NURS 330-001 peds lecture- units 3 & 4

Riah Hoffman

leukemia

Diseases of the bone marrow, blood, and lymphatic system.

Clinical Manifestations:

S&S- a result of infiltration of bone marrow: (1) anemia-decreased RBCs, (2) infection- from neutropenia, and (3) bleeding-from decreased platelet production.

May have elevated WBCs (>10,000/mm3), hepatosplenomegaly, splenomegaly, fever, lymphadenopathy, bleeding, petechiae or purpura, and bone pain

Diagnosis:

May be suspected when child: does not recover from infection or frequent infections, has weight loss, or has petechiae or bruising with no cause.

h&p, CBC w/ peripheral blood smear that contains leukemic blasts, bone marrow aspiration- PAINFUL. After definitive diagnosis, should have LP to assess for CNS involvement

Therapeutic Management: 3 phases.

• Can get chemo & stem cell transplantation – at risk for Graft vs Host Disease

Prevent Complications of Myelosuppression:

Neutropenia- handwashing, no live vaccines while immunosuppressed, avoid others with illnesses, limit visitors, caution when returning to school, avoid crowds. If infection- antibiotics, proper nutrition. Avoid fresh flowers, fruit and vegetables bc they can harbor bacteria

Hemorrhage-avoid skin punctures if possible (venipunctures instead). Observe for bleeding (meticulous mouth care, epistaxis- lean forward & apply pressure for 15 mins, avoid rectal temperatures and suppositories, avoid activities that might cause injury)

Anemia-blood transfusion.

Complications of chemo:

• Many are vesicants that cause cellular damage if infiltrated, may cause anaphylaxis.

Manage Side Effects:

• n/v- antiemetic before (30 minutes-1 hour) before chemotherapy begins and regularly afterward

• Altered Nutrition- assess nutritional status, intake, & energy expenditure

• Mucosal Ulceration- oral ulcers greatly compound anorexia. Provide bland, soft diet, a soft sponge toothbrush, frequent rinsing with mouthwash or sodium bicarbonate and salt rinses, local anesthetics

• Rectal Ulcers- meticulous toilet hygiene, warm sitz bath after each BM, ointment, stool softeners, avoid rectal temperatures and suppositories.

• Constipation-physical activity, stool softeners, laxatives, increased fiber.

• Foot drop and weakness and numbness of the extremities-high top tennis shoes or footboard for proper alignment.

• Jaw Pain-providing soft or liquid diet, analgesics.

• Hemorrhagic Cystitis (burning or bleeding on urination)- liberal fluid intake, frequent voiding when feeling the urge, administering chemotherapy early in day to allow for sufficient oral intake and frequent voiding, administering Mesna (an agent that provides protection to the bladder, inhibits urotoxicity). IV fluids

• Alopecia- inform hair regrows in 3-6 months but may be different color and texture, use head coverings and wigs.

• Moon Face-from short term steroid therapy

• Mood changes-from steroid therapy, range from euphoria to depression, warn parents

•Which signs and symptoms would the nurse suspect the client has thrombocytopenia? Select all that apply.

•1. Fever

•2. Petechiae

•3. Epistaxis

•4. Anorexia

•5. Bone Pain

•6. Shortness of Breath

Thrombocytopenia - low platelets - bleeding risk!

2, 3.

The pt may have all of these options with leukemia, but only 2-3 are bleeding sx

neuroblastoma

Most common malignant extracranial solid tumor in children.

• Sx: depend on location of tumor.

• Dx: H&P, blood chemistries and neurological exam, CT or MRI for tumor imaging, bone marrow aspiration and biopsy, urine for catecholamines monitor response to therapy

• Therapeutic Management: surgical removal, chemo, radiation

• Nursing Management: poor prognosis, high degree of metastasis, family support.

osteogenic sarcoma

• Bone tumor, mostly during rapid bone growth. Mostly in femur

• Management: surgery and chemotherapy, radiation is only palliative. Limb salvage procedure vs amputation risk.

• Nursing Care Management: Use prosthesis, chemotherapy and side effects, phantom limb pain with amputation (sensations of tingling, itching and pain) is REAL

Ewing’s sarcoma

Neuroectodermal tumor of the bone.

Therapeutic Management: radiation, chemo. Possible limb salvage procedures or amputation may be considered if radiation therapy renders the extremity useless.

Try to preserve affected limb.

Nursing Care Management: High-dose radiation causes a skin reaction → desquamation, hyperpigmentation; wear loose clothes over irradiated area, protect from sunlight and sudden changes in temperature (avoid heating pads/ice packs)

Complications of chemo:

• Many are vesicants that cause cellular damage if infiltrated, may cause anaphylaxis.

Manage Side Effects:

• n/v- antiemetic before (30 minutes-1 hour) before chemotherapy begins and regularly afterward

• Altered Nutrition- assess nutritional status, intake, & energy expenditure

• Mucosal Ulceration- oral ulcers greatly compound anorexia. Provide bland, soft diet, a soft sponge toothbrush, frequent rinsing with mouthwash or sodium bicarbonate and salt rinses, local anesthetics

• Rectal Ulcers- meticulous toilet hygiene, warm sitz bath after each BM, ointment, stool softeners, avoid rectal temperatures and suppositories.

• Constipation-physical activity, stool softeners, laxatives, increased fiber.

• Foot drop and weakness and numbness of the extremities-high top tennis shoes or footboard for proper alignment.

• Jaw Pain-providing soft or liquid diet, analgesics.

• Hemorrhagic Cystitis (burning or bleeding on urination)- liberal fluid intake, frequent voiding when feeling the urge, administering chemotherapy early in day to allow for sufficient oral intake and frequent voiding, administering Mesna (an agent that provides protection to the bladder, inhibits urotoxicity). IV fluids

• Alopecia- inform hair regrows in 3-6 months but may be different color and texture, use head coverings and wigs.

• Moon Face-from short term steroid therapy

• Mood changes-from steroid therapy, range from euphoria to depression, warn parents

Wilms tumor

“I WILL not palpate abdomen”

Malignant renal and intraabdominal tumor.

Diagnosis: history and physical, x-ray, abdominal imaging, lab studies.

Clinical Manifestations: abd swelling or a mass, hematuria, anemia (pallor, anorexia, lethargy), hypertension, weight loss and fever.

Therapeutic Management: surgery (ASAP)-Encapsulated tumor- if you bust it open, it can open & spread cancer cells all over child’s body. DO NOT palpate abdomen. Followed by chemo or radiation, post-operative radiation may be indicated

rhabdomyosarcoma

Soft tissue sarcoma.

Clinical Manifestations depend on tumor site.

Diagnosis: h&p, imaging studies, laboratory studies, biopsy to confirm diagnosis.

Therapeutic Management: surgery, chemotherapy and radiation.

Nursing Care Management: careful assessment for signs of a tumor especially during well child visits, follow-up-if relapse occurs, the prognosis for long term survival is poor,  preparation of the child and family for multiple tests, and supportive care.

retinoblastoma

Dx: symptoms and definitive diagnosis by opthalmoscopic exam under general anesthesia, ultrasound, CT, and MRI of orbit to determine extent of the disease.

Clinical Manifestations: cat’s eye reflex or leukocoria-whitish “glow” in the pupil, strabismus (cross-eyed), red, painful eye often with glaucoma, severe permanent visual impairment (late sign).

Therapeutic Management: enucleation therapy (removal of eyeball!) Brachytherapy (radiation delivered to tumor), photocoagulation (laser), cryotherapy (freezing), chemotherapy, radiation.

Nursing Care Management: side effects of treatment, eye patch after surgery, care of the socket, fitting for prosthesis.

hydrocele

A collection of fluid in the sac next to the testicles.

Common in newborns and often resolves by 1-3 years of age.

Surgical correction may be indicated if persists past 1 year old and symptomatic due to risk of incarcerated inguinal hernia.

Nursing management: outpatient procedure, may be temporary swelling and discoloration that resolves spontaneously, straddle toys are avoided for 2-4 weeks (bike, horse), in older boys strenuous activity avoided for 1 month, if dressing placed removed in 2-3 days, and child can bathe in 3 days.

Cryptorchidism

Failure of one or both testes to descend normally

Dx: detected by inability to palpate testes within the scrotum, assess in warm environment bc cold environment causes retraction of the testes

Therapeutic Management: surgery (Orchiopexy)- surgeon takes undescended testicle & permanently fixes it down), scrotal positioning reduces the risk of trauma and torsion.

At risk of fertility issues & testicular cancer

Nursing Care Management: no vigorous activities or straddle toys (bike / horse) for 2-4 weeks, teach self-testicular exams at puberty.

hypospadias

Urethral opening located behind the glans penis (ventral surface) rather than at tip

Objectives of Surgical Correction: enable child to void in the standing position and direct stream voluntarily in usual manner, improve physical appearance of genitalia, and produce a sexually adequate organ

Nursing Care Management: assess urinary output (may require urine diversion tube), pain control, oxybutynin for bladder spasms from catheter, the penis may be swollen, discolored or bruised (will resolve with time). Apply petroleum jelly to diaper to prevent sticking to incision

Neonatal circumcision should be delayed bc the foreskin may be used in reconstruction.

EXSTROPHY-EPISPADIAS COMPLEX

Severe defect involving the musculoskeletal and the urinary, reproductive, and intestinal tracts.

1. Bladder Exstrophy: an open, inside out bladder

2. Epispadias: exposed or open dorsal urethra. Allows bacteria entry into the urine.

3. Cloacal Exstrophy: also involves exstrophy of the large intestine.

In males → shortened penis.

In females → small labia minora and shortened vagina. May require vaginal dilatation for sexual intercourse.

Therapeutic Management:

1. preservation of renal function

2. attainment of urinary control

3. adequate reconstructive repair for acceptable appearance

4. prevent UTIs

5. preserve optimum external genitalia with sexual function.

Will require numerous surgeries to repair all defects, plastic surgery to reduce scarring.

Nursing Care Management: limit trauma to the exposed bladder, cover with a non-adherent plastic wrap or dressing. After closure- monitor UO (NORMAL IN KIDS= 1ml/kg/hr), watch for signs of UTI, immobilization of the pelvis in traction or hip spica for 2-4 weeks, vital signs, skin care and circulation, pain management, bladder reconstruction-wound care, UO, penile and urethral lengthening-same as hypospadias surgery, children who fail to attain urinary continence may need self catheterizations.

Glomerulonephritis

Acute inflammation of the glomeruli of the kidneys

Acute post streptococcal glomerulonephritis is most common of the post infectious renal diseases in childhood. (AKA caused by untreated strep)

Dx: kid experiences streptococcal infection (strep), onset of nephritis appears after 1-3 weeks. UA will show hematuria and proteinuria, elevated BUN and Creatinine (azotemia), strep culture positive, positive ASO titer -> reliable strep test. Xray- cardiac enlargement, pulmonary congestion, or pleural effusion.

Clinical Manifestations: hematuria fluid volume excess -> edema (especially periorbital, in morning), decreased urine (cloudy, smoky brown/tea colored), hypertension. pallor, lethargy, irritability, vomiting. Older children: headache, abdominal discomfort, and dysuria.

Therapeutic Management:

If satisfactory urine output and BP, can be treated at home.

Those with substantial edema, hypertension, gross hematuria, and significant oliguria- need hospitalization

Dietary restrictions-moderate sodium and even fluid restriction may be instituted for edema and hypertension. Restrict high potassium foods during period of oliguria (if they’re not peeing, their body is retaining potassium → hyperkalemia → arrythmias)

Monitor vital signs, daily weight to assess fluid balance, and I & O (urine output should be 0.5-1 ml/kg/hr).

Hypertension is anticipated (monitor BP, give anti-hypertensives and diuretics). Kid may complain of headache and blurred vision.

Rarely acute kidney injury occurs: hyperkalemia, hyperphosphatemia -> hypocalcemia, these cause metabolic acidosis.

Nursing Management:

Assess volume and character of urine.

Daily weight.

Assess child with fluid restriction for signs of dehydration.

Most on regular diet (no salt added); fluid restriction (if prescribed) should be divided during waking hours

Allow frequent rest periods.

nephrotic syndrome

Kidneys aren’t working properly →  massive proteinuria (2+), hypoalbuminemia, hyperlipidemia, edema.

Diagnosis: based on clinical manifestations, renal biopsy

Clinical Manifestations: weight gain, facial edema (around eyes, in am), ascites (measure abd circumference, belly button everts, striae, skin tight & glistening, fluid wave) irritability, easily fatigued, lethargic, decreased UO, frothy urine bc of proteinuria.

Therapeutic Management:

Objectives: reduce excretion of urinary protein, reduce fluid retention, prevent infection, and minimizing complications.

Dietary-low salt.

Severe cases-fluid restriction.

Edema-diuretics.

In some cases- Albumin infusions.

Infection-antibiotics.

Corticosteroids (Prednisolone) - side effects- weight gain, rounding of face AKA moon face, behavior changes, increased appetite, long term-hirsutism, growth retardation, cataracts, hypertension, GI bleeding, bone demineralization, infection and hyperglycemia.

Steroids reduce immune system so you’re at risk for infection, they also increase blood sugar.

If do not respond to steroids or have frequent relapses may be placed on immunosuppressants

Nursing Management: monitor fluid retention and excretion, strict I & O (weigh wet diapers), urine examination for albumin, daily weight, abdominal girth measurements, assess edema, vital signs, avoid infection (protect from infected individuals), diet (salt restricted during edema phase) and fluid restriction, activities according to tolerance level, anticipate mood swings and irritability with steroids.

osteogenesis imperfecta

•Rare genetic disorder characterized by bones that fracture easily.

•Clinical features: bone fragility and deformity, short stature, hearing loss, blue sclerae, and dentinogenesis imperfecta (hypoplastic discolored teeth- bones show thru)

dx- hx of multiple breaks, examine teeth & sclera, stature

Therapeutic Management: primarily supportive, biophosphonate (IV pamidronate- BONATE DRONATE- take on empty stomach with water, upright 30-60 mins) to promote increased bone density and prevent fractures, lightweight braces and splints to support limbs, prevent fractures, and aid in ambulation, PT to strengthen muscles and promote bone density, surgery to prevent and correct deformities, placement of rods to stabilize bones and prevent or correct deformities.

•Nursing Care Management: prevent fractures (support when positioning, turning, moving and holding), never hold by ankles when diapering (should gently lift buttocks)

Legg Calve Perthes

Femoral head loses blood supply. Can lead to bone weakening, collapse, or necrosis. It usually resorbs & reforms, but can be misshapen, leading to increased risk for arthritis.

1. stage 1- avascular necrosis or infarction (blood supply cut off)

2. stage 2- bone reabsorption and revascularization

3. stage 3- new bone formation

4. stage 4- gradual reformation.

Clinical Manifestations and Diagnosis: limping, hip soreness/ache/stiffness, pain in hip/thigh/knee, limited ROM

•Therapeutic Management: need to remain immobile- nonsurgical containment-abduction brace (Scottish Rite Brace), casts, NSAIDS, rest and limited bearing.

If not corrected after 2 years, then surgical containment.

Slipped Capital Femoral Epiphysis

spontaneous displacement of the proximal femoral epiphysis - usually from puberty-related growth spurts

•Diagnosis: clinical symptoms (very often obese, limp on affected side, inability to bear weight because of severe pain, pain in groin, knee or thigh, affected leg externally rotated, loss of hip flexion, abduction and internal rotation as severity increases, and affected leg may appear shortened) and x-ray.

•Therapeutic Management: non-weight bearing to prevent further slippage, pinning through the femoral neck, post op: non or limited weight bearing, crutches for weeks to months, restriction from sports/activities until fusion occurs

cerebral palsy

•Disorder of posture and movement from static brain injury perinatally or postnatally.

*THERAPEUTIC HYPOTHERMIA

Involves *motor disorders, disturbances in sensation, perception, communication, cognition, behavior; epilepsy, delayed development. & associated disabilities

usually a clearly defined postnatal cause (an event like meningitis or traumatic brain injury)

Spastic CP

• persistent primitive reflexes, positive Babinski, ankle clonus, exaggerate stretch reflexes, contractures, hypertonicity, impaired fine and gross motor skills.

Dyskinetic (athetoid)

• chorea-involuntary jerking movements, dystonia- slow twisting movements, drooling and dysarthria.

Ataxic

• wide gait, rapid-repetitive movements.

Early Signs: failure to meet milestones such as rolling over-6 months, raising head-good head control by 3 months, sitting up 6-8 months, crawling unassisted by 8 months, persistent reflexes (Moro, atonic neck), clenched fists after 3 months, failure to smile by 3 months, using one side of body or only arms to crawl, tongue thrust after 6 months.

•Therapeutic Management:

orthoses/braces- to prevent or decrease deformity. Adaptive Equipment: Wheelchairs/wheeled carts/stroller-mobility. Surgical intervention-correct contracture or spastic deformities

Medications

• Decreasing spasms (Baclofen), Diazepam (valium)

• Botox-reduce spasticity in targeted muscles.

• Anti-epileptic meds (Tegretol, Depakote)

• Airway clearance devices to mobilize secretions, neuromuscular electrical stimulation (NMES)

•Nursing Management:

• gastrostomy feedings may be needed). Also risk for aspiration.

• teaching the parents medication administration (tube or oral-manual jaw control)

• pt, ot, speech

Duchenne Muscular Dystrophy (DMD)

the most common and most severe form of MD.

Characteristics

• early onset (usually between 3-5)

• progressive muscle weakness, wasting, contractures, lordosis, waddling, frequent falls. Muscle atrophy, loss of independent ambulation by 9-12 years old

• Gower sign - Gower climb the Tower - (achieves standing by using hands to “climb” up the legs due to weakness in the hip & thigh muscles)

• relentless progression until death from respiratory or cardiac failure.

•Diagnosis:

• blood polymerase chain reaction (PCR) for gene mutation, may be recognized prenatally, muscle biopsy (degeneration of muscle fibers)

•Therapeutic Management:

• no cure

• corticosteroids (improve muscle strength and pulmonary function). Maintain optimal function (remain as active as possible, stretching, strength and muscle training, breathing exercises and incentive spirometry to increase lung capacity. Surgery to release contracture deformities, bracing, prevent respiratory and cardiac complications

developmental dysplasia of the hip (DDH)

•A broad spectrum of disorders related to abnormal development of the hip

2 major categories: idiopathic (infant neurologically intact) and teratologic (involves neuromuscular defect).

•Three degrees of DDH

1. acetabular dysplasia (no dislocation, mild form)

2. subluxation = partially dislocated hip (most common)

3. dislocation (femoral head loses contact with the acetabulum).

•Diagnosis: Ortolani and Barlow tests (most reliable, should be performed by experienced clinician):

• Ortolani-abduction of the thigh- Ortolani Outward

• Barlow-the thigh is adducted

• xrays

•Clinical Manifestations: infants-shortening of the affected limb (Galeazzi sign), restricted abduction, unequal gluteal folds, Positive Ortolani and Barlow sign, older children-shortening, telescoping or piston mobility of the joint (head of femur moves up and down in buttock when extended thigh is pushed forward), Trendelenburg sign (when child stands up on one foot than the other bearing weight on affected hip, pelvis on normal side tilts downward instead of upward), greater trochanter prominence, marked lordosis and waddling gait.

Newborn to Age 6 months: Pavlik harness worn continuously (22-24 hours per day) until hip is proved stable (by clinical exam and ultrasound) usually 6-12 weeks. when difficulty maintaining stabile reduction of the femoral head, a surgical closed reduction is performed and placement of a hip spica cast

•Ages 6 to 24 months: dislocation often not recognized until child begins to stand or walk. traction to gently stretch the hip to full abduction, child receives a surgical closed reduction for subluxation or dislocation, then placed in spica cast for 12 weeks, if remains unstable an open reduction is performed. 

•Older Children: more difficult, pre-operative traction, tenotomy of contracted muscles, operative reduction and reconstruction, and casting, after cast removal, need range of motion to restore movement, other rehab measures may include muscle strengthening, a period of crutch or walker use, and gait training.

•Nursing Management: teaching parents regarding reduction device, Pavlik harness-see HCP for strap adjustments, skin care (always wear an undershirt, check skin frequently, gentle massage skin to stimulate circulation, avoid lotions and powders, place diaper under straps, removal of harness determined by the HCP (some may allow removal for bathing), casts can not be removed, involve in activities, may need wheelchair, scooter or stroller for mobility.

club foot

•Complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus. The foot is pointed downward (plantarflexed) and inward in varying degrees.

•Can be isolated or associated with chromosomal anomalies, cerebral palsy, spina bifida.

•Classification: (1) positional (from intrauterine crowding and responds to stretching and casting, (2) syndromic (associated with other congenital anomalies, (3) congenital or idiopathic (occurs in otherwise normal child).

Diagnosis: apparent at birth, prenatal by ultrasound

•Therapeutic Management: correction of deformity (Ponsetti method-serial casting shortly after birth with weekly gentle manipulation and stretching), maintenance of the correction until normal muscle balance is regained and follow up observation to avert possible recurrence of the deformity (Ponseti sandals with a bar set in abduction) * if unable to achieve alignment then surgical intervention is indicated.

•Nursing Management: skin and circulation checks, parent education (cast care/bracing)

scoliosis

Diagnosis: observation behind an undresse child bending forward, noting shoulder height, scapular or flank shape, and hip height and alignment. Scoliometer-measure angle, definitive by x-ray.

•Therapeutic Management: bracing (Boston and Wilmington-plastic shells, TLSO-underarm plastic, Milwaukee-neck ring, Charleston nighttime bending brace) and exercise (bracing not curative, slows progression)-recommended for moderate curvature, surgical recommended for curves greater than 45-50 degrees to reduce respiratory issues caused by lateral curvature

•Nursing Management: body image disturbance, compliance with bracing.

•Pre-op care: x-rays, pulmonary function studies, laboratory studies, may need blood post-op, teaching.

•Post-op care: vital signs, wound care, skin care, PCA, log roll, ambulation as soon as possible, ROM

biliary atresia

atresia = a natural bodily passage or opening is missing ☹

Inflammatory process that affects biliary ducts of liver.

Clinical Manifestations:

• jaundice (yellowing of skin or sclera), dark urine, light clay-colored stools, hepatosplenomegaly, pruritus.

Dx:

• early is key to survival. Liver biopsy, exploratory laparotomy

Therapeutic Management:

• Hepatic portenterostomy- drains bile, or transplant

• Medications- nutritional support with infant formulas, supplement fat-soluble vitamins (ADEK) and minerals (iron, zinc, selenium)

• TPN for growth failure (monitor glucose on TPN!)

• Phenobarbital after surgery (sedates & stimulates bile flow),

• Ursodeoxycholic acid (pruritus).

Prognosis:

• untreated- cirrhosis and death.

Complications:

• cholangitis (infection of bile ducts), GI bleeding, ascites (fluid in abdomen, striae, fluid wave, resp problems from buildup)

Nursing Management:

• comfort measures for pruritus (baths in oatmeal and trimming of fingernails to avoid scratching)

food allergies

• Food allergens- recognized by allergen-specific immune response (more severe)

• Food intolerance- when food elicits an adverse reaction (less severe)

Common food allergy sources: nuts, eggs, wheat, legumes, fish, soy, chocolate, milk, pork, chicken, strawberries, melon, citrus fruits, corn, tomatoes, and spices.

Clinical manifestations:

• systemic (anaphylactic, airway can close, hives; growth failure)

• GI (abdominal, vomiting, cramping, diarrhea)

• respiratory (cough, wheezing, rhinitis, infiltrates)

• cutaneous (urticarial rash, atopic dermatitis -> hives)

Diagnosis:

• symptoms, food challenge, skin testing (ALWAYS have epinephrine / emergency equipment available)

Nursing Care Management:

• big on education (child, family, and caregivers), avoid unfamiliar restaurants, read food labels, breastfeeding is primary strategy to avoid developing allergies.

Treatment of anaphylactic reaction:

• airway support, epinephrine. Administer IM epi pen in children if life threatening anaphylaxis or severe symptoms (itching sensation or tightness of the throat, “barky” cough, difficulty swallowing, wheezing, cyanosis, respiratory or cardiac arrest, or loss of consciousness)

fractures in children - general definitions

Definition: a break in the continuity of the bone. Occurs when the bone is subjected to more stress than it can absorb.

Etiology: Accidental versus non-accidental injuries (child abuse- it’s suspicious if a non-ambulatory child breaks their leg)

The weakest point of long bones is the cartilage growth plate- Injury to this area can affect future longitudinal growth of the bone.

common fxs- School-age child = distal wrist fracture. Neonate = clavicular fracture from shoulder dystocia

Plastic deformation: bone is bent but not broken, children’s bones are more flexible

Buckle or torus fracture: compression of bone- raised or bulging projection at the fracture site, common in young children.

Greenstick fracture: incomplete fracture- bone is broken but not the entire way thru- pieces still connected

Complete fracture: divides the bone fragments.

Proximal: fragment closer to midline

Distal: fragment farther from midline

Closed: fracture does not break skin

Open: fracture protrudes through skin (infection risk)

Comminuted: (bone pieces want to join tissue community) bone fragments lie in the surrounding tissue. Can poke into nerves

Complicated: bone fragments cause damage to organs or tissues. Ex- rib fractures can puncture lungs

care of a child with a fx

sx-

• swelling, Pain or tenderness that worsens with movement, Diminished functional use (child may protect injured limb, refusing to reach, walk, or crawl), Deformity possible, bruising, rigidity, crepitus (grating sensation)

• Sensory & motor deficits may be seen if bone fragments are compressing neurovascular structures

Diagnosis: symptoms and x-ray.

Therapeutic Management:

regain alignment and length of the bony fragments (reduction-internal/external), immobilization-splint, cast, fixator, traction, restore function to the injured part, and prevent injury and deformity.

Nursing Management:

Cover open wounds, immobilize (including joints above and below the injury site), reassess neurovascular status, elevate, apply cold, call EMS.

Assess neurovascular status with the 6Ps (pain, pulselessness, pallor, paresthesia, pressure, paralysis)

Assess for sign of compartment syndrome (serious complication-compression of nerves & blood vessels. muscle fasciotomy (slice into compartment to relieve pressure):

• Pain: severe pain unrelieved by analgesics or elevation

• Pulselessness: inability to palpate pulse distal to fracture or compartment.

• Pallor: pale skin, poor perfusion, capillary refill > 3 seconds

• Paresthesia: tingling or burning sensations.

• Paralysis: inability to move extremity or digits.

• Pressure: may feel tense and warm, skin appears tight and shiny.

caring for a child in a cast

Hip spica cast

• keeps legs separated with 2 leg casts & a middle bar.

• must remain uncovered to allow drying, may experience heat during the drying process, turning child in plaster cast every 2 hours will help dry a body cast evenly, use regular or cool air dryer (do not use heated fans bc they can cause a burn)

Wet plaster cast

• should be covered in plastic for bathing and handled with palms to prevent indents to the cast

• any hot-feeling spots or foul smell (BO smell is normal) coming from cast indicates infection (report to physician)

Watch for signs of compartment syndrome and changes in neurovascular status.

• Bivalve - cuts holes to release edema or pressure

• petal- cover jagged inner edge of cast to prevent irritation.

teaching

• do not get wet, no placing items inside cast, elevate.

Cast removal:

• area will be atrophied, hairy, pale, and covered in dead skin. May soak in bathtub or baby oil or lotion to remove crusty skin cells (do not vigorously scrub).

caring for a child with traction

Purposes for Traction: fatigue muscles and reduce spasm so bones can be realigned, immobilize the fracture site, prevent or improve contracture deformity.

Maintain traction: check components-ropes, pulleys, weights, check bed position, never remove skeletal traction or release straps on skin traction bc this is doc’s job

Skeletal traction: check pin sites for bleeding, inflammation, or infection, cleanse and dress pin sites as ordered, topical anesthetic or antibiotic daily as ordered

Prevent skin breakdown: wash and dry skin daily, skin assessment checking pressure points, stimulate circulation with gentle massage, change position every 2 hours.

Prevent complications: neurovascular assessment, cough and deep breathe/incentive spirometer, ROM exercises, foot board to prevent foot drop

hypertrophic pyloric stenosis

When the pyloric sphincter muscle (connection of esophagus to the stomach) becomes thickened. Produces an outlet obstruction and compensatory dilation, hypertrophy and hyperperistalsis of the stomach.

Dx

• H & P, symptoms (olive-like mass easily palpated when stomach is empty, projectile vomiting 30-60 minutes after feeding, Ultrasound)

Clinical Manifestations

• projectile vomiting, infant “avid feeder” (hungry all the time bc not absorbing any nutrients bc of vomiting), weight loss or failure to gain, olive-like mass in epigastrium, visible peristalsis.

Surgery

• pyloromyotomy

Nursing Management:

• Pre-op: IV rehydration, NPO. VS, ABGs (metabolic alkalosis bc vomiting all the stomach acid), electrolytes (NA, K, CL), skin, mucous membranes, daily weight, if NG decompression ensure tube placement, patency and drainage.

• Post-op: vomiting common for first 24-48 hours, IV fluids, pain management, assess surgical wound and wound care. Post-op feedings begin with clears 4-6 hours post-op, small frequent feedings, if clears retained for 24 hours, formula is started in small increments.

Hirschsprung disease

Congenital anomaly that results in mechanical obstruction in the intestine.

Diagnosis: absence of meconium in first 48 hrs

Clinical Manifestations:

• newborn-failure to pass meconium within 24-48 hours, refusal to feed, bilious vomiting, infancy-abdominal distention, diarrhea, vomiting, childhood-ribbon-like, foul smelling stools, visible peristalsis.

Therapeutic Management: surgery to relieve the obstruction.

Nursing Management:

Pre-op: symptomatic treatment with enemas, a low fiber, high calorie & high protein diet and in severe situations TPN, watch for signs of enterocolitis (explosive watery diarrhea, fever, ill appearance), monitor vital signs, fluid replacement, and signs of bowel perforation (fever, abdominal distention, vomiting, increased tenderness, irritability), measure abdominal circumferences.

Post-op: same for abdominal surgery, diaper below dressing to avoid wound contamination, some require daily anal dilations, colostomy care, foley catheter.

Discharge Care: colostomy care; Low-fiber so they don’t stimulate bowel movements.

Enterocolitis – a complication. sx- watery or bloody explosive diarrhea

celiac disease

Intolerance to dietary gluten - genetic

• found in wheat, barley, rye, oats

Clinical Manifestations: classic sxs- GI manifestations - foul-smelling steatorrhea, malnutrition, anorexia, muscle wasting

Celiac Crisis: acute profuse watery diarrhea and vomiting, prolonged fluid and electrolyte depletion, and emotional disturbances.

Diagnosis: serological tests, upper GI endoscopy and biopsy of the small intestine.

Therapeutic Management: gluten-free diet (actually low in gluten, impossible to remove every source of gluten). if untreated may also have lactose intolerance (dairy). Gluten-free items are expensive, so budget concerns are real. Education- Reading all labels (gluten added to many foods). Noncompliance is common

GERD (gastroesophageal reflux disease)

The transfer of gastric contents back into the esophagus.

Certain conditions predispose children to GERD (neurologic impairment, chronic respiratory disorders, esophageal atresia and obesity)

Dx:

• H & P, upper GI series, ***24-hour intra-esophageal pH monitoring, endoscopy with biopsy

Clinical Manifestations:

• Infants-spitting up, regurgitation, arching back irritability after feeding (like trying to get away from the burning in throat), respiratory problems (cough, choking with feeding), older children-heartburn, chest pain, dysphagia, hoarseness.

• Complications- esophagitis, esophageal stricture, laryngitis, pneumonia, anemia

Therapeutic Management:

• Avoid foods that exacerbate acid reflux (caffeine, citrus, tomatoes, alcohol, peppermint, chocolate, spicy or fried foods).

• Lifestyle modifications (weight reduction, small frequent meals, smoking cessation).

• Feeding maneuvers (thickened feedings- rice cereal, enlarged nipple for easier suck, upright positioning-elevate head of bed 30 degrees for one hour after feedings). Avoid vigorous play after feedings and avoid large feedings just before bedtime.

• If v severe, may need NG feedings

• Prone position with caution can decrease of GERD. But not for sleeping bc of SIDS risk

Medications

• Zantac (ranitidine), Pepcid (famotidine), Proton pump inhibitors (-prazoles)

• take 30 mins before meals, acid suppression takes several days

Surgical management if severe - Nissen fundoplication- surgeon wraps the upper stomach around the lower esophagus to reinforce sphincter

hernias

protrusion of a organs through an abnormal opening.

Danger occurs when the protrusion is constricted, impairing circulation, or when the protrusion interferes with the function or development of other structures.

Big concern – incarcerated hernia cannot be reduced (pushed back into place). If the blood flow then gets cut off (strangulated hernia), this is a HUGE concern bc the tissue can die (NECROSIS!)

Umbilical hernia

• Common in infants.

• Organs protrude in the area where the umbilical vessels exit the abdominal wall.

• Usually responds spontaneously by 3-5 years of age. If persists beyond, usually surgically corrected.

• Reassure parents that the defect is not harmful, but NEVER try to flatten the protrusion

Inguinal hernia - inGROINal

• Most common childhood hernia, more common in girls

• Usually asymptomatic. can have painless inguinal swelling that disappears during periods of rest or is reducible by gentle compression or warm bath; it appears when crying, straining, coughing, standing for long time. In boys, contents can protrude into testes. Irritability, tenderness, weight loss, abdominal distension, and difficulty defecating

• tx- prompt, elective surgical repair. Post-op: keep the incision clean and dry, pain management, may cover with occlusive dressing if not toilet trained, change diapers promptly, no activity restrictions for infants or toddlers, older children no lifting, pushing, wrestling, bicycle riding or sports for 3 weeks.

Femoral hernia

• Rare in children.

• May manifest as recurrent hernia after inguinal hernia repair

• Sx- swelling in the groin (femoral region), severe abd pain and cramping.

• Tx- same as inguinal

anorectal malformations

Rectal atresia:

• atresia = a natural bodily passage or opening is missing ☹

• complete obstruction (unable to pass stool) and requires immediate surgical intervention.

Rectal stenosis:

• skinny rectal canal

• may not be apparent until later in infancy. Hx of difficult stooling, abdominal distention, and ribbon-like or pencil stools (rlly skinny to pass thru narrow anal canal)

Persistent cloaca:

• complex: rectum, vagina, and urethra opening drain into the common channel opening in the perineum.

Fistula:

• abnormal connection

• can be between rectum and the perineum or GU system.

• sx- Meconium in urine bc they get mixed up

Clinical Manifestations: abd distension, vomiting, absence of meconium passage within 48 hrs of life, meconium in urine. Assess for other congenital defects!

Therapeutic Management:

• Surgery, NPO, IV fluids.

• Some malformations may require colostomy- skin care, pain, IV fluids, antibiotics, wound care and colostomy care.

Discharge Planning:

• toilet training delayed (usually done ages 2-3), prevent constipation (fiber, fluids, activity, stool softeners)

omphalocele

Protrusion of intraabdominal viscera into an external sac covered with peritoneum

• Surgical repair ASAP

• Pre-op: protect sac from drying and trauma, keep moist with saline dressings, maintain thermoregulation, IV, antibiotics, NG, NPO.

• Post-op: vital signs, pain management, NG, IV fluids, monitor for return of bowel function.

gastroschisis

Protrusion of the intraabdominal contents through a defect in the abdominal wall - but there is no peritoneal sac covering the exposed bowel.

• Surgical repair ASAPPPP

Nursing Management:

Pre-op: keep bowels covered with bowel bag to prevent trauma and drying, maintain thermoregulation, monitor electrolyte status, IV, antibiotics, NG, NPO, observe exposed bowel for necrosis (turns black)

Post-op: vital signs, pain management, NG, IV fluids, monitor site for infection, monitor lower extremities for pulses and circulation (in case of vena cava compression by large bowel), monitor for return of bowel function. If bowels are too large, Silo pouch manually squeezes organs to fit back into stomach over 1 week.

Intussusception

Most common cause of intestinal obstruction. Occurs when a segment of the bowel telescopes into another segment, folding inward

• mostly in young kids

Clinical Manifestations: classic triad- abd pain (colicky pain, draws knees to chest), sausage-shaped abd mass, and red, jelly-looking/ currant stools (blood mixed with mucus).

Diagnosis: symptoms and ultrasound.

Therapeutic Management:

• Can spontaneously reduce (return to normal)

• Conservative treatment (radiology-guided gas enema), ultrasound-guided hydrostatic enema. We prefer US bc we’d like to reduce radiation

• IV fluids, nasogastric tube decompression, and antibiotics. If unsuccessful, requires surgical intervention

Nursing Management:

If surgical intervention needed: NPO, labs (CBC, UA), consent, pre-sedation meds, and monitor all stools-passage of formed brown stool indicates that the intussusception has reduced itself, notify MD to cancel surgery.

Post-op care: respiratory issues from post-op anesthesia. vital signs, wound assessment and dressing, assess for return of bowel sounds, monitor all stools.

appendicitis

Inflammation of the appendix, most common cause of emergency abd surgery in childhood

• Caused by obstruction of the appendix (from hardened fecal material), swollen lymph tissue after a viral infection, or rarely a parasite (pinworms). With obstruction, pressure on blood vessels can lead to peritonitis (fever, sudden relief of pain with perforation, progressive abd distention, tachycardia, shallow breathing, pallor, chills, irritability and small bowel ileus-notify MD).

Clinical Manifestations: fever, pain in RLQ (most intense pain at McBurney point), rigid abd, increased pain with movement, guarding, vomiting. If pain suddenly just stops, it means the appendix BURST! -> then they will have severe pain

Dx: symptoms, elevated WBCs (referred to as “shift to the left” -> indicates inflammatory process), elevated CRP, Ultrasound (imaging technique of choice) or CT.

Therapeutic Management: antibiotics and removal. If not ruptured- laparoscopic appendectomy. If ruptured appendix- IV fluids, IV antibiotics, NG suction, sometimes wound left open with drain.

Nursing Management:

• Avoid laxatives, enemas or heat to the abd (stimulates bowel motility and increases risk of perforation).

• Post-op care: IV fluids, NPO, NG tube to low intermittent suction, assess for return of bowel function, wound care, if left open-irrigation, pain management

congenital diaphragmatic hernia

Protrusion of abdominal organs through the opening in diaphragm.

Clinical Manifestations: respiratory distress at birth or within a few hours-tachypnea, dyspnea, cyanosis.

Diagnosis: symptoms confirmed by xray, often diagnosed prenatally

Therapeutic Management: treatment of respiratory distress, mechanical ventilation and GI decompression, oscillation (ventilator), sildenafil, or ECMO → external oxygenation! oxygenates the blood then pumps it into the body for severely damaged heart/ lungs.

Nursing Management:

Pre-op: monitor respiratory status (O2, mechanical vent), monitor cardiac status (inotropes), reduce stimulation, maintain NG, IV and O2, meds-sedatives, paralytics, inotropes, sildenafil- increases bloodflow

cleft lip & cleft palate

Facial malformations that occur during embryotic development.

Dx: apparent at birth, sometimes prenatally.

Therapeutic Management: surgical closure of the cleft(s), prevention of complications, and facilitation of normal growth and development.

Surgical Correction of Cleft Lip: typically occurs between 2-3 months of age, Naso-alveolar Molding may be used to bring segments closer together before repair.

Surgical Correction of Cleft Palate: typically occurs before 12 months of age to enhance normal speech development, may have multiple surgeries to get best aesthetic appearance.

Nursing Management:

Feeding-

CL interferes with feeding bc they can’t get a good lip seal, breast is best bc it’s soft, use wide nipple bottle

CP reduces the infant’s ability to suck. position infant in upright position with head supported by the caregiver’s hand or cradled in the arm (allows gravity to assist with the flow of liquid). Use special bottle & burp them a lot bc they suck in air

Pre-operative Care: parents taught syringe or special bottle feedings before surgery so infant gets accustomed to it

Post-operative Care: petroleum jelly to site for several days, elbow immobilizers to prevent infant from disturbing the site, syringe feeding for 7-10 days after repair, pain management, upright to feed, avoid suction or other objects in mouth (tongue depressors, thermometers, pacifiers, spoons, and straws), discharged on blenderized or soft foods.

Long Term Care: speech therapy, orthodontic appliances, good mouth care and proper brushing habits,, self esteem

esophageal atresia (EA) and Tracheoesophageal Fistula (TEF)

The esophagus fails to develop as a continuous passage and fails to separate from trachea as distinct structures. Normally they are separate (trachea= airway; esophagus= to stomach). HUGE aspiration risk

*risk = maternal polyhydramnios

Diagnostic Evaluation: based on clinical manifestations, suspected with polyhydramnios

Clinical Manifestations: excessively frothy/ foamy mucus from nose and mouth, three C’s (coughing, choking, cyanosis), apnea, increased respiratory distress during feeding, and abdominal distention.

Therapeutic Management:

• maintain patient airway, prevention of pneumonia, repair it!!!

• When suspected, infant is immediately made NPO and IV fluids are started. facilitate drainage of secretions & suction frequently

• Antibiotics

• Surgical correction.

• Watch for signs and symptoms of tracheomalacia – weaking of tracheal wall (cough, stridor-crowing, wheezing, cyanosis, apnea)

Nursing Care Management:

Post-op: radiant warmer or isolate, NG tube, parenteral nutrition, chest tube care if thoracotomy, caution if suctioning, G tube feedings may be initiated, careful observation of first oral feedings.

vomiting in pediatrics

Nurses must assess the amount and characteristics of the vomitus

Causes of bilious (green) vomiting: intestinal problem. (atresia, stenosis, intussusception, lesions, hernias, appendicitis)

Causes of nonbilious (non-green) vomiting: infectious, inflammatory, metabolic, endocrinologic, neurologic (IICP), psychologic causes (stress, anxiety), and obstructive pyloric stenosis

Can be a symptom associated with: infectious diseases, IICP, toxic ingestion, food intolerance and allergies, mechanical obstruction, metabolic disorders, and psychogenic disorders and stress.

Complications of vomiting: dehydration, hypovolemic shock, electrolyte imbalances (metabolic alkalosis bc vomiting acid), malnutrition, aspiration, and forceful vomiting can cause Mallory Weiss Syndrome (small tears in the esophagus) -> causes blood to obstruct airway!

Therapeutic Management: treatment of cause, and prevention of complications from loss of fluids.

• Anti-emetics: *Zofran (ondansetron), Reglan (metoclopramide), Phenergan (promethazine) -causes drowsiness, Dramamine (motion sickness)

Nursing Management:

• Encourage fluids, small/frequent meals, prevent aspiration, brush teeth or rinse mouth after vomiting to dilute hydrochloric acid, and monitor for fluid and electrolyte imbalances.

Coffee ground emesis = stomach acid mixed with blood*

diarrhea

Spread through contaminated food or water, or person to person contact.

Infectious causes of diarrhea:

• viral- Rotavirus

• bacterial- E coli, Salmonella, Shigella, Campylobacter, C Diff

Diagnosis: H & P, stool sample.

Complications: dehydration, metabolic acidosis (excreting bicarbonate), and hypovolemic shock.

Therapeutic Management: oral or IV rehydration, probiotics- reduces the stool frequency and duration of infectious diarrhea.

Prevention: Two Rotavirus vaccines, protect water supply from contamination and careful food preparation (Never thaw chicken on counter or eat uncooked meat) meticulous perianal hygiene to remove diarrhea from breaking down skin

Nursing Management: monitor for signs of dehydration, maintenance fluids, I & O, daily weights, examination of stools, meticulous skin care, avoid rectal temperatures bc it stimulates the bowel.

dehydration

Clinical Manifestations- *Poor perfusion= cold temp, gray skin, poor cap refill, poor turgor, dry mucous membranes, sunken eyes and fontanels, hypotension, rapid pulse and respirations, absence of tears, lethargy, mental status changes, decreased urinary output

Diagnosis: symptoms, blood draw to assess electrolyte levels.

Therapeutic Management:

Oral rehydration over 4-6 hours sometimes

• Mild dehydration- oral fluids 50ml/kg.

• Moderate dehydration- 100ml/kg.

• Child with diarrhea may be given 10ml/kg for each stool.

IV rehydration (parenteral) - fluid bolus of isotonic- 0.9% NSS & LR!

• 20ml/kg given bolus over 5-20 minutes and may repeat if needed

• Daily fluid maintenance calculation: 100 ml/kg for 1^st 10kg, 50 ml/kg for the next 10 kg, and 20 ml/kg each additional kg (ex- 22kg = 1540 ml for daily fluid maintenance)

Nursing Management:

Watch for s&s of dehydration.

Recognize conditions that precipitate it (diarrhea, vomiting, sweating, fever, DKA, renal disease, cardiac anomalies, certain drugs {Diuretics, Steroids}, and trauma)

Assess VS q 15-30 minutes (temperature instability, tachycardia, tachypnea, hypotension), poor capillary refill

Daily weight (same scale, same time each day). Weigh baby nude

*I & O- Intake- fluids or what becomes fluid consistency at room temp, IV fluids / meds, flushes. Output- urine, liquid stool, vomit, drains, tubes

Assess skin color (should be appropriate for ethnicity); mucous membranes (Should be pink and moist. If pale and dry= concerning). Assess for presence of thirst in older child.

constipation

Defined as a decrease in bowel movement frequency or trouble defecating for more than 2 weeks.

Therapeutic Management: diet, stool softeners, Polyethylene Glycol (MiraLax), enemas.

Nursing Management: assess history of bowel habits, diet, events associated with constipation (holding it in?), medications (esp opioids!), and consistency, color, frequency and other characteristics of stool, and increase fluid and fiber in diet.

Immobility + opioids = recipe for constipation. Can lead to fecal impaction