pediatric nursing Why are fluids so important in children?

Daily Care Adults should be at eye level when talking to a toddler Seems less overwhelming Flexible schedule organized around needs of entire household is best Clothing should be easily put on and removed Sunburn protection Daily Care (continued) Shoes should fit the shape of the foot and should be inch longer and inch wider than the foot Important for toddler to wear his or her regular shoes to the clinic because it shows the health care provider how the body is being used by the toddler Posture is greatly influenced by that of other family members Dehydration: Three Types Isotonic Hypotonic Hypertonic Etiology of Dehydration in Children Diarrhea Vomiting - nasogastric tubes Hemorrhage Burns Pathophysiology of Dehydration Initial dehydration (First 3 days) Treatment of Dehydration Oral rehydration solutions Intravenous fluid replacement Further Assessment: Fluid Imbalance Weight changes Vascular volume Interstitial volume Cerebral function Further Assessment: Electrolyte Imbalance Nursing Interventions: Dehydration Functions of Gastrointestinal (GI) System Ingestion, digestion, and absorption of fluids and nutrients Metabolism of needed nutrients Excretion of waste products General Principles of GI Illnesses Can result from

Congenital defect Acquired disease Infection Injury All gastrointestinal illnesses affect nutrient absorption Structural GI Defects Growth and development of GI tract interrupted in first trimester Affect one or more areas Atresia: Absence or closure of a normal body orifice Malposition Nonclosure Cleft Lip and Palate Occur singly or in combination Maxillary processes fail to fuse Multifactorial cause suspected Esophageal Atresia and Tracheoesophageal Fistula (TEF) Esophagus and trachea do not develop as parallel tracts Esophagus ends as either Pyloric Stenosis Hypertrophic obstruction of the pyloric sphincter Occurs in boys more than girls Hypertrophy of pyloric sphincter results in Intussusception One portion of the intestine prolapses and then invaginates (or, telescopes) into itself Results in: Abdominal Wall Defects Omphalocele

Gastroschisis Anorectal Malformations Common congenital defects Minor to complex Occur in isolation or with other defects - VACTERL Types Hernias Protrusion of an organ through the muscle wall of the cavity that normally contains it Types Diaphragmatic Hernia Abdominal contents protrude into lung cavity through the diaphragm Foramen of Bochdalek is most common location - left side of diaphragm Life-threatening problem Umbilical Hernia Results from weak or imperfectly closed umbilical ring; diastasis recti Gastroesophageal Reflux (GER) Affects half of all children

Lower esophageal sphincter relaxes Gastroesophageal Reflux Disease (GERD) Serious manifestation of GER Characterized by Requires treatment Hirschsprung Disease Congenital aganglionic megacolon Congenital anomaly Portion of large intestine lacks parasympathetic innervation Results in Gastroenteritis (Acute Diarrhea) Inflammation of stomach and intestines May be acute or chronic Nausea, vomiting, diarrhea Constipation Inflammatory Diseases Reactions of tissue in the GI tract to trauma caused by

May be acute or chronic Appendicitis Inflammation of vermiform appendix Occurs most often in adolescent boys Pathophysiology: Obstruction of appendiceal lumen Peptic Ulcer Erosion of muscle tissue in stomach or duodenum Etiology: H. pylori Necrotizing Enterocolitis Meckels Diverticulum Omphalomesenteric duct fails to atrophy Outpouching of ileum remains Inflammatory Bowel Disease Crohns Disease Ulcerative Colitis Celiac Disease Gluten-sensitive enteropathy - genetic predisposition Lactose Intolerance Inability to digest lactose - disaccharide found in milk, dairy products Short Bowel Syndrome

Intestine is shortened, usually from bowel resection Decreased surface area for nutrient absorption Results Biliary Atresia Closure or absence of bile duct Bile cannot flow from liver into duodenum Results in: Hepatitis Inflammation of liver due to viral infection Acute or chronic Children most likely to get hepatitis A or B Signs and Symptoms of GI Disorders Inability to gain weight or weight loss Vomiting Diarrhea Constipation Lack of energy - lethargy Abdominal distention Abdominal tenderness Signs and Symptoms of Specific Disorders Pyloric stenosis Intussusception GERD Hirshsprung disease Appendicitis Meckels diverticulum Hepatic disorders General Principles of Nursing Care: GI Disorders Cleft Lip and Palate Esophageal Atresia and TEF Detection Preparation for surgery Feeding regimen Pyloric Stenosis Rehydration Correction of electrolyte imbalances Postoperative care Feeding regimen Intussusception Fluid and electrolyte balance Postoperative care Nasogastric tube patency

Feeding regimen Hirschsprung Disease Bowel regimen pre-op Post-op care Colostomy teaching Appendicitis Pain control Hydration Emotional support Monitor for infection HOW? Prevent respiratory complications Crohns Disease and Ulcerative Colitis Body image Dietary changes TPN Gastroenteritis Fluids and electrolytes Infection control Oral rehydration Skin care Celiac Disease Dietary counseling (involve dietitian) Growth and Developmental Considerations: Diet Growth and Developmental Considerations: Diet (contd) Assist parents in making decisions about age-appropriate food choices for disorders that have special diets Hepatitis Celiac disease Crohns disease Ulcerative colitis Growth and Developmental Considerations: Ostomies Growth and Developmental Considerations: Body Image Steroids (side effects)

Ostomies Central venous catheters for TPN Short stature Delayed onset of puberty Abdominal Trauma in Children Blunt trauma (85%) Mechanism of injury can predict actual injury Abdominal Trauma: Nursing Assessment Clinical manifestations Abdominal Trauma: Nursing Management Post-op care and monitoring Emotional support - parents may feel guilty Prevention Poisoning Common in children Most common age: 1 to 4 years Most poisonings occur in the home - sources of toxins Role of poison control center Ingestion of Foreign Objects Most common in children ages 6 months to 3 years Ingestion of Foreign Objects: Nursing Management Detection of symptoms: Assist with endoscopic exam and/or removal Prevent recurrence Lead Poisoning Source of lead: Older houses may still have lead-based paint Effects of lead in body (highest risk in children less than 7 years) Lead Poisoning: Detection Routine screening with well-child visits Lead Poisoning Inteventions Nursing Management Burns: Background Common injury in pediatrics

Four types of burns Burn Risk: Developmental Considerations Infants: Toddlers: Preschool: School-age: Adolescents: Classification of Burns: Based On Depth of Injury Superficial Partial thickness Full thickness Assessment Diagnosis Acute pain Risk for infection Risk for deficient fluid volume Ineffective tissue perfusion Ineffective breathing pattern Planning and Implementation Burn care Pain management Prevent complications Provide emotional support Evaluation Adequate pain relief Free from infection Adequate urine output Adequate perfusion Improvement in breathing pattern Acute Postinfectious Glomerulonephritis (APIGN) Definition Common cause:

Pathophysiology Treatment supportive - most recover Acute Postinfectious Glomerulonephritis (APIGN) Diet Fluids: Hypospadias and Epispadias: Nursing Management Pre-op: Post-op Obstructive Uropathies Congenital anomalies that interfere with urine flow All result in hydronephrosis and eventually chronic renal failure Obstructive Uropathies: Post-op Nursing Management Nursing Care Plan Development Urinary tract infections (UTIs) Assessment Physiologic Psychosocial Diagnosis Impaired urinary elimination Risk for disproportionate growth Urinary retention Ineffective therapeutic regimen management Risk for deficient fluid volume Planning and Implementation Administering medications Rehydration Monitoring renal function Teaching: Evaluation Expected outcomes -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Why are children so vulnerable? Developmental Considerations Nervous system complete Infant born with all nerves he or she will have Myelination of nerves Development proceeds in Level of Consciousness (LOC) Most important indicator of neurologic dysfunction Describing LOC

Causes of Altered LOC Trauma and/or injury Hypoxia Infection Poisoning Seizures Endocrine or metabolic disturbances Electrolyte or acid-base imbalance Congenital structural defect Assessment of LOC: Monitoring Epilepsy Versus Status Epilepticus Epilepsy Status epilepticus Nursing Interventions for All Seizures History Details of seizure Seizure may be brief, self-limiting Protect child from harming self Interventions for Status Epilepticus Meningitis in College Video Case studies Christy is a 4-y-o child that is admitted to the hospital with extremely high fever on admission her temp is 104.6 o her HR id 124 and her RR is 36 Other symptoms include confusion, delirium, irritable, lethargic, vomiting, and joint pain She has a spinal tap and a diagnosis of Bacterial Meningitis is made. Case study What other symptoms would you expect to see if the child was an 8 month old infant? What organisms are common for this disorder? She develops a hemorrhagic rash what organism do you suspect? Create a concept map for this child. Case study Lindsey is a 3-y-o who had a mild viral infection. Her mother gave her medication for her upset stomach without realizing it contained aspirin. She presented with stupor, anxiety and sluggish pupillary reaction. What is her suspected diagnosis? How the does the condition progress? What are the nursing intervention for each stage? Case study Erin is a 5-y-o who at birth had a diagnosis of Myelodysplasia, He had surgery 2 days after birth and is now left with the following residuals. He has poor control over his legs and feet and walks with assistance in a brace. Most of the time he is in a wheel chair. He has bladder residual and must be straight

catheterized every 3-4 hours for urine. He has mild hydrocephalus and received a shunt. Case study Explain his condition? And the pre-op nursing implication of the infant. What are the nursing implications for his care now? Create a concept map Case Study You are working in an outpatient clinic and one of your patients is Sheila a 3 y-o who suffered shaken baby syndrome with moderate brain injury when she was 3 months old. She is diagnosed with CP. Her mother wants to be sure she has the best shot at a normal life. What are the causes of CP? How can you assist her mother? Cognitive Disorders Wide array occur, ranging from mild to severe Difficulties in school Physical signs visible at birth Learning Disabilities Common in childhood Affect about 5% of children Brain cannot receive or process information normally Can involve reading, writing, math, or understanding oral information IQ is usually normal Hearing ? Mental Health What is it? Mental Health Disorders in Childhood Pervasive developmental disorders Attention deficit and attention deficit hyperactivity disorder (ADD and ADHD) Mood disorders Anxiety disorders Tic disorders Schizophrenia Pervasive Developmental Disorders Begin in early childhood Affect 12% to 16% of children ADD/ADHD Affects 4% to 12% of children, boys more than girls Clinical Manifestations: ADD/ADHD Clinical Manifestations: Tic Disorders Brief motor movements or vocalizations that are Overarching Principles: Hospitalized Children Assess current level of functioning Continue prescribed treatments and medications if possible Ensure that dangerous objects are out of reach, and child is directly supervised Assess potential for self-harm Overarching Principles: Community Settings

Conduct ongoing assessment of level of functioning Provide individual and group therapy sessions Refer families to mental health resources and support groups Nursing Management: Pervasive Developmental Disorders Nursing Management: ADD/ADHD Down Syndrome Incidence: 1 in 1,000 infants At risk for cardiac defects, leukemia, hearing loss, thyroid disease Clinical manifestations Fetal Alcohol Syndrome Caused by effect of alcohol on developing fetus Clinical manifestations Nursing Management of Mental Retardation Early detection and screening Developmental milestones Denver II developmental screening test Nursing Management of Mental Retardation Provide emotional support and information Maintain safe environment Nursing Management of Mental Retardation Promote adaptive functioning Allow home routine during hospitalization Developmental Dysplasia of the Hip (DDH) Femoral head and acetabulum improperly aligned May include hip instability, dislocation, subluxation, or dysplasia Occurs in girls more than boys - unilateral in 80% of cases Cause: Unknown - genetic factors likely DDH: Treatment Pavlik harness (younger than 3 months of age) Skin traction (older than 3 months of age) Spica cast, surgery (older than 18 months of age) DDH: Nursing Care Assessment of hip during well-child visits Nursing care depends on the treatment Scoliosis Lateral S- or C- shaped curvature of the spine More than 10 degrees is abnormal Types

Most common in girls around adolescent growth spurt Scoliosis: Causes Idiopathic - cause unknown Congenital Acquired: Injury to spinal cord Scoliosis: Treatment Observation, serial x-rays Mild (10 to 20 degree curve): Moderate (20 to 40 degree curve): Severe (greater than 40 degree curve): Scoliosis: Nursing Care Screening (usually during fifth and seventh grades) Promote acceptance of care plan Post-op care Home care teaching Osteogenesis Imperfecta Brittle bone disease Genetic condition affecting collagen production Manifestations Osteogenesis Imperfecta: Treatment Fracture prevention, treatment Prevention of deformity Maximize mobility Support for family, child Muscular Dystrophy Group of inherited diseases Muscular Dystrophy: Treatment None specific Muscular Dystrophy: Nursing Care Promote independence and mobility Psychosocial support and acceptance Referral to resources for support Fractures: Nursing Care Sports Injuries Most common type of injury in youths 13 to 19 years Football, wrestling, soccer, gymnastics Risk Factors for Injury in Childhood Vulnerability of growth plates

Increased joint mobility leads to joint injuries Softer bones lead to fractures Lack of experience, training Not wearing protective gear Impatience with healing process Prevention of Injury Proper training and instruction Protective gear Supervision Warm up before activity -------------------------------------------------------------------------------------------------Why do kids act like kids? What are developmental theories? Who are the developmental theorists? 1 2 3 4 5 Freuds Stages of Development (birth to 1 year): (1 to 3 years): (3 to 6 years): (6 to 12 years): (12 years to adulthood): Eriksons Stages of Development (Pediatric) (birth to 1 year) (1 to 3 years) (3 to 6 years) (6 to 12 years) (12 to 18 years) Social Learning Theorists Behaviorism Theories Applied ideas of Pavlov and Skinner to children Nursing Interventions: Infants Nursing Interventions: Toddlers Nursing Interventions: Preschoolers Nursing Interventions: School-Age

Nursing Interventions: Adolescents Resilience: Basic Ideas Resilience: Ability to function with healthy responses, even when faced with stress and adversity Resiliency Theory All individuals experience crises that lead to adaptation and development of inner strengths Increases ability to handle future crises Growth VS Development How old am I? Possesses reading ability Rides a two-wheeled bike Jumps rope How old am I? Stands Able to say 1 or 2 words Uses pincer grasp well How old am I? Typically independent and negative Proud of new accomplishments Rate of growth and food intake slows How old am I? Undresses self Kicks a ball Has a vocabulary of 1,000 words - uses short sentences How old am I? Time of rapid growth and change Begins to understand meanings of sounds and words How old am I? Increased social activities and contacts Language skills well-developed Writing ability improved How old am I? Very industrious Contributes to sense of achievement, self esteem Peers becoming more important How old am I? Fine motor skills well-developed Gross motor skills improve due to growth spurts Able to apply abstract thought and analysis How old am I? Uses scissors Holds a bat Writes a few letters All parts of speech are well-developed How old am I? Identity formation: Who am I? New activities Less dependent on parents for transportation Peers are important Assessing Growth and Development

Use combination of developmental theories and assessments Holistic approach Categories of Assessment Physical growth Cognitive development Psychosocial development Personality and temperament Communication Sexuality Children at Play Play is the work of childhood Play contributes to: Cognitive growth Physical development: Gross motor skills and fine motor skills Social interaction Can be a form of therapy. Purposes of Play Facilitates normal development Helps child Learn about health care Express anxieties Work through feelings Achieve control Come up with a game for each age group Infant Toddler Preschool School age 5-8 School age 9-12 Adolescent Infants at Play Toddlers at Play Nursing Interventions and Development Assess growth and development - holistic approach Tailor nursing interventions based on this data General Principles: Interventions and Development Discuss proper nutrition and feeding techniques Conduct health teachings and screenings based on childs age Encourage family to discover childs personality and temperament Instruct parents about expected language skills General Principles: Interventions and Development Childrens Understanding of Health and Illness Different than adults Based primarily on Infants Can identify primary caregivers If left alone, hospitalization can be more traumatic - encourage parents to stay with infant Effect of Hospitalization on Family

Disrupts usual routines

May be anxious or fearful What Can Nurses Do? Tailor care to familys needs and preferences Honest and open communication View parent as the expert about the child Respect cultural practices Effects on Siblings Less attention from parents May fantasize about illness or injury May fear ill child will die Guilt, insecurity, anxiety, jealousy Behavioral or school problems Nursing strategies Family Assessment: Support Prior methods of coping - were they helpful? Support groups Referral to outside agencies Emergency Department (ED) Preoperative and Postoperative Units Allow parent to stay with child until surgery begins Need orientation to unit Explain equipment Children in Isolation During Hospitalization Methods to Promote Adaptation to Hospitalization Child life programs Rooming in Therapeutic play Therapeutic recreation Social and Environmental Factors that Influence Health of Children Many causes of death are preventable Social Factors Relating to Adolescents Same as children Others Additional Factors to Consider Poverty

Stress Family structure Child care Additional Factors to Consider Substance abuse Physical inactivity Violence/Abuse Types of Abuse Physical abuse Neglect Emotional abuse Sexual abuse The End