NURSING CARE OF A CHILD Etiology:

WITH PHYSICAL AND  It appears to be consistent with

DEVELOPMENTAL CHALLENGES multifactorial inheritance as evidenced by
incidences in relatives and monozygotic
1. Skeletal/Finger and toe conditions twins
2. Cleft lip & palate  Formation may be aided by teratogenic
3. Tracheoesophageal Atresia & Fistula factors present during 5-8 weeks if
4. Intestinal Obstruction intrauterine life such as viral infections
5. Neural Tube Disorders  Possibly due to a folic acid deficiency
6. Hydrocephalus
7. Trisomy 21 (Down’s Syndrome) Nursing Management:
8. Febrile Seizures
9. Meningitis 1. Assess for problem with feeding and breathing
2. Ensure adequate nutrition and prevent
aspiration
SYNDACTYLY
 Provide special nipples or feeding devices
-webbing of fingers/toes. for a child to be able to such adequately
 Hold the child in a semi upright position;
PLYDACTYLY
direct the formula away from the cleft and
-extra toes or fingers or unusually spacing of toes toward the side to prevent aspiration
 Feed the infant slowly and burp frequently
TALIPES EQUINOVARUS (CLUBFOOT)
to prevent excessive swallowing of air and
-if a foot does not align readily or will not turn a regurgitation
definite midline position  Stimulate sucking by gently rubbing the
nipple against the lower lip
3. Support the infant’s parents emotional and
CLEFT LIP & PALATE social adjustment
-the maxillary and medial nasal processes normally  Help facilitate the family’s attitude of
fuse at 5-8 weeks if intrauterine life
acceptance toward the infant by
-Palatal processes closes at 9-12 weeks of encouraging the parents to express their
intrauterine life feelings and concerns
 Emphasize the infant’s positive aspects and
CLEFT LIP express optimism regarding surgical
-a congenital anomaly characterized by the failure if correction
the maxillary and median nasal processes to fuse 4. Provide preoperative care
-the disorder range from a small notch in the upper  Depending on the defect and the child’s
lip to a total separation of the lip and facial general condition; surgical corrections are
structure up into the floor of the nose usually performed between 1-3 months age
-the deviation may be unilateral of bilateral for cleft lip and 6-18 months age for cleft
palate
-it occurs mostly among boys
5. Provide post-operative care
CLEFT PALATE
 Assess airway patency and signs of
-a congenital opening of the palate. The severity respiratory distress
ranges from the soft palate alone or involves the  Observe for edema of the operative site.
anterior hard palate or both Liquefy secretion to prevent or minimize
-it occurs mostly among girls edema
 Position the child with cleft lip on her back
Assessment: or propped on a side to avoid injury to the
operative site
 Before Birth – can be detected by sonogram
 Position the child with cleft palate on the
 After Birth – inspection soon after birth.
abdomen to facilitate drainage
Careful physical assessment should be
performed to rule out the extent of the  Monitor the operative site for signs of
defect infection
 Provide mouth care to prevent infection
 Clean the suture line and apply antibacterial
ointment as prescribed to prevent infection
  Feed the infant with rubber-tipped medicine  Difficult breathing as fluid as fluid is
dropper or bulb syringe to help preserve aspirated
suture integrity  Too much mucus in the mouth appearing
 Manage pain by administering analgesics as like “blowing bubbles”
prescribed  Catheter cannot pass through the infant’s
esophagus to the stomach
6. Provide child and family health teaching
 Flat x-ray reveals a stomach distended with
 Demonstrate surgical wound care air that is passed from the trachea into the
 Show proper feeding techniques and stomach
positions Nursing Management:
 Teach infection control measures
 Stress the importance of long term follow up  Emergency surgery – needed to prevent the
like speech therapy and dental development of pneumonia from leakage of
abnormalities stomach secretions into the lungs or
dehydration or an electrolyte imbalance
from lack of oral intake
TRACHEOESOPHAGEAL ATRESIA & FISTULA  Antibiotics – to prevent infection on the
operated site
ATRESIA  Gastrostomy – the creation of an artificial
-closed due to obstruction external opening into the stomach for
nutritional support or gastrointestinal
FISTULA compression
-opening GASTROSTOMY
ESOPHAGEAL ATRESIA -typically this would include an incision in the
patient’s epigastrium as part of a formal operation
-obstruction of the esophagus. This is a rare but
serious case
TRACHEOESOPHAGEAL FISTULA
-an opening occurs between the closed esophagus
and the trachea

INTESTINAL OBSTRUCTION
-the anus of the newborn is checked for patency and
not covered by a membrane by inserting the tip of a
little finger, gloved and lubricated or a rectal
thermometer
-if a newborn does not pass meconium in the first
24hours then, suspect for Imperforate anus or
Meconium ileus.
MECONIUM ILEUS
-an obstruction of the intestinal lumen due to
hardened meconium
Assessment:
Causes:
 Choking
 Cyanosis  Meconium plug – extremely hard portion of
meconium that has completely clocked the
intestinal lumen causing bowel obstruction
  The mesentery of the bowel is twisted as the 1. ANENCEPHALY
bowel reentered the abdomen (after being
-a severe defect involving absence of the entire
contained in the base of the umbilical cord
brain or cerebral hemispheres; the brain stem and
early in uterine life)
cerebellum may be present

Assessment:
 More than 30 ml of content can be aspirated
from the newborn’s stomach
 No meconium passed
 Abdomen is distended and tender
 Infant will vomit or spits up when burped
 Increased bowel sounds
 Increased respiratory rate due to the
pushing to the diaphragm against lungs and
the lung capacity decreases
 Abdominal x ray or sonogram reveals no air
below the level of obstruction in the
intestine
Nursing Management:
When the bowel obstruction is confirmed;
2. ENCEPHALOCELE
-occurs when meningeal and cerebral tissue
protrudes in sac through a defect in the skull, with
the occiput being the most common site
3. SPINA BIFIDA
-latin meaning “divided spine”
-collective term for all spinal cord disorders which
occur in any part of the spinal cord but most
commonly in the lumbosacral area
-a defective closure of the vertebral column and is
the most common defect of the central nervous
system.
TYPES OF SPINA BIFIDA
1. SPINA BIFIDA OCCULTA
-it does not affect the brain and the spinal cord
-external signs may include dimpling of the skin,
nevi or hair tufts over a dermal sinus of the hips
and clubfoot

 Orogastric or nasogastric tube is inserted

and then attached to low suction or left open
to the air to prevent further gastrointestinal
distention from swallowed air
 Provide intravenous therapy to restore fluid
and electrolyte balance
 Schedule for immediate surgery-repair of
the obstruction through abdominal incision.
The area of the stenosis or atresia is
removed and the bowel is anastomosed. A
temporary colostomy will be constructed
and close 3-6 months age

NEURAL TUBE DISORDERS

NEURAL TUBE
-forms in utero first as a flat plate and then molds
to form the brain and spinal cord
NEURAL TUBE DISORDERS
-occurs because of lack of fusion of the posterior
surface of the embryo in early uterine life
TYPES OF NEURAL TUBE DISORDERS

Etiology:
 50% of spina bifida is caused by nutritional
deficiency, particularly folic acid deficiency
 Other causes – Multifactorial
Pathophysiology:
 During the third and fourth week gestation
the neural plate closes to form the neural
tube
 Neural tube defects result from
malformation of the neural tube during the
embryonic development
Assessment:
Before Birth:
 Can be seen during intrauterine life
(sonography)
 Amniocentesis result reveals increased
alphafetoprotein (AFP) in the amniotic fluid
 If the condition is discovered while in utero;
fetus should be delivered by C/S to avoid
pressure and injury to the spinal cord
After Birth:
 Observe and record for spontaneous
movement of the lower extremities
 Observe and assess on the pattern of voiding
and defecation. Normal voiding is every 2-3
hours and 30ml in amount in every voiding
NOTE!:
 If there is continuous voiding; the infant has
no bladder and bowel control
Nursing Diagnosis:
 Risk for infection related to bacterial
invasion on the neural tube sac
 Risk for ineffective cerebral tissue perfusion
related to increased intracranial pressure
 Risk for impaired skin integrity related to
prone positioning
 Impaired physical mobility related to the
neural tube disorder
 Risk for impaired elimination related to
neural tube disorder
Therapeutic Management:
a. Spina Bifida
 No immediate surgical correction is needed
but eventually surgery should be done to
prevent vertebral deterioration due to
unbalanced spinal column
b. Menigocele, Myelinmnigocele, Encephalocele
 Treatment involves surgery to replace the
contents that are replaceable to close the
skin in order to prevent infection
 Usually surgery is done within 24-48 hours
age so that infection through the exposed
meninges does not occur
c. Parents need to be cautioned that the prognosis
for the child depends on the extent of the disorder
ENCEPHALOCELE
-may limit the child’s cognitive potential and the
loss of meninges due to surgery may limit the rate
of CSF absorption and results to Hydrocephalus
d. Parents need a great deal of support to care for
the child with Myelinmenigocele because this child
has multiple challenges. The child will continue to
have paralysis of the lower extremities and loss of
bowel and bladder function after srgery because the
absent lower cord cannot be replaced
e. Adminster prescribed medications
f. Prevent from infection (pre-op, intra op, post op)
and from injury
HYDROCEPHALUS
-a condition caused by an imbalance in the
production and absorption of the cerebrospinal
fluid in the ventricular system
Etiology:
a. Congenital Hydrocephalus – usually results from
defects like meningeal malignancy, arachnoid cyst,
tuberculosis, or spina bifida
b. Acquired Hydrocephalus – usually results from
space occupying lesions, intracranial infections, or
hemorrhage like meningitis, leukemia or trauma

Pathophysiology:
Causes of Hydrocephalus are varied but result is
either
 Impaired absorption of CSF within the
arachnoid space (referred to as
communicating Hydrocephalus)
 Obstruction to the flow of CSF through the
ventricular system (referred to as non-
communicating Hydrocephalus)
Assessment:
 Abnormal head growth
 Tense (bulging) anterior fontanelle
 Sluggish & unequal pupils
 Dilated scalp veins
 Ultrasound reveals the diagnosis
Nursing Management:
1. Teach the family about the management required
for the disorder
 Treatment is surgical by direct removal of
the obstruction and insertion of shunts to
provide primary drainage of the CSF to the
extracranial compartment usually the
peritoneum (usually called ventriculo-
peritoneal shunt or VP Shunt)
 The major complications of shuts are;
infections and malfunctions like peritonitis,
abdominal abscess, hernias & ileus.
2. Provide pre-operative nursing care
 Assess head circumference, fontanelles,
cranial sutures
 Check for signs of irritability, altered
feeding habits and high pitched cry
 Firmly support the head and neck when
holding the child
 Provide skin care for the head to prevent
breakdown
 Give small frequent feedings to decrease the
risk of vomiting
 Encourage parent-newborn bonding
3. Provide pot-operative nursing care
 Assess for signs of intracranial pressures
like bulging fontanelle, high pitch cry, and
irritability
 Administer prescribed medications to
include; antibiotics to prevent infections
and analgesics for pain
 Provide shunt care; monitor shunt infection
and malfunction like redness on the site,
fever irritability, frequent vomiting, fluid
along shunt tract & monitor shunt over
drainage headache, dizziness and nausea
which leads to slit ventricle syndrome
 Arrange for child to have frequent
developmental screening and routine
medical check up
4. Teach home care
A. Encourage the child to participate in age
appropriate activities
B. Encourage the parents to provide a normal
lifestyle as possible
C. Explain how to recognize signs and
symptoms of increased intracranial pressure
TRISOMY 21 (DOWN’S SYNDROME)
-also called as Mongolism or Down’s Syndrome
-most common chromosomal abnormality is with
47 xx or 47 xy chromosomes (normal is 46xx or 46
xy wherein 23 spermatozoa and 23 ova)
-In trisomy 21, there is an extra in the 21st
chromosomes
Incidence:
 Born to parents of all ages but more
common among women over age 35 and
men over 55 years of age
Assessment:
Physical Manifestations
 Back of head – flat, with extra pad of fat at
the base of the head.
 Eyelids – have extra fold in the inner
canthus (epicanthal fold) and opening
between the eyelids (palpebral fissure) tends
to slant laterally upward
 Iris of the eye – may have white specks in it
(Brushfield’s spots)
 Nose – broad and flat
 Mouth and tongue – tongue protrudes from
the mouth because oral cavity is smaller
than normal
 Ears – low set
 Neck – short
 Muscle tone – poor giving the baby a “rag
doll” appearance
 Fingers – short & thick, little finger –
curved inward; toes – widely spaced
 Palm of hand – shows a peculiar crease
(simian crease – a single horizontal palm
crease)
  Cognitive challenge – not evident at birth
(IQ – 50 to 70 – less involved. Near average
IQ represents a Mosaic chromosomal
patterns)
Nursing Management:
1. Assess for associated problems
 Congenital Anomalies – congenital heart
disease, (GI) Duodenal Atresia or Stenosis,
Hirschsprung Disease, Tracheoesophageal
Atresia
 Congenital Heart Disease – Atrioventricular
Disorders
 Sensory Problems – strabismus, myopia,
cataract, hearing loss
 Altered Immune Functions – making them
prone to URTI
 Acute Lymphocytic Leukemia – very
common to Trisomy 21
 Sexual Development – is delayed &
incomplete
2. Implement a plan of care
 Including planning and intervention
strategies for associated problems and
features
3. Encourage genetic counselling
4. When feeding infants and young children, use a
small straight-handled spoon to push food to the
side and back of the mouth. Feeding difficulties
occur due to a protruding tongue and hypotonia
5. Encourage fluids & foods rich in fiber
 Constipation results from decreased muscle
tone which affects gastric motility
6. Provide good skin care
 Because the skin is dry and prone to
infection
7. Prevent respiratory infections
 Clearing the airways
 Perform chest physiotherapy
 Provide good handwashing
 Avoid exposure to infections
FEBRILE SEIZURES
SEIZURES
-is an involuntary contraction of muscles caused by
abnormal electrical brain discharges
FEBRILE SEIZURES
-are seizures that are associated with an illness
characterized by a high fever (38.9 to 40˚C)
-it lasts for 15-20 seconds; generalized and occur to
children without neurologic disability age 3 months
to 7 years.
CONVULSIONS
-is a violent involuntary contraction or spasm of the
muscles
-are usually associated with urinary tract infection,
upper respiratory tract infection and roseola
FEBRILE CONVULSIONS
-are considered benign if underlying neurologic and
physical problems are ruled out
TYPES OF SEIZURES
1. PARTIAL SEIZURES
-originates from a specific brain area
-no altered level of consciousness; seizures with
motor signs begins in the fingers and spreads to the
wrist, arms and face in a clonic contraction.
-seizures with sensory signs includes numbness,
tingling sensation; paresthesia or pain originating
in one area then spreads to other parts of the body
-caused by a rapidly growing tumors
2. GENERALIZED SEIZURE
-the disturbances involves the entire brain and loss
of consciousness usually occurs
a. TONIC SEIZURES – contraction of muscles,
extension of extremities, loss of bowel and bladder
control, cyanosis
b. CLONIC SEIZURES – rhythmic contraction &
relaxation of the extremities
Etiology:
 Unknown
 It is usually associated with an acute benign
febrile illness
Pathophysiology:
MENINGITIS
-an infection of the cerebral meninges (the 3rd layer
membranes that cover and protect the brain)
3 LAYERS OF THE CEREBRAL MENINGES
1. DURA MATER
-the outer most layer and the toughest of the layers
2. ARACHNOID
-middlemost and resembles a spider’s web
3. PIA MATER
-closest to the brain, it is transparent one that
touches the brain and spinal cord

 It is initiated by a consistent high fever or by

a sudden spike of temperature
 The seizures is characterized by an active
tonic-clonic pattern and lasts in less than 1
minute and associated with acute benign
febrile seizure
 The seizures subsides quickly once the fever
is lowered
Etiology:
Assessment:
(Common to children less than 24 month’s age)
 Fever 38.9 to 40˚C
 Tonic-clonic seizures  Viral infection – if the spread of organisms
 Diagnostic findings: are from URTI through the lymphatic
drainage on the mastoid or sinuses by direct
a. Computed Tomography (CT Scan) and Magnetic introduction like lumbar puncture or skull
Resonance Imaging (MRI) – are performed to rule fracture
out abnormalities
 Bacterial infection – caused by organisms
b. Lumbar puncture – done to rule out meningitis like;

c. Electroencephalography (EEG) – done to rule out a. Streptococcus Pneumonia

the likelihood of seizures disorder
b. Escherichia Coli
Nursing Management:
c. Pseudomonas
1. Maintain a stable body temperature
d. Haemophilus influenza (rare now due to
 Do sponge bath using tepid water to reduce immunization)
fever quickly Pathophysiology:
 Apply cool wash cloth on the child’s
forehead, axilla and groin Organisms Pass throughout CSF

2. Prevent injury and the recurrence of seizures Meningeal space brain infection

 By providing child and family health Brain abscess brain tissues results to =
teachings BLINDNESS, DEAFNESS & FACIAL PARALYSIS
3. Administer Medications: Assessment:
 Paracetamol – to lower body temperature 1. Physical Manifestation
 Antibiotic Therapy – should be given in a
complete dose depending on the type of  2-3 days URTI (cough, colds, irritable due to
infection colds & moderate fever)
 Phenobarbital & Diazepam – both  Seizures
anticonvulsant  Shows signs of meningeal irritation
KERNIG’S SIGN
-let the patient lie down, flex the hip and knee
forming a 90˚ angle positive sign (+) patient will
feel pain, resistance and spasms
BRUDZINSK’S SIGN
-let the patient lie down, flex the neck; positive sign
(+) patient can do bilateral hip, knee, ankle flexion

(con.t to #1)

 Opisthotonos Position – back is arched and

neck is hyperextended
 Cranial nerve paralysis – (3rd and 6th nerves
affected) child is unable to follow a light
through full visual fields
 Bulging and tense fontanelles (if open)
 Shows signs of increased intracranial
pressures such as;
a. nuchal rigidity (nape of the neck becomes stiff)
b. poor sucking reflex
c. bulging and tense fontanelles
d. weak cry
e. lethargy
f. apnea Laboratory findings:
g. seizures  Lumbar puncture – CSF has increased level
of WBC and protein and decreased glucose
 Papilledema – swelling of the optic nerves of
 Blood culture – confirms septicemia and to
the eyes (if fontanelle is closed)
classify the type of organism
 Septic Arthritis – poisoning and
 Tuberculin skin test (Purified Protein
inflammation of the joints (if it’s caused by a
Derivative or PPD) – used to rule out
Haemophilus Influenza); purple petechial
tuberculosis meningitis
skin rash if caused by Neiseria meningitides
 CT Scan, MRI or ultrasound – to examine
for presence of abscess
Nursing Management:
1. Perform careful assessment to note clinical
characteristics in their early stages
2. Check for neurologic signs and monitor level of
consciousness by assessing for signs of ICP and
measuring the head circumference
3. Monitor intake and output and fluid and
electrolyte balance

 Fluid intake is limited to 2/3 or normal

maintenance to prevent cerebral edema
 Client with diminished consciousness
Assessment: should be on NPO
4. Monitor temperature and vital signs frequently
5. Administer prescribed medications

 Massive antibiotics (Ampicillin & 3rd

generation cephalosporin – Rocephin)
 Anticonvulsants
 Antipyretics – analgesics
6. Provide supportive interventions and spread of
infection through reverse isolation and pain
management
7. Keep the environment quiet to decrease stimulus