Many of these red blood cells show an elongated crescent shape characteristic of sickle cell anemia.

Figure 28–5 The etiology, pathophysiology, and disease process of sickle cell anemia.

Table 28–2 White Blood Cells and Their Functions

..

LEARNING OUTCOME 1 Describe the function of red blood cells, white blood cells, and platelets.

CONCEPTS FOR LECTURE 1. The three types of blood cells in the body are red blood cells, white blood cells, and platelets.

2. Red bloods cells (RBCs), or erythrocytes, are the most abundant of the cellular elements of blood. The primary function of red blood cells is to transport oxygen from the lungs to the tissues. The RBCs also help to carry carbon dioxide from the tissues back to the lungs.

3. White blood cells (WBCs), or leukocytes, are the mobile units of the body’s protective system. They are formed in the bone marrow and lymph tissue. There are five types of WBCs and each has a distinct function. The WBC count increases in a response to infections and illness.

4. Platelets, or thrombocytes, are cell fragments that can form hemostatic plugs to stop bleeding. The function of platelets is primary coagulation and capillary hemostasis.

POWERPOINT LECTURE SLIDES Types of Blood Cells (Figure 28–1) •

Red blood cells (RBCs) °

Erythrocytes – Primary function—transport oxygen – Carry carbon dioxide back to lungs

..

• White blood cells (WBCs) °

Leukocytes – Body’s protective system – Five types of white blood cells (Table 28–2)

•

Platelets °

Thrombocytes – Primary function—coagulation and capillary hemostasis

SUGGESTIONS FOR CLASSROOM ACTIVITIES Instruct students to draw and label the three types of blood cells. Students should identify the function of each type of blood cell.

LEARNING OUTCOME 2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

CONCEPTS FOR LECTURE 1. Anemia is a reduction in the number of RBCs, the quantity of hemoglobin, and the volume of packed red cells to below-normal level. Anemia etiology may be iron deficiency, normocytic, sickle cell, hereditary spherocytosis, thalassemia, or aplastic anemia.

2. Physiologic anemia is a normal occurrence in infancy because, after birth, erythropoietin synthesis and production of RBCs abruptly decreases in response to higher oxygenation of

..

tissues and presence of fetal hemoglobin. Levels return to normal around 4 to 6 months of age.

3. Iron deficiency anemia is the most common type of anemia and the most common nutritional deficiency in children. The body requires iron for the production of hemoglobin. Insufficient quantities of iron limit hemoglobin production. This in turn affects the production of red blood cells. The red blood cells appear hypochromic as a result of decreased hemoglobin synthesis. Clinical manifestations and severity of symptoms are directly related to the amount of iron deficiency anemia. Pallor, fatigue, and irritability are characteristic findings. A behavior associated with anemia is pica. Premature infants are more susceptible to iron deficiency because they have less time in utero and therefore smaller iron stores that quickly deplete in postnatal life.

4. Normocytic anemia occurs when there is a decreased number of RBCs but they are of normal size, with a pale center. This type of anemia may occur as a result of hemorrhage, diseaseinduced inflammation, disseminated intravascular coagulation, G6PD deficiency, hemolyticuremic syndrome, or several other conditions. The anemia will often resolve itself once the cause is corrected. Clinical manifestations are similar to those seen in iron deficiency anemia, with the possible occurrence of hepatomegaly and splenomegaly as well.

5. Sickle cell anemia is characterized by the partial or complete replacement of normal hemoglobin with abnormal hemoglobin S. This forms a genetic mutation. The RBCs change shape from a doughnut-shaped cell to an elongated, crescent, or sickle shape. Pathologic changes occur in most body systems due to sickling and sequestration of red blood cells. This results in local tissue hypoxia, further sickling, and large areas of infarction.

6. Thalassemias are a group of blood disorders of hemoglobin synthesis characterized by ..

anemia that can be mild or severe. There are three types of betathalassemias. This disorder most often occurs in people of Mediterranean descent but is also found among Middle Eastern, Asian, and African populations. Clinical manifestations are based on the severity of the defective synthesis. The presentation may vary: pallor, failure to thrive, hepatosplenomegaly, and severe anemia that leads to chronic hypoxia.

7. Hereditary spherocytosis is a congenital hemolytic anemia in which there is no abnormality of hemoglobin. The cells are disproportionately permeable to sodium, leading to an unusual characteristic cell structure. The blood cells are sequestered and hemolyzed in the spleen.

Clinical manifestations appear in the neonatal period or during early infancy. Severity of the anemia varies.

8. Goals for care of the child with anemias include: adequate nutrition, hydration and fluid balance, promotion of adequate tissue perfusion, promotion of growth and development, and family and patient education.

POWERPOINT LECTURE SLIDES Anemia •

Definition

• Physiologic anemia •

..

Iron deficiency anemia °

Lack of iron

o

Anemia of prematurity

°

Affects production of RBCs

°

RBCs appear hypochromic, decreased hemoglobin synthesis

° Manifestations based on severity – Pallor – Fatigue – Irritability – Pica •

Normocytic anemia °

Decreased number of RBCs

°

Normal size with pale center

°

Associated with multiple causes

° Manifestations similar to iron deficiency anemia •

Sickle-cell anemia °

Genetic mutation

°

Hemoglobin S replaces normal hemoglobin

°

RBCs lose doughnut shape, become sickle shaped (Figure 28–4)

° Manifestations appear in multiple body systems ° •

Thalassemias °

..

Severity based on pathologic changes (Figure 28–5)

Groups of hereditary disorders

°

Hemoglobin synthesis abnormal

°

Range from mild to severe

°

Three types

°

Clinical manifestations based on type and severity – Pallor – Fatigue – Failure to thrive

° •

Severe anemia leads to chronic hypoxia

Hereditary spherocytosis °

Congenital hemolytic anemia

°

No abnormality of hemoglobin

°

Cells have unusual structure

° Manifestations appear in neonatal period or infancy ° •

..

Severity varies

Goals of care o

Adequate nutrition

o

Hydration and fluid balance

o

Promotion of adequate tissue perfusion

o

Promotion of growth and development

o

Family and patient education

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students to groups and give each group one of the disorders of RBCs. Have the groups present the etiology, manifestation, medical treatment, and nursing care to the class.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students, as schedules permit, to a sickle cell or hematology clinic or unit within the hospital.

LEARNING OUTCOME 3 Discuss the pathophysiology and clinical manifestations of the major disorders of white blood cells affecting the pediatric population.

CONCEPTS FOR LECTURE 1. Aplastic anemia is a deficiency of the blood cells that results from failure of the bone marrow to produce adequate numbers of circulating blood cells. The disorder may be idiopathic or acquired. Clinical manifestations vary depending on the degree of thrombocytopenia, anemia, and neutropenia. The most common symptom is bleeding secondary to thrombocytopenia.

2. Goals for care include: prevention of bleeding, administration and monitoring of blood transfusions, prevention of infection, and education of the patient and family.

POWERPOINT LECTURE SLIDES

..

Aplastic Anemia •

Failure of bone marrow to produce blood cells

•

Disorder is idiopathic or acquired

•

Clinical presentation varies depending on degree

• Most common is bleeding secondary to thrombocytopenia SUGGESTIONS FOR CLASSROOM ACTIVITIES Engage students in active discussion regarding disorders of the WBCs. SUGGESTIONS FOR CLINICAL ACTIVITIES Explore in the clinical setting ways to improve outcomes for children who are experiencing a disorder of the WBCs.

LEARNING OUTCOME 4 Discuss the pathophysiology and clinical manifestations of the major bleeding disorders affecting the pediatric population.

CONCEPTS FOR LECTURE 1. Hemophilia is a group of hereditary bleeding disorders that result from a deficiency in specific clotting factors. The most common type, factor VIII deficiency, is caused by a deficiency of clotting factor VIII in the blood and accounts for 80% of persons with hemophilia. The genes for the clotting factors are located on the X chromosome, which makes this an X-linked recessive trait that manifests almost exclusively in affected males and

..

carrier females. Clinical manifestations differ and range from mild to moderate to severe.

Children may not manifest symptoms until after age 6 months. Once the disease manifests, the presentation is noted as spontaneous bleeding, hemarthrosis, deep tissue hemorrhage, nosebleeds, hematuria, and easy bruising.

2. von Willebrand disease is similar to hemophilia. There are approximately 20 different disorders involving a deficiency of von Willebrand factor (vWF). The most common form of the disorder is transmitted as an autosomal dominant trait and may occur in both males and females. Manifestations are easy bruising and epistaxis.

3. Goals for care of the child with hemophila include: restoration of clotting function, prevention of complications associated with bleeding, management of bleeding episodes, and patient and family education.

4. Clotting disorders result in various bleeding tendencies.

5. Disseminated intravascular coagulation (DIC) is a life-threatening process that occurs when the clotting system is abnormally activated during serious illnesses. The most common cause of DIC in children is infection. The clinical manifestations of DIC result from bleeding and clotting disorders ranging from minor oozing to frank hemorrhage.

6. Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder that is characterized by increased destructions of platelets, even though platelet production in the bone marrow is normal. The disorder usually follows a viral infection and symptoms include multiple ecchymoses, petechiae, and purpura; bleeding from gums; nosebleeds; blood in urine; and blood in stools.

7. Henoch–Schönlein purpura (HSP) is a vasculitis of the small vessels with unknown etiology.

..

The child presents with raised purpuric lesions, joint pain, colicky abdominal pain, and GI bleeding. HSP is generally self-limiting; severe cases may have renal involvement.

8. Goals for care of the child with clotting disorders include: prevention of bleeding and associated complications, promotion of gas exchange, maintenance of skin integrity, and family and patient education.

POWERPOINT LECTURE SLIDES Hemophilia •

Hereditary bleeding disorder

• X-linked—expressed in males, females have carrier status • Manifestations range mild to moderate to severe °

Spontaneous bleeding

°

Hemarthrosis

°

Deep tissue hemorrhage

°

Nosebleeds

°

Hematuria

°

Easy bruising

von Willebrand Disease •

Autosomal dominant trait

•

Equal expressivity in males and females

• Manifestations

..

°

Easy bruising

°

Epistaxis

Bleeding Disorders: Clotting Disorders •

Disseminated intravascular coagulation (DIC) °

Complication from another illness

° Most common following infection in children ° Manifestation range – Minor oozing – Frank hemorrhage •

Idiopathic thrombocytopenic purpura (ITP) °

Autoimmune disorder

°

After a viral illness

° Manifestations – Ecchymoses – Petechiae – Purpura – Bleeding from gums – Nosebleeds – Blood in urine

..

– Blood in stools • HSP o

Vasculitis –

Raised purpuric lesions

–

Joint pain

– Colicky abdominal pain –

GI bleeding

– Renal involvement

SUGGESTIONS FOR CLASSROOM ACTIVITIES • Review genetic passage of traits. Present several case studies to the students and, based on the genetic information in the case study, have the students identify the risk to a child for expressing the disorder or being a carrier.

• Assign students to research and bring to class a picture presentation of the types of clotting disorders. Have each student present the picture or write the etiology of why the picture looks the way it does.

SUGGESTIONS FOR CLINICAL ACTIVITIES • Identify specific nursing interventions that would apply to care of patients with hereditary disorders and how care would affect the child, family, and other children in the family.

• Assign students to rotations in the PICU or NICU where there is an increased chance of caring for patients who are receiving blood.

..

LEARNING OUTCOME 5 Compare and contrast the major bleeding disorders, disorders of red blood cells, and disorders of white blood cells affecting the pediatric population.

CONCEPTS FOR LECTURE 1. Red blood cell disorders are characterized by a change in the number or shape of red blood cells. White blood cell disorders are characterized by a deficiency of either white blood cells or all blood cells. Bleeding disorders are characterized by destruction of, deficiency in, or absence of platelets or clotting factors.

2. Manifestations vary by type of disorder and severity.

3. Oxygenation and circulation are priorities for nursing care.

POWERPOINT LECTURE SLIDES Comparison of Hematologic Disorders •

Red blood cell disorders o Characterized by a change in the number or shape of red blood cells

• White blood cell disorders o Characterized by a deficiency of white blood cells or all blood cells • Bleeding disorders

..

o Characterized by destruction of, deficiency in, or absence of platelets or clotting factors • Manifestations vary by type of disorder and severity • Oxygenation and circulation are priorities for nursing care SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students to groups. Have each group develop an education plan for children and families with a different hematologic disorder.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students, as schedules permit, to a hematologic care unit or a hematology clinic.

LEARNING OUTCOME 6 Develop a family-centered nursing care plan for the management of a child with a hematologic disorder.

CONCEPTS FOR LECTURE 1. Nursing care will be based on the disorder.

2. Disorders of RBCs focus nursing care on oxygenation and circulation. Fluid and nutrition encouragement is required for all disorders. Pain management should also be a consideration.

3. Disorders of WBCs focus on prevention of infection and oxygenation. Nutrition must meet metabolic needs and maintain growth and development.

..

4. Disorders affecting platelets and clotting factors focus on prevention of bleeding, oxygenation, circulation, and injury prevention.

5. Collaborative care requires a team approach to manage long-term treatment. Family involvement to plan and implement care is necessary for the best possible outcome.

POWERPOINT LECTURE SLIDES Nursing Care of a Child with a Hematologic Disorder Is Based on the Disorder •

RBCs °

Oxygenation

°

Circulation

°

Fluid

°

Nutrition

°

Pain management

• WBCs

•

..

°

Infection

°

Oxygenation

°

Nutrition

Platelets and bleeding disorders °

Bleeding

°

Oxygenation

°

Circulation

°

Injury prevention

Collaborative Care Approach for a Child with a Hematologic Disorder •

Team approach

•

Family involved °

Decisions with family and child

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students to groups. Give each group one disorder of the hematologic system. Have the students develop a nursing plan for the disorder and present their findings to the class. Engage the class to determine differences and similarities for all the disorders.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students, as schedules permit, to a hematologic care unit or a hematology clinic.

LEARNING OUTCOME 7 Prioritize nursing interventions for a child receiving hematopoietic stem cell transplantation (HSCT).

CONCEPTS FOR LECTURE 1. Hematopoietic stem cell transplantation (HSCT) is a treatment for diseases that are unresponsive to other modalities of care. Three types of HSCT exist: autologous, isogeneic, and allogeneic.

2. Pretransplant care requires HLA typing and evaluation of organ functions. The child will ..

have total body irradiation, which is directed at destroying circulating blood cells and the diseased bone marrow. The child is placed on strict isolation in a negative-pressure environment.

3. During the transplant phase, the child will receive an intravenous transfusion with the donor stem cells. The transplanted marrow should start producing hematopoietic blood cells in approximately 2 to 4 weeks.

4. The posttransplant phase lasts for several weeks. The major risks are infection, anemia, and bleeding. The child may be on immunosuppressive agents to prevent graft-versus-host disease.

5. Nursing care is similar in all phases of HSCT, and goals for care include: prevention of infection, control of bleeding, maintenance of adequate nutrition and hydration, promotion of tissue perfusion, monitoring for signs of rejection, prevention of injury, provision of psychosocial support, promotion of normal growth and development, and patient and family education.

PowerPoint Lecture Slides Hematopoietic Stem Cell Transplant (HSCT) •

Treatment for disorders unresponsive to other therapy

•

Pretransplant phase

•

..

°

Total body irradiation

°

Strict isolation

Transplant phase

•

°

Intravenous transfusion of donor stem cells

°

Transplant starts to grow in 2 to 4 weeks

Posttransplant phase °

Lasts several weeks

° Major risk is infection ° •

Immunosuppressive agents prevent graft-versus-host disease

Nursing care °

Prevent infections

°

Injury prevention

°

Growth and development

°

Nutrition

°

Physical activity limits

°

Oral health

° Mental and spiritual health °

Family and social relationships

SUGGESTIONS FOR CLASSROOM ACTIVITIES Engage students in an active discussion about the special needs of children who undergo such strict isolation guidelines. Discuss ways the nurse can assist in comfort and continued development based on the child’s age.

..

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students a clinical day in the hematology-oncology unit when possible, or have students develop a patient case study for care of a child undergoing HSCT.

..

CHAPTER 29 THE CHILD ITH WC

ANCER

Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Adolescent with Leukemia Case Study:Teen with Ewing’s Sarcoma Media Links:Pediatric Cancer Support and Resources Media Link Applications Videos and Animations:Genetics of Cancer; Leukemia; Nursing in Action: Central Venous Catheter Care

Pediatric Dosage Calculations Image Library Figure 29–1Percentage of primary tumors by site of origin for different age groups.

Figure 29–2A proto-oncogene normally regulates cellular growth and development.

Figure 29–3Computed tomography (CT) can be a frightening procedure for children.

Figure 29–13 Approximately 1,700 children under the age of 14 years are diagnosed annually as having tumors of the brain and central nervous system.

Figure 29–16 Lymph nodes and organs affected in Hodgkin disease in children.

Figure 29–17 Rhabdomyosarcoma is characterized by ptosis and swelling.

..

Figure 29–18 Retinoblastoma is characterized by leukokoria, a white reflection in the pupil.

Table 29–4 Selected Diagnostic Tests for Childhood Ce–7 Diagnostic Tests for Ne–8 National Wilms Tumor Study Staging System Table 29–10 St. Jude Children’s Research Hospital Staging CeNon-Hodgkin Lymphoma

LEARNING OUTCOME 1 Describe the incidence, known etiologies, and common clinical manifestations of cancer.

CONCEPTS FOR LECTURE 1. Cancers in children often have a different etiology than those of adults. Adult cancers are epithelial in origin and in children they are nonepithelial or embryonal. Adult cancers are slow growing; childhood cancers are fast growing. A major physiologic difference between adults and children involves the immune system and how well it functions.

During the first month of a child’s life, the nonspecific immune response is immature; it is also impaired in prema- ture and SGA infants. The specific immune response is also below adult levels.

2. In the United States, cancer is diagnosed in approximately 11,000 children, and about 1,500 children die from cancer annually. In children under 15 years of age, cancer is the leading cause of disease-related death, and it is the second leading cause of death overall followed by unintentional injury. Survival rates vary for different types of cancer.

3. The etiology of cancer is variable. Alterations in cellular growth occur in response to external and internal stimuli. Cancer may be caused by one or a combination of three factors: external stimuli, innate immune system and gene abnormalities, and chromosomal abnormalities.

..

4. Clinical manifestations vary by the type of cancer and location. Many of the symptoms of cancer are typical of common childhood illnesses and a delay in diagnosis may occur. Common presenting symptoms are pain, cachexia, anemia, infection, bruising, neurologic symptoms, and a palpable mass.

POWERPOINT LECTURE SLIDES Incidence of Cancer in Childhood •

Approximately 11,000 children under the age of 15 diagnosed annually

•

Under age 15, cancer is leading cause of disease-related death

•

Approximately 1,500 children die annually of cancer

•

Types of tumors vary by age and affect survival rate (Figure 29–1)

Etiology Is Variable •

Alterations in cellular growth (Figure 29–2)

•

Single or combination of factors °

External stimuli

°

Innate immune system and gene abnormalities

°

Chromosomal abnormalities

Manifestations •

..

Vary by type and location °

Pain

°

Cachexia

°

Anemia

°

Infections

°

Bruising

°

Neurologic

°

Palpable mass

SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Prior to class, assign students various types of cancer and ask them to research the percentage of occurrence, survival rate, and recurrence rate for that specific cancer.

•

Have the students present findings to the class or in a poster board or web-based presentation format.

LEARNING OUTCOME 2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

CONCEPTS FOR LECTURE 1. The diagnostic tests most commonly used for children with cancer include complete blood count (CBC), bone marrow aspiration (BMA) and bone marrow biopsy (BMBX), lumbar puncture (LP), radiographic examination, magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, tumor markers, and biopsy of the tumor. Additional testing may be done when certain cancers are involved.

..

2. Clinical therapy is extremely complex and is managed by a specialist in pediatric oncology.

Cancer may be treated with one therapy or a combination of therapies and the goal may be either curative or palliative.

3. Options for clinical therapy treatment may be surgery, chemotherapy, radiation, biotherapy, hematopoietic stem cell transplantation (HSCT), complementary therapies, and palliative care.

4. The care plan for a child with cancer will vary based on the type of cancer and clinical therapy treatment plan. Infection control, pain, nutrition, growth and development, and emotional and spiritual needs should be included in the plan of care for the child and family.

POWERPOINT LECTURE SLIDES Diagnostic Tests (Table 29–4) •

Complete blood count and differential

•

Bone marrow aspiration

•

Bone marrow biopsy

•

Lumbar puncture

•

Radiographic examination

• MRI

..

•

CT (Figure 29–3)

•

Ultrasound

•

Tumor biopsy

Clinical Therapy •

Child managed by pediatric oncologist

•

Therapy may be singular or a combination of treatments °

Surgery

°

Chemotherapy

°

Radiation

°

Biotherapy

°

HSCT

°

Complementary therapies

°

Palliative care

Nursing Care Plan •

Based on type of cancer and therapy °

Infection control

°

Pain

°

Nutrition

°

Growth and development

°

Emotional needs

°

Spiritual needs

SUGGESTIONS FOR CLASSROOM ACTIVITIES

..

Assign specific diagnostic tests and/or clinical treatment therapies to students. Have the students develop specific plans of care for their test and treatment plan. Have students present the plans to the class and discuss the similarities and differences.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students, as schedules permit, to a hematology–oncology clinic or unit.

LEARNING OUTCOME 3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

CONCEPTS FOR LECTURE 1. Oncologic emergencies result from the cancer itself or as a side effect of treatment. The emergencies can be classified into three groups: metabolic, hematologic, and those involving space-occupying lesions. The most common emergencies are tumor lysis, septic shock, brain herniation, spinal cord compression, and superior vena cava compression from a mass.

2. Metabolic emergencies result from the lysis of tumor cells. Septic shock may occur with changes in the metabolic system. The final type of metabolic emergency is hypercalcemia due to bone destruction. Treatment is based on the metabolic occurrence and reversal or acute management as indicated by signs, symptoms, and lab data.

3. Hematologic emergencies result from bone marrow suppression or infiltration of brain and respiratory tissue with high numbers of leukemic blast cells. This may become life threatening. Treatment involves infusion of packed red blood cells, platelet transfusion, vitamin K,

..

and fresh frozen plasma.

4. Space-occupying lesions are tumors with extensive growth that may result in spinal cord compression, increased intracranial pressure, brain herniation, seizures, massive hepatomegaly, cardiac and respiratory complications, and superior vena cava syndrome. Treatment involves radiation therapy, chemotherapy, and corticosteroids.

POWERPOINT LECTURE SLIDES Three Types of Oncologic Emergencies • Metabolic

•

°

Tumor lysis syndrome

°

Septic shock

°

Hypercalcemia

Hematologic °

Caused by bone marrow suppression

° Require transfusion and careful RBC and WBC assessment •

..

Space-occupying lesions: tumors with extensive growth o

Spinal cord compression

o

Increased ICP

o

Brain herniation

o

Seizures

o

Hepatomegaly

o

Gastrointestinal obstruction

o

Cardiac and respiratory complications

o

SVC syndrome

SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Engage students in active discussion regarding the various types of oncologic emergencies and management of each of the types of emergencies.

•

Have the students compare and contrast the care of the three types of oncologic emergencies.

SUGGESTIONS FOR CLINICAL ACTIVITIES Review any hospital or provider protocols for hematologic emergencies. Ask the students to identify the role of the nurse and other healthcare providers in a case scenario.

LEARNING OUTCOME 4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

CONCEPTS FOR LECTURE 1. Brain and central nervous system tumors are the most commonly occurring solid tumors in children and the second most common malignancy, after leukemia. Treatment depends on the type of tumor. Surgery is a common treatment, and might be done to debulk or excise the tumor. Radiation is commonly used in treatment following surgery. Chemotherapy may be

..

indicated in some cases.

2. Neuroblastoma is a solid tumor most commonly occurring outside of the cranium of children.

It is the most common tumor in infancy. The stage of the tumor determines the treatment protocol. Surgical excision followed by chemotherapy is one option. Chemotherapy and/or radiation may be required prior to removal depending on the location and size of the tumor.

HSCT may be considered in advanced cases of the disease.

3. Wilms tumor (nephroblastoma) is an intrarenal tumor. Wilms tumor has been associated with congenital anomalies. Treatment requires surgical removal of the tumor. Based on the stage of the tumor, radiation or chemotherapy may or may not be required.

4. Bone tumors (osteosarcomas) are rare and occur most frequently in adolescent males. Surgery for removal of affected bone, with either a salvage of limb or amputation, must be performed. Aggressive chemotherapy after surgery is noted to improve survival rates. Physical therapy and rehabilitation are necessary postoperatively. Ewing’s sarcoma is similar, but involves a smaller, round cell tumor of the diaphyseal portion of the long bones.

POWERPOINT LECTURE SLIDES Solid Tumors •

Brain and central nervous system (Figure 29–13) ° Most common malignancy in children, next to leukemia

..

°

Treatment depends on type and location of tumor

°

Surgery

°

Radiation

° •

Chemotherapy

Neuroblastoma °

Definition

°

Treatment based on protocol (Table 29–7) – Surgical – Chemotherapy – Radiation – HSCT

• Wilms’ tumor °

Define

°

Treatment based on stage (Table 29–8) – Requires surgical removal – Radiation – Chemotherapy

•

Bone tumors (osteosarcomas) °

Definition

°

Treatment – Surgery required – Chemotherapy

..

– Radiation •

Ewing’s sarcoma °

Similar to osteosarcoma

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students one of the solid tumor cancers prior to class. Ask the students to bring in pictures of the tumors with case study information for discussion in class.

LEARNING OUTCOME 5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

CONCEPTS FOR LECTURE 1. Leukemia is the most commonly diagnosed pediatric malignancy in children under 14 years of age. Leukemia is a cancer of the blood-forming organs and is characterized by a proliferation of abnormal white blood cells in the body. There are several types of leukemia depending on the blood cells affected.

2. Nursing management is difficult due to complex multisystem effects of the disease, and the long period of time required for therapy. Thorough assessments are an ongoing requirement.

Observe for signs of bleeding and infection.

3. Monitor for toxic side effects from chemotherapy and/or tumor cell lysis. Renal function, nutrition, CNS infiltration, and pain assessment should be completed not more than every 8 hours.

..

4. Pay special attention to renal status for children receiving cyclophosphamide. Hydration status and precise calculation of fluid requirements are required. Drug side effects may necessitate infusion of platelets or packed red blood cells.

5. Bone marrow suppression may require isolation and transmission precautions. Education for family and child includes careful hand washing and oral care.

6. Nurses play a key role in the long-term multidisciplinary treatment of children with leukemia.

POWERPOINT LECTURE SLIDES Leukemia • Most commonly diagnosed malignancy in children under 14 •

Definition

Nursing Management •

Difficult due to multisystem effect

•

Long period of treatment required

•

Assessment complete and thorough °

Observe for signs of bleeding

°

Observe for signs of infection

• Monitor for toxic side effects of chemotherapy or tumor cell lysis

..

°

Renal function

°

Special attention for children on cyclophosphamide

•

Nutrition

•

CNS infiltration

•

Pain

•

Bone marrow suppression °

Isolation and transmission precautions

•

Child and family coping

•

Education of family and child °

Careful hand washing

°

Prevention of spread of infection

°

Oral care

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign students to work in groups. Give the groups one body system and have them investigate the potential problems for the system from leukemia, chemotherapy, radiation, or other treatment options.

SUGGESTIONS FOR CLINICAL ACTIVITIES Ask students to attend an area support group or clinic for leukemia patients.

LEARNING OUTCOME 6 Recognize the most common soft tissue tumors in children, describe their treatment, and plan

..

comprehensive care.

CONCEPTS FOR LECTURE 1. Hodgkin disease is a disorder of the lymphoid system. Diagnosis is based on lymph node biopsy and a staging classification is used to determine disease severity. Treatment is performed in an outpatient setting unless complications develop that require hospitalization.

Chemotherapy using a four-drug combination has been found to be the most effective drug treatment.

2. Non-Hodgkin lymphoma has three different types that may present in the pediatric population. The lymphoma must be staged and the treatment is tailored to the type of cancer and stage. Stages I and II are treated with drugs and possibly intrathecal medication. Stages III and IV are treated with additional drugs and for a longer period of time.

3. Rhabdomyosarcoma is a soft tissue cancer that is common in children. It occurs most often in the muscles around the eyes and neck, and less commonly in other locations. Treatment includes surgical removal of the tumor when possible. Surgery is followed with wide-field radiation and chemotherapy.

4. Retinoblastoma is an intraocular malignancy of the retina. Treatment for retinoblastoma may include removal of the eye (enucleation) when there is permanent retinal damage or failure to respond to other treatment. Radiation is nearly always used. Chemotherapy is sometimes used but is often ineffective as the drugs fail to penetrate sufficiently into the eye.

5. Nursing management for soft tissue tumors is similar to solid mass tumors. Physiologic assessment, psychosocial assessment, and collaboration with family and team members are im-

..

portant. Assessment and interventions based on potential side effects of therapies and treatment along with pain management should be priorities.

POWERPOINT LECTURE SLIDES Soft Tissue Tumors •

Hodgkin disease °

Definition (Figure 29–16)

°

Treatment based on staging – Outpatient setting – Chemotherapy

•

Non-Hodgkin lymphoma °

Definition

°

Three types

°

Treatment tailored to stage (Table 29–10) – Stages I and II treat with drugs – Stages III and IV treat with additional drugs and longer period

•

..

Rhabdomyosarcoma °

Definition

°

Locations (Figure 29–17)

°

Treatment

– Surgical when possible – Wide-field radiation – Chemotherapy •

Retinoblastoma °

Definition (Figure 29–18)

°

Treatment – Radiation almost always used – Chemotherapy sometimes used, but often ineffective – Removal of eye if other treatment fails

Nursing Management •

Similar to other cancers

•

Physiologic assessment

•

Psychosocial assessment

•

Collaboration with family

•

Collaboration with medical team

•

Intervention based on assessment and side effects of therapy

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students select types of soft tissue disorders prior to class. Ask the students to seek pictures of cases and present their findings in class.

..

LEARNING OUTCOME 7 Analyze the impact of cancer survival on children and use this information to plan for ongoing physiologic and psychosocial care.

CONCEPTS FOR LECTURE 1. Children with cancer have a variety of common psychologic and physiologic problems, regardless of their specific type of cancer. The impact of this experience extends into all areas of body and life function for the child and family.

2. Therapy for cancer can leave devastating effects on the body, both external and internal. Surgery can leave external reminders and place some children at risk for other problems.

3. Radiation has long-term effects, such as impairment of growth in various body systems. Secondary cancers may occur subsequent to the primary cancer and treatment but are of a different type.

4. Chemotherapy can cause a wide variety of effects, both during and after administration. The effects may not be noted for years.

5. General long-term management of cancer survival should plan for stress and coping for the family and child. Issues of concern range from loss of life or limb to ability to pay for treatment and care afterward. Children surviving cancer require frequent and thorough physical, physiologic, developmental, and cognitive assessment. Interventions should be started as soon as possible if any concern arises in the child’s follow-up care.

POWERPOINT LECTURE SLIDES

..

Psychologic and Physiologic Problems of Cancer Survival •

Cancer affects all areas of function

•

Effects of therapy °

Surgery – External and internal body changes

°

Radiation – Long-term effects – Growth – Secondary cancers

°

Chemotherapy – Effects immediate – May present years later

•

Long-term planning °

Family stressors – Questions regarding outcomes – Financial concerns

°

Frequent follow-up – Physical – Physiologic

..

– Developmental – Cognitive – Interventions started as soon as deficit noted SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Ask students to develop a long-term plan of care for a child who has survived cancer.

•

Review several different care plans and investigate how each student may see one area as a higher priority for planning long-term care.

SUGGESTIONS FOR CLINICAL ACTIVITIES Ask students to interview cancer survivors. The survivors may be children or adults. Encourage the students to seek information regarding the emotional and spiritual aspects of long-term follow-up.

LEARNING OUTCOME 8 Recommend methods for an oncology team including nurses, social workers, psychologists, and child life specialists to partner with school personnel, children and adolescents, families, and others to meet the needs of children with cancer.

CONCEPTS FOR LECTURE 1. Collaborate with the family to provide family-centered care. Team meetings should include the family and child if appropriate.

2. Teams providing and planning care for the child with cancer include nurses, primary and specialty healthcare providers, social workers, case managers, child life therapists, and psy-

..

chologists. The team requires a collaborative environment and a team leader to maintain contact and update team members as needed on changes in the status of the child and family.

3. The child, if school age, will have specific needs regarding communication and involvement with school activities. The child should be encouraged to maintain active participation in studies, even if not attending school.

4. Spiritual and emotional needs should be addressed on a regular basis. Encouragement to join support groups and interact with others to seek support is appropriate.

POWERPOINT LECTURE SLIDES Collaboration to Provide Family-Centered Care •

•

•

..

Team meetings °

Include family

°

Include child when appropriate

Team members °

Nurses

°

Primary and specialty care providers

°

Social workers

°

Case managers

°

Child life therapist

°

Psychologist

For the school-age child

•

°

Encourage maintenance of learning

°

Involvement of school appropriate with permission

Spiritual and emotional needs °

Encourage participation in support groups

SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Have students role-play for the class a team meeting on a specific case study.

•

Review how the team members interact and what each individual does as part of a team caring for a child with cancer.

SUGGESTIONS FOR CLINICAL ACTIVITIES Ask students to interview individuals who are actively involved in an oncology team. Students should seek information on the team experience and the positives and negatives of a team health approach.

..

CHAPTER 30 ALTERATIONS INGASTROINTESTINAL FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Managing Emesis in Pediatric Conditions Case Study:The Child with a Cleft Palate Media Links:Cleft Lip/Palate Resources and Support; Ostomy Resources and Support Media Link Applications Videos and Animations:Activated Charcoal; Digestive System; Lead Poisoning; Stool Toileting: Refusal and Rewards; Nursing in Action: Ostomy Care Pediatric Dosage Calculations Image Library Figure 30–1 The internal anatomic structures of the stomach, including the pancreatic, cystic, and hepatic ducts; the pancreas; and the gallbladder.

Figure 30–3 Unilateral cleft lip.

Figure 30–7 In the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch connected to the trachea; the fistula connects the lower segment to the trachea.

..

Figure 30–9 In pyloric stenosis, the hypertrophied pyloric muscle causes symptoms of projectile vomiting and visible peristalsis.

Figure 30–10 In omphalocele, the size of the sack depends on the extent of the protrusion of abdominal contents through the umbilical cord.

Figure 30–11 The newborn with gastroschisis has abdominal contents located outside the abdominal wall.

Figure 30–12 In infants, intussusception is commonly associated with viral illnesses and gastroenteritis.

Figure 30–13 This infant has several gastrointestinal problems and requires ostomies for both gastric feedings and for drainage of fecal material.

Table 30–5 Causes of Diarrhea in Children Table 30–7 Comparison of Hepatitis Types Clinical Manifestations Common Intestinal Parasitic Disorders

LEARNING OUTCOME 1 Describe the anatomic and physiologic characteristics of the developing gastrointestinal system.

CONCEPTS FOR LECTURE 1. There are anatomic and physiologic differences in organs of the digestive system between the pediatric and adult patient.

2. The child ingests and absorbs food, and any defect in the gastrointestinal system can impair growth.

..

3. There are differences between the child and adult gastrointestinal systems.

POWERPOINT LECTURE SLIDES Gastrointestinal System (Figure 30–1) •

Digestion takes place in the duodenum

•

Enzymes aid in the digestion process

Child vs. Adult Gastrointestinal System •

Liver function immature at birth

•

Enzymes deficient until 4 to 6 months old

•

Abdominal distention from gas common with infants

•

Stomach capacity smaller

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students divide into groups. Give students blank stomach pictures, similar to the one in Figure 30–1, with lines drawn to the various parts. Have them fill in the names of the parts. Give each group a diagnosis of a defect that occurs in the stomach, such as pyloric stenosis, and have students use their textbooks to define the abnormality. Have each group present their abnormality to the class. It is important that they identify in their presentation the definition of the abnormality, as well as when and where this occurs in children.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students assess their assigned patients for gastrointestinal problems with whatever illness

..

the patients may have. For example, if a child is in the hospital for a burn, assess the gastrointestinal problems that occur with a burn.

LEARNING OUTCOME 2 Discuss the pathophysiologic processes associated with specific gastrointestinal disorders in the pediatric population.

CONCEPTS FOR LECTURE 1. Gastrointestinal disorders are the result of a congenital defect, acquired disease, infection, or injury.

2. Congenital gastrointestinal defects occur when the fetus is in utero.

3. Cleft lip and cleft palate are two distinct facial defects that can occur singly or in combination. Cleft lip with or without cleft palate results from a failure of the maxillary processes to fuse with the elevations on the frontal prominence during the sixth week of gestation. Normally, union of the upper lip is complete by the seventh week. Fusion of the secondary palate occurs between 5 and 12 weeks of gestation. Failure of the tongue to move downward at the correct time will prevent the palatine processes from fusing.

4. Esophageal atresia is a malformation that results from failure of the esophagus to develop as a continuous tube during the fourth and fifth weeks of gestation. Esophageal atresia occurs in approximately 1 in 4,000 neonates with 90% of those affected also having a tracheoesophageal fistula.

..

5. Pyloric stenosis is a hypertrophic obstruction of the circular muscle of the pyloric canal. Hypertrophy of the circular pylorus muscle results in stenosis of the passage between the stomach and the duodenum, partially obstructing the lumen of the stomach. The lumen becomes inflamed and edematous, which narrows the opening until the obstruction becomes complete.

At this time, vomiting becomes more forceful. As the obstruction progresses, the infant becomes dehydrated and electrolytes are depleted, resulting in metabolic imbalances.

6. Gastroesophageal reflux (GER), the return of gastric contents into the esophagus, is the result of relaxation of the lower esophageal sphincter. Gastroesophageal reflux disease (GERD) is a more serious manifestation of GER. The lower esophageal sphincter of the gastrointestinal tract contains a band of smooth muscle that relaxes during feeding but remains contracted between meals to prevent reflux of stomach contents into the esophagus. If the esophageal sphincter relaxes inappropriately, GER results. Transient lower esophageal sphincter relaxations (TLESRs) occur after eating and during normal digestion; however, children who have GERD may have an increased incidence of reflux secondary to this relaxation. The smaller stomach, shorter esophagus, and immaturity of the lower esophageal sphincter muscle in infants account for the frequency of GER in this population.

7. Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. An omphalocele results when the intestines fail to return to the abdomen when the abdominal wall begins to close by the 10th week of gestation. The size of the sac varies depending on the extent of the protrusion. Large defects may contain the intestines, stomach, liver, and spleen. Omphalocele occurs at the base of the umbilical cord. The abdominal contents are covered with peritoneum and amniotic membrane. Rupture of the sac results in evisceration of the abdominal contents.

..

8. Gastroschisis is a congenital defect of the ventral abdominal wall, characterized by protrusion of bowel through a defect in the abdominal wall to the side (most often to the right) of the umbilicus. The most common abdominal organs involved are the small intestine and ascending colon. Unlike the omphalocele, no membrane covers the organs.

9. Intussusception occurs when one portion of the intestine prolapses and then invaginates or telescopes into another.

10. When malrotation of the intestine occurs, the child is at risk for volvulus, a twisting of the intestine. Volvulus disrupts blood flow in the intestines and can lead to necrosis of the bowel, short bowel syndrome, and death. Volvulus is considered a surgical emergency.

11. Hirschsprung disease, also known as congenital aganglionic megacolon, is a congenital anomaly in which inadequate motility causes mechanical obstruction of the intestine. Hirschsprung disease is the congenital absence of ganglion cells in the wall of a variable segment of rectum and colon. The absence of autonomic parasympathetic ganglion cells in the colon prevents peristalsis at that portion of the intestine, resulting in the accumulation of intestinal contents and abdominal distention. In most cases, the area lacking ganglion cells is limited to the rectosigmoid region of the colon.

12. A hernia is the protrusion or projection of an organ or a part of an organ through the muscle wall of the cavity that normally contains it. This protrusion may result from the failure of normal openings to close during fetal development or from weakness in the supporting musculature. When intra-abdominal pressure increases (as when the infant cries or strains to pass stool), the weakened area separates, causing a protrusion of underlying organs. Inguinal hernias are the most common type of hernia occurring in children.

..

13. Inflammatory disorders include appendicitis (the most common cause of emergency surgery in children), necrotizing enterocolitis, Meckel diverticulum, inflammatory bowel disease, and peptic ulcer. Disorders of motility include gastroenteritis (acute diarrhea) and constipation.

14. Intestinal parasitic disorders may result from exposure to untreated water, incorrectly prepared food, poor sanitation, pets, and wildlife.

POWERPOINT LECTURE SLIDES Disorders of the Gastrointestinal System •

Structural defects

•

Acquired disease

•

Infection

•

Injury

Types of Pathophysiology Associated with Structural Defects of the Gastrointestinal System •

Cleft lip and cleft palate (Figure 30–3) °

Definition

°

Failure of the maxillary processes to fuse between 5 and 12 weeks’ gestation

°

Failure of the tongue to move down at the correct time prevents the palatine processes from fusing

° Multifactorial causes •

Esophageal atresia and tracheoesophageal fistula (Figure 30–7) °

..

Definition

°

Foregut fails to lengthen, separate, and fuse into two parallel tubes (esophagus and trachea) at 4 to 5 weeks’ gestation – Associated with maternal polyhydramnios

•

•

Pyloric stenosis °

Definition (Figure 30–9)

°

Etiology unknown

°

Hypertrophy of the circular pylorus muscle

°

Stenosis occurs between stomach and duodenum

Gastroesophageal reflux °

Definition

°

Three mechanisms allow reflux to occur – Lower esophageal relaxations – Incompetent lower esophageal sphincter – Anatomic disruption of esophagogastric junction

•

°

Reflux acidity damages the esophageal mucosa

°

Causes

Gastroschisis and omphalocele °

Definition (Figures 30–10 and 30–11)

°

Gastroschisis usually occurs to the right of the umbilicus and omphalocele occurs through the umbilical cord

..

°

Occurs in week 11 of gestation when abdominal contents fail to return to the abdomen

° Multifactorial causes •

Intussusception (Figure 30–12) °

Intestine invaginates into another

° Mesentery becomes inflamed and obstruction can occur ° •

•

Multifactorial causes

Volvulus o

Occurs in 7th to 12th week of gestation

o

1 in 6,000 live births

o

Malrotation of bowel interrupts blood flow and causes bowel necrosis

o

Surgical emergency

Hirschsprung disease o

Definition

o

Congenital absence of ganglion cells in the rectum and colon

o

Genetically acquired and occurs when there is failure of the migration of neural crest cells in utero

o

•

Anorectal malformations o

..

Colon becomes a “megacolon”

Anal stenosis and anal atresia

o

Failure of growth of urorectal septum, lateral mesoderm structures, and ectodermal structures

o

•

•

Associated anomalies up to 70% of the time

Congenital diaphragmatic hernia o

Protrusion of abdominal contents into thoracic cavity

o

Occurs in 4th week of gestation

o

Failure of pleuroperitoneal musculature to close

Umbilical hernia (Figure 30–13) o

Definition

o

Etiology unknown

o

Around week 11 of gestation, the obliterated umbilical vessels occupy the space in the umbilical ring

Pathophysiology Associated with Inflammatory Disease •

Appendicitis °

Definition

°

Caused by an obstruction of the appendiceal lumen, causing edema

°

As edema continues, vascular supply is compromised and bacteria invade, which can lead to a ruptured appendix

•

Necrotizing enterocolitis °

..

Inflammatory disease producing vascular compromise of bowel mucosa

° More common in premature infants °

Caused by intestinal ischemia, bacterial or viral infection, and immature gastrointestinal mucosa

• Meckel’s diverticulum °

Omphalomesenteric duct fails to atrophy

°

Outpouching of the ileum remains and contains gastric contents, causing ulceration

° •

Bowel obstruction, perforation, or peritonitis can occur

Inflammatory bowel disease (Crohn disease and ulcerative colitis) °

Faulty regulation of the immune response of the intestinal mucosa

°

Usually genetically triggered

°

Crohn disease can cause inflammation and ulcers anywhere throughout the GI tract

° •

Ulcerative colitis affects large intestine and rectal mucosa

Peptic ulcer °

Definition

°

Primary, secondary, or depends on the cause

°

Usually caused by Helicobacter pylori

Pathophysiology Associated with Motility Disorders •

..

Pathophysiology of motility disorders

•

•

Gastroenteritis °

Definition

°

Acute vs. chronic diarrhea caused by viruses, bacteria, or parasites

°

Causes of diarrhea in children (Table 30–5)

Constipation and encopresis °

Definition

°

Constipation can be caused by underlying disease, diet, or psychologic factors

°

Three types of constipation – Normal-transit constipation – Defecation disorders – Slow-transit constipation

°

Primary vs. secondary encopresis

Pathophysiology of Disorders of Malabsorption •

Short bowel syndrome o

Shortened intestine resulting from bowel resection

o

Extent of bowel loss determines severity of disorder

o

Location of bowel resection determines type of malabsorption

Pathophysiology of Hepatic Disorders •

..

Hepatic disorders

o

Hyperbilirubinemia of the newborn

o

Biliary atresia

o

Viral hepatitis (Table 30–7)

o

Cirrhosis

Pathophysiology of Injuries to the Gastrointestinal System • Abdominal trauma o

Blunt or penetrating trauma to the abdomen

o

Common causes –

Falls

– Motor vehicle accidents – Automobile vs. pedestrian accidents

o

–

Child abuse

–

Gunshot wounds

Organs commonly involved –

Liver

–

Spleen

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students divide into groups and assign each group either a congenital or acquired gastrointestinal disorder. They must define the disease, onset or origin, cause, and population ages usually affected. Groups should then present their disorder to the class, with pictures if applicable. ..

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students define the pathophysiology and causes of their patients; gastrointestinal disorders.

Have them report their findings in postconference. If the student is assigned to a patient who does not have a gastrointestinal problem, have the student report on how the gastrointestinal system is affected by the patient’s particular illness.

LEARNING OUTCOME 3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system.

CONCEPTS FOR LECTURE 1. Vomiting, diarrhea, jaundice, failure to thrive, congenital malformations, cyanosis with coughing, abdominal pain, constipation, and hernias can all be signs of a gastrointestinal disturbance.

2. Identify signs of a congenital gastrointestinal disturbance after birth.

3. Identify gastrointestinal emergencies in infants and children.

POWERPOINT LECTURE SLIDES Signs of Hepatic Disorders •

Jaundice

•

Easy bruising, intense itching

• White or clay-colored stools •

..

Tea-colored urine

Clues to Gastrointestinal Disorders in Children •

Vomiting or abdominal pain

•

Failure to thrive

•

Stool changes

Potential Signs of Gastrointestinal Emergencies in Infants •

Excessive salivation with cyanosis, coughing, and choking in newborn °

•

Abdominal viscera outside the abdominal cavity when born °

•

Esophageal atresia and tracheoesophageal fistula

Gastroschisis and omphalocele

Anorectal malformations

Potential Signs of Gastrointestinal Emergencies in Children •

Abdominal pain

•

Changes in appearance of stool

•

Vomiting and/or anorexia

•

Changes in activity

•

Changes in level of consciousness

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students separate into groups. Give each group a list of gastrointestinal symptoms and ask them to decide what disorder the child may be exhibiting. Have them determine if it is con-

..

sidered an emergency. Have the students present their findings to the class.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students assess their patient for signs of gastrointestinal disorders. Have them present their assessments to the group during postconference.

LEARNING OUTCOME 4 Summarize preoperative and postoperative family-centered care for the child born with a cleft lip/palate.

CONCEPTS FOR LECTURE 1. Surgical techniques for children with cleft lip/palate vary based on severity. Severe defects may require more than one operation.

2. Preoperative care focuses on facilitating feeding, providing psychosocial support to the family, and preventing aspiration.

3. Postoperative care includes assessing vital signs, measuring intake and output, positioning upright for feedings, and cleaning the suture line after feedings. Maintaining the suture line is essential.

POWERPOINT LECTURE SLIDES Care of Child Born With Cleft Lip/Palate Undergoing Surgery •

Technique varies on severity

• Severe defects may require more than one operation.

..

Preoperative Care of the Child With a Cleft Lip/Palate •

Facilitate feeding o

Special feeding devices

o

Support for mothers who are breastfeeding

•

Provide psychosocial support

•

Prevent aspiration o

Position upright for feedings

o

Suction equipment and bulb syringe

o

Feed slowly, use adaptive equipment as needed

Postoperative Care of the Child With a Cleft Lip/Palate •

Assess vital signs

• Measure intake and output •

Position upright for feedings

•

After feedings, clean suture line

• Maintain suture line o

Antibiotic ointment, pain management

o

Soft elbow immobilizers for two weeks

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students divide into groups. Each group is assigned to develop a nursing care plan for

..

either preoperative or postoperative care of the child with cleft lip/palate.

LEARNING OUTCOME 5 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

CONCEPTS FOR LECTURE 1. Identify various plans of care based on type of gastrointestinal disorder the child is experiencing.

2. Describe pre- and postoperative care for a child with a surgical gastrointestinal problem.

3. Each particular gastrointestinal diagnosis has its own nursing management issues.

POWERPOINT LECTURE SLIDES Esophageal Atresia and Tracheoesophageal Fistula •

Nursing care °

•

Identifying signs and symptoms of these infants

Pre- and postoperative care °

Suction is important preoperatively

°

Care of the gastrostomy tube postoperatively

Pyloric Stenosis •

..

Nursing care

•

Pre- and postoperative care

Gastroesophageal Reflux •

Nursing care

•

Important education

Appendicitis •

Nursing care

•

Pre- and postoperative care

Inflammatory Bowel Disease (Crohn’s Disease and Ulcerative Colitis) •

Nursing care

•

Important education

Constipation and Encopresis •

Nursing care

•

Important education

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students divide into groups. Each group is assigned to a particular gastrointestinal diagnosis. The students will then present the entire spectrum of the nursing process with that problem. They should include assessment, diagnosis, planning, implementation, and evaluation. They should include any pre- and postoperative care if applicable.

SUGGESTIONS FOR CLINICAL ACTIVITIES

..

Have the students present in postconference their nursing care for gastrointestinal problems with their patients. For example, if the patient is on a feeding tube, students describe the proper management of this problem and what teaching they would give to the parent.

LEARNING OUTCOME 6 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

CONCEPTS FOR LECTURE 1. Identify differences in gastrointestinal disease processes and the age at which they occur. For example, pyloric stenosis would not be an issue for a 10-year-old child.

2. Some congenital defects could have implications for the older child as well. For example, cleft lip issues can be apparent for a lifetime.

3. Meckel diverticulum usually becomes symptomatic around 2 years of age.

4. Gastroesophageal teaching varies depending on age. An infant’s parent will be taught to burp frequently whereas an adolescent will be taught what foods to avoid.

5. If the toddler is hospitalized, childproof the room with outlet covers, gates, and safety devices.

6. Some illnesses are observed in early childhood, but patients may need surgery when older, such as umbilical hernia, which is usually repaired by 4 years of age.

POWERPOINT LECTURE SLIDES

..

Infant (Birth to 1 Year Old) •

Congenital defects

•

Gastroesophageal reflux in infant vs. older child

•

Gastrointestinal disorders specific to this age group

Toddlers (1 Year Old to 3 Years Old) • Meckel’s diverticulum •

Offer age-appropriate toys

•

Childproof the room

•

Use pictures for education of older toddler

Children (3 Years Old to 12 Years Old) •

Body image starts becoming important after 5 years old

•

Offer age-appropriate toys

•

Use pictures for education of younger child

•

Umbilical hernia repaired

Adolescents (13 Years Old to 17 Years Old)

..

•

Appendicitis (10 to 19 years old)

•

Body image extremely important

•

Allow use of phone to satisfy peer needs

•

Give them handouts about peers with conditions and experiences

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups to represent the four age groups (infant, toddler, child, and adolescent). Provide a handout with three gastrointestinal disorders that span a lifetime. Have each group decide what would be the appropriate nursing care based on each age group. Tell them to include play, safety, education, and nursing interaction. (They may also need to use another chapter for research in addition to Chapter 30.)

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students present at postconference the gastrointestinal findings and how they relate to nursing management based on their patient’s age. How did they have to assess and implement care specific to their patient’s age?

LEARNING OUTCOME 7 Summarize etiology, pathophysiology, symptoms, and management for the child with a parasitic or viral infection of the gastrointestinal system.

CONCEPTS FOR LECTURE 1.

Intestinal parasitic disorders result from exposure to untreated water, incorrectly prepared food, poor sanitation, exposure to pets and wildlife.

..

Young children are most at risk; childcare centers are a concern, and sandboxes should be

2.

kept covered when not in use.

Nursing care centers around teaching prevention (e.g., hand washing). After diagnosis,

3.

teaching centers around the need to take medications as ordered.

POWERPOINT LECTURE SLIDES Intestinal Parasitic Disorders •

•

•

Occurrence related to: o

Untreated water

o

Incorrect food preparation

o

Crowded conditions with poor sanitation

Young children most at risk o

Childcare settings

o

Exposure to pets and wildlife

Nursing care = teaching o

Preventive—good hygiene practices

o

After diagnosis—take medications as ordered (Clinical Manifestations)

SUGGESTIONS FOR CLASSROOM ACTIVITIES

..

Have the students compare and contrast the clinical manifestations and therapies for different internal parasitic disorders.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students do parent teaching with their assigned patients at clinicals on hand washing and prevention of intestinal parasitic disorders.

LEARNING OUTCOME 8 Plan nursing care for the child with an injury to the gastrointestinal system.

CONCEPTS FOR LECTURE 1. Parents and children need emotional support for abdominal trauma.

2. The parents may feel guilty if the accident could have been prevented.

3. Children may need IV fluids or blood transfusions.

POWERPOINT LECTURE SLIDES Abdominal Trauma •

Blunt trauma

• Penetrating trauma • Pediatric abdominal frame makes children more exposed and vulnerable to injury ..

Clinical Manifestations of Abdominal Trauma •

Pain

• Abdominal distention •

Guarding

•

Decreased or absent bowel sounds

• Nausea and vomiting •

Hypotension

•

Shock

• Penetrating wounds, bruising, marks Nursing Care for Abdominal Trauma • Provide emotional support •

Follow care orders

•

Prevention teaching once stabilized

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students compare and contrast care issues between the child with abdominal trauma from an ATV accident versus a gunshot wound. Have the students present their findings to the class.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students do parent teaching with their assigned patients at clinicals. They can pick a topic such as accident prevention or childproofing the home. ..

..

CHAPTER 31 ALTERATIONS INGENITOURINARY FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Adolescents and Sexual Activity Case Study:Child with Chronic Kidney Failure Care Plan:A School-Age Child with Enuresis; A School-Age Child with Nephrotic Syndrome; Child with Acute Renal Failure (ARF) Media Links:Acute and Chronic Renal Failure Resources and Support Media Link Applications Videos and Animations:Circumcision; Gonorrhea; Herpes; Renal Function; Nursing in Action: Central Venous Catheter Care Pediatric Dosage Calculations Image Library Figure 31–5 Hypospadias and epispadias.

Figure 31–7 Obstruction may occur in either the upper or lower urinary tract.

Table 31–1 Assessment Guidelines for the Child with a Genitourinary Condition Table 31–2 Diagnostic Tests and Laboratory Procedures for the Genitourinary System Box 31–1 Expected Urine Output According to Age

..

Clinical Manifestations Urinary Tract Infection Clinical Manifestations Electrolyte Imbalances in Acute and Chronic Renal Failure Partnering with Families Preventive Strategies for UTI Partnering with Families Care for the Child After Hypospadias and Epispadias Repair Partnering with Families Preventing STIs and Their Consequences

LEARNING OUTCOME 1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

CONCEPTS FOR LECTURE 1. The urinary system has four parts: kidneys, ureters, bladder, and urethra.

2. The urinary system maintains balance of fluid and electrolytes, acid–base regulation, blood pressure regulation, erythropoietin production, and regulation of calcium metabolism.

3. Nephrons are the structural and functional unit of the kidneys.

4. With children under 2 years of age, the kidneys are less efficient at acid–base regulation, electrolyte balancing, and eliminating some drugs from the body.

5. Bladder capacity is estimated in ounces by adding 2 to the child’s age (3 year old = 5-oz capacity in bladder).

POWERPOINT LECTURE SLIDES

..

Urinary System • Maintains balance of fluid and electrolytes •

Removal of waste products

•

Functionally immature until puberty

Kidneys •

Function through filtration, reabsorption, and secretion

• Nephrons—the kidney’s functional unit •

Filtration occurs at the glomerulus, Bowman’s capsule, and the basement membrane

•

As child grows, concentration of urine becomes more efficient (Box 31–1)

•

Under 2 years old, kidneys less efficient

Ureters •

Carry waste fluid from kidneys to bladder

Bladder •

Stores urine

•

Bladder capacity in ounces estimated by adding 2 to child’s age

• Muscular organ—contraction of detrusor and relaxation of sphincters result in bladder emptying Urethra •

..

Excretes urine

•

Urine excretion occurs around the 12th week of gestation

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students divide into groups and list how the genitourinary system is different in children versus adults. Have the students identify ways this could be dangerous, especially for children under 2 years of age (e.g., dehydration).

SUGGESTIONS FOR CLINICAL ACTIVITIES During postconference, have the students identify ways the genitourinary system is affected with the problem their patient is experiencing. How is the blood pressure maintained? How is the input and output calculated?

LEARNING OUTCOME 2 Develop a nursing care plan for the child with a urinary tract infection.

CONCEPTS FOR LECTURE 1. Causes of urinary tract infection can be urine stasis, anatomic malformation, neurogenic bladder, and sexual activity. Usually the urinary tract is sterile, and infection develops when bacteria invades.

2. Children with complicated urinary tract infections will need to be hospitalized, and care centers on administering antibiotics, facilitating rehydration, assessing renal function, and educating the family. Toileting regression may occur if the child was recently toilet trained.

3. Assessment should focus on urinary symptoms and physical exam.

..

4. Nursing diagnoses may be related to a history of recurrent urinary tract infections, infrequent voiding habits, and inadequate fluid intake.

5. Planning and implementation—administration of antibiotics is necessary as well as antipyretics for children with a fever. Maintenance of fluid intake is important to dilute the urine and flush the bladder.

6. Evaluation—expected outcomes of nursing care include increased fluid intake and voiding, and reduction of risk factors.

POWERPOINT LECTURE SLIDES Urinary Tract Infection (Clinical Manifestations Urinary Tract Infection) • Definition—viral, bacterial, or fungal infection of the lower or upper urinary tract • Pathophysiology—organism enters genitourinary tract and ascends from the urethra to the bladder toward the kidney • Assessment

•

o

History of UTI

o

I&O

o

Physical exam of abdomen and perineal region

o

Collection of urine

Nursing diagnosis o

..

Impaired Urinary Elimination

o

Urinary Retention

o

Risk for Deficient Fluid Volume

• Nursing management o

Medication administration

o

Hydration status

o

Assess renal function

• Teaching (Partnering with Families: Preventive Strategies for UTI) o

Prevention

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students divide into groups and develop educational tools for presenting to families and children when educating about urinary tract infections. Have them educate the class with their educational tools.

SUGGESTIONS FOR CLINICAL ACTIVITIES When students are at preconference, have them identify the children who could possibly be at risk for a urinary tract infection. Have them identify ways to educate the family to aid in prevention strategies.

LEARNING OUTCOME 3 Discuss the collaborative care and nursing management of the child with a structural defect of

..

the genitourinary system.

CONCEPTS FOR LECTURE 1. There can be many malfunctions within the genitourinary system. Structural defects can occur anywhere along the system. Symptoms of a genitourinary problem could include failure to thrive, decreased output, dehydration, dysuria, edema, or fever. It is the role of the nurse to assess for structural defects of infants when they are born. The nurse should check for urethra placement, output, vital signs, and abdominal mass.

2. Hypospadias and epispadias are congenital anomalies of the urethral meatus. Both result from failure of the urethral folds to fuse completely.

3. Obstructive uropathy occurs when structural abnormalities interfere with urine flow. An obstruction can occur if there is a thin membrane over the posterior urethra valves. Symptoms could be abdominal mass, palpable bladder, or increased or decreased urinary output. With posterior urethra valve obstruction, symptoms may include sepsis, enlarged kidney, distended bladder, polyuria, urinary tract infection, increased creatinine level, or failure to thrive. The nurse must assess for urine output and bladder distention postoperatively after an obstructive uropathy surgery. The family may need catheter education if applicable. Postoperatively, the goal is to keep the child or infant free from infection and manage pain effectively.

4. Vesicoureteral reflux occurs when there is backflow of urine from the bladder, which prevents bladder emptying and creates bacterial growth. This can be caused by a structural abnormality where the ureters insert into an abnormal position in the bladder. Of children with posterior urethral valves (a membrane obstructs the posterior urethra), 50% can have

..

vesicoureteral reflux. Vesicoureteral reflux surgery would include reimplantation of the ureters. Postoperative care would include: watch urine to lose blood-tinged appearance by day 2 or 3, administer IV fluids at a higher rate than usual, monitor urine output for decreasing amount to minimize the chance of blood clots, and administer medication. Teaching the family about observing for fever, back pain, incision infection, and avoiding active play for 3 weeks is an important nursing role.

5. Cryptorchidism (undescended testes) occurs at 7 to 9 months of gestation. Normally, the testes would descend from the inguinal canal to the scrotum at that time. Causes may include testosterone deficiency, short spermatic cord, or adhesions. This can cause damage to the testicles if not surgically corrected by 2 years of age.

6. Scrotal swelling can be indicative of an inguinal hernia (abdominal tissue in scrotum) or hydrocele (fluid in scrotum). During fetal development, the tunica vaginalis can trap fluid and cause the hydrocele.

POWERPOINT LECTURE SLIDES Clinical Manifestations of Genitourinary Problems •

Structural defects and various disorders

• May result in reduced or obstructed urine flow •

Testing (Tables 31–1 and 31–2)

Structural Defects of Urinary System •

Congenital abnormalities: abnormal location of urethral meatus (Figure 31–5) o Hypospadias—urethral meatus located on ventral surface

..

o Epispadias—urethral opening located on dorsal surface o Pathophysiology—result from failure of urethral folds to fuse completely over urethral groove °

Nursing management – Preoperative teaching – Fluid intake and output documentation – Education

°

▪

Catheter and stent care

▪

Incision and penis care

Postoperative care (Partnering with Families: Care for the Child After Hypospadias or Epispadias Re-pair)

•

–

Protect surgical site

–

Pain management

–

Double diapering

Obstructive uropathy and posterior urethral valves (Figure 31¬–7) ° Definition—abnormalities that result in urine backflow into the kidneys ° Pathophysiology—caused by several congenital lesions °

Nursing management – Monitor urine output –

..

Pain management

– Monitor for infection °

•

Pre- and postoperative care –

Diaper placement

–

Ostomy care

Vesicoureteral reflux o Definition—retrograde flow of urine from bladder into ureters o Pathophysiology—reflux prevents complete emptying of bladder, reservoir for bacterial growth °

Postoperative care – Monitor urine –

o

IV administration

Family teaching – Monitor for infection –

Incision care

Structural Defects of the Reproductive System •

Cryptorchidism o Definition—undescended testes o Pathophysiology—occurs when one or both testes fail to descend through inguinal canal into scrotum

..

•

Inguinal hernia and hydrocele ° Definition—painless inguinal or scrotal swelling ° Pathophysiology—peritoneal sac precedes the testicles’ descent into scrotum

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the students into groups. Assign each group a different type of structural defect in the uri- nary system. Have them create nursing care plans for their patients, starting with assessment and diagnosis of the problem and continuing through planning, intervention, and evaluation. Make sure they include parent teaching of postoperative care in their management.

SUGGESTIONS FOR CLINICAL ACTIVITIES Pick someone in the clinical group who is caring for a child with a structural defect of the urinary system. During preconference, have the group decide on the plan of care of that child. Have the student report to the group at postconference.

LEARNING OUTCOME 4 Identify growth and development issues for the child with chronic renal failure.

CONCEPTS FOR LECTURE 1. Chronic renal failure (CRF) is progressive and irreversible. The reduction in kidney func-

..

tion develops slowly over months or years. Congenital defects and cystic and inherited diseases are the most common causes of CRF in young children. Glomerulonephritis, hereditary disorders, and acquired disorders are the most common causes of CRF in older children.

2. Children with renal failure are usually hospitalized due to multiple organ system failure.

3. Delay in growth and development is a common outcome related to the decreased protein and calorie intake and loss of protein in dialysate. Additional disturbances in metabolism of calcium, phosphorus, and vitamin D contribute to growth retardation.

4. A high-quality protein diet is needed to support growth. Optimal intake is 2.5 g/kg/day.

POWERPOINT LECTURE SLIDES Chronic Renal Failure • Slow, irreversible reduction in kidney function over months or years • Caused by congenital defects, cystic and inherited diseases, glomerulonephritis, hereditary disorders, and acquired disorders • Delay in growth and development is a common outcome •

High-quality protein diet is needed to support growth

• Small, frequent feedings, attractive presentation Nursing Management (Clinical Manifestations: Electrolyte Imbalances in Acute and Chronic Renal Failure)

..

•

Monitor height and weight

•

Assess development

•

Meet nutritional needs

•

Provide emotional support

SUGGESTIONS FOR CLASSROOM ACTIVITIES Invite a pediatric nutritionist to class to discuss meal planning for a child with chronic renal failure. Have students develop a meal plan for children of different ages and weights.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students plot the growth of a child with renal disease. Discuss findings in postconference.

LEARNING OUTCOME 5 Outline a plan to meet the fluid and dietary restrictions for the child with a renal disorder.

CONCEPTS FOR LECTURE 1. Children with kidney disease have restrictions in diet, often in sodium, potassium, and phosphorous. Children with renal disease are at risk for malnutrition because of the high metabolic rate. The diet should be tailored to the child’s individual likes and needs. A nutritionist is often needed.

..

2. Chronic renal failure requires: small frequent meals high in protein; high calorie intake; adequate calcium; may require enteral feedings, especially in children under 1 year of age; complex carbohydrates and fruits and vegetables low in potassium; vegetable oils, hard candy, honey, and jelly add calories to child’s diet; limit phosphorous, potassium, and sodium.

3. Nephrotic syndrome requires regular protein, low-sodium diet. Excessive or restricted protein may accelerate protein loss in urine.

4. Acute glomerulonephritis requires a low-protein, no-added-salt diet. Anorexia is common; meals should be attractive and offer the child’s favorite foods.

POWERPOINT LECTURE SLIDES Nutrition Management for Children with Kidney Disease • Children with kidney disease—risk for malnutrition •

Chronic renal failure: o Small, frequent meals high in protein o High calorie intake o Adequate calcium o May require enteral feedings o Complex carbohydrates o Fruits and vegetables low in potassium o Limit phosphorous, potassium, and sodium

..

•

Nephrotic syndrome o Regular protein o Low-sodium diet

•

Acute glomerulonephritis o Low protein o No-added-salt diet

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide students into groups. Assign a renal disorder to each group. Have the groups evaluate food labels and decide if the food is appropriate for the child’s diet.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to observe the dietary department. Identify differences in meals for children with renal disorders.

LEARNING OUTCOME 6 Summarize psychosocial issues for the child requiring surgery on the genitourinary tract.

CONCEPTS FOR LECTURE

..

1. For children undergoing surgery for genitourinary tract disorders, surgery may be emergent in nature or can be delayed until 1 to 2 years of age.

2. Genitourinary structural defects that may require surgery include cryptorchidism, hernia repair, bladder extrophy, hypospadias and epispadias, obstructive uropathy, and vesicoureteral reflux.

3. Parents may be concerned with possible injury, infection, disfigurement, and preservation of renal and reproductive function.

4. Parental teaching may include learning to perform bladder elimination procedures, special dressing and diapering, bathing, hydration assessment, wound care, and infection control.

5. Assessment of family coping mechanisms and support systems is essential in families of an infant diagnosed with a defect necessitating surgery. Assess child (if older) and family’s level of understanding of the surgery and concerns.

6. Provide parents with the opportunity to discuss concerns.

7. Psychologic counseling may be beneficial for the parent and later for the child, especially during adolescence.

POWERPOINT LECTURE SLIDES Genitourinary Surgery—Nonemergent vs. Emergencies •

Infancy vs. older child

•

Parental concerns o Injury, infection, disfigurement, and preservation of renal and reproductive

..

function •

Parental teaching o

Bladder elimination procedures, special dressing and diapering, bathing, hydration assessment, wound care, and infection control

• Assess family coping mechanisms and support systems •

Assess level of understanding of the surgery and concerns

•

Provide parents with the opportunity to discuss concerns

• Psychologic counseling may be beneficial Nursing Management • Reduce postoperative complications •

Reduce parental and child stress

• Promote positive body image

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the students into groups and assign each group a different type of reproductive system defect. Identify the psychosocial aspects of a child undergoing surgery for each defect. Each group should present findings to the class.

SUGGESTIONS FOR CLINICAL ACTIVITIES During postconference, discuss postoperative teaching for care of an infant undergoing emergen-

..

cy surgery of the genitourinary tract.

LEARNING OUTCOME 7 Plan nursing care for the child with acute and chronic renal failure.

CONCEPTS FOR LECTURE 1. Nursing care of the child with renal failure focuses on preventing complications through careful monitoring and compliance with the treatment plan. Maintaining fluid balance, administering medications as ordered, and meeting the child’s nutritional needs are essential to caring for children with renal failure.

2. Nursing care of the child with renal failure also includes preventing infection and providing emotional support and anticipatory teaching for the family and caregivers.

3. Nurses also provide care for children who require dialysis. Hemodialysis is a process in which the blood flows from the child to a machine with a special filter that removes the body’s wastes and fluids.

4. Children over 20 kg have an arteriovenous fistula for long-term vascular access.

5. In peritoneal dialysis, the peritoneum of the abdomen is the membrane through which the body’s waste products pass from the blood to the abdominal cavity. Dialysate enters the abdomen through a catheter and pulls the body’s wastes, and is then drained out of the body.

6. Nursing care for a child with renal failure necessitating dialysis focuses on careful monitoring of fluid and electrolyte balance, administration of heparin, and control of bleeding.

..

Intake and output and vital signs are monitored every half hour while on dialysis.

7. Complications include hypotension, rapid fluid and electrolyte exchange, and disequilibrium syndrome.

8. Monitor fluid and dietary limitations, and review risks of infection and care of the catheter site.

9. The nurse also may administer medication, including sodium bicarbonate and other electrolytes and vasoactive agents.

POWERPOINT LECTURE SLIDES Nursing Management of Child with Renal Failure • Prevent complications o

Compliance with treatment plan

o

Careful monitoring

• Maintain fluid balance •

Administer medications

•

Meet nutritional needs

•

Prevent infection

•

Provide emotional support

•

Provide anticipatory teaching

Types of Dialysis

..

• Hemodialysis •

Peritoneal

Nursing Management • Electrolyte monitoring •

Intake and output

•

Vital signs

• Heparin administration • Monitor for bleeding and infection • Complications: hypotension, rapid fluid and electrolyte exchange, and disequilibrium syndrome SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students develop a nursing care plan for a child on peritoneal dialysis and hemodialysis.

Divide the students into groups and assign each a different type of kidney disorder. Have them create nursing care plans for their patients, starting with assessment and diagnosis of the problem and continuing through planning, intervention, and evaluation.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to observe a child in the dialysis unit. When students are presenting their patient information at postconference, have them explain the assessments they performed to check for renal function. Have them present the results and whether the results were normal.

..

LEARNING OUTCOME 8 Plan a teaching session for the adolescent with a sexually transmitted infection.

CONCEPTS FOR LECTURE 1. The main role of the nurse in working with children with sexually transmitted infections (STIs) is identifying the possibility of an STI through assessment and education.

2. Symptoms of STIs can include vaginal or penile discharge, lesions, asymptomatic problems, and dysuria. A person must have direct contact with someone with an STI in order to get it.

Condoms will not offer 100% protection, but will help in prevention.

3. Once it is determined what type of STI the child has, education is vital to provide information on this type of STI and how it is treated. Sexual partners must be identified and treated also. Prevention of reoccurrence is an extremely important aspect of nursing care. Sexual abuse must also be considered, especially if the child is young.

POWERPOINT LECTURE SLIDES Sexually Transmitted Infections (STIs) • Pathophysiology: numerous bacterial, parasitic, and viral organisms transmit sexually due to avoidance of protective barriers, multiple sexual partners, frequent sexual activity, failure to seek medical treatment, and sexual abuse • Nursing management o Identify signs and symptoms, assess for asymptomatic STI

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– Symptoms: 75% are asymptomatic – Symptoms may include endocervical discharge, pelvic pain, vaginal spotting, urethritis, dysuria o

Assess for psychosocial impact

o

Good communication and nonjudgmental approach

o

Education and prevention (Partnering with Families: Preventing STIs and Their Consequences)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Pair the students into groups of two to three. One student should act as an adolescent and the other two should act as nurses. Assign each group an STI. The “nurses” need to educate their teen about the signs of the STI, how it is treated, and how to prevent it from returning.

SUGGESTIONS FOR CLINICAL ACTIVITIES Discuss in preconference the signs of pelvic inflammatory disease. This illness may require the adolescent to be hospitalized. Develop a teaching plan for the adolescent hospitalized for treatment of PID.

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CHAPTER 32 METABOLIC AND FUNCTION ALTERATIONS IN ENDOCRINE Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Child with Inborn Errors of Metabolism and Diet Case Study:Child with Type 1 Diabetes Returning to Elementary School Media Links:Diabetes Resources and Support; Turner Syndrome Resources and Support; Growth Hormone Deficiency Resources and Support Media Link Applications Videos and Animations:Adolescent Diabetes and Quality of Life; Diabetes, Responding to Hypoglycemia; Physiology of Diabetes Pediatric Dosage Calculations Image Library Figure 32–1Major organs and glands of the endocrine system.

Figure 32–2Feedback mechanism in hormonal stimulation of the gonads during puberty.

Figure 32–3Actions of the major hormones of the anterior pituitary.

Figure 32–5Child with congenital hypothyroidism.

Figure 32–10 Insulin injection sites.

Figure 32–14 What characteristic physical manifestation of Turner syndrome can you identify in this girl?

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Figure 32–10 Insulin injection sites.

Table 32-1 Endocrine Glands and Their Functions Box 32-8 Questions to Ask to Identify Problems with Diabetic Control Clinical Manifestations Hyperthyroidism (Graves Disease) Clinical Manifestations Hypoglycemia and Hyperglycemia Parterning with Families Hydrocortisone Administration Partnering with Families Treating Hypoglycemic Episodes

LEARNING OUTCOME 1 Describe the general function of the endocrine system.

CONCEPTS FOR LECTURE 1. The five main functions of the endocrine system are fetus differentiation, growth regulation, coordination of gender-specific reproductive systems, hormone maintenance, and homeostasis.

POWERPOINT LECTURE SLIDES General Functions of Endocrine System (Table 32–1) •

Differentiate the reproductive and central nervous system in the fetus (Figure 32–1)

• Regulate the pace of growth and development (with the central nervous system) • Coordinate the male and female reproductive systems

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•

Maintain an optimal level of hormones for body functioning

•

Maintain homeostasis

SUGGESTIONS FOR CLASSROOM ACTIVITIES Separate the class into three teams. Compete to see which team can answer the most questions about the endocrine system correctly. The team that scores the most points wins a bonus point on the next exam about the endocrine system.

SUGGESTIONS FOR CLINICAL ACTIVITIES In postconference, have students identify potential endocrine problems with their patients. They can use Table 32–1 to help them identify any potential problems.

LEARNING OUTCOME 2 Identify the function of important hormones of the endocrine system.

CONCEPTS FOR LECTURE 1. The endocrine system controls cellular activity through release of hormones, chemical messengers secreted by various glands. The hormones have specific controlling effects on the cells in the body. Many hormones have overlapping functions.

2. The glands of the endocrine system include the anterior pituitary, posterior pituitary, thyroid, parathyroid, adrenal, pancreas, ovaries, and testes.

POWERPOINT SLIDES FOR LECTURE

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Endocrine System—Hormones • Endocrine system controls cellular activity through release of hormones •

Hormones have specific controlling effects on the cells in the body

• The glands of the endocrine system o Anterior pituitary, posterior pituitary, thyroid, parathyroid, adrenal, pancreas, ovaries, and testes •

Endocrine glands and their functions

• Feedback mechanism in hormonal stimulation of the gonads during puberty (Figure 32– 2) • Actions of the major hormones in the anterior pituitary (Figure 32–3)

SUGGESTIONS FORCLASSROOM ACTIVITIES Assign students a hormone. Have students state the gland that produces the hormone, the hormone’s function, and diseases that result from hypo- and hypersecretions of the hormone.

SUGGESTIONS FOR CLINICAL ACTIVITIES During clinical, ask students to look in the charts for lab reports of hormone levels. Have students report findings in postconference.

LEARNING OUTCOME 3 Summarize signs and symptoms that may indicate a disorder of the endocrine system. ..

CONCEPTS FOR LECTURE 1. Growth hormone deficiency signs for infants include below the third percentile by 1 year of age on a growth chart, hypoglycemic seizures, hyponatremia, neonatal jaundice, pale optic discs, micropenis, and undescended testicles. Growth hormone deficiency signs in children include youthful facial features, higher-pitched voices, delayed dentition, “ripply” abdominal fat, decreased muscle mass, and delayed skeletal maturation.

2. Signs of diabetes insipidus include polyuria, polydipsia, hypernatremia, dilute urine, and dehydration.

3. Signs of syndrome of inappropriate diuretic hormone (SIADH) are increased blood pressure, distended jugular veins, crackles auscultated in lungs, and intake exceeding output.

4. Signs of precocious puberty are secondary sexual characteristics prior to 8 years of age in girls and 9 years of age in boys. These children will also usually have an accelerated growth rate, advanced bone age, and behavioral changes.

5. Congenital hypothyroidism is not evident until the infant is a few months old. Signs in the infant include protruding tongue, thick lips, dull appearance, jaundice, hypotonia, respiratory distress, mottling, pallor, greater than 1 cm posterior fontanel, difficulty feeding, swollen eyes, constipation, and hoarse cry.

6. Acquired hypothyroidism signs include decreased appetite, dry skin, constipation, hair loss, and goiter.

7. Parathyroidism is usually secondary to another problem with the child. Signs of hyperparathyroidism are bone pain, nephrolithiasis, and bone fractures. Signs of hypoparathyroidism

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are muscle rigidity, muscle pain, and seizures.

8. Addison disease has a slow onset. Signs include lethargy, weight loss, salt craving, hyperpigmentation (especially in creases), abdominal pain, vomiting, diarrhea, dehydration, tachycardia, and developmental delay. Children with this problem may develop an Addisonian crisis where severe hypotension, weakness, fever, abdominal pain, hypoglycemia, seizures, dehydration, circulatory collapse, shock, and coma can occur if left untreated.

9. The classic signs of type 1 diabetes are polyphagia, polydipsia, and polyuria with weight loss. Usually, symptoms are present for less than 1 month. The nurse should also be able to recognize signs of diabetic ketoacidosis.

10. Primary amenorrhea is defined as no menses or secondary sexual characteristics by 14.5 years of age. Secondary amenorrhea is the absence of three or more menstrual cycles after a girl has achieved menarche.

11. Dysmenorrhea is defined as painful cramping associated with menses.

12. Characteristics of children with Turner syndrome include short stature, neck webbing, low hairline, cubitus valgus, scoliosis, wide-spaced nipples, hyperconvex fingernails, nevi, and delayed puberty.

13. Characteristics of children with Klinefelter syndrome include sudden disruptive behavior in school, tall and thin stature, decreased testicular size, abnormal pubertal development, and long legs.

14. Clinical signs of an inherited metabolic disease or inborn error of metabolism include lethargy, poor feeding, vomiting, abnormal muscle tone, seizures, apnea, and unusual urine or body odor.

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POWERPOINT LECTURE SLIDES Disorders of the Endocrine System •

Disorders of pituitary function °

Growth hormone deficiency – Signs and symptoms

°

Diabetes insipidus – Signs and symptoms

•

Syndrome of inappropriate diuretic hormone (SIADH) °

•

Precocious puberty °

•

Signs and symptoms

Signs and symptoms

Disorders of thyroid function °

Hypothyroidism – Signs and symptoms

°

Hyperthyroidism – Signs and symptoms (Figure 32–5 and Clinical Manifestations: Hyperthyroidism)

•

Disorders of the parathyroid °

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Hyper- and hypoparathyroidism

– Signs and symptoms •

Disorders of adrenal function °

Cushing syndrome – Signs and symptoms (Partnering with Families: Hydrocortisone Administration)

°

Adrenal insufficiency (Addison disease) – Signs and symptoms

•

Disorders of pancreatic function °

•

Diabetes mellitus

Disorders of gonadal function °

Amenorrhea – Signs and symptoms

°

Dysmenorrhea – Signs and symptoms

•

Disorders related to sex chromosome abnormalities °

Turner syndrome (Figure 32–14)

°

Klinefelter syndrome

°

Inherited metabolic diseases

SUGGESTIONS FOR CLASSROOM ACTIVITIES

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Divide students into groups and assign each a type of endocrine disorder. Have them present the disorder’s pathophysiology and clinical manifestations to the class without saying the name of the disorder. They can use pictures, lectures, or role-play to present their endocrine disorder, and the other students should try to name the disorder.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students who are assigned to children with an endocrine disorder present their findings in postconference. They should present initial clinical manifestations and current symptoms.

LEARNING OUTCOME 4 Identify all conditions for which short stature is a sign.

CONCEPTS FOR LECTURE 1. Growth hormone stimulates linear growth, bone mineral density, and growth of all body tissues.

2. Pituitary disorders can affect a child’s growth. Decreased production and/or release of growth hormone can be caused by several factors.

3. Most short stature in children is caused by a growth hormone deficiency. Other causes include familial short stature, hypothyroidism, Turner syndrome, constitutional growth delay, chronic renal failure, malnutrition, Cushing syndrome, Down syndrome, inborn error of metabolism, and severe cardiac, pulmonary, immunologic, or gastrointestinal dis-

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ease. Psychosocial dwarfism is a short stature resulting from emotional deprivation causing a transient growth hormone deficiency.

POWERPOINT SLIDES FOR LECTURE Growth Hormone • Stimulates linear growth, bone mineral density, and growth of all body tissues Short Stature in Children • Growth hormone deficiency • Familial short stature • Hypothyroidism • Turner syndrome •

Constitutional growth delay

•

Chronic renal failure

• Malnutrition • Cushing syndrome • Down syndrome • Inborn error of metabolism • Severe cardiac, pulmonary, immunologic, or gastrointestinal disease • Psychosocial dwarfism SUGGESTIONS FOR CLASSROOM ACTIVITIES

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Invite a parent of a child with short stature to the class to discuss the child’s stressors. Ask the parent to discuss when the short stature was first noticed, assessment and diagnostic testing, and psychosocial aspects.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students plot children’s height on a growth chart. Have students identify which height ranges for age are considered short stature.

LEARNING OUTCOME 5 Prioritize nursing care for each type of acquired metabolic disorder.

CONCEPTS FOR LECTURE 1. Disorders of pituitary function Growth hormone deficiency • Assessment: Nurses should be meticulous about documenting height and weight on the growth chart when evaluating a child with growth hormone deficiency.

Nurses should assess the psychosocial implications involved with short stature.

•

Nursing diagnoses include: Risk for Disproportionate Growth, Disturbed Body Image, and Risk for Chronic Low Self-Esteem.

• Planning and implementation: It is important to educate the family on the cause of the growth hormone deficiency and how to treat with injections.

• Evaluation: Outcomes of nursing care include that the child will achieve linear

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growth, parents are compliant with treatment, and the child demonstrates positive body image and self-esteem.

Diabetes insipidus • Assesssment: The child with diabetes insipidus should be assessed for fluid volume deficit, and fluids should be kept within reach at all times. Monitor vital signs and levels of responsiveness. The child may be irritable secondary to hypernatremia.

• Nursing diagnoses include: Impaired Urinary Elimination, Deficient Fluid Volume, and Speech Pattern Disturbance.

• Planning and implementation: parent education is important to identify signs of fluid loss and electrolyte imbalance. The child should also have access to a bathroom at all times.

• Evaluation: Outcomes of nursing care include that the child’s urinary frequency is reduced.

Syndrome of inappropriate diuretic hormone (SIADH) • Assessment: Assess for changes in level of consciousness, mentation and cognition, and headache and seizure activity.

• Nursing diagnoses include: Fluid Volume Excess, Deficient Knowledge, and Risk for Injury.

• Planning and implementation: Nursing management of a child with SIADH includes monitoring fluid balance and nutrition, weighing the child daily, and checking urinal-

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ysis. Medication education may need to be given depending on the cause of SIADH. Nursing care of a child focuses on educating about the cause, psychosocial support, and assessing growth and development.

• Evaluation: Outcomes of nursing care include that the child will have fluid balance restored, adequate nutritional intake, and remains free from injury. The family will demonstrate understanding of the disorder and its treatment.

Precocious puberty • Assessment: Assesses the child for secondary sex characteristics using Tanner staging, psychosocial adaptation to body changes, and parental anxiety.

• Nursing diagnoses include: Disturbed Body Image, Risk for Disproportionate Growth, and Compromised Family Coping.

• Planning and implementation: The goal of nursing care is to promote a positive body image. Support the family and emphasize the need to provide the child with social, cognitive, and emotional developmentally appropriate activities. Medications can be administered to cease the development of secondary sex characteristics.

• Evaluation: Outcomes of nursing care include the child demonstrating a positive body image, stabilization of growth and cessation of the development of secondary sex characteristics, and family acceptance and understanding of the disorder.

2. Disorders of thyroid function Hypothyroidism

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• Assessment: Neonatal screening is performed before discharge and reevaluated as necessary. Assess the child for inadequate growth and achievement of developmental milestones.

• Nursing diagnoses include: Risk for Delayed Development, Risk for Disproportionate Growth, Disturbed Body Image, and Fatigue.

• Planning and implementation: Children and parents dealing with hypothyroidism need education on the disorder and the need for lifelong medication (every morning, 1 hour before or 2 hours after a meal). Growth is monitored closely on a growth chart. Increased pulse could indicate too much thyroid hormone medication. Parents should report signs of fatigue.

• Evaluation: Outcomes of nursing care include the child maintaining adequate growth, cognitive development, and a positive body image. The parents demonstrate understanding of the disorder and medication compliance.

Hyperthyroidism • Assessment: Assess for goiter, sleep pattern, and exophthalmos, and assess surgical site if surgery is needed.

• Nursing diagnoses include: Ineffective Thermoregulation, Imbalanced Nutrition, Fatigue, and Disturbed Body Image.

• Planning and implementation: Nursing care of a child with hyperthyroidism includes education and monitoring of vital signs (increased blood pressure and pulse could occur). The nurse needs to promote increased nutritional needs to five or six meals per day. If exophthalmos is present, parents should be educated about eye care.

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• Evaluation: Outcomes of nursing care include the child achieving balanced thermoregulation, maintaining adequate nutritional intake, and being able to participate in activities of daily living without fatigue.

3. Disorders of the parathyroid Hyper- and hypoparathyroidism • Assessment: Assess for respiratory distress and potential airway obstruction in children who require surgery. Assess for signs of irritability, muscle rigidity, seizures, vomiting, abdominal distention, muscle pain, and cramping.

• Planning and implementation: In hyperparathyroidism, serum calcium and phosphorus levels are monitored closely. Parents should be taught the signs of hypocalcemia.

In hypoparathyroidism, children should be monitored for airway, breathing, and circulation. They should have a cardiorespiratory monitor. Seizure precautions are implemented until normal calcium levels are reached.

4. Disorders of adrenal function Cushing syndrome • Assessment: The nurse should monitor the child’s fluid status, vital signs, nutritional status, and weight.

• Nursing diagnoses include: Excess Fluid Volume, Risk for Infection, Disturbed Body Image, and Anxiety.

• Planning and implementation: Children with Cushing syndrome always need to have hydrocortisone injections at home and available for times of stress, such as with vom-

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iting or diarrhea. Pre- and postoperative care is important, including checking the incision site and elevating the bed 30 degrees to ensure effective breathing. Alert the family to signs of acute adrenal insufficiency.

• Evaluation: Outcomes of nursing care include the child achieving fluid volume balance, being free from infection, exhibiting a positive body image, and being free from anxiety.

Adrenal insufficiency (Addison disease) • Assessment: Assess for dehydration, nutritional intake, elimination patterns, muscle strength, and level of consciousness.

• Nursing diagnoses include: Deficient Fluid Volume, Deficient Knowledge, and Disturbed Body Image.

• Planning and implementation: Children with adrenal insufficiency must be on hydrocortisone daily for the rest of their lives. The family needs to be educated about the use of hydrocortisone and when to use the injectable form. If the child vomits within 1 hour of taking medication, the dose should be repeated. Educate the family about the illness and make sure they report symptoms including dizziness, bleeding, lethargy, changes in blood pressure or pulse, and weight gain.

• Evaluation: Outcomes of nursing care may include that the child maintains hemodynamic stability, achieves a fluid balance, demonstrates understanding of the disease and treatment, and has a positive body image.

5. Disorders of gonadal function Amenorrhea ..

•

Assessment: Elicit a thorough history and include sexual history. A physical examination and laboratory evaluation will determine cause.

•

Planning and implementation: Treatment of amenorrhea depends on the cause. The nurse should educate the family about the cause, if any, and discuss normal menstruation cycles and how the first 2 years after menarche can be irregular. If the adolescent is starting birth control pills, provide education.

•

Evaluation: The child will maintain normal growth and development.

6. Disorders related to sex chromosome abnormalities Turner syndrome • Assessment: The nurse should assess the other body systems to look for signs associated with this disorder, and plot findings on a growth chart.

• The nurse should address psychosocial needs of the girl with Turner syndrome in relation to self-image. The family should be educated about the use of growth hormone.

Klinefelter syndrome • Nursing care of a male with Klinefelter syndrome focuses on education and addressing educational needs. It is important to get the child involved in activities that will enhance his own personal skills. Testosterone replacement therapy is begun at puberty.

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PowerPoint Slides for Lecture Nursing Care Plan for Acquired Metabolic Disorders •

Disorders of pituitary function o Growth hormone deficiency -

Assessment

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Diagnosis

-

Planning and implementation

-

Evaluation

o Growth hormone deficiency: Assessment -

Monitor height and weight

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Assess psychosocial adaptation to short stature

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Assess family coping

o

Growth hormone deficiency: Planning and education - Injection administration - Developmental screening - Promote activity participation

•

Diabetes insipidus o

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Assessment

•

•

Diagnosis

o

Planning and implementation

o

Evaluation

Diabetes insipidus: Assessment o

Assess for fluid volume deficit

o

Assess skin integrity, mucous membranes

o

Monitor intake, output, vital signs

o

Monitor level of consciousness

o

Assess sleeping patterns

Diabetes insipidus: Parent education o

Maintaining fluid balance

o

Unrestricted toilet access

•

Provide family support

•

Syndrome of inappropriate diuretic hormone (SIADH)

•

..

o

o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

SIADH: Assessment

•

•

o

Assess for changes in LOC, mentation, cognition (headaches, seizure activity)

o

Monitor intake, output, vital signs

o

Measure weight daily

SIADH: Implementation o

Prevent injury

o

Monitor fluid balance

o

Administer medications

o

Manage nutrition

o

Parent education -

Fluid restrictions

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Hidden sources of water, fluids

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Home care

Precocious puberty o

Assessment - Tanner staging - Height/weight - Psychosocial—body image

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o

Diagnosis

o

Planning and implementation

- Promote positive body image - Provide family education • Medication administration • Adherence to treatment o

Evaluation

•

Disorders of thyroid function

•

Hypothyroidism o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

• Hyperthyroidism

•

o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

Disorders of the parathyroid

• Hyper- and hypoparathyroidism o

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Assessment

Diagnosis

o

Planning and implementation

o

Evaluation

•

Disorders of adrenal function

•

Cushing syndrome

•

..

o

o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

Adrenal insufficiency (Addison disease) o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

•

Disorders of gonadal function

•

Amenorrhea o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

• Disorders related to sex chromosome abnormalities •

Turner syndrome o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

• Klinefelter syndrome o

Assessment

o

Diagnosis

o

Planning and implementation

o

Evaluation

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide students into groups and assign each group a type of endocrine disorder. Have them present the disorder’s characteristics to the class, along with nursing management of the child with this type of disorder. They can use pictures, lectures, or role-play to present the endocrine disorder.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students who are assigned to children with an endocrine disorder present their findings

..

in postconference. They should also present the nursing care that the patients need.

LEARNING OUTCOME 6 Develop a family education plan for the child who needs lifelong cortisol replacement.

CONCEPTS FOR LECTURE 1. Disorders of the adrenal gland can affect the production and release of steroid hormones, glucocorticoids that affect protein and carbohydrate metabolism and protect against stress, as well as mineralocorticoids that are involved in the regulation of fluid and electrolytes.

2. Cortisol is the main glucocorticoid and affects the metabolism of proteins, glucose, and fats; affects stress response; and inhibits inflammation. Disorders that have a deficiency in cortisol require replacement therapy. Children may also need cortisol replacement therapy following surgical removal of adrenal glands.

3. Cortisol replacement must be carefully explained to parents. Administering cortisol early in the morning or every other day mimics the normal diurnal pattern of cortisol secretion.

4. Hydrocortisone (Cortef, Solu-Cortef, and cortisone acetate) is available in liquid, tablet, or injectable form. Oral forms are bitter and may cause gastric irritation. Giving the dose at meal time or using antacids will assist in reducing the gastric side effects. Injectable forms of cortisol become necessary when child is vomiting or cannot take the oral form.

Parental teaching on administering an injection is required.

5. Parents need to be educated about the necessity of compliance. Failure to administer cor-

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tisol when the child is ill can lead to severe illness and cardiovascular collapse.

POWERPOINT SLIDES FOR LECTURE Family Education and Cortisol Replacement • Disorders of the adrenal gland affect production and release of steroid hormones and mineralocorticoids • Cortisol—main glucocorticoid o

Affects the metabolism of proteins, glucose, and fats; affects stress response; and inhibits inflammation

• Disorders that involve a deficiency in cortisol require replacement therapy • Administering cortisol early in the morning or every other day mimics the normal diurnal pattern of cortisol secretion •

Hydrocortisone (Cortef, Solu-Cortef, and cortisone acetate) is available in liquid, tablet, or injectable form

• Educate parents regarding medication compliance •

Educate parents regarding side effects

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students develop a teaching plan for a parent whose child was started on cortisol treatment. Present the teaching plan to the class.

SUGGESTIONS FOR CLINICAL ACTIVITIES Discuss with students the different preparations of cortisol. Have students list advantages and

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disadvantages of each preparation.

LEARNING OUTCOME 7 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

CONCEPTS FOR LECTURE 1. Diabetes type 1 and 2 are both disorders of pancreatic function and require both similar and different nursing care. The nurse caring for a child with diabetes mellitus type 1 should assess the child’s physiologic status, as well as the child’s and parents’ psychosocial responses.

2. Nursing care includes administration of insulin, fluids, and electrolytes and monitoring for complications. Extensive teaching of the child and parents about the disease and its management, including planning dietary intake, is necessary. Nursing care should also focus on providing emotional support.

3. Nursing care for type 2 diabetes focuses on managing the child’s blood glucose levels and hypertension. The nurse should assess for growth and dietary intake, and evaluate for weight loss and exercise. The nurse should review the child’s knowledge about management at home.

POWERPOINT SLIDES FOR LECTURE Nursing Care for a Child with Type 1 or Type 2 Diabetes ..

•

Diabetes type 1 and 2 are both disorders of pancreatic function

•

Nursing management—type 1 o Assess the child’s physiologic status and the child’s and parents’ psychosocial responses o Administer insulin, fluids, and electrolytes o Monitor for complications o

Provide extensive teaching

o Provide emotional support • Nursing management—type 2 o Manage the child’s blood glucose levels and hypertension o Assess for growth and dietary intake o Evaluate for weight loss and exercise o Review the child’s knowledge about management at home SUGGESTIONS FOR ADDITIONAL CLASSROOM ACTIVITIES Have the students list the similarities and differences in nursing care for children with type 1 and type 2 diabetes. Answers should be written on the board.

SUGGESTIONS FOR ADDITIONAL CLINICAL ACTIVITIES Assign students to care for patients with type 1 and type 2 diabetes. During postconference, focus on the similarities and differences.

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LEARNING OUTCOME 8 Outline collaborative management for the child with type 1 and type 2 diabetes.

CONCEPTS FOR LECTURE 1. Many specialists are involved in the care of the child with diabetes, including endocrinologists, diabetic educators, nutritionists, behaviorists, and school personnel, to ensure the child maintains optimum blood sugar levels.

2. The child is usually admitted to the hospital when initially diagnosed with diabetes. The nurse should assess vital signs, fluid balance, consciousness, and initially collect blood every hour. Assess the family’s ability to understand and cope with diabetes. Assess the child’s fine motor skills and ability to perform self-care (usually by 6 to 8 years of age).

POWERPOINT LECTURE SLIDES Care of the Child with Diabetes (Box 32–8; Figure 32–10) •

Collaborative management

•

Insulin action

•

Insulin pump therapy criteria

•

Hospitalization

•

Discuss with the family signs of hyperglycemia, hypoglycemia, and diabetic ketoacidosis (Clinical Manifestations—Hypoglycemia and Hyperglycemia)

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•

Educate family about ways to treat hypoglycemia (Partnering with Families— Treating Hypoglycemic Episodes)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the students divide into groups, and give each group an area of nursing management of type 1 diabetes care. Assign the groups: assessment; teaching about insulin (family and child), insulin pumps, hyper-/hypoglycemia, and DKA; and evaluation of understanding. Have each group educate the rest of the class.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have a student care for a child with diabetes (perhaps by following the diabetic educator in the hospital). Have that student report on the experience in postconference.

LEARNING OUTCOME 9 Plan care for the child with an inherited metabolic disease.

CONCEPTS FOR LECTURE 1. Nursing assessment focuses on identifying these disorders and ensuring the newborn screening test is done before the infant leaves the hospital. Most disorders involve protein intolerance, so symptoms will appear shortly after birth.

2. Phenylketonuria (PKU) is treated by removing phenylalanine from the child’s diet. The child will need a special formula or can breastfeed. Older children should avoid high-protein

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foods. If dietary control is not achieved by 8 years of age, there can be a significant impact on the child’s IQ. 3. Children with galactosemia need to eliminate galactose from their diet. They can use a commercial formula such as Nutramigen. This child should avoid milk and cheese products. Even with a compliant diet, complications may still arise, such as learning disabilities or neurologic problems.

4. Children with mitochondrial oxidation of fatty acids are usually identified through newborn screening. Advise the parents that fasting can result in a coma or hypoglycemia. These children should not go more than 8 to 12 hours without eating. This is usually a problem when the child becomes sick with gastroenteritis or flu. Infants should be fed every 2 to 4 hours around the clock.

5. An infant with maple syrup urine disease (MSUD) will exhibit symptoms within the first 3 to 7 days after birth. The symptoms include poor appetite, lethargy, vomiting, variable muscle tone, irritability, seizures, high-pitched cry, severe ketoacidosis, and a sweet odor of maple syrup in body fluids. Treatment is with special formulas rich in amino acids and other nutrients (three types of amino acids are removed from these formulas). The child eats lowprotein foods, and daily urine tests for ketones are vital. These children commonly have neurologic sequelae. The nurse should partner with the family to provide education and a plan for when the child goes to school.

POWERPOINT LECTURE SLIDES Inherited Metabolic Diseases (Inborn Errors of Metabolism) •

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Nursing assessment

•

Phenylketonuria (PKU)

•

Galactosemia

•

Mitochondrial oxidation of fatty acids

•

Maple syrup urine disease

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups. Have each group present an assigned inborn error of metabolism.

Have them present assessment, diagnosis, planning, implementation, and evaluation portions of the nursing process.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students working with an infant in the hospital assess for signs of an inborn error of metab- olism. Have students check newborn screenings, if applicable; take a family history to identify possible genetic predisposition; and present in postconference why this infant does or does not have an inborn error of metabolism.

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CHAPTER 33 ALTERATIONS INNEUROLOGIC FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Traumatic Brain Injury Death Prevention Case Study:Postconcussion Return to Competitive Play Care Plan:Newborn with Neonatal Abstinence Syndrome Media Links:Spinal Cord Injury Support; Spina Bifida Resources; Epilepsy and Seizure Resources and Support; Cerebral Palsy Resources and Support Media Link Applications Videos and Animations:Absence Seizure; Brain and Brainstem (3D); Complex Partial Seizure; Components of a Reflex Arc; Coup-Contre Coup Injury; Tonic-Clonic Seizure; Synaptic Transmission Pediatric Dosage Calculations Image Library Figure 33–2 The skull and brain grow and develop rapidly during early childhood.

Figure 33–3A, Flexor or decorticate posturing, characterized by rigid flexion, is associated with lesions above the brainstem in the corticospinal tracts. B, Extensor or decerebrate posturing, distinguished by rigid extension, is associated with lesions of the brainstem.

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Figure 33–4 Pupil findings in various neurologic conditions with altered consciousness.

Figure 33–8 The child with bacterial meningitis assumes an opisthotonic position, with the neck and head hyperextended, to relieve discomfort.

Figure 33–19 A child with cerebral palsy has abnormal muscle tone and lack of physical coordination.

Figure 33–20 Child having baclofen pump filled.

Table 33–3 Assessment Guidelines for the Child with a Neurologic Condition Table 33–5 Glasgow Coma Scale for Assessment of Coma in Infants and Children Table 33–6 Assessment of Cranial Nerves in the Unconscious Child Box 33–1 Assessment of Infant Responsiveness Clinical Manifestations Traumatic Brain Injury by Severity

LEARNING OUTCOME 1 Describe the anatomy and physiology of the neurologic system.

CONCEPTS FOR LECTURE 1. Major structures include the brain, spinal cord, and nerves. Any insult in gestation can cause CNS malformation.

2. The skull and brain grow and develop rapidly during early childhood. Infants and young children are at higher risk for injury to the brain and spinal cord because of developing anatomic structures.

..

3. Primitive reflexes include tonic neck, Moro, and rooting reflexes.

POWERPOINT LECTURE SLIDES The Neurologic System • Major structures:

•

o

Brain, spinal cord, and nerves

o

Covered by meninges

o

CSF circulates in and around brain and spinal cord

o

Formed in the first trimester of pregnancy

Any insult in gestation can cause CNS malformation

Maturation of Nerve Cells •

The number of glial cells and dendrites increases until 4 years old

•

Brain growth continues through puberty

• Lack of blood supply and oxygen can damage brain cells Myelination •

Covering of axons with myelin

•

As myelination increases, primitive reflexes disappear

Neurologic Anatomic Differences in Children (Figure 33–2) •

Cranial bones are not completely ossified o

..

Allows for brain growth

• The posterior fontanel closes at 3 months •

The anterior fontanel closes at 4 months

•

Increases risk for brain and spinal cord injury

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have students divide into three teams and ask questions related to the anatomy and physiology of the neurologic system. The team that answers the most questions correctly will earn an extra point on the neurologic exam.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students identify in postconference the neurologic difference between the children in their care for that day and adults.

LEARNING OUTCOME 2 Choose the appropriate assessment guidelines and tools to examine infants and children with altered levels of consciousness and other neurologic conditions.

CONCEPTS FOR LECTURE 1. Several things can cause increased intracranial pressure or decreased cerebral perfusion in children.

2. The categories of consciousness range from confusion—which is disorientation to time, place, or person—to coma (totally unresponsive).

..

3. Posturing can occur when there is damage to the brain.

4. The Glasgow Coma Scale can help quantify the level of consciousness and should be performed with the criteria based on developmental and age level.

5. The nurse should encourage the parent to take part in assessing some of the child’s neurologic status to reduce the child’s anxiety.

6. The child’s respiratory, cardiac, and vital signs should also be assessed when there is a neurologic problem. For example, the child may have an absent gag reflex or difficulty swallowing if the neurologic system is compromised.

7. Prepare the area for the possibility of seizures.

8. If the corneal reflex is absent, routine eye care is important.

9. The nurse should prevent complications associated with immobility, such as contractures.

10. Encourage and talk to the patient in case he or she can hear. Encourage the parents to bring toys and music from home.

11. Teach the parents the feeding, range of motion, assessment skills, and care of their child with the neurologic problem so they are also able to perform these at home if needed.

POWERPOINT LECTURE SLIDES Nursing Assessment of Altered Levels of Consciousness and Other Neurologic Conditions • Levels of consciousness—most important indicator of neurologic dysfunction • Consciousness—receptiveness to stimuli • Alertness—arousal, ability to react

..

• Cognition—ability to process data and respond • Altered levels of consciousness ° •

•

•

Causes

Levels of consciousness assessment °

Categories: confusion, delirium, lethargy, obtunded, stupor, and coma

°

Decorticate and decerebrate posturing (Figure 33–3)

Increased intracranial pressure (Table 33–3) °

Scales for responsiveness (Box 33–1)

°

Glasgow Coma Scale (Table 33–5)

Unconscious and pupil assessment (Figure 33–4) °

Assessment of cranial nerves in the unconscious child (Table 33–6)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have the class form groups of three to four people each. Have them assess each other using the various scales presented in class for neurologic function. They can also role-play an infant or a young child.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have all students perform a Glasgow Coma Scale on their patients. Have them report findings in postconference.

..

LEARNING OUTCOME 3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and plan appropriate nursing management for each condition.

CONCEPTS FOR LECTURE 1. Newborn seizures are usually the result of brain hemorrhage, inborn error of metabolism, infection, or other underlying disease. Newborn seizures are usually more subtle (eye blinking, tongue thrusting, or repetitive movement of an extremity).

2. There is usually a postictal period after the seizure where consciousness is slowly regained.

The length of this period varies.

3. An aura before a seizure is a sensation (taste, visual, auditory, or motor) that allows the child to know it is about to occur.

4. Give oxygen if pulse ox falls below 95%.

5. During a seizure, place the child on his or her side on the floor and remove any dangerous objects.

6. Stress with the parents the need to treat the child as normally as possible.

7. Medication education is important, as well as regular dental care to prevent the gingival hyperplasia that some of the medications can cause. Adolescent females should be warned about the teratogenicity of the medications.

POWERPOINT LECTURE SLIDES

..

Epilepsy •

A chronic disorder of recurrent seizures

•

Two types °

Partial (focal)

°

Generalized

•

Some children have an aura

•

Types vary according to age

• Newborn seizures vs. children Status Epilepticus •

An acute seizure that lasts over 30 minutes

•

Electrolytes, glucose, blood gases, temperature, and blood pressure need monitoring if a seizure occurs for longer than 10 minutes

•

Nurses need to administer medications as ordered

•

Collaborative care

Nursing Management for Seizures • Maintain airway

..

•

Ensure safety

•

Administer medications

•

Provide emotional support

•

Provide education

SUGGESTIONS FOR CLASSROOM ACTIVITIES Separate the class into groups and assign each a seizure disorder and have them complete the nursing process of the disorder. The process should include assessment, diagnosis, implementation, and planning.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign one of the students a patient with a seizure disorder. In preconference, the group should discuss safety measures and equipment needed for the room of this child. Have the student carry out this task and also educate the family about safety at home.

LEARNING OUTCOME 4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, and GuillainBarré syndrome in infants and children.

CONCEPTS FOR LECTURE 1. Signs of bacterial meningitis in infants can include any of the following: fever, change in feeding pattern, vomiting, diarrhea, bulging fontanel, irritability, and hyperextension of head.

Signs in the child can include fever for several days with increasing lethargy, confusion, vomiting, muscle pain, petechiae, headache, photophobia, and nuchal rigidity.

2. Newborn encephalitis is usually caused by herpes simplex type I, and if the infant survives, he or she usually has neurologic problems.

..

3. Symptoms of encephalitis can include severe headache, fever, malaise, vomiting, and neurologic changes.

4. Infants with Guillain-Barré syndrome usually exhibit rapidly progressive hypotonia, possible respiratory distress, and feeding difficulty. The child with this syndrome exhibits rapidly progressive muscle weakness and pain, numbness, and diminished deep tendon reflexes. Facial weakness can indicate impending respiratory distress.

POWERPOINT LECTURE SLIDES Meningitis • An inflammation of the meninges covering the brain and spinal cord • Caused by either viral or bacterial agents Bacterial Meningitis • More virulent than viral, can be fatal • Infants at greatest risk • May occur secondary to other bacterial infections (otitis media, sinusitis) •

Assessment o

Signs and symptoms differ for infant vs. child (Figure 33–8)

Viral Meningitis •

Symptoms are the same as those of bacterial meningitis, but child does not seem quite as ill

•

..

Child is treated with antibiotics on an emergency basis until bacterial meningitis can

be ruled out Encephalitis •

Acute inflammation of the brain

•

Symptoms do not include nuchal rigidity or positive Kernig or Brudzinski signs

•

Symptoms depend on the causative organism

Guillain-Barré Syndrome •

Inflammatory demyelinating polyradiculoneuropathy

•

Rarely fatal

SUGGESTIONS FOR CLASSROOM ACTIVITIES Assign five groups of students the five different types of neurologic disorders presented. Have them role-play to the class their disorder without telling them what it is. Have them start from when the patient comes to the nurse initially. This nurse could be an office, emergency department, or school nurse.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students discuss in postconference if any of their patients could develop one of the five types of neurologic disorders presented. Discuss causative organisms and problems that can increase the risk for developing a neurologic disorder. If one of the students has or has had a patient with a neurologic disorder, have the student present that case at postconference.

LEARNING OUTCOME 5 ..

Plan family-centered nursing care for the child with myelodysplasia and hydrocephalus.

CONCEPTS FOR LECTURE 1. Develop nursing care plans as a class. See instructions in the classroom section.

POWERPOINT LECTURE SLIDES Myelodysplasia • Malformation of the spinal cord and canal •

Impaired physical mobility related to neuromuscular impairment

•

Impaired urinary elimination related to sensory impairment

•

Risk for latex allergy response related to multiple surgical procedures

Hydrocephalus •

Imbalance between production and absorption of CSF

•

Leads to increased CSF volume in brain

•

Commonly associated with myelomeningocele (spinal fluid–filled sac protruding through vertebrae)

• Treatment may include placement of a shunt Nursing Diagnosis for Myelodysplasia and Hydrocephalus

..

•

Risk for Infection related to the presence of shunt

•

Risk for Caregiver Role Strain related to care of a child with a chronic condition

•

Risk for Delayed Development related to compression of brain tissue with excess cerebral spinal fluid

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into six groups. Assign each group one of the nursing diagnoses listed. Have them develop a nursing care plan for each one and present to the class the final care plans.

SUGGESTIONS FOR CLINICAL ACTIVITIES The student who is taking care of a child with hydrocephalus or myelodysplasia should develop a nursing care plan based on the care of that child. The plan can be presented in postconference.

LEARNING OUTCOME 6 Plan family-centered nursing care for the child with cerebral palsy in a community setting.

CONCEPTS FOR LECTURE 1. The child will need a case manager to coordinate new adaptive devices, ongoing developmental assessment, care planning, and possibly surgery.

2. As the child grows and reaches various developmental milestones, changes in the cerebral palsy can occur. For example, once the child learns to walk, the Achilles tendon may tighten, and the child will need ongoing orthopedic surgeon care.

3. Speech therapy and regular eye exams are also important.

4. Early intervention programs can also help meet therapy and developmental needs in the

..

community. These programs are usually state or federally funded and free to the child and family.

5. Financial assistance may be needed to obtain new adaptive devices and medical care, such as the Bureau for Children with Medical Handicaps (BCMH) and SSI. 6. Individualized education plans are needed throughout the school system.

POWERPOINT LECTURE SLIDES Cerebral Palsy • Group of permanent disorders of movement and posture • Causes activity limitations •

Nonprogressive in nature

• May have additional sensory, cognition, communication, and behavior problems Children with Cerebral Palsy •

Community care °

Case manager

°

Early intervention (Figure 33–19)

°

Financial needs

°

School assistance and IEP needed

• Multidisciplinary care °

..

Orthopedic surgeon care

°

Speech therapy

°

Regular eye exams

°

Pediatric nurse practitioner or pediatrician

°

Support groups

SUGGESTIONS FOR CLASSROOM ACTIVITIES Discuss as a class how a child with cerebral palsy needs help from the community for care.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the student who cares for someone with cerebral palsy address community needs. Does the patient have a caseworker? Is the patient connected with eye doctors, therapy, and so on?

LEARNING OUTCOME 7 Contrast the initial nursing management for the child with mild traumatic brain injury and severe traumatic brain imagery.

CONCEPTS FOR LECTURE 1. Primary injury to the brain is when cellular damage initially occurs. The secondary injury or phase is when there is a biochemical and cellular response to the initial insult, which happens over hours, days, or weeks. Neurotransmitters are released in excessive amounts and may intensify brain damage.

2. Cushing triad is characterized by hypertension, increased systolic pressure with wide pulse

..

pressure, bradycardia, and irregular respirations, which can indicate increased intracranial pressure or compromised blood flow to the brainstem.

3. Initially, the nurse needs to care for the child with a severe brain injury in the hospital. Nursing care should include maintaining airway, breathing, and circulation; assessing vital signs; and possibly intubating the child. The Glasgow Coma Scale can be used for assessment. Any deterioration in condition must be quickly identified and addressed. Use suctioning as needed, but note that it may cause increased intracranial pressure. Keep the environment quiet.

The nurse provides oral and skin care. Clustering care to decrease intracranial pressure problems can help.

4. Mild brain injuries can take up to 6 weeks for recovery. The child may have altered behavior until full recovery is achieved. Typical behavior prior to healing can include tiring easily, memory loss, difficulty concentrating, irritability, and needing help with tasks. Teachers should be informed of these behavior changes.

5. Children with severe brain injuries can have school performance problems, social inappropriateness, behavior problems, impaired learning, and retention problems. They will need ongoing care for these behaviors.

POWERPOINT LECTURE SLIDES Mild, Moderate, and Severe Brain Injury •

..

Traumatic brain injuries

°

Falls are a major cause

°

Primary vs. secondary

° Cushing triad (Clinical Manifestations—Traumatic Brain Injury by Severity, and Figure 33–20) •

Nursing management of mild vs. severe brain injury °

Emergency care

°

Long-term care

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have a group discussion on how students would feel as a parent if their child had a severe brain injury. What types of education and care would they want their nurse to provide?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the student caring for a child with a brain injury discuss at preconference how that patient will be most appropriately cared for. Develop a plan for assessment and routine care for that pa- tient in order to cluster care and decrease intracranial pressure.

LEARNING OUTCOME 8 Discuss initiatives to prevent drowning in children.

..

CONCEPTS FOR LECTURE 1. Drowning is defined as the process resulting in primary respiratory impairment from submersion/immersion in a liquid medium resulting in death. Submersion injury is the term used when the child survives.

2. Drowning is a leading cause of injury death for children between 1 and 19 years of age.

3. A child can drown in as little water as it takes to cover the nose and mouth. Infants and young children do not have the physical or cognitive ability to rescue themselves.

4. Children who are submerged for short periods (less than 5 to 10 minutes who are resuscitated at the scene) have few symptoms, and often fully recover without neurologic impairment.

Signs and symptoms in the rescued child may be decreased level of consciousness ranging from stupor to total unresponsiveness, apnea or irregular respirations, gastric distention, and seizures. The child who waits for basic life support to be started for more than 10 minutes or is pulseless for more than 25 minutes is most likely to have a poor prognosis.

5. Drowning can be prevented through education, legislation, and changes in the environment.

Infants and toddlers should never be left unattended in a bathtub. Pool owners can take a number of precautions and should be trained in CPR. Additional preventive measures relate to activities such as using hot tubs, boating, and drinking alcohol or using substances in the vicinity of water.

POWERPOINT LECTURE SLIDES Drowning Prevention •

..

Education

•

Legislation

•

Environmental safety

•

Never leave infants and young children unsupervised near water—bathtubs included

•

Use fencing, alarms around swimming pools

•

Use pool and hot tub drain covers

•

Pool owners should know CPR

•

Educate adolescents about mixing alcohol and swimming

SUGGESTIONS FOR CLASSROOM ACTIVITIES 1. Assign students to small groups. Ask each group to prepare an educational activity for parents of children of different ages, having each group choose to address drowning prevention for either 1) families who have pools at home; 2) families who have hot tubs at home; or 3) families who enjoy boating.

2. Have students research community-wide initiatives to prevent drowning, particularly those used in coastal communities. What organizations typically sponsor these activities?

What information is available about their effectiveness? What information do these initiatives usually provide? How is it disseminated?

..

CHAPTER 34 Alterations in Mental Health and Cognition Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Females and Posttraumatic Stress Disorder Case Study:SSRI Dosage Media Links:Mental Health Resources; Suicide Prevention Media Link Applications Videos and Animations:ADD and ADHD; What Is Autism?; Autism: A Neurological Disease; Autism: The Healthcare Team; Autism: Lack of Communication; Autism: Missing the Diagnosis; Autism: Progress Is Possible; Down Syndrome Pediatric Dosage Calculations Image Library Table 34–5 Risk Factors for Child and Adolescent Depression Table 34–6 Risk and Protective Factors for Suicide in Children and Adolescents Table 34–7 Common Condition Associated with Intellectual Disability Table 34–8 Characteristics of Three Common Conditions Associated with Intellectual Disability

..

LEARNING OUTCOME 1 Define mental health and describe major mental health alterations in childhood.

CONCEPTS FOR LECTURE 1. Mental health involves successful engagement in life and the ability to cope with change.

2. Autism spectrum disorders (ASDs), also known as pervasive developmental disorders (PDDs), involve impaired social reciprocity, communication, and behavior. Clinical features usually present by the time the child is 3 years of age. The cause is unknown.

3. Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are characterized by inappropriate developmental behavior due to inattentiveness. Some children have ADD and some have ADD with hyperactivity (ADHD). Sometimes the disorder will manifest itself into adulthood.

4. Depression can range from mild to severe. Cause is thought to be from biological factors or possibly physiologic. Obesity is more common in depressed adolescents.

5. Bipolar disorder is characterized by extreme changes in mood from mania to depression. Little is known about the cause of this disorder.

6. Anxiety disorders are usually characterized by excessive worry and helplessness. The person may also have physiologic signs, such as increased pulse, trembling, and perspiration.

7. Suicide is the third leading cause of death for adolescents aged 15 to 19 years.

8. Tics are sudden, brief motor movements. Tourette syndrome is characterized by verbal utterances.

..

POWERPOINT LECTURE SLIDES Mental Health Disorders • Mental health—foundational to a sense of personal well-being • Developmental and behavioral disorders °

Autism spectrum disorders (pervasive developmental disorders)

°

Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD)

• Mood disorders °

Depression

°

Bipolar disorder

•

Anxiety and related disorders

•

Suicide

•

Tic disorders and Tourette disorder

• Trichotillomania •

Schizophrenia

•

Cognitive disorders

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have a group discussion about how mental health disorders in children are perceived by society.

Ask the students if they think, from a social services perspective, we are doing enough for these children? ..

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students present their findings in postconference regarding patients they have assessed who have a mental health disorder. Did some of the children have posttraumatic stress disorder from a car accident? Were any of the teens depressed?

LEARNING OUTCOME 2 Contrast pediatric differences and issues related to mental health and cognition.

CONCEPTS FOR LECTURE 1. Mental health and cognition in children is different from adults because developmental progression and abilities influence perceptions and reactions.

2. Children differ from adults both in mental healthcare needs and in the types and progression of mental health disruptions. During childhood, the necessity for bonding and attachment to significant adults forms the cornerstone of the child’s healthy mental development. Therefore, young children rely on adults for establishment of mental health.

3. Children with mental health disruptions sometimes display different clinical manifestations for mental illness than adults; therefore, diagnosis is difficult and challenging. For example, a child with a tic syndrome may be mistakenly diagnosed as hyperactive.

4. Children are more vulnerable to external forces that affect cognition and mental health.

Drugs, nutrition, traumatic brain injury, and lack of attachment are some of the factors that can impact child cognition and mental health.

..

POWERPOINT LECTURE SLIDES Pediatric Differences in Mental Health and Cognition •

Risk for injury from fetal environment

•

Young children vulnerable to external forces o

Drugs

o

Nutrition

o

Traumatic brain injury

o

Absence of emotional nurturance

• Child’s developmental stage influences perceptions and reactions • Children rely on adults for establishment of mental health

SUGGESTIONS FOR CLASSROOM ACTIVITIES Have a group discussion about the differences in child mental health and cognition. What factors do the students see as most relevant for infants? For school-age children? For adolescents?

SUGGESTIONS FOR CLINICAL ACTIVITIES

..

If possible, have the students observe in a neonatal intensive care unit and assess the conditions of the children in the unit. In postconference, discuss which of these infants are likely to experi- ence challenges in cognition or mental health. Why?

LEARNING OUTCOME 3 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence.

CONCEPTS FOR LECTURE 1. The baby with an autistic spectrum disorder may not make eye contact or enjoy cuddling.

These children may have normal motor skills.

2. Signs of depression in children could include poor school performance, withdrawing, irritability, sleep changes, appetite changes, and multiple somatic complaints.

3. Labile moods and sleep disturbances are associated with bipolar disorder; irritability and elation may also occur.

4. The nurse should be alert to signs of anxiety disorders, especially if the child has just been through a traumatic event. The nurse should inquire about recent behavior changes, family history, and the child’s past reactions to stressful events.

5. The major role of the nurse is to identify teens who may be suicidal and aid in prevention strategies.

..

6. When tics are severe or last over 1 year, they may need to be evaluated by a mental health provider.

POWERPOINT LECTURE SLIDES Clinical Manifestations of Major Childhood Mental Health Disorders •

Developmental and behavioral disorders °

Autism spectrum disorders – Clinical manifestations—essential features become apparent by age 3 years

• Impairment involves four areas

•

o

Social interaction

o

Communication

o

Adapting to new situations

o

Attention span and organizing responses to situations

Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) o Clinical manifestations—problems related to decreased attention span, impulsiveness, and/or increased motor activity

• Mood disorders °

..

Depression

– Clinical manifestations—characteristic findings include declining school work, withdrawal from school activities, sleep disturbances, appetite disturbances, multiple somatic complaints, decreased energy, difficulty concentrating, low selfesteem, and feeling of hopelessness – Symptoms will vary according to child’s developmental level – °

Risk factors (Table 34-5)

Bipolar disorder – Clinical manifestations—extreme changes in affect and energy, cycles between: • Manic phase—hyperactivity, high energy, irritability, aggression, hallucinations • Depressive phase—sad, alterations in sleep and eating, feeling of worthlessness, lack energy, socially withdrawn

•

Anxiety and related disorders o Clinical manifestations—CNS signs including restlessness, trembling, perspiration, rapid pulse, excessive fatigue, poor concentration, irritability, muscle tension, and sleep disturbance o

Children worry excessively and are difficult to reassure; they cannot distract themselves from worrying

•

Suicide o Clinical manifestations—most common precursor is depression exacerbated by recent psychosocial stress (loss, perceived rejection)

..

Many risk and protective factors (Table 34–6)

o

•

Tic disorders and Tourette disorder o Clinical manifestations—sudden, rapid, recurrent, nonrhythmic brief motor movements or vocalizations o May involve head and upper body and occur in times of stress

•

•

Trichotillomania o

Chronic hair pulling

o

Impulse-control disorder

Schizophrenia o

Psychotic disorder that can manifest in childhood but is more common in adolescence

o Characteristic behaviors—social withdrawal, impaired relationships, flat affect, regression, loose associations of ideas, poor judgment, anxiety, delusions, hallucinations, rocking, arm flapping

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups and assign each a mental health disorder. Each group will develop a list of 10 questions that would be important to ask the family about problems the child with this disorder is experiencing.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students assess their patients for mental health disorder. Have them report findings in post..

conference.

LEARNING OUTCOME 4 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

CONCEPTS FOR LECTURE 1. The nurse working with a child with an autistic spectrum disorder should stabilize the environment, enhance communication, maintain a safe environment, and provide guidance to the parents.

2. Nursing management of the child with ADD/ADHD needs to assist in administering medications (especially in school nursing), minimizing environmental distractions, setting up a behavioral modification plan, providing support, promoting self-esteem, and ensuring care in the community.

3. Youth hospitalized for mood disorders will need medication management, vital sign monitoring, and therapy. Educate family about signs of worsening depression.

4. The goal with an anxiety disorder is to return the child to a normal level of functioning through multidisciplinary care.

5. When a child is hospitalized for suicide, ensure the environment is free from any harmful objects. Physical or chemical restraints, if ordered, may be used if the child is extremely selfdestructive. In the community, it is important to make resources available and to encourage

..

peers to report any suspicious behavior.

6. Children with tic disorders should be taught relaxation techniques.

POWERPOINT LECTURE SLIDES Nursing Management of Children and Adolescents with Mental Health Disorders • Developmental and behavioral disorders °

Autism spectrum disorders

°

Nursing management – Stabilize environmental stimuli – Provide supportive care – Enhance communication – Maintain a safe environment – Provide anticipatory guidance

•

Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) °

Nursing management – Administer medication – Minimize environmental distractions – Implement behavior management plans – Provide emotional support – Promote self-esteem

..

°

School issues

• Mood disorders °

Depression

°

Bipolar disorder

°

Nursing management – Medication management – Psychotherapy

•

Anxiety and related disorders °

° •

Nursing management −

Medication management

−

Psychotherapy

−

Relaxation techniques

Communication management

Suicide o

Nursing management: – Safety – 24-hour monitoring – Medication – Care in community

..

•

Tic disorders and Tourette disorder o

Nursing management – Support – Minimize stress – Medication

• Trichotillomania o

Referral

o

Develop trusting relationship

• Schizophrenia o

Administer medications, assess for side effects

o

Educate, involve family in treatment plan

o

Communicate with school personnel

SUGGESTIONS FOR CLASSROOM ACTIVITIES Discuss as a group the nursing management of a child in the school system with a mental health disorder. What can be done to reduce the stigma on that child? How can the school nurse and parents play a role?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students determine if they are working with a child who has a mental health disorder and apply the proper nursing management for this problem. Discuss findings in postconference.

..

LEARNING OUTCOME 4 Describe characteristics of common cognitive alterations of childhood.

CONCEPTS FOR LECTURE 1. The brain of a child with a learning disability does not receive and process information in a normal manner.

2. One cause of learning disabilities could be related to a problem in the perinatal period or prematurity.

3. Children with intellectual disability usually have an IQ below 75 and impairment with adaptive functioning.

4. Causes of intellectual disability can be grouped into three categories: prenatal error of development, prenatal or postnatal changes in the biological environment, and external forces leading to CNS damage.

5. Children with intellectual disability will have developmental delays.

POWERPOINT LECTURE SLIDES Learning Disabilities • Affect 5% to 10% of school children • Children do not process information correctly Intellectual Disability (Table 34–7)

..

•

Limitations in adaptive and intellectual functioning

•

Conditions associated:

•

o

Down syndrome

o

Fragile X syndrome

o

Fetal alcohol syndrome

Characteristics (Table 34–8)

SUGGESTIONS FOR CLASSROOM ACTIVITIES Discuss as a group the identification of a child in the school system with a cognitive disorder.

What can be done to reduce the stigma on that child? How can the school nurse and parents play a role? What community organizations are available to help?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students determine if they are working with a child who has a cognitive disorder. Discuss findings in postconference.

LEARNING OUTCOME 6 Use evidence-based practice to plan nursing management for children with cognitive alterations.

CONCEPTS FOR LECTURE

..

1. Nurses should help identify a child with a learning disability. The nurse should collaborate with the family and teachers to develop a plan to work with the problem. An IEP may need to be implemented.

2. Children with intellectual disabilities need to have community support through early intervention programs, IEP if in school, and resources on laws protecting people who are disabled. Safety procedures should be implemented with constant supervision because children with mental retardation can be unaware of hazards.

POWERPOINT LECTURE SLIDES Learning Disabilities • Nursing management o

Provide emotional support and information

Intellectual Disability • Nursing management o

Maintain safe environment

o

Provide assistance with adaptive functioning

SUGGESTIONS FOR CLASSROOM ACTIVITIES Discuss as a group the nursing management of a child in the home with a cognitive disorder.

What can be done to reduce the stress on the parents? What community organizations are available to help?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students determine if they are working with a child who has a cognitive disorder and apply ..

the proper nursing management for this problem. Discuss findings in postconference.

LEARNING OUTCOME 7 Establish and evaluate expected outcomes of care for the child with a cognitive alteration.

CONCEPTS FOR LECTURE 1. The child should have an individualized education plan, which is developed through an interdisciplinary approach. There should be specific goals in the plan. If the child achieves those goals, that is the evaluation of the problem.

2. Children with intellectual disabilities should also have an IEP. POWERPOINT LECTURE SLIDES Learning Disabilities •

Individual education plan (IEP) o

Developed through an interdisciplinary approach

o

Specific goals are included

Intellectual Disability • Evaluation depends on needs and developmental level • First, evaluation needs to assess the family’s understanding of the disorder

SUGGESTIONS FOR CLASSROOM ACTIVITIES

..

Discuss as a group the nursing evaluation of a child in the school with a cognitive disorder. What can be done to enhance the achievement of these goals by the nurse? What community organizations are available to help?

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students determine if they are working with a child who has a cognitive disorder and apply the proper nursing evaluation for this problem. Discuss findings in postconference.

..

CHAPTER 35 ALTERATIONS INMUSCULOSKELETAL FUNCTION Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Autosomal Dominant Disorders Case Study:Fracture Assessment Media Links:Musculoskeletal Function Media Link Applications Videos and Animations:Muscle Contraction Physiology; Muscle Physiology Pediatric Dosage Calculations Image Library Figure 35–3 Skeletal and muscle development throughout childhood.

Figure 35–4 Metatarsus adductus is characterized by convexity (curvature) of the lateral border of the foot.

Figure 35–5 Parents of a child with clubfoot will have many questions.

Figure 35–6 This girl has a long leg cast, which was applied after surgery to correct her clubfoot.

Figure 35–8 A, Genu valgum, or knock-knees.

B, Genu varum, or bowlegs.

..

Figure 35–9 The asymmetry of the gluteal and thigh fat folds is easy to see in this child with developmental dysplasia of the hip.

Figure 35–10 The most common treatment for DDH in a child under 3 months of age is a Pavlik harness.

Figure 35–11 The infant treated for DDH is often in a hip spica cast after surgery.

Figure 35–12 Although the Toronto brace used for treatment of Legg-Calvé-Perthes disease may seem formidable for a child to wear, you can see by this photograph that, as usual, children adapt quite well to it.

Figure 35–13 In slipped capital femoral epiphysis, the femoral head is displaced from the femoral neck at the proximal epiphyseal plate.

Figure 35–14 A child may have varying degrees of scoliosis.

Figure 35–15 In severe scoliosis, the child may wear a halo brace, shown here, to hold the body in position after surgery.

Figure 35–17 This boy from Kenya had surgery to correct severe kyphosis and scoliosis, caused by tuberculosis of the spine.

Figure 35–18 Because the leg muscles of children with muscular dystrophy are weak, they must perform the Gowers maneuver to raise to a standing position.

Figure 35–19 This young boy with muscular dystrophy needs to receive tube feedings and home nursing care.

Figure 35–20 The Salter-Harris classification system is based on the angle of the fracture in relation to the epiphysis.

..

LEARNING OUTCOME 1 Describe pediatric variations in the musculoskeletal system.

CONCEPTS FOR LECTURE 1.While primary ossification is complete at birth, bones are more cartilaginous and continue sec- ondary ossification as the bones grow. A child’s bone is more pliable, more porous, and less dense than an adult’s.

2.Infant skull fontanel closure is complete by 18 months; overall skull size is complete by 2 years.

3.Long bone growth takes place at the epiphyseal plates. While a child’s bones heal quickly, injury to the epiphyseal plate can inhibit growth.

4. A child is born with a complete set of musculature. Muscles only increase in length and circumference. Ligaments and tendons are stronger than bone until puberty. Fractures are sometimes mistaken for sprains.

POWERPOINT LECTURE SLIDES Musculoskeletal Differences •

•

Child’s bones o

More porous and pliable

o

Less dense

Infant skull o

Fontanel closure: 18 months

o

Overall growth completion: 2 years

• Child bone growth from epiphyseal plate

..

• Muscles

•

o

Number same as adult

o

Only length and circumference grow

Ligaments and tendons o o

Stronger than bone until puberty (Figure 35–3)

SUGGESTIONS FOR CLASSROOM ACTIVITIES • Review musculoskeletal positions and joint positions. Have students split into pairs. In turn, have each student select a position and have the other student demonstrate the position.

• Discuss how children’s head size reaches close to adult size by 2 years of age. Discuss how changes in head size, or problems with skull growth, affect neurologic development.

• Review the differences between ligaments, tendons, sprains, and muscle strains.

SUGGESTIONS FOR CLINICAL ACTIVITIES • Go to a medical imaging department and look at radiographs of children’s bones. Note the growth plates in long bones. Ask a radiologist or technician to explain how to read a radio- graph.

• Ask a physical therapist to demonstrate range of motion for each limb. Discuss how physical therapy is used with children.

• Talk with a sports trainer about the recommended interventions for musculoskeletal sports injuries in adolescents.

..

LEARNING OUTCOME 2 Plan nursing care for children with structural deformities of foot, hip, and spine.

CONCEPTS FOR LECTURE 1. Disorders of the feet and legs include metatarsus adductus (intoeing), talipes equinovarus (clubfoot), genu valgum (knock-knees), and genu varum (bowlegs).

2. Disorders of the hip include hip dysplasia, Legg-Calvé Perthes disease, and slipped capital femoral epiphysis (SCFE).

3. Disorders of the spine include scoliosis, kyphosis, lordosis, and torticollis.

4. Most deformities are congenital and treated progressively with bracing, casting, or surgery.

5. Nursing care focuses on preventing the complications of immobility, helping the child cope with immobility during treatment, and managing pain control. Longer-term care may involve adaptation to the effects of the disorder.

POWERPOINT LECTURE SLIDES Structural Deformities •

Feet and legs o

Metatarsus adductus (intoeing) (Figure 35–-4)

o

Talipes equinovarus (clubfoot) (Figure 35–5)

o o

Genu valgum (knock-knees) (Figure 35–-8) Genu varum (bowlegs)

•

..

Hip

•

o

Dysplasia (Figure 35–9, Figure 35–10)

o

Legg-Calvé-Perthes

o

Slipped capital femoral epiphysis (SCFE) (Figure 35–-13)

Spine (Figure 35–-14) o

Scoliosis, kyphosis, lordosis

o

Torticollis

Deformities: Nursing Care • Prevent complications of immobility • Assist coping with treatment o

•

Support long-term adaptation

Facilitate pain control

SUGGESTIONS FOR CLASSROOM ACTIVITIES • Divide the class into groups and assign each one of the structural deformities listed in this chapter. Have each group present the assessment and nursing management of the child with this condition.

• Discuss how to identify structural deformities of the feet, legs, and hips in infants. Show photos or use a mannequin to demonstrate the visualization and manipulation of the legs.

• Discuss any personal experiences students may have had regarding scoliosis and its treatment. What are the physical and psychosocial effects of the disorder and its treatment? What is the nursing role when an adolescent has scoliosis?

• Have students create a plan of care for an infant who is in a brace for treatment of a structural deformity. What are the risks of immobility for the child? What can be done with the child to prevent complications and provide sensory stimulation? How will parents have to modify

..

their care of the child?

SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students care for a child with a structural musculoskeletal problem. Have them present in postconference their nursing management for that day.

• Visit a school nurse and discuss, or help conduct, scoliosis screenings.

• Discuss with a child life therapist ways to play with an infant, toddler, school-age child, and adolescent who is immobilized due to treatment for a structural deformity of the feet, legs, hips, or spine.

LEARNING OUTCOME 3 Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care.

CONCEPTS FOR LECTURE 1. Osteomyelitis is an infection of the bone. The cause can be idiopathic but more commonly it is associated with trauma or surgical intervention with the bone. Symptoms of osteomyelitis include bone pain, edema, decreased joint mobility, and fever. It usually has a rapid onset.

2. IV antibiotics are started for osteomyelitis after the culture is obtained.

POWERPOINT LECTURE SLIDES Osteomylitis

..

•

Bone infection

• Etiology: idiopathic or nosocomial o

Due to trauma, pins

• Symptoms o

Bone pain

o

Edema

o o

Joint pain Fever

Rarer Bone Infections (Figure 35–-17) •

•

Skeletal tuberculosis o

Pain, spasms, muscle atrophy

o

“Doughy” swelling over joints, limited mobility

Septic arthritis o

Pain, fever, local inflammation, joint tenderness, loss of spontaneous movement

SUGGESTIONS FORCLASSROOM ACTIVITIES •

Involve students in a group discussion on how parents may feel if their child has a musculoskeletal infection. How can the nurse help alleviate some of their concerns?

• Discuss the medical difficulties in treating osteomyelitis. Why are long-term intravenous antibiotics needed? How does this treatment affect children and families?

•

Show students the equipment used to maintain long-term intravenous access for antibiotic administration. Review the procedures for insertion, use when administering an antibiotic, home care instructions, and emergencies.

SUGGESTIONS FOR CLINICAL ACTIVITIES

..

•

Have students identify the patients at risk for an infectious musculoskeletal problem. Have them present in postconference their nursing management for that day to prevent this type of problem from occurring.

• Review the literature on prevention of osteomyelitis when caring for the patient with skeletal pins. What evidence-based literature is available to support recommended pin care?

•

Review the clinical agency’s policies regarding skeletal pin care. Are they based on evidence-based research? How are pin care and the observed condition of the skin around the pins documented?

•

Discuss with the clinical nurse the procedures for long-term care of access ports for longterm antibiotic administration. What is taught? What equipment is needed? What are parents and children taught to do in case of emergencies with the IV access port?

LEARNING OUTCOME 4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

CONCEPTS FOR LECTURE 1. Achondroplasia is a form of dwarfism resulting in short legs and arms and a prominent forehead. Nurses can provide education for families with a child with achondroplasia. Nursing management focuses on building positive self-esteem and adaptation to short stature. The nurse can provide care by promoting a positive self-concept and adaptation to short stature, encouraging families to get an IEP through the school, obtaining a special growth chart, and

..

suggesting activities that put little stress on the bones.

2. Marfan syndrome is a genetic condition of connective tissue that is manifests with skeletal changes and alterations in cardiac functioning, vision, and respirations. Nursing management focuses on early identification, assessment of cardiac functioning, and teaching about the need for preoperative antibiotics.

3. Osteogenesis imperfecta, or brittle-bone disease, is a congenital defect in collagen production. Children have frequent fractures; thin, soft skin; increased joint flexibility; short stature; weak muscles; and eventual hearing loss. Nursing care focuses on injury prevention and teaching about coping with effects of the disease.

4. Muscular dystrophies comprise a group of inherited diseases that result in muscle fiber degeneration and muscle wasting. Weakness and hypotonia are early signs. Nursing management focuses on promoting independence and mobility, and providing family support to cope with a progressive, life-threatening disease.

POWERPOINT LECTURE SLIDES Chronic Conditions • Achondroplasia o

Short stature, prominent forehead

• Marfan syndrome o

Connective tissue disorder

o

Skeletal changes

o

Cardiac, respiratory, vision changes •

..

Osteogenesis imperfecta o

Brittle-bone disease, collagen defect

o

Thin, soft skin; increased flexibility; short stature; weak muscles; hearing loss

•

Muscular dystrophies o o o

Muscle degeneration and wasting Early signs: weakness and hypotonia (Figure 35–18) Life threatening

•

(Figure 35–19) Nursing management o o

Maintenance of body systems Promote safety

o o

Child and family support

o

Maximize independence Assess for and treat infections

o

Perioperative care when surgery required

SUGGESTIONS FOR CLASSROOM ACTIVITIES • Connect to the Little People of America web site (http://lpaonline.org) and show the support pages for children with dwarfism and achondroplasia. Discuss how little people prefer to be addressed, their needed accommodations, and the subculture of little people.

• Discuss the ethical issues currently discussed in the little people community. Discuss the issues surrounding the ethics of conducting leg-lengthening surgery, and knowingly having children who will also be little people.

• Discuss how to identify muscular dystrophies in children. Review the signs and motor changes that children begin to exhibit in the early stages of the disease.

• Have students create a plan of care for a young adolescent with Duchenne muscular dystrophy. How can nurses help the family adapt to their child’s weakening condition?

..

•

In small groups, assign each group a psychosocial nursing diagnosis associated with longterm musculoskeletal disorders. Have students create measurable goals and specific interventions for diagnoses such as Caregiver Role Strain, Activity Intolerance, Hopelessness, Powerlessness, Compromised Family Coping, and Anticipatory Grieving.

SUGGESTIONS FOR CLINICAL ACTIVITIES • Visit a local agency that provides assistance to families with children who have chronic musculoskeletal disorders. What services does the agency provide? What are the eligibility requirements? What are the costs to the family?

•

Review the literature on the ethics surrounding leg-lengthening procedures for children with achondroplasia. What are the benefits and risks of the surgery? Why do many little people, and physicians, object to the procedure?

• Have the students present in postconference the nursing management of the care of a child with a chronic musculoskeletal problem.

LEARNING OUTCOME 5 Plan nursing interventions to promote safety and developmental progression in children who require orthopedic braces, casts, traction, and surgery.

CONCEPTS FOR LECTURE 1. All children with immobilizing medical devices need interventions to prevent the complications of immobility, learn to cope with the limitations to mobility, and provide self-care while in the brace, cast, or traction.

..

2. Braces limit movement or hold a joint into a preferred position. Braces need to fit snugly without impeding circulation or applying friction to the skin; they should not directly touch the skin. Neurovascular and skin assessments should be done frequently.

3. Casts immobilize a bone or joint for healing that would be impaired by movement. Neurovascular assessment should be done frequently after application. Risk of edema can be mitigated through elevation. Itching can be problematic; children must be taught not to put objects, lotions, or powders down the cast. Hygiene requires careful teaching to prevent water going down the cast.

4. Traction applies force and/or positioning to a joint during healing. External traction requires careful skin assessment; skeletal traction requires careful pin care. All children in traction require neurovascular assessment, protection from skin breakdown due to pressure, and help in coping with immobility.

5. After surgery, children must be protected from infection to bone and lungs, damage to skin, and feelings of social isolation.

POWERPOINT LECTURE SLIDES Braces ( Figure 35–15 and Figure 35–12) •

Limit movement o

Snug but do not impair circulation

o

No direct contact with skin

o

Assess neurovascular and skin status Casts •

Immobilize joint and/or bone o

..

Perform frequent neurovascular assessment

– More when applied, fewer after stable o o o

Elevate limb Manage itching Teach cast care

Traction •

•

Applies force and/or positioning to joints and bones o

Maintain positioning and force

o

Protect skin from pressure, wetness

Skin traction Assess skin

o

•

Skeletal traction o o

•

Pin care Prevent infection

( Figure 35–11)

Surgery: Postoperative Needs • Protect from infection Lung, bone o •

Protect skin o

•

Pressure, breakdown

Avoid social isolation

SUGGESTIONS FOR CLASSROOM ACTIVITIES •

Have a group discussion about how to promote safety and developmental progression in children with traction and braces.

• Demonstrate how to apply a brace to a child. Review what assessments need to be made after application. Discuss ways to help a child cope with the brace.

..

•

Show photographs of different types of skin, skeletal, and halo traction. Discuss the nursing responsibilities for each type. What are the risks to the child in each type of traction? What nursing interventions can prevent problems?

• Have students create a list of the risks of immobility. Discuss each risk and how nurses can prevent these complications in children of different ages.

• Discuss neurovascular assessment for children in braces, casts, and traction. How often should the assessments be made? How do nurses determine when to change the frequency of assessment? What changes in neurovascular status need to be reported to a physician?

•

Have students develop plans of care for children of different ages with casts. Consider how to modify mobility, hygiene, and injury prevention interventions for a child of the assigned age.

SUGGESTIONS FOR CLINICAL ACTIVITIES •

Have the student taking care of the child with traction discuss in pre- and postconference the nursing management of this child.

•Go to a casting room at a clinical agency. What equipment is used to apply casts? What information is provided to children and families about cast care?

• Examine the equipment used in traction at the clinical setting. Who is responsible for setting up traction? What are the nursing responsibilities for putting a child into traction, and what documentation is required by the agency?

• Review the documentation for neurovascular assessments at the clinical setting. What forms are used? Is there a form? Is its use clear?

LEARNING OUTCOME 6

..

Recommend nursing care for fractures, including teaching for injury prevention and nursing implementations for the child who has sustained a fracture.

CONCEPTS FOR LECTURE 1. Children are more prone to fractures due to their active nature, and their more porous and less dense bones.

2. Fracture prevention requires teaching of correct athletic techniques, use of protective equipment, and avoidance of dangerous situations.

3. Assessment of a fracture is made by visualization of abnormal positioning, crepitus, severe pain, edema, and limited mobility.

4. Fractures are usually treated with immobilization. Surgery may also be needed. Postcasting swelling can impede circulation, requiring frequent neurovascular assessment. Bleeding under a cast after surgery is normal and usually does not require intervention.

5. Plaster casts can take up to 2 days to dry. They must be handled carefully, be elevated to reduce swelling, and not be placed under fans or heat lamps.

6. Casts must be kept clean, dry, and without rough edges.

POWERPOINT LECTURE SLIDES Fractures •

•

..

Prevention o

Greater risk for children

o

Teach use of protective equipment, safe play

Types (Figure 35–-20)

o

Closed – Casting

o Open – Surgery and casting Fracture Assessment • Abnormal positioning •

Crepitus

•

Severe pain

• Edema • Limited mobility Casting (Figure 35–6) • Plaster cast o

Up to 2 days to dry

o

Do not speed drying with heat or fans

• Elevate extremity •

Careful handling of wet cast

• Perform frequent neurovascular assessment o

Capillary refill, color, warmth, movement, sensation

• Keep edges clean, dry, smooth SUGGESTIONS FORCLASSROOM ACTIVITIES •

Discuss how to assess if a child has a fracture before a radiograph is done. How can a nurse determine after an injury if the child should be referred to a physician for a radiograph?

•

Discuss the differences in fractures due to accidents and those indicative of physical abuse.

What other signs and statements may indicate the injury was due to abuse?

..

• Ask students about their experiences having a cast. What did they do for hygiene, periods of itching, and ambulation?

•

In small groups, have students develop a plan to prevent fractures for children of different ages. What information should be taught? What would be the best way to teach this information?

SUGGESTIONS FOR CLINICAL ACTIVITIES • Examine the equipment used for cast care at the clinical setting. What materials are used when a child needs to bathe? What materials are used to protect the skin from the edges of the cast?

• Develop a handout for families about the home care of a child in a cast. Include information about hygiene, protection of the cast, safe ambulation, and how to recognize changes in neu- rovascular status.

..

CHAPTER 36 ALTERATIONS IN SKIN INTEGRITY Resource Library Student Resource Site Audio Glossary NCLEX Review Critical Thinking:Community Education Plan—Dog Bite Reduction Care Plan:Teaching Plan—Atopic Dermatitis Media Links:Eczema Resources and Support; Burn Resources and Support Media Link Applications Videos and Animations:Features of Integument (Drag and Drop); Integumentary Repair; Nursing in Action: Burn Wound Care Pediatric Dosage Calculations Image Library Figure 36–1 Layers of the skin with accessory structures.

Figure 36–3 Wound healing occurs in three overlapping phases: hemostasis and inflammation, tissue formation, and maturation. Figure 36–4 Contact dermatitis. Figure 36–19 Characteristics of burns by depth of thermal injury. Figure 36–20 Lund and Browder Chart for determining percentage of body surface area in pedi- atric burn injuries. Clinical Manifestations Tinea Infections

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Clinical Manifestations Drug Reactions Medications Used to Treat Atopic Dermatitis Medications Used to Treat Acne Based on Severity Partnering with Families Care for Acne Partnering with Families Caring for Minor Burns Partnering with Families Preventing Sunburn

LEARNING OUTCOME 1 Describe important pediatric differences in the anatomy and physiology of the child’s skin.

CONCEPTS FOR LECTURE 1. Children are at a greater risk for some skin conditions because of differences in anatomy and physiology of the skin.

2. The newborn’s skin is thin with little subcutaneous fat. This leads to heat loss, difficulty maintaining body temperature, and easier absorption of substances though the skin.

3. The infant’s skin contains more water and has loosely attached cells. As the infant grows, the skin toughens and becomes less hydrated.

4. The adolescent’s skin thickens and cells are tightly bound, increasing resistance to infection. Eccrine and apocrine glands mature. Melanin reaches adult levels.

POWERPOINT LECTURE SLIDES Pediatric Differences in Anatomy and Physiology of Child’s Skin ..

•

Differences in anatomy and physiology of the skin = higher risk

•

Newborn’s skin: thin, little subcutaneous fat

•

Infant’s skin: more water, loosely attached cells

•

Adolescent’s skin: thickens, cells tightly bound, eccrine and apocrine glands mature

SUGGESTIONS FOR CLASSROOM ACTIVITIES Write the anatomic structures of the skin on note cards. Pass out in class and post Figure 36–1 on the overhead screen. Have each student come up to the screen and point to the location of the structure on their card.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students children of different ages. Have students assess the skin of the patients and compare differences in postconference.

LEARNING OUTCOME 2 Classify the characteristics of skin lesions caused by irritants, drug reactions, mites, infection, and injury.

CONCEPTS FOR LECTURE 1. Atopic dermatitis is also known as eczema. The lesions are erythematous, dry, and scaly, which makes them more susceptible to infection. There is usually intense pruritus. The cause is unknown.

2. Contact dermatitis is skin irritation in response to an irritant. Common irritants can include soaps, detergents, poison ivy, fabric softener, and lotions. The lesions are erythematous and

..

can have edema, pruritus, vesicles, or bullae. The lesions develop within 24 hours and peak in 3 to 5 days.

3. Diaper dermatitis is a reaction to urine or feces in the diaper. Symptoms include glazed red plaques over the area where the diaper touches.

4. Seborrhea is a recurrent inflammatory skin condition. It is found where there are many sebaceous glands—for example, the scalp, the postauricular region, and the periorbital region. It is characterized by scaly, red-yellow patches.

5. Impetigo is highly contagious and is characterized by a vesicle with erythema surrounding that progress to a honey yellow crust. Bullous impetigo is a bullae, either one or several.

6. Cellulitis is a bacterial skin infection that is characterized by erythema, tenderness, edema, and is usually the result of trauma. Sometimes the child may have fever, chills, and lymphadenopathy.

7. Dermatophytoses are fungal infections that can happen at any age. Children can get them from people, inanimate objects, or pets.

8. Oral candidiasis (thrush) is characterized by white patches in the mouth that may bleed when removed. It is most common in infants, especially after birth. The infant may have pain with the lesions.

9. Molluscum contagiosum is characterized by dome-shaped, smooth papules with umbilicated centers. They can appear anywhere on the body and are usually in groups of 10 or more.

Usually the lesions spontaneously resolve in about 6 months.

10. Warts appear as skin-colored, scaly, rough papules. They usually are not painful unless on an area such as the foot.

..

11. Pediculosis is an infestation of lice on the hair and scalp. They are caught from hair-to-hair contact or from sharing accessories. Signs of the lice are intense itching and dandruff-like nits that attach to the hair and the person is unable to remove them. The nits are in the shape of a teardrop.

12. Scabies are highly contagious through skin-to-skin contact. The female mite burrows under the skin and lays eggs and feces in the path. Itching occurs approximately 1 month after infestation. Lesions can be noted anywhere and especially in between the fingers, folds of skin, and neck.

POWERPOINT LECTURE SLIDES Skin Lesions and Their Causes • Dermatitis Atopic dermatitis

°

Contact dermatitis

°

Diaper dermatitis

°

Seborrheic dermatitis

•

Drug reactions

•

Bacterial infections

•

..

°

°

Impetigo

°

Cellulitis

Fungal infections

° Tinea infections (Clinical Manifestations—Tinea Infections) ° •

Thrush

Viral infections ° Molluscum contagiosum ° Warts

•

Infestations °

Pediculosis capitus

°

Scabies

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups and assign each a type of skin disorder presented in this chapter.

Bring in dermatology books and have them present the nursing management of their skin disorder.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students assess their patients for any type of skin disorder. Have them present their findings and nursing management in postconference.

LEARNING OUTCOME 3 Differentiate between the stages of wound healing.

CONCEPTS FOR LECTURE ..

1. Wound healing is a process of three phases: inflammation, proliferation/reconstruction, and remodeling/maturation.

2. Inflammation is an initial response to injury that lasts 3 to 5 days. It is characterized by swelling, blood clotting, and wound sealing that prevents bacterial invasion.

3. Proliferation/reconstruction is the second phase where epithelial cells grow into wound from surrounding healthy tissue, and lasts from 5 days to 2 weeks. The wound contracts, collagen is produced, and granulation tissue fills in the wound (a red and shiny tissue).

4. Remodeling/maturation is continued collagen production for scar formation. This stage may take months to years.

POWERPOINT LECTURE SLIDES Stages of Wound Healing (Figure 36–3) • Inflammation o

Initial response to injury

o

Lasts 3 to 5 days

o

Swelling, blood clotting

o Wound sealing to prevent bacterial invasion •

Proliferation/reconstruction o

Epithelial cells grow into wound

o

Lasts from 5 days to 2 weeks

o Wound contracts, collagen is produced

..

o

•

Granulation tissue fills in the wound

Remodeling/maturation o

Continued collagen production

o

Scar formation

o

Takes months to years

SUGGESTIONS FOR CLASSROOM ACTIVITIES Show the students pictures of wounds in different stages of healing. Ask students to name the stage and support their answer.

SUGGESTIONS FOR CLINICAL ACTIVITIES Assign students to shadow a wound nurse for the day. Report observations in postconference.

LEARNING OUTCOME 4 Compare the skin conditions that have a hereditary cause or predisposition.

CONCEPTS FOR LECTURE 1. Skin conditions that have a hereditary cause or predisposition include atopic eczema and psoriasis.

2. Atopic eczema is a chronic, relapsing superficial inflammatory skin disorder characterized by intense pruritus. The etiology of atopic dermatitis is unknown; a complex interaction of genetic predisposition, environmental exposure, infectious agents, defects in the

..

skin barrier, and immunologic responses contributes to its development. A genetic mutation involving filaggrin, a protein essential for the skin barrier function, may play a role in the increased loss of water through the epidermis, infections, and inflammation.

3. Psoriasis is a chronic, pruritic, papulsquamous skin condition characterized by thick, scaly, pruritic plaques. A family history of psoriasis is often present, but a multifactorial inheritance is suspected. The dermis and epidermis become thickened along with excessive proliferation of keratinocytes, abnormal differentiation of keratinocytes, and inflammation. Because cells proliferate so rapidly, the keratinocytes do not mature. The epidermis thickens and plaques form with a silvery, scaly appearance.

4. Nursing management for atopic eczema includes the following: •

Hydrate and lubricate skin.

•

Reduce pruritus.

• Minimize inflammatory changes.

• Determine triggers.

•

Apply topical corticosteroids.

• Provide emotional support.

5. Nursing management for psoriasis includes the following: • Application of topical steroids and vitamin D • Tar shampoo

..

•

Ultraviolet B phototherapy

•

Systemic drug therapy

•

Provide emotional support

POWERPOINT LECTURE SLIDES Nursing Interventions for Skin Conditions with Hereditary Predisposition • Atopic eczema—chronic, relapsing, superficial inflammatory skin disorder • Nursing management o

Hydrate and lubricate skin

o

Reduce pruritus

o

Minimize inflammatory changes

o

Determine triggers

o

Apply topical corticosteroids (Medications Used to Treat Atopic Dermatitis)

o

Provide emotional support

• Psoriasis—chronic, pruritic, papulsquamous skin condition • Nursing management

..

o

Application of topical steroids and vitamin D

o

Tar shampoo

o

Ultraviolet B phototherapy

o

Systemic drug therapy

o

Provide emotional support

SUGGESTIONS FOR CLASSROOM ACTIVITIES Invite a parent of a child with a hereditary skin disorder to class to discuss how it impacts the child and the family.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have students assess children’s skin for the presense of hereditary skin disorders. Have the students discuss their nursing management during clinical.

LEARNING OUTCOME 5 Prepare an education plan for adolescents with acne to promote self-care.

CONCEPTS FOR LECTURE 1. The more teaching presented to the adolescent, the better his or her understanding of the acne.

2. The nurse should clear misconceptions about acne; for example, it is not caused by anything in the diet.

3. The nurse should address psychosocial concerns about acne.

POWERPOINT LECTURE SLIDES Acne • Teaching (Partnering with Families—Caring for Acne)

..

• Medications (Medications Used to Treat Acne Based on Severity) •

Nursing care

SUGGESTIONS FOR CLASSROOM ACTIVITIES Discuss as a group the myths about acne that students have heard.

SUGGESTIONS FOR CLINICAL ACTIVITIES When the students are caring for adolescents, they can address their concerns about acne. They can discuss how they care for their face and any medications they have tried. The students can give suggestions on how to care for the face and acne.

LEARNING OUTCOME 6 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

CONCEPTS FOR LECTURE 1. The goal in the treatment of contact dermatitis is to remove the irritant causing the problem.

Possible treatments can include corticosteroids, calamine lotion, and cool compresses.

2. Treatment for diaper dermatitis involves changing the diaper as soon as it is wet, applying a barrier cream or ointment, and using an antifungal cream or low-potency steroid if needed.

3. Treatment of seborrheic dermatitis includes washing with a baby shampoo, applying an emollient for 20 minutes, removing scales with a soft brush, and rinsing completely.

..

4. Treatment of drug reactions depends on the type of reaction. The drug should not be given again.

5. A topical antibiotic ointment is normally used for impetigo for 5 to 7 days. If the patient is not responding, use an oral antibiotic. The child is contagious until the antibiotic has been used for 48 hours. Toys should be sanitized when the child uses them and all clothes and towels should be washed in hot water after use.

6. Cellulitis of the skin is treated with either oral or IV antibiotics depending on the severity and response to oral antibiotics. Parents should be taught to watch for fever or for the redness to spread while being treated at home.

7. All members of the family, including pets, should be checked for fungal infections. Advise parents if their child is taking griseofulvin to give with a fatty food such as a full glass of milk. Hair regrowth with tinea capitis can take 6 to 12 months.

8. Thrush is treated with oral nystatin. Parents should be educated about sterilizing bottles and pacifiers and washing toys.

9. Molluscum contagiosum will fade in 6 to 9 months. Treatment includes tretinoin, curettage, or cryotherapy, by choice of the parent or physician. The disease can be spread more easily when the child is wet, so public swimming pools should be avoided. Towels should not be shared.

10. Warts usually go away in a couple of years. With treatment, it may take several months to work.

11. A permethrin (NIX)–based shampoo must be used to treat lice. Advise the parent to not use any conditioner before applying the shampoo. All nits should be removed daily for 7 days.

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All bedding and clothing should be washed in hot water and dried in the dryer. Anything that cannot be washed should be tied in a plastic bag for 2 weeks. Furniture and carpet should be vacuumed. All family members should be treated.

12. Treatment of scabies is with a permethrin 5% cream applied from the chin down. Leave the cream on for 8 to 12 hours and rinse off in the morning. A second treatment is used 1 week later. All bedding and clothing should be washed in hot water and dried in the dryer. Anything that cannot be washed should be tied in a plastic bag for 1 week. Furniture and carpet should be vacuumed. All family members should be treated.

POWERPOINT LECTURE SLIDES Skin Lesions and Their Treatments • Dermatitis °

Contact dermatitis (Figure 36–4)

°

Diaper dermatitis

°

Seborrheic dermatitis

• Drug reactions (Clinical Manifestations—Drug Reactions) •

•

Bacterial infections °

Impetigo

°

Cellulitis

Fungal infections °

..

Tinea infections

° •

Thrush

Viral infections ° Molluscum contagiosum ° Warts

•

Infestations °

Pediculosis capitis

°

Scabies

SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups and assign each a type of skin disorder presented. Bring in dermatology books and have them present the clinical manifestations of their skin disorder.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students examine their patients for any type of skin disorders presented in the lecture.

Have them assess and describe the lesions in postconference.

LEARNING OUTCOME 7 Summarize the process to measure the extent of burns and burn severity in children.

CONCEPTS FOR LECTURE

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1. Burns may be thermal, chemical, electrical, or radioactive. Children are at risk for different types of burns at different ages.

2. Full-thickness burns can occur in children after immersion for only 5 seconds in water of 140˚F. This is a lower temperature than most beverages served hot, such as coffee. Fullthickness burns are classified as burns that involve all of the epidermis and dermis, and may involve underlying tissue.

3. Physical assessment parameters include measurement of burn depth, percentage of body surface affected, and involvement of specific body parts. The Lund and Browder chart is used to determine the percentage of body surface area in pediatric burn injuries. Reassessment after 48 hours post–burn injury will reveal the true extent of the injury. Monitor vital signs, pain, electrolytes, and intake and output. Monitor for signs of infection in burned skin.

4. Obtain information about the burn; avoid accusatory questioning. Be alert for burn injuries related to child abuse. Psychosocial assessment should identify child and family stressors.

POWERPOINT LECTURE SLIDES Burns and Burn Severity (Figures 36–19 and 36–20) • Four main types of burns

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o

Thermal

o

Chemical

o

Electrical

o

•

Radioactive

Children are at risk for different types of burns at different ages

Suggestions for Classroom Activities Discuss the different types of burns and the ages at which children are at greatest risk for each.

Assign students to small groups and have each group design a prevention activity for teachers and childcare workers for infants, preschoolers, school-age children, or adolescents.

LEARNING OUTCOME 8 Develop a nursing care plan for the child with a full-thickness burn injury.

CONCEPTS FOR LECTURE 1. Treatment of a child with a full-thickness burn injury involves an emergency assessment of airway and circulation, identifying signs of respiratory distress and sources of bleeding.

2. Physical assessment parameters include measurement of burn depth, percentage of body surface affected, and involvement of specific body parts. Reassessment after 48 hours post-burn injury will reveal the true extent of the injury. Monitor vital signs, pain, electrolytes, and intake and output. Monitor for signs of infection in burned skin.

3. Obtain information about the burn; avoid accusatory questioning. Be alert for burn injuries related to child abuse. Psychosocial assessment should identify child and family stressors.

4. Nursing diagnoses may include: • Hyperthermia

..

• Disturbed Body Image •

Anxiety

•

Risk for Infection

5. Planning and implementation include various treatments to promote healing and prevent complications. Nursing intervention includes dressing changes, antibiotic and analgesia administration, nutrition management, and play therapy.

6. Evaluation of nursing intervention includes effective pain management and prevention of complications, such as reduced risk for infection and fluid overload.

POWERPOINT LECTURE SLIDES Nursing Care Plan: Child with Full-Thickness Burns • Assessment o

Airway and circulation

o

Measure burn depth, percentage of body surface affected, and involvement of specific body parts

•

..

o

Reassessment after 48 hours

o

Vital signs and pain assessment

o

Monitor electrolytes, intake and output

o

Monitor for signs of infection in burned skin

o

Psychosocial assessment should identify child’s and family’s stressors

Nursing diagnoses

•

o

Hyperthermia

o

Disturbed Body Image

o

Anxiety

o

Risk for Infection

Planning and implementation o

•

Treatments to promote healing and prevent complications

Evaluation o

Effective pain management

o

Prevention of complications

SUGGESTIONS FOR CLASSROOM ACTIVITIES List nursing interventions for a child with a full-thickness burn on the board. Point to an intervention and ask students to identify the rationale for the intervention.

SUGGESTIONS FOR CLINICAL ACTIVITIES Present a case scenario regarding a child who sustained a full-thickness burn. Have students outline their plan of care.

LEARNING OUTCOME 9 Evaluate preventive strategies to reduce the risk of injury from burns, bites, and stings.

CONCEPTS FOR LECTURE

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1. A major role of nurses is to aid in the prevention of burns. Parents should be educated about prevention, including setting hot water heaters below 125°F, turning pot handles inward and keeping hot liquids out of reach, keeping flammables away from children, and installing smoke detectors. Parents should be educated about the doctor’s orders for burn care when needed.

2. Treatment of sunburn is usually supportive, including increased fluids, cool compresses, and NSAIDs. 3. Prevention education for frostbite includes layered clothing, packing extra blankets, and removing wet clothing immediately. Treatment of frostbite includes protecting the extremity from further damage because it is numb, warming the area in water slowly (102°F), giving analgesics, and giving fluids. Initial frostbite management is usually done in the hospital.

4. DEET in insect repellent helps prevent insect stings. The amount of DEET should not exceed 10% when used on children. Sweet foods and beverages and perfumes can attract stinging insects, so parents should try to avoid their use.

POWERPOINT LECTURE SLIDES Preventive Strategies to Reduce the Risk of Injury from Burns, Bites, and Stings •

Burns °

Prevention

° Management (Partnering with Families—Caring for Minor Burns) •

Sunburn ° Prevention (Partnering with Families—Preventing Sunburn)

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° Management •

Bites and stings °

Prevention

° Management SUGGESTIONS FOR CLASSROOM ACTIVITIES Divide the class into groups and have them develop a teaching plan to present to groups of parents about prevention and management with each of the skin alterations listed. Have students present their education plans to the class. Remind students that they are presenting to parents, not nurses.

SUGGESTIONS FOR CLINICAL ACTIVITIES Have the students work on burn prevention with their patients. Have students develop a plan to prevent this with their patients and present it to the parents.

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