Nancy Pares, RN, MSN Metro Community College

Nancy Pares, RN, MSN Metro Community College
NURS Unit 6 and 7 Nancy Pares, RN, MSN Metro Community College

Objective 1 Identify pathophysiology and nursing process of selected sensory/neurological system alterations inclusive of: Visual, hearing, retinoblastoma (covered in onco unit), hydrocephalus, cerebral palsy, spina bifida, muscular dystrophies, spinal cord injuries and systemic lupus

Disorders of Eye Visual disorders Myopia Astigmatism Strabismus
Amblyopia

Disorders of Eye Visual disorders Cataracts Glaucoma Retinoblastoma
Color blindness Retinopathy of prematurity (ROP)

Disorders of Ear Otitis media Otitis externa Hearing impairment

Figure Of the three anatomic differences in the eustachian tube between adults and small children (shorter, wider, more horizontal), which do you think could cause more problems for the child and why? Answer: More horizontal. Small children who are bottle fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks and the horizontal angle provides easy access to the middle ear. In older children the greater angle helps keep foreign substances and germs away from the middle ear.

Disorders of Nose and Throat
Epistaxis Nasopharyngitis Sinusitis Pharyngitis Tonsillitis

Vision Screening 20/20 by age 6 or 7 (visual acuity)
Screening starts at well-child exams when cooperative (screening timing and frequency)

Hearing Screening Infant in hospital Observation for cues to hearing
Screening timing and frequency Many states mandate Observation for cues to hearing Clinical manifestations

Risk Factors Chronic ear infections Chronic fluid/effusion
Follow-up needed for hearing deficit

Abnormalities of Eyes Conjunctivitis Periorbital cellulitis Bacterial
Antibiotic eye drops Viral and allergic Supportive care Periorbital cellulitis Oral or intravenous antibiotics

Abnormalities of Eyes Other disorders
Multiple types of treatments based on etiology Occlusion therapy Compensatory lenses Surgery Vision therapy Refer to eye specialist

Abnormalities of Ears Otitis media Antibiotic usage Supportive care

Figure Acute otitis media is characterized by abrupt onset, pain, middle ear effusion, and inflammation. Note the injected vessels and altered shape of cone of light. See Chapter 7for a normal tympanic membrane. Source: Courtesy of Kevin Kavanagh, MD, FACS.

Figure Otitis media with effusion is noted on otoscopy by fluid line or air bubbles. Pneumatic otoscopy or tympanometry shows a nonmobile tympanic membrane. Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles. Where would you expect to see the light reflex? (See Chapter 7 for a description of normal findings.) Source: Courtesy of Kevin Kavanagh, MD, FACS.

Abnormalities of Ears Recurrent otitis media or effusion
ENT referral for possible tympanostomy tube placement Otitis externa Antibiotic ear drops

Abnormalities of Ears Hearing loss Sensorineural Cochlear implant

Box 24-7 (continued) Cochlear Implants

Abnormalities of Nose and Throat
Collaborative care includes antibiotics if bacterial in etiology Nasopharyngitis Pharyngitis Tonsillitis Tonsillectomy Criteria for surgery Sinusitis

Eye Abnormalities Primary intervention is prevention
ROP interventions and prevention strategies Protective eyewear

Ear Abnormalities Prevention focus Decrease otitis media
Increase access to care Increase frequency of hearing screens Reduce noise-induced hearing loss

Nose, Throat, and Mouth Abnormalities
Prevention measures Education to prevent communicable diseases Home care for common communicable diseases Injury prevention Dental emergencies Tooth avulsion

Nursing Management of Systemic Lupus Erythematosus
Avoid triggers Long-term planning for chronic illness Maintain fluid balance Promote adequate and appropriate nutrition

Nursing Management of Systemic Lupus Erythematosus
Promote skin integrity Promote rest and comfort Emotional support Community activities and support groups

Collaborate with Family of a Child with Human Immunodeficiency Virus (HIV)
Plan care Age and developmentally appropriate Medication regimen Education on importance of regimen Education on side effects Promotion of general health Avoid infectious individuals

Collaborate with Family of a Child with Human Immunodeficiency Virus (HIV)
Promotion of growth and development Proper food Proper atmosphere, toys, friends Emotional support Caregiver Child Support groups

Latex Allergy Increasingly common Children at risk for allergy
Testing for latex allergy Latex allergy questionnaire

Nursing Care for Child with Latex Allergy
Alternative products Medical-alert ID bracelet Epinephrine kit at home and school Education of caregivers related to hypersensitivity reactions Preparation to provide care

Hypersensitivity Reactions in Children
Type I Definition Type II Type III Type IV

Nursing Management History Assessment Type I and Type II carry EpiPen

Neurological Anatomic Differences in Children
Cranial bones are not completely ossified Allows for brain growth The posterior fontanel closes at 3-4 months The anterior fontanel closes at 18 months Increases risk for brain and spinal cord injury

Figure The skull and brain grow and develop rapidly during early childhood. Infants and young children are at higher risk for injury to the brain and spinal cord because of developing anatomic structures.

Consciousness—receptiveness to stimuli
Nursing Assessment of Altered Levels of Consciousness and Other Neurological Conditions Levels of consciousness—most important indicator of neurological dysfunction Consciousness—receptiveness to stimuli Alertness—arousal, ability to react Cognitive power—ability to process data and respond Altered levels of consciousness Causes

Levels of consciousness assessment
Nursing Assessment of Altered Levels of Consciousness and Other Neurological Conditions Levels of consciousness assessment Categories: confusion, delirium, lethargy, obtunded, stupor, and coma Decorticate and decerebrate posturing

Figure A, Decorticate posturing, characterized by rigid flexion, is associated with lesions above the brainstem in the corticospinal tracts.

Figure 33-3 (continued) B, Decerebrate posturing, distinguished by rigid extension, is associated with lesions of the brainstem.

Increased intracranial pressure
Nursing Assessment of Altered Levels of Consciousness and Other Neurological Conditions Increased intracranial pressure Scales for responsiveness

Increased intracranial pressure
Nursing Assessment of Altered Levels of Consciousness and Other Neurological Conditions Increased intracranial pressure Glasgow coma scale

Figure Pupil findings in various neurological conditions with altered consciousness. A, A unilateral dilated and reactive pupil is associated with an intracranial mass. B, A fixed and dilated pupil may be a sign of impending brainstem herniation. C, Bilateral fixed and dilated pupils are associated with brainstem herniation from increased intracranial pressure.

Status Epilepticus An acute seizure that lasts over 30 minutes
Electrolytes, glucose, blood gases, temperature, and blood pressure need monitoring if a seizure occurs for longer than 10 minutes

Nursing Management for Seizures
Maintain airway Ensure safety Administer medications Provide emotional support Provide education

Myelodysplasia Malformation of the spinal cord and canal
Impaired physical mobility related to neuromuscular impairment Impaired urinary elimination related to sensory impairment Risk for latex allergy response related to multiple surgical procedures

Hydrocephalus Imbalance between production and absorption of CSF
Leads to increased CSF volume in brain Commonly associated with myelomeningocele (spinal-fluid-filled sac protruding through vertebrae) Treatment may include placement of a shunt

Nursing Diagnosis for Myelodysplasia and Hydrocephalus
Risk for infection related to the presence of shunt Risk for caregiver role strain related to care of a child with a chronic condition Risk for delayed development related to compression of brain tissue with excess cerebral spinal fluid

Cerebral Palsy Group of permanent disorders of movement and posture
Causes activity limitations Nonprogressive in nature May have additional sensory, cognition, communication and behavior problems

Children with Cerebral Palsy
Community care Case manager Early intervention Financial needs School assistance and IEP needed

Figure 33-19 A child with cerebral palsy has abnormal muscle tone and lack of physical coordination.

Children with Cerebral Palsy
Multidiscipline care Orthopedic surgeon care Speech therapy Regular eye exams Pediatric nurse practitioner or pediatrician Support groups

Mild, Moderate, and Severe Brain Injury
Traumatic brain injuries Falls are a major cause Primary vs. secondary Cushing’s triad Nursing management of mild vs. severe brain injury Emergency care Long-term care

Figure 33-20 Child having baclofen pump filled.

Objective 2 Explain the pathophysiology and nursing process of congenital defects of the musculoskeletal system inclusive of: Cranial malformations, club foot, kyphosis/scoliosis, hip dysplasia, Bone tumors covered in oncology (unit 7)

Musculoskeletal Differences
Child’s bones More porous and pliable Less dense Infant skull Fontanel closure: 18 months Overall growth completion: 2 years Child bone growth from epiphyseal plate

Musculoskeletal Differences
Muscles Number same as adult Only length and circumference grow Ligaments and tendons Stronger than bone until puberty

Figure 35-3 Skeletal and muscle development throughout childhood.

Figure 35-3 (continued) Skeletal and muscle development throughout childhood.

Structural Deformities
Feet and legs Metatarsus adductus (intoeing)

Figure Metatarsus adductus is characterized by convexity (curvature) of the lateral border of the foot. The child’s right foot demonstrates the disorder. Note that the forefoot turns inward and appears out of alignment with the remainder of the foot.

Feet and legs Talipes equinovarus (clubfoot)

Figure 35-5 Parents of a child with clubfoot will have many questions
Figure Parents of a child with clubfoot will have many questions. Can the condition be treated? Will the child be able to walk normally after surgery? Will they need help caring for the infant? How much will surgery and other care cost? Will any subsequent children have a clubfoot? Source: Modified from Staheli, L. T. (1992). Fundamentals of pediatric orthopedics (p. 5.10). New York: Raven Press.

Feet and legs Genu valgum (knock-knees) Genu varum (bowlegs)

Figure 35-8 A, Genu valgum, or knock-knees
Figure A, Genu valgum, or knock-knees. Note that the ankles are far apart when the knees are together. B, Genu varum, or bowlegs. The legs are bowed so that the knees are far apart as the child stands.

Hip Dysplasia Legg-Calvé-Perthes Slipped capital femoral epiphysis (SCFE)

Figure The asymmetry of the gluteal and thigh fat folds is easy to see in this child with developmental dysplasia of the hip.

Figure The most common treatment for DDH in a child under 3 months of age is a Pavlik harness. A shirt should be worn under the harness to prevent skin irritation (it was omitted for clarity in this photograph).

Figure In slipped capital femoral epiphysis, the femoral head is displaced from the femoral neck at the proximal epiphyseal plate.

Spine Scoliosis, kyphosis, lordosis Torticollis

Figure 35-14 A child may have varying degrees of scoliosis
Figure A child may have varying degrees of scoliosis. For mild forms, treatment will focus on strengthening and stretching. Moderate forms will require bracing. Severe forms may necessitate surgery and fusion. Clothes that fit at an angle, such as this teenage girl’s shorts, and anatomic asymmetry of the back provide clues for early detection.

Deformities: Nursing Care
Prevent complications of immobility Assist coping with treatment Support long-term adaptation Facilitate pain control

Osteomyelitis Bone infection Etiology: idiopathic or nosocomial
Due to trauma, pins Symptoms Bone pain Edema Joint pain Fever

Rarer Bone Infections Skeletal tuberculosis Septic arthritis
Pain, spasms, muscle atrophy “Doughy” swelling over joints, limited mobility Septic arthritis Pain, fever, local inflammation, joint tenderness, loss of spontaneous movement

Figure This boy from Kenya had surgery to correct severe kyphosis and scoliosis, caused by tuberculosis of the spine. A Risser cast has been applied to maintain stability of the spine and thoracic cage during healing. Notice the area cut out of the cast to allow for auscultation of the abdomen, as well as to facilitate the child’s comfort and adequate intake of food.

Nursing Management of Juvenile Arthritis
Pain relief Maintain joint mobility Prevent deformities Promote self-care Well-balanced diet Hydration Medication management

Chronic Conditions Achondroplasia Marfan syndrome
Short stature, prominent forehead Marfan syndrome Connective tissue disorder Skeletal changes Cardiac, respiratory, vision changes

Chronic Conditions Osteogenesis imperfecta
Brittle-bone disease, collagen defect Thin, soft skin; increased flexibility; short stature;weak muscles; hearing loss

Chronic Conditions Muscular dystrophies
Muscle degeneration and wasting Early signs:weakness and hypotonia Life-threatening

Figure Because the leg muscles of children with muscular dystrophy are weak, they must perform the Gowers maneuver to raise to a standing position. A and B, The child first maneuvers to a position supported by arms and legs.

Figure (continued) Because the leg muscles of children with muscular dystrophy are weak, they must perform the Gowers maneuver to raise to a standing position. A and B, The child first maneuvers to a position supported by arms and legs.

Figure (continued) Because the leg muscles of children with muscular dystrophy are weak, they must perform the Gowers maneuver to raise to a standing position. C, The child next pushes off the floor and rests one hand on the knee.

Figure (continued) Because the leg muscles of children with muscular dystrophy are weak, they must perform the Gowers maneuver to raise to a standing position. D and E, The child then pushes himself upright.

Figure This young boy with muscular dystrophy needs to receive tube feedings and home nursing care. He attends school when possible and is able to use an adapted computer.

Braces Limit movement Snug but do not impair circulation
No direct contact with skin Assess neurovascular and skin status

Figure In severe scoliosis, the child may wear a halo brace, shown here, to hold the body in position after surgery.

Figure Although the Toronto brace used for treatment of Legg-Calvé-Perthes disease may seem formidable for a child to wear, you can see by this photograph that, as usual, children adapt quite well to it.

Fractures (review) Prevention Types Greater risk for children
Teach use of protective equipment, safe play Types Closed Casting Open Surgery and casting

Objective 3 Describe pathophysiology and nursing process of inflammatory diseases of childhood Meningitis, Reyes syndrome, tetanus, Kawasaki disease

Meningitis An inflammation of the meninges covering the brain and spinal cord Caused by either viral or bacterial agents

Encephalitis Acute inflammation of the brain
Symptoms include nuchal rigidity or positive Kernig or Brudzinski Symptoms depend on the causative organism

Objective 4 Discuss the psychopathology and nursing process of alterations in the psycho-social functions of the childrearing period Learning disabilities ADHD Mental health

Nursing Management of Children and Adolescents with Mental Health Disorders
Developmental and behavioral disorders Pervasive developmental disorders Nursing management Stabilize environmental stimuli Provide supportive care Enhance communication Maintain a safe environment Provide anticipatory guidance

Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) Nursing management Administer medication Minimize environmental distractions Implement behavior management plans Provide emotional support Promote self-esteem

Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) School issues

Suicide Nursing management: Safety 24-hour monitoring Medication Care in community

Learning Disabilities
Effects up to 5 of school children Children do not process information correctly

Learning Disabilities
Individual education plan (IEP) Developed through an interdisciplinary approach Specific goals are included

Mental Retardation Limitations in adaptive and intellectual functioning Conditions associated: Down syndrome Fragile X syndrome Fetal alcohol syndrome

Mental Retardation Nursing management Maintain safe environment
Provide assistance with adaptive functioning

Mental Retardation Evaluation depends on needs and developmental level
First evaluation needs to assess the family’s understanding of the disorder

Unit 7- Objective 1 Discuss pathophysiology and nursing process associated with blood dyscrasias inclusive of: Sickle cell anemia, iron deficiency anemia, von willenbrand disease, thalassemias Objective 2 Describe nursing process and procedure for pediatric blood transfusions (covered in NURS 2520)

Anemia Iron deficiency anemia Lack of iron Anemia of prematurity
Affects production of RBCs RBCs appear hypochromic, decreased hemoglobin synthesis

Anemia Iron deficiency anemia Manifestations based on severity Pallor
Fatigue Irritability Pica

Anemia Normocytic anemia Decreased number of RBCs
Normal size with pale center Associated with multiple causes Manifestations similar to iron deficiency anemia

Anemia Sickle-cell anemia Genetic mutation
Hemoglobin S replaces normal hemoglobin RBCs lose doughnut shape, become sickleshaped

Figure Many of these red blood cells show an elongated crescent shape characteristic of sickle cell anemia. Source: Courtesy of Dr. Ed Wong, Laboratory Medicine, Children’s National Medical Center, Washington, DC.

Anemia Sickle-cell anemia
Manifestations appear in multiple body systems Severity based on pathologic changes

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

Anemia Thalassemias Groups of hereditary disorders
Hemoglobin synthesis abnormal Range from mild to severe Three types

Anemia Thalassemias Clinical manifestations based on type and severity
Pallor Fatigue Failure to thrive Severe anemia leads to chronic hypoxia

Anemia Hereditary spherocytosis Congenital hemolytic anemia
No abnormality of hemoglobin Cells have unusual structure Manifestations appear in neonatal period or infancy Severity varies

Anemia Goals of Care Adequate nutrition Hydration and fluid balance
Promotion of adequate tissue perfusion Promotion of growth and development Family and patient education

Aplastic Anemia Failure of bone marrow to produce blood cells
Disorder is idiopathic or acquired Clinical presentation varies depending on degree Most common is bleeding secondary to thrombocytopenia

Hemophilia Hereditary bleeding disorder
X-linked—expressed in males, females have carrier status

Hemophilia Manifestations range from mild to moderate to severe
Spontaneous bleeding Hemarthrosis Deep tissue hemorrhage Nosebleeds Hematuria Easy bruising

von Willebrand Disease
Autosomal dominant trait Equal expressivity in males and females Manifestations Easy bruising Epistaxis

Bleeding Disorders: Clotting Disorders
Disseminated intravascular coagulation (DIC) Complication from another illness Most common following infection in children Manifestation range Minor oozing Frank hemorrhage

Idiopathic thrombocytopenic purpura (ITP) Autoimmune disorder After a viral illness

Idiopathic thrombocytopenic purpura (ITP) Manifestations Ecchymoses Petechiae Purpura Bleeding from gums Nosebleeds Blood in urine Blood in stools

HSP Vasculitis Raised purpuric lesions Joint pain Colicky abdominal pain GI bleeding Renal involvement

Nursing Care of a Child with a Hematologic Disorder Is Based on the Disorder
RBCs Oxygenation Circulation Fluid Nutrition Pain management

WBCs Infection Oxygenation Nutrition

Platelets and bleeding disorders Bleeding Oxygenation Circulation Injury prevention

Collaborative Care Approach for a Child with a Hematologic Disorder
Team approach Family involved Decisions with family and child

Objective 3 Discuss the pathophysiology and nursing process of pediatric oncology Leukemia, Hodgkins disease, Wilm’s tumor

Clinical Therapy Therapy may be singular or combination of treatments
Surgery Chemotherapy Radiation Biotherapy HSCT Complementary therapies Palliative care

Nursing Care Plan Based on type of cancer and therapy
Infection control Pain Nutrition Growth and development Emotional needs Spiritual needs

Three Types of Oncological Emergencies
Metabolic Tumor lysis syndrome Septic shock Hypercalcemia Hematologic Caused by bone marrow suppression Require transfusion and careful RBC and WBC assessment

Space-occupying lesions: tumors with extensive growth Spinal cord compression Increased ICP Brain herniation Seizures

Space-occupying lesions: tumors with extensive growth Hepatomegaly Gastrointestinal obstruction Cardiac and respiratory complications SVC syndrome

Solid Tumors Brain and central nervous system
Most common malignancy in children, next to leukemia Treatment depends on type and location of tumor Surgery Radiation Chemotherapy

Figure Approximately 1,700 children under the age of 14 years are diagnosed annually as having tumors of the brain and central nervous system. The four most common brain tumors in children are medulloblastoma, cerebral astrocytoma, ependymoma, and brainstem glioma.

Solid Tumors Neuroblastoma Definition Treatment based on protocol
Surgical Chemotherapy Radiation HSCT

Solid Tumors Wilms’ tumor Define Treatment based on stage
Requires surgical removal Radiation Chemotherapy

Table 29-8 (continued) National Wilms Tumor Study Staging System

Solid Tumors Bone tumors (osteosarcomas) Ewing’s sarcoma Definition
Treatment Surgery required Chemotherapy Radiation Ewing’s sarcoma Similar to osteosarcoma

Leukemia Most commonly diagnosed malignancy in children under 14
Definition

Nursing Management Difficult due to multisystem effect
Long period of treatment required Assessment complete and thorough Observe for signs of bleeding Observe for signs of infection

Nursing Management Monitor for toxic side effects of chemotherapy or tumor cell lysis Renal function Special attention for children on cyclophosphamide

Nursing Management Nutrition CNS infiltration Pain
Bone marrow suppression Isolation and transmission precautions

Nursing Management Education of family and child Careful handwashing
Prevention of spread of infection Oral care

Soft Tissue Tumors Hodgkin’s disease Definition
Treatment based on staging Outpatient setting Chemotherapy

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

Soft Tissue Tumors Non-Hodgkin lymphoma Definition Three types
Treatment tailored to stage Stages I and II treat with drugs Stages III and IV treat with additional drugs and longer period

Soft Tissue Tumors Rhabdomyosarcoma Definition Locations Treatment
Surgical when possible Widefield radiation Chemotherapy

Figure 29-17 Rhabdomyosarcoma is characterized by ptosis and swelling
Figure Rhabdomyosarcoma is characterized by ptosis and swelling. Source: From Vaughn, D., Asbury, T., & Riordan-Eva, P. (1995). General opthalmology (14th ed.). Norwalk, CT: Appleton & Lange.

Soft Tissue Tumors Retinoblastoma Definition Treatment
Radiation almost always used Chemotherapy sometimes used, but often ineffective Removal of eye if other treatment fails

Figure Retinoblastoma is characterized by leukokoria, a white reflection in the pupil. Source: From Hathaway, W. E., Hay, W. W., Jr., Groothuis, J. R., & Paisley, J. W. (1993). Current pediatric diagnosis and treatment (11th ed.). Norwalk, CT: Appleton & Lange.

Nursing Management Similar to other cancers Physiologic assessment
Psychosocial assessment Collaboration with family Collaboration with medical team Intervention based on assessment and side effects of therapy

Psychological and Physiological Problems of Cancer Survival
Cancer affects all areas of function Effects of therapy Surgery External and internal body changes Radiation Long-term effects Growth Secondary cancers

Effects of therapy Chemotherapy Effects immediate May present years later

Long-term planning Family stressors Questions regarding outcomes Financial concerns Frequent follow-up Physical Physiological Developmental Cognitive Interventions started as soon as deficit noted

Collaboration to Provide Family-Centered Care
Team members Nurses Primary and specialty care providers Social workers Case managers Child life therapist Psychologist

Collaboration to Provide Family-Centered Care
For the school-age child Encourage maintenance of learning Involvement of school appropriate with permission Spiritual and emotional needs Encourage participation in support groups

Hematopoietic Stem Cell Transplant (HSCT)
Treatment for disorders unresponsive to other therapy Pretransplant phase Total body irradiation Strict isolation Transplant phase Intravenous transfusion of donor stem cells Transplant starts to grow in 2 to 4 weeks

Posttransplant phase Lasts several weeks Major risk is infection Immunosuppressive agents prevent graftversus- host disease

Nursing care Prevent infections Injury prevention Growth and development Nutrition Physical activity limits Oral health Mental and spiritual health Family and social relationships

Nancy Pares, RN, MSN Metro Community College

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