Monday, March 9, 2009

Pediatric Nursing: skin disorders/burns


Skin – Immune Disorders


Key Function of Skin

Protection – shield from internal injury.


Immunity – contains cells that ingest bacteria and other substances.


Thermoregulation – heat regulation through sweating, shivering, and
subcutaneous insulation


Communication / sensation / regeneration



Developmental Variances

Sweat glands function by the time the child is 3-years-old.


The visco-elastic property of the dermis becomes completely functional at
about 2 years.


The neonate’s dermis is thin and very hydrated, thus is at greater risk for
fluid loss and serves as an ineffective barrier.



Diagnostic Tests


Cultures


Scraping


Skin biopsy


Skin testing


Woods lamp



Neonatal skin lesions





Vascular birth marks: hemangioma


Port wine stain


Abnormal pigmentation: Mongolian spots


Neonatal acne: small red papules and pustules appear on face trunk.


Milia: white or yellow, 1-2mm papules appearing on cheeks, nose, chin, and
forehead



Inflammatory Skin Disorders





Diaper dermatitis


Contact dermatitis


Atopic dermatitis or eczema



Diaper Dermatitis


Diaper Dermatitis





Identify causative agent


Cleanse with mild cleaner


Apply barrier


Expose to air


Teach hazards of baby powder



Cradle Cap





Rash that occurs on the scalp.


It may cause scaling and redness of the scalp.


It may progress to other areas.



Treatment





If confined to the scalp


Wash area with mild baby shampoo and brush with a soft brush to help remove
the scales.


Do not apply baby oil or mineral oil to the area - this will only allow for
more build up of the scales.



Cradle Cap


Baby Care


Atopic dermatitis or Eczema





Chronic, relapsing inflammation of the dermis and epidermis characterized
by itching, edema, papules, erythema, excoriation, serous discharge and
crusting.


Patients have a heightened reaction to a variety of allergens.



Dermatitis


Dermatitis


Assessment





History of asthma, allergic rhinitis


Lesions generally occur in creases.


Management:





Control the itching: OTC Benadryl


Reduce inflammation: topical corticosteroids


Hydrate the skin


Elidel Cream


Preventing infection






Acne Vulgaris





A chronic, inflammatory process of the pilosebaceous follicles.


Occurrence; 85% of teenager aged 15 to 17 years.


More common in females than males.



Acne





Over activity of oil glands at the base of hair follicles


Hormone activity


Skin cell "plug" pores causing white heads and blackheads.


No "cure"



Acne


Management of Acne





Topical medications





OTC preparations


Prescription - Topical retinoid preparations


Prescription - Topical antibiotics




Systemic medication





Antibiotics


Hormonal therapy – birth control pills


Accutane * use with extreme caution when all else fails





Pediculosis





Head lice infestation ranges from 1% to 40% in children.


Most common in ages 5 to 12.


Less common in African American due to the shape of the hair shaft.


Transmission by direct contact with infected person, clothing, grooming
articles, bedding, or carpeting.



Pediculosis





Head lice


Pubic lice


Body lice



Signs and Symptoms





Symptoms: itching, whitish colored eggs at shaft of hair, redness at site
of itching.



Nits


Interventions






Anti-lice shampoo


Removal of nits


Washing bedding, towels, anything child’s head may have
come in contact with in hot soapy water.


Vacuum all floors and rugs


Do not need to fumigate the house


Child can return to school after 1 day of treatment






Scabies





A contagious skin condition caused by the human skin mite.


Tiny, eight-legged creature burrows within the skin and penetrate the
epidermis and lays eggs


Allergic reaction occurs


Severe itching



Assessment





Pruritus especially profound at night or nap time.


Lesions may be generalized but tend to distribute on the palms, soles and
axillae


In older children: finger webs, body creases, beltline and genitalia



Management





Permethrin cream is drug of choice


Massage into all skin surfaces – neck to soles of feet - leave on for 8 to
14 hours.


Clothing bedding and other contact items need to be washed in hot soapy
water.


Vacuum upholstered furniture - rugs



Scabies


Scabies


Impetigo





The most common skin infection in children.


Causative agent is carried in the nasal area.


Bacteria invade the superficial skin.



Causative agent





Group A beta-hemolytic streptococcal (GABHS)


Staph aureus



Impetigo


Spread





Highly contagious skin infection.


Most common among children.


Spread through physical contact.


Clothes, bedding, towels and other objects.



Interventions


Outcomes





Self-limiting


No scarring or pox marks post infection.


Super-infection especially in the neonate.



Impetigo / cellulitis


Cellulitis





A full-thickness skin infection involving dermis and underlying connective
tissue.


Any part of the body can be affected.


Cellulitis around the eyes is usually an extension of a sinus infection or
otitis media.



Assessment





History and physical exam


WBC count


Blood culture


Culturing organism from lesion aspiration.


CT scan with peri-orbital cellulitis






Clinical Manifestations





Characteristic reddened or lilac-colored, swollen skin that pits when
pressed with finger.


Borders are indistinct.


Warm to touch.


Superficial blistering.



Cellulitis


Cellulitis


Interventions





Hospitalization if large area involved or facial cellulitis.


IV antibiotics.


Tylenol for pain management.


Warm moist packs to area if ordered.


Assess for spread


If peri-orbital test for ocular movement and vision acuity



Poison Oak, Ivy and Sumac





Three potent antigens that characteristically produce an intense
dermatologic inflammatory reaction when contact is made between the skin and
the allergens contained in the plant.



Poison Ivy


Poison Oak


Interventions





Prevention:


Wear long pants when hiking or playing in the brush.


Wash with soap and water to remove sticky sap.


Cleanse under finger nails.


Sap on fur, clothing or shoes can last up to 1 week if not cleansed
properly.


Topical cortisone to lesions.



Systemic Response


Burns in Children





Young children who have been severely burned have a higher mortality rate
than adults.


Shorter exposure to chemicals or temperature can injure child sooner.


Increased risk for for fluid and heat loss due to larger body surface area.



Burns in Children





Burns involving more that 10% of TBSA require fluid resuscitation.


Infants and children are at increased risk for protein and calorie
deficiency due to decreased muscle mass and poor eating habits.


Scarring in more severe.



Burns in Children





Immature immune system can lead to increased risk of infection.


Delay in growth may follow extensive burns.






Management of Burns





Ascertain adequacy of airway, oxygen, intubation


Large bore needle to deliver sufficient fluids at a rapid rate.


Remove clothing and jewelry and examine.



Alert





The most common cause of unconsciousness in the flame burn patient is
hypoxia due to smoke inhalation.


Look for ash and soot around nares.



Management of Burns





Admission weight.


Nasogastric tube to maintain gastric decompression.


Foley catheter for urine specimen and monitor output.


Evaluate burn area and determine the extent and depth of injury.



Flame Burn


Management





NG tube in place.


Catheter for fluid replacement.


Ambulation to prevent problems


associated with immobilization



Percentage of Areas Affected


Depth of Burns


First Degree Burn





Involves only the epidermis and part of the underlying skin layers.


Area is hot, red, and painful, but without swelling or blistering.


Sunburn is usually a first-degree burn.



Second Degree Burn





Involves the epidermis and part of the underlying skin layers.


Pain is severe.


Area is pink or red or mottled.


Area is moist and seeping, swollen, with blisters.



Third Degree or Full-thickness





Involves injury to all layers of skin.


Destroys the nerve and blood vessels


No pain at first


Area may be white, yellow, black or cherry red.


Skin may appear dry and leathery.



Wound Management


Wound Management


Wound Management





Hydrotherapy is used to cleanse the wound. Gauze pads are used


To debride the wound by removing exudates and previous applied


Medication.



Skin Grafts


Compartment Syndrome


Burn Wound Covering


Therapy to Prevent Complications


Burns


Keep Kids Safe


Infants Immune System





No active immune response at birth


Passive immunity from mother


Potential for immune response is present / active response is lacking



Immune Response





IgG is received from mother trans-placental and in breast milk


6 to 9 months infants start to produce IgG


Immune system starts to assume defensive role


Active immunity begins after exposure to antigens



Neonatal Sepsis





Can be caused by bacterial, fugal, parasitic or viral pathogens.


Etiology: complex interaction of maternal-fetal colonization,
transplacental immunity and physical and cellular defenses of the fetus and
mother.



Sepsis





Laboratory confirmed blood stream infection






Neonatal sepsis





Mortality rate 50%


1 to 8 cases per 1000 live births


Meningitis occurs in 1/3



Major Risk Factors





Maternal prolonged rupture of membranes > 24 hours


Intra-partum maternal fever > 38C


Prematurity


Sustained fetal tachycardia > 160



Minor Risk Factors





Twin gestation


Premature infant


Low APGAR


Maternal Group B Streptococcus


Foul lochia



Etiology





Group B beta-hemolytic Streptococcus


Escherichia coli


Haemophilus Influenza



Diagnostic Tests





C-Reactive Protein * earliest indicator of infectious / inflammatory
process


CBC with differential



WBC



Blood Culture – rule out blood borne bacteria – sepsis (take 3 days for
final culture results)


Lumbar Puncture – rule out meningitis


Urine Culture – rule out UTI



Clinical Manifestations





Respiratory distress





Tachypnea / apnea / hypoxia



Temperature instability





> 99.6 (37 C) or < 97 (36 C)



Gastrointestinal symptoms





Vomiting, diarrhea, poor feeding



Decreased activity: lethargic / not eating




Blood Test



C-Reactive Protein





Protein appears within 6 hours or exposure


Blood culture to identify causative agent




Medical Management





Ampicillin


Gentamicin


Cefotaxime


Acyclovir: herpes



Nursing Interventions





Administer IV antibiotics


Monitor therapeutic levels


Monitor VS, temperature, O2 saturation


Activity level


Sucking


Infant parent bonding



Outcomes





Newborn will achieve normalization of body function


Parents will participate in care


Newborn will demonstrate no signs of CV, neurological or respiratory
compromise


Newborn will experience no hearing loss as a result of antibiotic therapy



SCIDS





Severe Combined Immunodeficiency Disease


Hereditary disease


Absence of both humoral and cell mediated immunity



Clinical Manifestations





Susceptibility to infection


Frequent infection


Failure of infection to respond to antibiotic treatment



Treatment





Manage infection


Bone marrow transplant



Acquired Immunodeficiency Syndrome / AIDS



Human immunodeficiency virus type 1


is a retro virus that attacks the immune


system by destroying T lymphocytes.



AIDS





T lymphocytes are critical to fighting infection and developing immunity.


HIV renders the immune system useless and the child is unable to fight
infection.



Killer T-cells


Blood Testing in Infants





Babies born to HIV-positive mothers initially test positive for HIV
antibodies.


Only 13 to 39% of these infants are actually infected.


Infants who are not infected with HIV may remain positive until they are
about 18- months-old.



Treating Infants in Utero





Routinely offer HIV testing to all pregnant women.


Administration of zidovudine (AZT) can decrease the likelihood of perinatal
transmission from 25% to 8%.




Modes of Transmission





Three chief modes of transmission:





Sexual contact (both homosexual and heterosexual).


Exposure to needles or other sharp instruments contaminated with blood or
bloody body fluids.


Mother-to-infant transmission before or around the time of birth.






Symptoms in Children





An infant who is HIV positive will generally exhibit symptoms between 9
months to 3 years.


Failure to thrive


Pneumonia, chronic diarrhea, opportunistic infections


Encephalopathy: leading to developmental delay, or loss of previously
obtained milestones.



Interdisciplinary Interventions





Maternal treatment during pregnancy.


Newborn receives zidovudine for 6 weeks after birth.


Prophylaxis with Septra or Bactrim when CD4 level starts to drop.



Interventions





Age-appropriate immunizations except those containing live attenuated
viruses. Can be given when T-Cell count is adequate





Chicken pox - Varicella


MMR – measles, mumps, rubella




Community Interventions





Education and prevention are the best ways to manage AIDS.


Safe sexual practices


Monogamous relationship


Avoidance of substances such as alcohol and drugs that can cloud judgment.



Changes in HIV





Number of infected newborns has dropped due to treatment of HIV infected
mothers.


HIV has become a chronic disease in children


Team approach


Emphasis on community teaching


Pediatric nursing: Orthopedic Disorders


Orthopedic Disorders


Alterations in Musculoskeletal Status


Musculoskeletal Differences in Children





Epiphyseal growth plate present


Bones are growing / heal faster


Bones are more pliable


Periosteum thicker and more active


Abundant blood supply to the bone


The younger the child the faster the healing.



Focused Physical Assessment





Inspect child undressed


Observe child walking


Spinal alignment


ROM


Muscle strength


Reflexes



Assessment





Concerns:


Pain or tenderness


Muscle spasm


Masses


Soft tissue swelling



CoREminder





If an injury has occurred, examine that area last and be gentle when
palpating the injury site



Nursing Alert





A child younger than 1 year who presents with a fracture should be
evaluated for possible physical abuse or an underlying musculoskeletal
disorder that would cause spontaneous bone injury.



Neurovascular Assessment





Pain


Where is it?


Is it reduced by narcotics?


Does the pain become worse when fingers or toes are flexed?



Neurovascular Assessment





Sensation


Can the child feel touch on the affected extremity


Motion


Can the child move fingers or toes below area of injury / nerve injury


Temperature


Is the extremity warm or cool to touch



Neurovascular Assessment





Capillary refill


Sluggish capillary refill may signals poor circulation


Color


Note color of extremity and compare with unaffected limb


Pulses


Assess distal to injury or cast



Neurovascular Impairment





Restriction of circulation and nerve function from injury or immobilizing
device.



Clinical Manifestations





Increased pain


Edema


Decreased movement or sensation


Diminished or absent pulses distal to injury


Patient often described as restless – pain medication do not work – pain
described as deep



Interventions





Assess area distal to injury, cast, splint, traction for adequate
circulation


Release pressure by splitting the cast or loosening restrictive bandage.


Notify physician



Compartment Syndrome





Pain is the hallmark sign, pain out of proportion to the normal clinical
course.


Must be diagnosed immediately or irreversible neurovascular, muscular,
vascular damage occurs that can lead to renal failure and death.



Clinical Manifestations





A combination of signs and symptoms characterize compartment syndrome. The
classic sign of acute compartment syndrome is pain, especially when the muscle
is stretched.


There may also be a tingling or burning sensation (paresthesias) in the
muscle.


A child may report that the foot / hand is "a sleep"


If the area becomes numb or paralysis sets in, cell death has begun and
efforts to lower the pressure in the compartment may not be successful in
restoring function.






Physical Assessment



Frequent pain assessment


If pain med does not work something is wrong


The muscle may feel tight or full.


Measure the affected muscle group and compare with the unaffected side


Pulses below area of injury







Treatment





Prevention



Don’t elevate the affected limb above or below the level of the heart.


Dressings should be removed if CS is suspected.


Casts should be bi-valved in high risk situations.



Assessment





Don’t forget the five P’s


Pain


Paresthesia


Passive stretch


Pressure


Pulse-less-ness



Surgical Management


Nerve Assessment





Important to due on admission from ER or to the unit


Repeat after cast, traction, or surgery done on the extremity



Radius and ulna nerve assessment


Ulnar Nerve Injury


Medial Nerve Injury


Radial Nerve Injury


Peroneal Nerve Distribution


Treatment Modalities





Goals of fracture care:


To regain alignment and length of the bony fragments


To retain alignment and length


To restore function of the injured part



Traction





Realign bone fragments


Provide rest


Prevent or improve deformity


Pre or post operative positioning


Reduce muscle spasm


immobilization



Fractures


Fractures


Salter Fracture I and II


Salter Fracture III, IV and V


Salter-Harris Classification


Bucks Traction


Principles of Traction





Counter traction with weights


Make sure all ropes and pulleys are aligned and weights are hanging freely


Do not remove weights unless instructed to do so


Traction must be applied at all times



Bryants Traction


Bryants Traction





Used for child under 3 yrs


Hip dysplasia / fractured femur


Buttocks do not rest on mattress


Assess neurovascular and restriction by ace bandages – compartment syndrome



Skeletal Traction


External Fixator


External Fixation


External Fixator


Pin Care





Provide pin care as ordered. Cleanse area around pin with normal saline or
half-strength hydrogen peroxide.


Have parent / caretaker demonstrate pin care before discharge



External Fixator


External Fixator


Plates and Pins


Post-operative Care





Assess color, sensation, cap refill, movement, pain, and pulses


Circle any drainage noted on cast or dressing.


Pain control


Edema = ice to area


Pulmonary function = C&DB



Pulmonary Embolism





A complication of a fractured leg is a pulmonary embolism. Fat escapes the
marrow when the bone is fractured and can travel through the blood stream and
become lodged in small vessels like the arterioles and capillaries of the
lung.


Primary symptom is shortness of breath and chest pain.



Interventions





Place patient in high fowlers


Administer oxygen


Call MD


Chest x-ray


Outcomes are better for a health person; poorer for person with
pre-existing lung problems.



Orthopedic Disorders





Congenital


Acquired / trauma


Infectious



Tales Equinovarus


Tales Equinovarus





Club Foot


1 to 2 per 1000


Males more affected


Involves both the bony structures and soft tissue.


The entire foot is pointing downward.



Interventions



Manipulation and serial casting immediately


Surgery is performed between 4 to 12 months if full correction is not
achieved with casting



Nursing Diagnosis





Impaired physical mobility related to cast wear


Altered parenting related to emotional reaction following birth of child
with physical defect


Risk for impaired skin integrity related to cast wear.


Knowledge deficit: cast care and home care



Metatarsus Adductus





Most common foot deformity


2 per 1000


Result of intrauterine positioning


Forefoot is abducted and in varus, giving the foot a kidney bean shape.



Metatarsus Adductus


Dysplasia of the Hip





Abnormality in the development of the proximal femur, acetabulum, or both.


Girls affected 6:1


Familial history


Breech presentation


Maternal hormones


Other ortho anomalies



Clinical Manifestations





Head of femur lies outside the acetabulum


+ Ortolani maneuver


Asymmetrical lower extremity skin folds


Discrepancy in limb length



Asymmetry of skin fold


Hip Exam


Interventions





Maintain hips in flexed position


Traction to stretch muscles


Pavlik harness


Hip surgery



Pavlik Harness


Nursing Diagnosis





Knowledge deficit regarding care of harness or cast


Impaired physical mobility


Risk for impaired skin integrity related to pressure from casts or braces


Altered skin perfusion due to casts or braces


Risk for altered growth and development due to limited mobility



Harness


Osteogenesis Imperfecta


Osteogenesis Imperfecta





Genetic disorder


Caused by a genetic defect that affects the body’s production of collagen


Collagen is the major protein of the body’s connective tissue


Less than normal or poor collagen leads to weak bones that fracture easy



Osteogenesis Imperfecta





Often called "brittle bone disease"


Characteristics





Demineralization, cortical thinning


Multiple fractures with pseudoarthrosis


Exuberant callus formation


Blue sclera


Wide sutures


Pre-senile deafness




Genetic Defect





Type I: autosomal dominant: age at presentation 2 – 6 years.


Common age for child abuse.


Often present as suspected child abuse



3-month-old with OI


Type II



Autosomal Recessive


Pre- or perinatal death


Pulmonary hypoplasia



Fetus with severe OI


New Born with OI


Nursing Diagnosis





Risk of injury related to disease process


Risk for altered growth and development


Knowledge deficit: disease process and care of child



CaReminder





Signs of a fracture, especially in an infant, are important items to teach
caregivers. In a baby, these signs are general symptoms, such as fever,
irritability, and refusal to eat.


Bowden, 1998



Cerebral Palsy





Group of disorders of movement and posture





Prenatal causes = 44%



Labor and delivery = 19%


Perinatal = 8%


Childhood = 5%




Cerebral Palsy


Assessment





Developmental surveillance is key


Diagnoses often made when child is 6 to 12 months of age


Physical exam:





Range of motion


Evaluation of muscle strength and tone


Presence of abnormal movement or contractures




caReminder





Reflexes that persist beyond the expected age of disappearance (e.g., tonic
neck reflex) or absence of expected reflexes are highly suggestive of CP.


Bowden, 1998



Clinical Manifestations





Hypotonia or Hypertonia


Contractures


Scoliosis


Seizures


Mental Retardation


Visual, learning and hearing disorders


Osteoporosis – long term due to lack of movement



Team Management


Legg-Calve-Perthes





Self-limiting disease


Femoral head loses blood supply


Four times more common in males


Peak age 4 to 7 years



Clinical Manifestations





Pain


Limping


Limited hip motion especially internal rotation and abduction is classic
sign



Management





Goal of care is to: Keep femoral head in the hip joint





Traction


Anti-inflammatory


Physical therapy




Osgood-Schlatters


Assessment





Tip: Asking the child to squat or extend his or her knee against resistance
usually elicits pain and is a good indicator of Osgood-Schlatter Disease.



Osgood-Schlatters





Due to repetitive motion


Affects children 10 to 14 years old


Males 3:1


Diagnosis is based on clinical signs and symptoms





Pain, heat, tenderness, and local swelling




Management


Slipped Capital Femoral Epiphysis





Top of femur slips through growth plate in a posterior direction.


Ages 10 to 14 in girls


Ages 10 to 16 in boys


High proportion are obese



Clinical Manifestations





Pain in groin


Limp


Limited abduction


Leg may be shorter



Clinical Manifestations


Management





Surgery


Crutch walking



Scoliosis


Clinical Manifestations





Pain is not a normal finding


for idiopathic scoliosis


Often present with uneven hemline


Unequal scapula


Unequal hips



Screening


Screening


Mild Scoliosis


Severe Scoliosis


Assessment





Alert: If pain is a reported symptom of the child’s scoliosis, it should be
investigated immediately. Pain is not a normal finding for idiopathic
scoliosis, and the presence of this symptom could be signaling an underlying
condition such as tumor of the spinal cord.



Bracing


Moderate Scoliosis


Scoliosis


Post-operative Care





Pain management


Chest tube in many cases


Turn, cough, and deep breath


Log-roll



Nursing Diagnoses





Body image disturbance related to bracing


Risk of injury related to brace


Impaired physical mobility related to brace wear


Risk for non-compliance with treatment regimen



Inflammatory Process





Osteomyelitis


Septic arthritis


Juvenile arthritis



Osteomyelitis


Osteomyelitis





Infection of bone and tissue around bone.


Requires immediate treatment


Can cause massive bone destruction and life-threatening sepsis



Pathogenesis of Acute Osteo


Osteomyelitis


Clinical Manifestation





Localized pain


Decreased movement of area


With spread of infection





Redness


Swelling


Warm to touch




Diagnostic Tests:





X-ray


CBC


ESR / erythrocyte sedimentation rate


C-reactive protein


Bone scan – most definitive test for osteomyelitis



X-Ray


Osteomyelitis


Management





Culture of the blood


Aspiration at site of infection


Intravenous antibiotics x 4 weeks


PO antibiotics if ESR rate going down


Monitor ESR





Decrease in levels indicates improvement




Goals of Care





To maintain integrity of infected joint / joints



Septic Arthritis





Infection within a joint or synovial membrane


Infection transmitted by:





Bloodstream


Penetrating wound


Foreign body in joint




Septic Arthritis of Hip





Difficulty walking and fever


Diagnosis: x-ray, aspirate fluid from joint, ESR



Septic Hip


Diagnostic Tests





Erythrocyte Sedimentation Rate





ESR


Used as a gauge for determining the progress of an inflammatory disease.


Rises within 24 hours after onset of symptoms.


Men: 0 - 15 mm./hr


Women: 0 – 20 mm./hr


Children: 0 – 10 mm./hr





C-Reactive Protein





During the course of an inflammatory process an abnormal specific protein,
CRP, appears in the blood.


The presence of the protein can be detected within 6 hours of triggering
stimulus.


More sensitive than ESR / more expensive



Joint Space Fluid


Management





Administration of antibiotics for 4 to 6 weeks.


Oral antibiotics have been found to be effective if serum bactericidal
levels are adequate.


Fever control


Ibuprofen for anti-inflammatory effect



Goals of Care





Maintain integrity of affected joint



Juvenile Rheumatoid Arthritis





Chronic inflammatory condition of the joints and surrounding tissues.


Often triggered by a viral illness


1 in 1000 children will develop JRA


Higher incidence in girls



Clinical Manifestations





Swelling or effusion of one or more joints


Limited ROM


Warmth


Tenderness


Pain with movement



Diagnostic Evaluation





Elevated ESR / erythrocyte sedimentation rate


+ genetic marker / HLA b27


+ RF 9 antinuclear antibodies


Bone scan


MRI


Arthroscopic exam



Goals of Therapy





To prevent deformities


To keep discomfort to a minimum


To preserve ability to do ADL



Management





ASA


NASAIDS around the clock


Immunosuppressive drugs: azulvadine


Enbrel: new class of drugs to treat JRA





Attacks a specific aspect of the immune response




ASA Therapy





Alert: The use of aspirin has been highly associated with the development
of Reye’s syndrome in children who have had chickenpox or flu. Because aspirin
may be an an ongoing p art of the regimen of the arthritic child, parents
should be warned of the relationship between viral illnesses an aspirin, and
be taught the symptoms of Reye’s syndrome.



Management





Physical therapy


Exercise program


Monitor ESR levels


Regular eye exams: Iriditis





Iriditis





Intraocular inflammation of iris and ciliary body


2% to 21% in children with arthritis


Highest incidence in children with multi joint involvement disease.





Iriditis

Pediatric nursing: Gastrointestinal disorders


Gastrointestinal Disorders


Embryonic Development





Failure to fuse = cleft lip and palate


Failure to differentiate = duodenal stenosis


Atresia or abnormal closing of structure:



Esophogeal atresia


Anal-rectal malformation


Biliary atresia




Fetal Development





Fistula is an abnormal connection


Tracheal esophageal fistula


Anal-rectal malformations with fistula


Incomplete or abnormal placement


Mal-rotation


Diaphragmatic hernia



Prenatal History





Birth weight


Prematurity


History of maternal infection


Polyhydramnios


Down Syndrome



Health History





Congenital anomalies


Growth or feeding problems


Travel


Economic status


Food preparation


General hygiene


Family history of allergies



Present Illness





Onset and duration of symptoms


Weight loss or gain


Recent changes in diet



Vomiting





Reflexive = infection or allergy


Central = central nervous system





head trauma


meningitis


CNS tumor






Nursing Assessment





Abdominal distention


Abdominal circumference


Abdominal pain


Acute / diffuse / localized


Abdominal assessment


Inspect / auscultation / palpation / measure



Measuring Abdominal Girth


Diagnostic Tests





Flat plate of abdomen



Fluid


Gas


Structural changes



Barium swallow or UGI



Strictures


Foreign body


Motility disorder





Diagnostic Tests





Ultrasound



Visualize organs


Cysts


Abscess


appendicitis



CT scan = tumors, abscess, obstruction


24 hour probe = Gastro esophogeal reflux


Biopsy of liver, esophagus, stomach, intestine





Stool and Blood





White blood cells


Ova and Parasite


Bacterial cultures


Blood





Failure to Thrive





Inadequate growth resulting from inability


to obtain or use calories required for


growth.





FTT





Organic



Physical cause identified: heart defect, GER, renal insufficiency,
malabsorption, endocrine disease, cystic fibrosis, AIDS.



Non-organic



Inadequate intake of calories


Disturbed mother-infant bonding



Idiopathic: unexplained



Cleft Lip and Palate





Most common craniofacial anomaly


1 in 700 births


Males 3 to 1


Higher in Asians


Familial history


Often diagnosed in utero by ultrasound



Cleft Lip





Incomplete fusion of the primitive oral cavity


Obvious at birth


Infant may have problems with sucking


Surgery in 2 to 3 months


Goals of surgery


Close the defect


Symmetrical appearance of face



Post Surgery Care





Airway management


Pain control


Position in infant seat – upright position


Elbow restraints


Wound care as ordered by MD


Minimizing crying


Feeding techniques



Cleft Palate





Cleft palate occurs when the palatine plates fail to migrate and fuse
between the 7th and 12th week of gestation.


Diagnosed by looking into infants mouth.



Cleft Palate Repair



Babies should be weaned from bottle or breast prior to the surgical
procedure.


Done around 1 year of age after teeth have erupted and before the child is
talking to promote better speech outcomes


Poor speech outcomes if done after 3 years of age.



Palate Repair





Pre-surgery feeding


Alternate nipple design


Breast feeding consultant


ESSR





Enlarge / stimulate / swallow / rest





Post Surgery Repair





Position on side


NPO for 48 hours


Suction with bulb syringe only


Avoid injury to palate with syringes, straws, cups etc.



Long Term Referrals





Hearing


Speech


Dental


Psychological


Team approach to care



Esophageal Atresia





Esophagus ends in a blind pouch.


Infant has a lot of mucous at birth.


The rationale for giving sterile water for the first feed.



E.A. Tracheo- esophageal Fistula


Clinical Manifestations





Excessive drooling / frothy mucus


Inability to pass NG tube


Choking and cyanosis with feeding


High risk for aspiration of HCL from stomach causing a chemical pneumonia.



X-ray Findings


Pre-surgery Care





NPO


Up in infant seat or HOB elevated


Continuous suction


G-tube to decompress stomach



Post Operative Care





Respiratory support


Gastric decompression


Chest Tube


Gentle suctioning


TPN until taking PO’s


Antibiotics




Long Term Complications





5 to 15% experience leaking at operative site.


Aspiration


Dysphagia / difficulty swallowing


Stricture of esophagus


Coughing


Regurgitation



Pyloric Stenosis





Most common cause of gastric outlet obstruction in infants.


1 in 500


More common in males


3 weeks to 2 months of age


History of regurgitation and non-bilious vomiting shortly after feeding.


Vomiting becomes projectile



Pyloric Stenosis : Clinical Manifestations





Projectile vomiting


Visible peristaltic waves


Olive shape mass in the upper abdomen to right of the midline


Electrolyte imbalance



Management Pre-surgery





NPO / document any emesis


IV therapy / Correct electrolyte imbalance


Comfort infant and caretakers



Feeding Post-operatively





Give 10 ml oral electrolyte solution after recovered from anesthesia


Start pyloric re-feeding protocol.


Increase feeding volumes from clear fluids to dilute to full-strength
formula.


Keep feeding record


Assess for vomiting


Discharged when taking full-strength formula



Hernias





A hernia is a protrusion of an organ or


part of an organ through the wall of the


cavity in which it is containe



Inguinal Hernia





Inguinal hernia is the most common congenital anomaly requiring surgical
repair in infants: 80%


It is a protrusion of peritoneal sac into the processus vaginalis


Most common in males and pre-term infants.



Hydrocele





Caused by peritoneal fluid communication with the scrotal area through a
patent processus vaginalis.


Often will resolve on its own unless associated with an inguinal hernia.



Umbilical Hernia


Diaphragmatic Hernia





Congenital diaphragmatic hernia is the protrusion of abdominal contents
into the chest cavity through a defect in the diaphragm.


1 in 5,000 births


Mortality rate is 40 to 50%



Diaphragmatic Hernia:Clinical Manifestations





Chest appears barrel-like


Abdomen is sunken


Bowel sounds in chest


Breath sound decreased


Severe respiratory distress



Treatment





ECMO


Ventilator support


Chest tube


Umbilical artery catheter


NG tube


Surgical correction when stable



Long Term Problems





Gastro Esophogeal Reflux


Respiratory infections


Obstructions



Abdominal Defects





Omphalocele



Gastroschisis



Omphalocele





Congenital malformation in which abdominal contents protrude into the base
of the umbilical cord.



Gastroschisis





Defect in the abdominal wall that allows the abdominal contents to protrude
outside the body.


There is no covering over the bowel or contents.


Defect does not involve the umbilicus.



Gastroschisis


Immediate Nursing Intervention:





Cover with warm normal saline dressing in the delivery room.


New standard: put child in small bag to retain heat and keep intestines
warm.



Gastroschisis Repair





If a small defect can be repaired with one surgery.


I abnormality is large surgeon may use Silastic Silo to gradually return
the bowel to the abdominal cavity.



Silastic Silo


Treatment



Long term complications:


Obstruction


Weak abdominal wall



Prune Belly


Intussusception



Clinical Manifestation





Child appears with intermittent pain which is colicky, severe


Child will often draw legs up


Episodes occur 2-3 times / hour


Vomiting is prominent feature – bile stained vomiting a late sign


Bowel movements – bloody / mucous


Classic current jelly stool is a late sign



Management





Reduce the obstruction before the bowel becomes necrotic.


Contrast Enema is diagnostic in 95% of cases and therapeutic curative in
most cases.


Surgical reduction is radiologic reduction is not achieved.



Surgical Intervention





IV fluids + antibiotics pre-operatively.


Manual reduction is attempted.


If bowel perforation is noted during operative procedure a temporary
colostomy may be needed.



Hirschsprung Disease


Definition





Lack of ganglion cells in colon prevents


bowel from transmitting peristaltic


waves needed to move fecal material.





Clinical Manifestations





No meconium in the first 24 hours.


History of constipation or fecal mass.


Distended abdomen.



Diagnosis and Treatment





Rectal biopsy


Removal of the aganglionic portion of the colon.


1st stage surgery is often a colostomy


2nd stage is pull-through surgery to connect the working colon
to a point near the anus





Long Term Complications





Anal stricture


Incontinence of stool


Short bowel syndrome



Appendicitis


Pathophysiology





Inflammation of the vermiform appendix.


Obstruction at base blocks outflow of mucus.


Pressure builds up


Blood vessels are compressed.


Perforation and rupture



Clinical Manifestations





Abdominal pain


Generalized to localized


Mc Burney’s point


Rebound tenderness


Loss of appetite


Vomiting


Low grade fever



Appendectomy


Ruptured Appendix


Perforation





Alert: With perforation of appendix, abdominal pain is suddenly
relieved, but as peritonitis develops, it returns, along with signs of
generalized acute abdomen.


Child will guard area of pain


Abdominal distension


High fever


May appear dehydrated



Interventions for Perforation





Extra fluids may be needed – a bolus of normal saline


NG may be inserted to decompress the stomach


IV antibiotics prior to surgical procedure


Fever control



Post Operative Care


Nursing Interventions





Monitor I & O


Assess for bowel sounds


Dressing change as ordered


Ambulate ! Ambulate ! Ambulate !


Cough and deep breath


Pain Management



Inflammatory Bowel Disease





A virus or bacteria interacts with the body’s immune system to trigger an
inflammatory reaction in the intestinal wall.



Inflammatory Bowel Disease





Refers to two chronic diseases that cause inflammation of the intestines.


Ulcerative Colitis


Crohn’s Disease



Causes





Most likely a genetic link that affects the immune system.



Ulcerative Colitis





Inflammatory disease of the large intestine. The inner lining or mucosa
becomes inflamed, swells and ulcers develop.


Affects the lining of the bowel.


Most severe in the rectal area and anus.



Crohn’s Disease





Differs from ulcerative colitis in the areas of the bowel affected.


Most often affects the small intestine and parts of the large intestine.


Inflammation that extends deeper into the layers of the intestinal wall
than ulcerative colitis.



Clinical Manifestations





Diarrhea


Rectal bleeding


Abdominal pain


Weight loss


Anemia



Diagnostic Tests





Erythrocyte sedimentation rate ESR


Stool for gross or occult blood


Colonoscopy evaluation and biopsy


Genetic marker / family history



Drug Therapy





Corticosteroids during acute phase


Mesalazine – anti-inflammatory drug for mild to moderate cases.


Immunosuppression drugs: Azathioprine, methotrexate, 6-mercaptopurine


Remicade has been approved in severe cases



Long Term





Surgical removal of bowel if not managed by medical management.


Complications:


Alteration in body image due to steroids


Arthritis


Osteoporosis


Increase risk of colorectal cancer



Gastro-esophageal Reflux


GER





Common condition involving regurgitation, or "spitting-up" which is the
passive return of gastric contents retrograde into the esophagus.


Peaks between one to four months.


Usually resolved by 12 months.



Clinical Manifestations GEF





Regurgitation of formula after feeding


No weight loss



Conservative Management GER





Positioning: upright, semiprone after feeding to promote gravity resistance
to reflux


Dietary: thicken feedings


Feeding modifications: small feedings with frequent burping to decrease
gastric distention



GERD: Gastro-esophageal Reflux Disease





Infant older than 6 months, infant / child with congenital or neurological
problems.


GER not relieved by simple measures.


Clinical Manifestations:


Regurgitation of feedings with slow growth / poor weight gain


Esophagitis = excessive crying


Apnea / Respiratory problems


Anemia



Diagnostic Work-up for GERD





Upper GI series


Esophageal pH monitoring


Endoscopic exam



Pharmacologic Therapy







Medications to reduce symptoms including antacids or histamine-2 blocking
agents


Histamine 2 blocker: cimetadine


Reglan or metaclopramide to enhance gastric emptying



Surgical Management: GERD


Necrotizing Enterocolitis





Necrotizing = damage and death of cells


Entero = refers to intestines


Colitis = inflammation of the colon



NEC





60 to 80% are premature infants


Feeding of concentrated formulas


Infants who have received blood transfusion


Infants with GI infections


Infants with polycythemia: congenital heart disease



Clinical Manifestations





History of formula feeding


Feedings stay in stomach


Abdominal distention / shiny abdomen


Bile-green fluid in stomach


Bloody bowel movements



Management





NPO


Nasogastric tube to decompress gas


IV fluid replacement


Antibiotics


Extra oxygen


Abdominal x-rays to monitor progress


Measure abdominal girth every four hours





Complications





Intestinal perforation


Surgery to remove dead bowel


Colostomy or ileostomy


Bowel is reconnected when infection and inflammation have resolved



Celiac Disease





Malabsorption caused by a permanent intolerance to dietary gluten.


1 in 3000 in USA


1 in 300 in European countries


Genetic predisposition



Celiac Disease: Assessment





FTT after gluten products introduced into diet


Chronic diarrhea


Foul smelling, greasy stools


Abdominal distention


Anemia


Muscle wasting



Management





Gluten free diet


Limit the intake of wheat, barley, rye containing foods



Dietary Restrictions


Lactose Intolerance





Inability to digest significant amounts of lactose.


Lactose that is not broken down can cause abdominal distention and
bloating.


Lactose tablets to help breakdown lactose containing foods.