General Presentation

CONDITIONS AFFECTING
CHILDREN
❖ MENINGITIS ❖ ACUTE
GLOMERULO
NEPHRITIS
Group 6
Group members:
● Nicketia Walker
● Marvette Roberts Grant
● Jermain Smith
● Shenise Stewart
● Renae Reid
● Bethanie Kelly
Meningitis
DEFINITION
❏ Meningitis is an inflammation ❏ The tough outer membrane

(swelling) of the protective is called the dura mater, and
membranes (meninges) covering the delicate inner layer is
the brain and spinal cord. A the pia mater.
bacterial or viral infection of the ❏ However, injuries, cancer,
fluid surrounding the brain and certain drugs, and other
spinal cord usually causes the types of infections also can
swelling. cause meningitis.
INCIDENCE AND PREVALENCE
Before the routine use of the pneumococcal conjugate vaccine, the incidence
of bacterial meningitis in the United States was about 6000 cases per year;
roughly half of these were in pediatric patients (≤18 years). N meningitidis
caused about 4 cases per 100,000 children (aged 1-23 months). While in
Jamaica, meningitis occur in 23% of cases; resulting in mortality and high
morbidity among Jamaican children (Muller, 2019).
PATHOPHYSIOLOGY
There are two main cause of meningitis, these are: viral which is the most
common cause and bacterial which is the most contagious. Bacteria colonize
the nasopharynx and enter the bloodstream after the mucosal invasion. Upon
making their way to the subarachnoid space, the bacteria cross the blood-brain
barrier, causing a direct inflammatory and immune-mediated reaction. Much of
the damage from this infection is believed to result from cytokines released
within the CSF as the host mounts an inflammatory response, (PUBMED, 2009).
Medication
Induction therapy: Prednisone (remission induction), Vincristine (cell division

inhibition), Daunorubicin or Doxorubicin (leukemia cell destruction),
L-asparaginase (deprives leukemia cells of asparagine), Methotrexate (prevents
central nervous system involvement).
Consolidation therapy: High-dose Methotrexate (leukemia cell destruction),
Cytarabine (DNA replication interference), Thioguanine (DNA synthesis
inhibition), Mercaptopurine (DNA synthesis disruption), Pegaspargase
(depletion of asparagine).
Maintenance therapy: Mercaptopurine (leukemia cell growth suppression),
Methotrexate (prevents relapse), Vincristine (intermittent leukemia cell
destruction), Corticosteroids (enhance effectiveness of other medications).
Central nervous system prophylaxis: Intrathecal chemotherapy (Methotrexate,
Cytarabine - prevents spread to the central nervous system), Cranial irradiation
(in some cases - targets leukemia cells in the brain).
Targeted therapies: Imatinib, Dasatinib (Philadelphia chromosome-positive ALL
- target abnormal proteins), Blinatumomab, Inotuzumab ozogamicin
(immunotherapy drugs - recognize and destroy leukemia cells).
MANIFESTATIONS
● Fever or hypothermia ● Positive kernig’s sign (older

● Headache, photophobia, irritability children)- Severe stiffness of the
or lethargic, stiff neck (nuchal hamstrings cause an inability to
rigidity), altered loss of to strengthen the legs when the
consciousness, vomiting hip and knee is flexed at 90°
● Seizures ● Positive brudzinski’s sign- severe
● Neurological deficits neck stiffness causes the
● High pitch crying patient’s hips and knees to flex
● Buldging fontanels, ↑ Head when the neck is flexed
circumference
COMPLICATIONS
● Developmental delay ● Cerebral edema

● Hearing loss/impairment ● Cerebral infarction
● Visual impairment ● Death
● Learning disability
● Seizure disorders
● Hydrocephalus
RISK FACTORS
● There is an infection caused by a number of viruses, bacteria, or

fungi such as tuberculosis, pneumonia, pharyngitis, otitis media,
sinusitis
● Weakened immune system
● Brain trauma
● Neurosurgical procedures
Interdisciplinary care
To reduce morbidity a collaborative approach is used. The triage nurse should

be knowledgeable of the signs and symptoms of the illness and refer the
patient immediately to the emergency department clinician. Other specialists
involved in the care of these patients are neurologists, pediatricians,
intensivists, infectious disease specialists, and pharmacists. If bacterial
meningitis is suspected, prompt antibiotics should be started even in the
absence of laboratory results.
Diagnosis True diagnosis is made through CSF analysis
from a lumbar puncture, this includes WBC,
The diagnosis is dependent on history clinical glucose, protein, culture and sometimes
presentation. polymerase chain reaction.
Incomplete vaccinations Additional testing of the CSF is dependent on

the cause:
Children younger than 5 years
Multiplex and specific PCR test for Viral
Immunosuppression, season, head injury,
meningitis
confusion , seizures, neurosurgical intervention
Acid fast Bacilli smear and culture for bacterial
meningitis
NURSING CARE: Health Promotion
Educate parents on :
● Ensuring children are vaccinated ● The signs and symptoms of the

against meningitis. disease and when to return to
● The need for prophylactic the ER
treatment when a family member ● Providing a diet rich in
has meningitis antioxidants, omega 3 fatty acids
and probiotics to boost the
immune system.
NURSING CARE: Fluid Management
Careful management of fluid to prevent overhydration and dehydration is important.
Fluids is given because many children have increased antidiuretic hormone secretion and will have
dehydration due to vomiting and poor fluid intake or septic shock.
The fluid of choice is 5% DW or 0.9% normal saline. Fluid maintenance is based giving 3ml/kg/hr.
NURSING CARE: Assessment
Jack a nine-year-old male, was brought to the emergency department by his parents
due to a sudden onset of severe headache, neck stiffness, photophobia, high-grade
fever, vomiting (x3), and increasing confusion. His parents also observed that he had
become increasingly lethargic and was unable to perform his usual daily activities.
On examination, Jack’s vital signs reveal an elevated temperature, rapid heart rate,
and high blood pressure. On examination, he appears acutely ill, lethargic. Neck
stiffness is noted, and he experiences pain upon flexion. Kernig's and Brudzinski's
signs are positive. Neurological examination reveals altered mental status (confused),
irritability, no seizure activity.
NURSING CARE: Nursing Diagnosis
Careplan #1: Ineffective tissue perfussion (cerebral)
Assessment
Subjective data:
Patient c/o a headache and neck stiffness
Objective data:
● Lethargic
● Restless
● Vomiting x2
● Decreased pulse (70 bpm), (Normal range: 80-120 bpm)
● Decreased respirations (13 bpm) (Normal range 15-20 bpm)
● Increased BP (128/94 mmHg) (Normal range: 90-110 mmHg)
Nursing diagnosis:
Ineffective tissue perfusion (cerebral) r/t increased intracranial pressure secondary
to bacterial meningitis AEB patient’s complaint of a headache, patient lethargic,
restless, Vomiting x2, Decreased pulse (70 bpm), Decreased respirations (13 bpm),
Increased BP (128/94 mmHg) (cushing’s triad)
Plan:
Within two (2) hours of the nursing shift, patient’s ineffective cerebral tissue
perfusion will begin to improve as there will be no further increase of ICP as
evidenced by increased pulse (80- 110 bpm) and respiratory rate (15-20 bpm), less
irritable and restless, no vomiting or only vomit x1.
Interventions and Rationales:
1. Monitor for changes in neurological status (consciousness, reflexes, and pupillary

reaction). R: These assessments will determine changes in child neurological conditions
associated with ICP.
2. Elevate head of bed to a 300- 450 angle and maintain the patient’s head in neutral
position. R: This position aids with venous drainage thereby reducing ICP and enhancing
cerebral perfusion. This position also aids with lung expansion, thereby improving
oxygenation.
3. Provide a non-stimulating environment and adequate rest periods. R: Continual activity
and stimulation may increase intracranial pressure.
4. Carefully administer IV fluids, ensuring the correct volume and rate as ordered. R:
Careful IV fluid administration is necessary to prevent overhydration, which increases
ICP.
5. Monitor for signs of increased ICP (vomiting, restlessness, irritability, lethargy, decreased
respiratory or pulse rate, etc.). R: These signs indicate increased ICP and an ICP can hinder
cerebral tissue perfusion.
6. Advocate for the administration of anti-epileptic medication (e.g. dilantin). R: To prevent

the occurrence of a seizure.
7. Carry out seizure precautions including removing toys and objects from the bed. R:
Prevents injury to self during seizure activity caused by increased ICP and brain activity.
8. Monitor and report signs of seizure activity (staring, stiffening of body, jerky movements,
loss of bladder or bowel control, apnea, etc). R: Allows for prompt intervention.
Careplan #1: Ineffective tissue perfusion (cerebral)
9. Formulate seizure activity chart (time, type of seizure, how long it lasts, and description of
seizure). R: Monitoring the type and frequency of a seizure helps to improve the treatment
regime for the patient.
10. Monitor patient’s vital signs hrly (especially respiratory rate, blood pressure and pulse
rate). R: Monitoring vital signs can help with early recognition of ICP (such as fluctuating
blood pressure, tachycardia, and shallow breathing).
Evaluation:
Goal met. Within two (2) hours of the nursing shift, patient’s ineffective cerebral tissue began
to improve as there was no further increase in ICP as evidenced by increased pulse (85 bpm)
and respiratory rate (16 bpm), less restless, and no vomiting observed.
Careplan #2: Acute Pain
Assessment
Subjective data:
Patient c/o photophobia, headache and neck stiffness, rated pain 7/10
Objective data:
● Nuchal rigidity (resistance to neck flexion), difficulty moving neck,
● Facial grimacing,
● Restlessness,
● Guarding of affected areas.
Nursing diagnosis:
Acute pain r/t inflammation and meningeal irritation secondary to bacterial
meningitis AEB patient complaining of a headache, and neck stiffness, and difficulty
moving neck rating pain 7/10 on pain scale, facial grimacing, restlessness, and
guarding of affected areas noted.
Plan:
At the end of 30 minutes following nursing and collaborative interventions, the
patient will achieve an improvement in acute pain AEB the patient verbalizing a
reduction in acute pain from 7/10 to 4/10 on the pain scale, and minimal or no facial
grimacing and guarding of affected areas.
1. Assist the patient into a comfortable position. R: This helps to alleviate intensity of pain
and promotes rest and comfort.
2. Administer analgesics such as ibuprofen and an antipyretic such as Panadol as
prescribed. R: To relieve pain.
3. Administer antibiotic and corticosteroid as prescribed. R: Antibiotic and corticosteroid
therapy are used to reduce the inflammation and therefore decrease pain.
4. Encourage diversional therapy ( deep breathing, hold hands, talk with patient). R: To
distract patient from pain.
5. Provide a dark and quiet environment. R: Helps to decrease photophobia.
6. Minimize tactile stimulation. R: Sensory stimulation increases discomfort
7. Reassess pain level. R: To evaluate whether pharmacological and non-pharmacological
therapy is working.
Evaluation:
patient achieved an improvement in acute pain AEB the patient verbalizing a
reduction in acute pain from 7/10 to 4/10 on the pain scale, and minimal facial
grimacing and guarding of affected areas.
Careplan #3: Hyperthermia
Assessment:
Subjective data:
“I’m feeling hot, I’m burning up.”
Objective data:
● T- 38.80C,
● Diaphoresis noted,
● Patient hot and dry to touch.
Nursing Diagnosis:
Hyperthermia related to displacement of the set point of the hypothalamic
thermoregulatory centre secondary to bacterial meningitis as evidenced by patient's
complaint of "feeling hot" and "burning up". T 38.80C, diaphoresis noted, patient hot
and dry to touch.
Plan:
Within 30 minutes to 1 hour of nursing and collaborative interventions the patient
will experience a decrease in body temperature (closer to the normal range) as
evidenced by temperature reading between 37 and 37.8 degrees Celsius, absence of
diaphoresis and patient stating that he feels less "hot".
Interventions and rationales:
1. Loosen clothing and remove non-essential clothing. R: This prevents heat trapping and
enhances heat loss by evaporation.
2. Administer antipyretic (Panadol 1g po/IV) as prescribed. R: Panadol is an antipyretic
that helps to reset the hypothalamic thermoregulatory centre.
3. Assist the patient with a tepid shower. R: This enhances heat loss by evaporation and
conduction.
4. Provide fan therapy and open neighbouring windows for increased ventilation. R: This
helps to dissipate heat by convection.
5. Maintain IvF therapy as ordered. R: This replaces fluid loss through diaphoresis that can
lead to dehydration and further worsen fever.
6. Monitor V/S especially, temperature. R: To evaluate effectiveness of antipyretic therapy.
Evaluation:
At the end of one (1) hour following nursing and collaborative interventions,
the patient experienced a decrease in body temperature (closer to the normal
range) as evidenced by temperature reading of 37oC degrees Celsius, absence
of diaphoresis and patient stating that he feels less "hot".
NURSING CARE : Infection control
To prevent this infection, the education of the public is vital. Nurses should
educate patients and parents in regards to vaccine-preventable meningitis (H.
influenzae type B, S. pneumoniae, N. meningitidis). Across the board, the
incidence of meningitis has decreased with the implementation of generalized
vaccination. Family members should be educated about the need for
prophylaxis when there is a family member with Neisseria and H. influenzae type
B meningitis. All contacts should be educated about the signs and symptoms of
MEDICATIONS
Ampicillin IV 200-300mg) kg
Cefotaxime IV 200-300mg/kg
Vancomycin IV 60-80mg/kg
Dexamethasone IV 0.15mg/kg
Paracetamol syrup 10-15mg po
(Smith, 2018).
Nursing responsibilities
1. Checking and monitoring patient for 1. Position on side with head supported
allergies in extention
2. Administering medication as ordered 2. Maintain droplet precaution for
by doctor on time. atleast 48 hours
3. Document the administration of 3. Monitor for complications eg septic
medications shock ICP
4. Ensuring that the medication is
stored properly and securely. (Smith, 2018).
- Health education for patient and family
1. Provide parents with appropriate 3 Give specific instructions about

information if they and other family medications to be administered at home.
members are to receive antibiotic 4. Encourage regular health

prophylaxis. maintenance visits to chart growth and
development and assess for any delay
2. Discuss symptoms for which the parents
(Smith, 2018).
should watch as signs of possible latent
complications, especially hydrocephalus
- Discharge teaching
1. Educating the family about the ● Keep follow up appointments to

importance of completing the full the clinic
course of treatment prescribed.
2. Keep immunization schedules

after patient is well.
(Smith, 2018).
References
Axton, S., & Fugate, T. (2009). Pediatric nursing care plans for the
hospitalized child (3rd ed). New Jersey: Pearson Education Inc.
CDC, (2022), Meningistis. Retrieved from:

https://www.cdc.gov/meningitis/index.html#:~:text=Meningitis%20is%20an%2
0inflammation%20(swelling,infections%20also%20can%20cause%20meningiti.
Muller., L, M, (2019). Medscape. Pediatric Bacterial Meningitis. Retrieved from:

https://emedicine.medscape.com/article/961497-overview#:~:text=Before%20t
he%20routine%20use%20of,aged%201%2D23%20months).
References
Smith, S. M. (2018). Meningitis: Diagnosis, treatment, and prevention. New

York, NY: Springer.
ACUTE GLOMERULONEPHRITIS
DEFINITION
Acute glomerulonephritis results from inflammation of tiny tubes (glomeruli) in

the kidney. These tubes act as a filter, cleaning the blood by separating wastes
and extra fluid. When the glomeruli do not function properly, waste products
build up in blood. This is often referred to as acute poststreptococcal
glomerulonephritis or APSGN
INCIDENCE AND PREVALENCE
Most cases occur in patients aged 5-15 years; only 10% occur in patients older
than 40 years. Outbreaks of PSGN are common in children aged 6-10 years.
Acute nephritis may occur at any age, including infancy. AGN predominantly
affects males (2:1 male-to-female ratio), (Parmar, 2022).
PATHOPHYSIOLOGY
Acute glomerulonephritis (AGN) comprises a specific set of kidney diseases in
which an immunologic mechanism triggers inflammation and proliferation of
glomerular tissue that can result in damage to the basement membrane,
mesangium, or capillary endothelium.
In children, a common cause of glomerulonephritis is from a streptococcal

infection, such as strep throat or upper respiratory infection. Glomerulonephritis
usually occurs more than one week after an infection (Parmar, 2022).
MANIFESTATIONS
● Dark brown-colored urine

● Diminished urine output ● Fluid accumulation in the
● Fatigue tissues (edema)
● Lethargy ● Weight loss
● High blood pressure ● Pale skin color
● Seizures (may occur as a result ● Hematuria and proteinuria
of high blood pressure)
COMPLICATIONS
● Even with proper treatment, complications may develop. The kidney

function may decrease to the point of kidney failure. If this happens,
dialysis or a kidney transplant is needed.
Risk factors
● A systemic autoimmune ● Focal segmental

disease such as lupus glomerulosclerosis, which causes
● Henoch-Schönlein purpura- this scarring in some of the glomeruli.
disease causes small or large ● Streptococcal infection
purple lesions (purpura) on the ● Polyarteritis nodosa-
skin and internal organs. inflammatory disease of the
arteries.
INTERDISCIPLINARY CARE
The goal of treatment is to maintain renal function, prevent complications and

support the healing process. Members involved in the care: Physician,
pharmacist, nurses, family members.
Diagnosis is made based on:
Throat and skin cultures, Anistreptolisin O titer and erythrocyte sedimentation

rate to determine the cause of the disease.
KUB, abdominal x-ray will show enlarged kidneys in acute glomerulonephritis.

INTERDISCIPLINARY CARE
A CBC reveals decreased hematocrit, anemia, increased electrolyte levels, BUN

and creatinine levels reveals renal impairment and decreased GFR.
Urinalysis shows dark urine, S.G of >1.020, proteinuria and cast cells are
present.
Diet
Sodium and fluid restriction , protein restriction for patients with azotemia.
Encourage parents to :
Feed child healthy unprocessed food.
Prevent the child contracting an infection by practising good hygiene.
The nurse should emphasize the importance of getting treatment for sore
throat and skin infections.
The importance of completing the course of given antibiotics.

Approximately two weeks ago, Ethan a six-year-old male, had a sore throat and mild fever, which
resolved spontaneously after a couple days. However, his parents noticed he had had gained a
significant amount of weight in a short span of time, as well as swelling in his face, hands, and
feet starting a few days ago. They also observed that Ethan's urine output decreased significantly,
and his urine appeared dark in colour. More recently, Ethan has been experiencing rapid
breathing, coughing, and difficulty breathing, which prompted their visit to the emergency
department.
On examination, Ethan's vital signs are slightly elevated for his age, He has an elevated pulse rate
(130bpm), respiratory rate (28 bpm), and blood pressure (128/90 mmHg), decreased spO2 (93%).
He appears fatigued, and in mild respiratory distress with breathlessness with speech and use of
accessory muscles noted. There is bilateral crackles (rales) heard on auscultation of the lung
fields. He has significant puffy eyelids, facial edema, and pedal edema (swelling in the feet and
ankles). His abdomen is soft, non-tender. Urinalysis reveals protein 2+, and blood 2+.
Careplan #1: Ineffective breathing pattern
Assessment:
Subjective data:
● Patient c/o SOB
Objective data:
● Rapid and shallow breathing

● Use of accessory muscles
● Increasing breathlessness with speech and movement
● Increased respiratory rate (28 bpm) (Normal range for age: 15-20 bpm)
● Decreased oxygen saturation level (93%)
● Presence of crackles upon auscultation of lung field.
Nursing Diagnosis:
Ineffective Breathing Pattern related to fluid overload and pulmonary edema AEB Rapid and
shallow breathing, Use of accessory muscles, Increasing breathlessness with speech and
movement, Increased respiratory rate (Normal range for age: 15-20 bpm), Decreased oxygen
saturation level (93%), Prescence of crackles upon auscultation of lung field.
Plan:
At the end of one (1) hour following nursing and collaborative interventions, the patient will
achieve an improvement in breathing pattern AEB patient verbalizing ease of breathing,
minimal or no use of accessory muscles, reduced respiratory rate from 28 bpm to 22-18 bpm,
and spO2 increasing from 93% on room air to 95%-99% on oxygen.
1. Place the patient in the semi-fowler’s position. R: To allow for maximal lung expansion.
2. Provide supplemental humidified oxygen (5L/min) via face mask as ordered. R: Oxygen
supplies the lungs with additional oxygen, thereby increasing oxygen levels and
improving patient’s breathing.
3. Administer antibiotics as ordered. R: To treat any underlying infection that may have
caused respiratory issues.
4. Monitor patient’s respiratory rate, depth, quality as well as oxygen saturation and lung
sounds hourly. R: To determine adequacy of ventilation. An elevated respiratory rate,
laboured breathing, a decreased oxygen saturation level and adventitious lung sounds such
as rhonchi and wheezing are signs of inadequate ventilation and respiratory distress.
5. Demonstrate and instruct patient to do deep breathing exercises. Ask parent to assist child
with these exercises. R: Deep breathing exercises, help to improve ventilation by increasing
oxygenation.
6. Group nursing activities and move patient’s items closer to bed. R: This helps to reduce the
patient’s oxygen consumption and physical exertion.
Careplan #2: Excess Fluid Volume
Assessment
Subjective data:
● Patient c/o SOB

● Patient verbalized “I have difficulty passing urine, and when i do i only let out a little.”
Objective data:
● Oliguria (decreased urine output <30 mls/hr)

● Increased BP (148/92 mmHg)
● Haematuria and Proteinuria
● Weight gain (gained 15 pounds within a week)
● Periorbital edema
● Puffiness in the face
● 3+ pitting edema to feet and ankles
● Crackles heard upon auscultation of the lung field
Nursing Diagnosis:
Excess Fluid volume R/T decreased glomerular filtration and increased sodium AEB
(decreased urine output <30 mls/hr); Increased BP (148/92 mmHg); Haematuria and
Proteinuria; Weight gain (gained 15 pounds within a week); Periorbital edema; Puffiness in the
face; 2+ pitting edema to feet and ankles; Crackles heard upon auscultation of the lungs
Plan:
At the end of eight (8) hours following nursing and collaborative interventions, the patient will
achieve an improvement in excess fluid volume AEB urine output greater than or equal to 30
mL/hr,
1. Strictly monitor intake and output. R: To ascertain patient’s fluid balance and hydration
status.
2. Implement dietary modifications, such as sodium and fluid restrictions. R: High sodium
intake leads to increased water retention that causes edema. Therefore, restriction of salt
and fluid intake can help to decrease edema.
3. Monitor and document the patient’s weight daily using the same scale daily, at the same
time and observe for sudden weight gain. R: Sudden weight gain may indicate fluid
retention, and standardized measurement techniques ensure accurate assessment of
changes in fluid status over time.
4. Administer a diuretic such as Lasix as ordered. R: Lasix (a loop diuretic) helps the body
to increase urine production and fluid excretion by inhibiting the reabsorption of water
and sodium by the kidneys, thereby helping to reduce edema and lower blood pressure.
5. Administer an anti-hypertensive such as Enalapril as ordered. R: Enalapril (a ACE inhibitor)

helps to reduce the BP by preventing an enzyme (ACE) in the body from producing
angiotensin II, a substance that narrows blood vessels. This medication widens the blood
vessels and helps to reduce the amount of water put back into your blood by your kidneys.
6. Measure and record abdominal girth daily. R: Edema is normally observed in the abdomen
which may increase as the condition progresses.
7. Conduct a urine dipstick analysis and note the colour, specific gravity and note the presence
of proteinuria or haematuria. R: The presence of protein and blood in the urine, as well as a
concentrated urine and an elevated specific gravity of urine (>1.030) can indicate renal
dysfunction due to glomerular damage and dysfunction.
8. Monitor patient’s V/S q 4 hours, especially pulse rate, respiratory rate and BP. R: Signs such
as tachycardia, hypertension, tachypnea, can indicate fluid volume excess and guide
appropriate fluid management interventions.
9. Monitor laboratory studies, including sodium, potassium, BUN, and ABGs, as indicated. R:
Helps to evaluate electrolyte imbalances, renal function, and acid-base status, providing
insights into the underlying causes of fluid volume excess and informing appropriate
interventions.
Evaluation:
Goal met. At the end of eight (8) hours following nursing and collaborative interventions, the
patient achieved an improvement in excess fluid volume AEB urine output greater 30 ml/hr
(55mls/hr).
Careplan #3: Risk for impaired skin integrity
Assessment:
Subjective data:
Objective data:
NURSING CARE: Infection Control
● Impaired renal function puts the child at risk for infection.

● Monitor for signs of infection, including fever, increased malaise, and an elevated
white blood cell count.
● Screen family members for the presence of streptococcal infection and refer for
treatment if necessary.
● Instruct the family in good hand hygiene technique.
● Limit visitors, and screen for upper respiratory infections.
Medication
Loop diuretics (furosemide) for volume, BP, and potassium control
Antihypertensive agents; vasodilators such as calcium channel blockers (e.g.,

nifedipine, isradipine, amlodipine)
Serum potassium-lowering agents (sodium polystyrene sulfonate [Kayexalate],

furosemide, bicarbonate, insulin/glucose, B-agonists).
IV calcium is used to stabilize the myocardium in severe hyperkalemia (Johnson,

Medication
Immunosuppressive agents such as prednisone, cyclophosphamide, mycophenolate
mofetil, and rarely rituximab or eculizumab are used in the treatment of
vasculitis-associated glomerulonephritis
Penicillin is used in active poststreptococcal glomerulonephritis to prevent rheumatic

fever and the spread of nephritogenic strains but generally does not affect the course
of the renal disease (Johnson, Feehally, & Floege, 2015).
Maintain fluid restrictions of Na K and Ca
Administering medications as ordered
Providing emotional support to the patient and their family, addressing their
concerns and promoting coping strategies during the acute phase of the illness.
Documenting promptly medication administration
Reporting any abnormalities in patient condition to doctor.

Monitoring laboratory values, such as urine output, serum electrolytes, and

renal function tests, to assess kidney function and detect any abnormalities
Implementing infection control measures to prevent the spread of infection,

including proper hand hygiene and isolation precautions if necessary.
Assisting with dietary management by providing guidance on a low-sodium and

low-protein diet, as recommended for patients with renal impairment
Health education for patient and family
1. Reinforce medical explanation of the disease process
a. Emphasize the need for medical evaluation and culture of all sore throats for all
family members.
b. Alert the family to signs and symptoms of disease recurrence.
c. Be aware that microscopic hematuria may persist up to 2 years.

2. Reinforce activity recommendation; usually not restricted.
3. Advise that tonsillectomy or other oral surgery is not recommended for several
months after the acute phase of glomerulonephritis.
a. If this type of surgery is necessary, penicillin may be recommended before and after
the procedure to prevent bacterial infection.
b. Obtain information regarding drug allergies before administering penicillin (Johnson,

Feehally, & Floege, 2015).
Discharge teaching
● Inform the parents about the need for regular follow-up appointments with the
healthcare provider to monitor the child's progress
● Educate the parents about the signs and symptoms that may indicate a worsening
condition or the development of complications. These may include persistent high
fever, worsening swelling, decreased urine output, increased blood pressure, or
blood in the urine (Johnson, Feehally, & Floege, 2015).
Discharge teaching
● Discuss the prescribed medications, their purpose, and the importance of

adhering to the medication schedule.
● Explain the importance of monitoring the child's fluid intake and output.
Encourage the parents to provide an adequate amount of fluids to prevent
dehydration but avoid excessive fluid intake (Johnson, Feehally, & Floege,
2015).
References
Johnson, R. J., Feehally, J., & Floege, J. (201). Comprehensive clinical

nephrology (5th ed.). Philadelphia, PA: Elsevier Saunders
Parmar, S., Malvinder, (2022). Acute Glomerulonephritis. Medscape. Retrieved

from:
https://emedicine.medscape.com/article/239278-overview#:~:text=Acute%20
glomerulonephritis%20(AGN)%20comprises%20a,%2C%20mesangium%2C%20
or%20capillary%20endothelium.
Tonsillitis
Definition
Tonsillitis is inflammation of the tonsils which is usually caused by a viral
infection or less commonly a bacteria infection (Anderson & Paterek, 2022).

Incidence and Prevalence
Tonsillitis is a common condition in children between the ages of 5 and 15 as
they are constantly exposed to germs from their peers also among teenagers
and young adults.This condition makes up approximately 1.3% of outpatient
Visits (Waldman & Bianchi, 2019).

Pathophysiology
Tonsillitis is generally the result of an infection, which may be viral or bacterial.

Viral etiologies are the most common. The most common viral causes are
usually those that cause the common cold, including rhinovirus, respiratory
syncytial virus, adenovirus, and coronavirus. These typically have low virulence
and rarely lead to complications. Other viral causes such as Epstein-Barr
(causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may
also cause tonsilitis.
Manifestations
The main symptom of tonsillitis is sore ● High temperature (fever) over 38C
throat (100.4F
● Coughing
● The tonsils will be red and swollen, ● Earache
and the throat may be painful, ● Swollen, painful lymph glands in your
making swallowing difficult. neck
● Loss of voice or changes to your
● In some cases, the tonsils are voice
coated or have white, pus-filled ● Difficulty breathing and snoring
spots on them.
Complications
Complications of tonsillitis are rare and usually only occur if it's caused by a
bacterial infection. They are usually the result of the infection spreading to another
part of the body. These include:
● Middle ear infection (otitis media)- where fluid between the eardrum and inner
ear becomes infected by bacteria
● Obstructive sleep apnea- where the walls of the throat relax during sleep, which
causes breathing difficulties and poor sleep
● Peritonsillar abscess- an abscess (collection of pus) that develops between one
of the tonsils and the wall of the throat
Risk factors
Risk factors for bacterial tonsillitis include:
Childhood and adolescence.
● Bacterial tonsillitis is more frequent in young children and teenagers.

● Bacterial tonsillitis is more common in children of age group 5-15 .
● Viral tonsillitis can be experienced more by younger children, children
between the age group of 2-5.
● Tonsillitis in children below 2 years is comparatively rare.
Risk factors cont’d
Exposure to pathogens.
● School going children are more exposed to infections compared to adults

due to their close proximity with their peers.
Diagnosis is made by:
Throat swab- using latex agglutination antigen or enzyme linked immunoassay

test to test for streptococcus antigen.
Complete blood count- will show normal or low WBC in viral infections and are
elevated in bacterial infections.
Health care team members involved in the care of tonsillitis are; general
physician, respiratory physician, pharmacist, nurse, pediatric ENT specialist.
The vast majority of children need only symptomatic treatment
Treatment includes antipyretics, mild analgesia such as acetaminophen for

relief of throat pain and fever.
Penicillin is the drug of choice for group A streptococci infections, if allergic to

penicillin cefuroxime, amoxicillin or erythromycin can be given. Antibiotic
therapy is usually given for 10 days.
Tonsillectomy is indicated for recurrent or chronic infections, hypertrophy of the

tonsils with airway obstruction, repeated otitis media, peritonsillar abscess and
tonsil malignancy.
Nurses should encourage parents to allow child to get plenty of rest, drink cool
fluids to soothe throat, give child analgesics such as paracetamol to relieve
pain.
Parents can also give child warm saline gargle to soothe throat dependent on
the age of the child.
Ethan is brought to the emergency department by his parents due to complaints of a sore throat,
difficulty swallowing, and fever. His parents note that Ethan has been experiencing these
symptoms for the past two days, and they have progressively worsened. Parents gave history of
a recent respiratory illness (the common cold).
Ethan's symptoms started with a mild sore throat and gradually worsened over the past two
days. He now experiences significant pain while swallowing, which has affected his appetite.
Ethan's parents have also noticed that he has developed a fever and occasional bad breath.
On examination, Ethan appears unwell. His throat is red and swollen, with visible enlargement
and inflammation of the tonsils. The tonsils may have a white coating, indicating the presence
of pus. Cervical lymph nodes may be palpable and tender.
Nursing Careplan#1: Acute Pain
Assessment
Subjective data:
● The patient complaint of experiencing pain to his throat and stated that it is of a scratchy and sharp
characteristic which started suddenly when he awoke in the morning two days ago, and that the pain has
been constant since. Patient states that the pain is normally a 7/10 however it increases to 9/10 when
eating (coarse/dry food). He states that resting his voice, and receiving pain medications (e.g., panadol),
helps to alleviate his pain. The patient sates that the pain does not radiate. Other associated symptoms
that the patient experience is a fever.
● Patient also complaint of difficulty swallowing
Objective data:
● Swollen and red tonsils noted,

● Enlarged lymph nodes noted that are tender to touch upon palpation,
● Hoarse voice
● Facial grimacing noted.
Nursing Diagnosis
Acute pain related to inflammation of the tonsils AEB patient c/o a sore throat and
difficulty swallowing, patient rates pain as 7/10, swollen and red tonsils noted,
enlarged lymph nodes noted that are tender to touch upon palpation, hoarseness of
voice and facial grimacing noted.
Plan:
patient will achieve a reduction in acute pain AEB the patient verbalizing a reduction
in pain from 7/10 to 3/10 - 4/10, and minimal or no facial grimacing noted.
1. Assist patient into a comfortable position. R: This helps to alleviate intensity of pain
and promotes rest and comfort.
2. Administer analgesics such as Panadol 1g PO as ordered. R: This medication helps to
alleviate pain by inhibiting the COX- 1 and COX- 2 enzymes that help with the
production of prostaglandin (a hormone-like substance that causes inflammatory
pain).
3. Administer an antibiotic (Amoxicillin 250 mg PO) and a corticosteroid
(Dexamethasone 0.6mg/Kg/dose) as prescribed. R: Antibiotic and corticosteroid
therapy are used to reduce the inflammation and therefore decrease pain.
4. Have the child gargle a solution of baking soda and salt (1/2 teaspoon each) in a glass
of water. R: To soothe an irritated throat.

5. Encourage diversional therapy (allow patient to play games on phone, deep
breathing, hold hands, talk with patient). R: To distract patient from pain.
6. Apply an ice collar on the neck and give the child adequate cool drinks and a
popsicle to eat. R: Cold promotes vasoconstriction and decreases swelling that
contributes to pain.
7. Instruct patient to avoid eating hot, spicy, and coarse foods such as chips or
crackers. R: These food items can aggravate the pain and can cause bleeding.
8. Reassess pain level. R: To evaluate whether pharmacological and
non-pharmacological therapy is working.
Evaluation:
At the end of thirty minutes following nursing and collaborative
interventions, the patient achieved a reduction in acute pain AEB the
patient verbalizing a reduction in pain from 7/10 to 4/10, and
minimal or no facial grimacing noted.
Nursing Careplan#2: Risk for deficient Fluid Volume
Assessment:
Subjective dat
● Patient c/o difficulty swallowing

● Patient state that last meal was last night and that he only ate a small amount
Objective data:
● Documentation of last meal: 7p.m.- Patient only ate a small portion of his meal.
● Urine output 40 mls/hr
● Mucous membranes pink and moist
● Skin turgor prompt
● BP 105/68 mmHg (Normal range: 97/57 mmHg – 115/76 mmHg)
● PR 110 bpm (Normal range: 75- 120 bpm)
● Inflamed tonsils noted (red, edema)
Nursing Diagnosis:
Risk for deficient fluid volume AEB inadequate fluid intake- Patient c/o difficulty
swallowing; Documentation of last meal: 7p.m.- Patient only ate a small portion of his
meal; mucous membranes of eyes and mouth pink and moist; skin turgor prompt;
urine straw coloured, urine output 40mls/hr, BP 105/68 mmHg, PR 110 bpm.
Plan:
At the end of the 4-hour nursing shift following nursing and collaborative
interventions, the patient will maintain an adequate hydration status AEB pink and
moist mucous membranes, straw coloured urine, urine output >30mls/hr, prompt skin
turgor.
1. Maintain IvF therapy as ordered. R: For fluid maintenance, prevention of dehydration and to ensure that
the patient is receiving fluids in a timely manner.
2. Set a drinking schedule and encourage the patient to take small, frequent sips of the preferred beverage(if
not contraindicated) of his choice (as tolerated) and use colourful and fun drinking containers when
giving the patient fluids. R: Offering small, frequent sips of a drink throughout the day makes drinking
less overwhelming and ensure a steady intake. Giving the child a drink of his choice makes it more
appealing to drink, and utilizing colourful and attractive cups that may capture the child's attention can
make drinking more enjoyable.
3. Create a positive reinforcement system to motivate the child by providing rewards or incentives every
time they finish a certain amount of fluid (give stickers, small toys, or praise). R: This can encourage
them to continue drinking.
4. Keep fluids within easy reach of the child. R: This reduces the effort required to get a drink and increases
the likelihood of them taking regular sips.
5. Monitor intake and output and urine colour. R: To determine fluid and hydration status. A urine output
less than 30mls/hr and concentrated urine indicates fluid deficit.
6. Monitor for signs of insensible losses (increased respiratory effort, sweating), as well as the patient’s
mucous membrane, and skin turgor for signs of dehydration (slow skin turgor, dry mucous membranes).
R: To assess hydration status.
7. Monitor BP and P q 2 hours. R: Changes in BP and HR can indicate hypovolemia, electrolyte

imbalances, or compensation mechanisms.
8. Perform and monitor dipstick urine analysis. R: High specific gravity (>1.030) suggests that the
concentration of urine is too high. This can be a sign of dehydration.
9. Monitor laboratory studies such as a U&Es. R: This is used to check for any electrolyte imbalances.
R: Dehydration can lead to imbalances in electrolyte levels, such as low sodium or potassium.
Evaluation:
interventions, the patient maintained an adequate hydration status AEB pink
and moist mucous membranes, straw coloured urine, urine output 60mls/hr,
prompt skin turgor.
Nursing Careplan#3: Impaired Swallowing
Assessment
Fluid management in a child with tonsillitis involves assessing their hydration status and
encouraging oral intake if possible. Intravenous fluids may be necessary if oral intake is
inadequate. Calculate maintenance fluid requirements based on weight and age. Monitor
vital signs, urine output, and weight regularly. Administer anti-inflammatory and analgesic
medications for pain and fever. Provide throat care and support adequate nutrition.
Educate caregivers about fluid intake and signs of dehydration. Individualize the plan
based on the child's condition and healthcare provider's recommendations.
Vaccine
Respiratory etiquette
Hand hygiene
Treat respiratory infections

Medications
The most common antimicrobial agent is oral penicillin, which is taken for 7
days. Amoxicillin and erythromycin are alternatives.
continuous nursing observation immediately after surgery
monitor patient for signs of bleeding
place in most comfortable position prone with head turned to side allow drainage from
mouth to pharynx.
patient is refrianed from doing too much talking and coughing.

Explain and write instructions concerning the care of the child at home after
discharge.
a. Diet should still consist of large amounts of fluids and soft, cool, nonirritating
foods. (Supply a list of suggestions for the family.)
b. Eating helps promote healing because it increases the blood supply to the
tissues
.c. Bed rest should be maintained for 1 to 2 days and then daily rest periods for about
1 week. Resume normal eating and activities within 2 weeks after surgery.
d. Avoid contact with people with infections.
e. Discourage the child from blowing nose and frequent coughing and clearing of his
or her throat.
f. Avoid gargling. Mouth odor may be present for a few days after surgery; only
mouth rinsing is acceptable.g. Discourage use of red dye enhanced foods or
analgesics if possible—can be difficult to differentiate from bleeding.
2. Advise the parents to call the health care provider if the following occur. (Ensure
that the parents have the phone numbers of the health care provider and hospital
emergency department.)
a. Earache accompanied by fever.
b. Any bleeding, often indicated only by frequent swallowing; most common between the
5th and 10th postoperative days when membrane sloughs from surgical site.
3. Teach about medications prescribed or suggested for pain relief.
4. Discuss with the parents what results they can expect from the surgery such as
.a. Decreased number of sore throats.
b. Lessened evidence of obstructive symptoms.

Explains that halitosis and some minor ear pain may occur for a few days
avoid vigorous tooth brushing or gargling since the action could cause bleeding
Discharge teaching
Report frank red blood after surgery
Signs and symptoms of hemorrhage
Expect sore throat, a stiff neck and vomiting may that can occur in the first 24 hours
A liquid or semi liquid diet is acceptable for several days
avoid spicy, hot, acidic or rough foods
Milk and milk products may make removal of mucus more difficult
References
Anderson, J., & Paterek, E. (2022, September 18). Tonsillitis - statpearls - NCBI bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK544342/.
Asthma
Definition
Asthma is a long term disease caused by inflammation and swelling of the
airways in that the bronchi and bronchioles within the lungs becomes narrowed
(Goff, 2022).
Nearly 26 million people in the USA alone have asthma, which is 1 in every 13 person.
Asthma is more common in female adults than male adults with around 9.7% of
female adults have asthma when compared to 6.2% are male adults.
Asthma is the leading chronic disease in children where there is currently about
4.8million children under the age of 18 with asthma.
Asthma is more common in male children than female children which about 7.3% are
male while 5.6% are female children (Goff, 2022).
Incidence and Prevalence Cont’d
In 2019, asthma accounted for 4.9 million doctors’ office visits with about
169,330 discharges from hospital inpatient care and 1.5 million emergency
department visits.
Black people in the U.S. are nearly six times more likely than white people in the
U.S. to visit the emergency department due to asthma (Goff, 2022).
Pathophysiology
The pathophysiology of asthma is complex and involves airway inflammation,

intermittent airflow obstruction, and bronchial hyperresponsiveness.
Asthma is a multifactorial disease in which susceptible individuals have an

exaggerated response to various stimuli. The disease process is driven by as
vast array of mediators that lead to airway obstruction, and in more severe
disease, airway remodelling.Classical allergic asthma is driven by Th2 type
T-cells. Allergens are presented to these cells by dendritic cells, which in these
individuals leads to a disproportionate immune response.
Pathophysiology
The TH2 cells are activated by dendritic cells, and cytokines released from them
result in the activation of the humoral immune system, with an increased
proliferation of mast cells, eosinophils and dendritic cells as a result.
In turn, cytokines released by these cell contribute to the underlying inflammatory

process and bronchoconstriction. One particular example of this is leukotriene C4,
which is directly toxic to epithelial cells. Other mediators further exacerbate the
situation by favouring the production of an exudate, such as the histamine released
from mast cells (Holding et. al, 2018).
Manifestations
● Symptoms of Asthma in children is usually presented between the ages

3-8 years.
● The symptoms of Asthma typically occurs at night or in the early morning
and vary from mild to moderate to severe from person to person.
● Wheezing on expiration is a classic sign.
● Hunched shoulders, tripod position, refusal to lie down
Manifestations cont’d
● Tightness in the chest, shortness of breath.

● Coughing that maybe dry, non productive, or productive and may
commonly occur at night.
● Suprasternal and substernal retractions, use of accessory muscles. Infant
may head bob.
● ‘Silent Chest” is an ominous sign of impending respiratory arrest
Complications
● Severe asthma attacks that require emergency treatment or hospital

care.
● Missed school days or falling behind in schoolwork.
● Poor sleep and fatigue.
● Symptoms that interfere with play, sports or other activities.
● Permanent decline in lung function
● Status asthmaticus
Risk factors
Triggers are anything that provoke inflammation in the airway and are usually
specific to the individuals. They include:
● Dust mites
● Animals
● Cockroaches
● Moulds
● Pollens
● Viral infections
● Air pollutants
Symptom trigger that provoke ‘twitchy’ airways include:
● Smoke, exercise, cold air, strong smells such as perfumes, food

allergies(Egg and tree nut),food additives such as sulphites, air pollutants,
moulds and mildew, dust and intense emotions.
Diagnosis is made by history and physical exam
Lab test such as pulmonary function tests ( incentive spirometry) to show if

there is airway obstruction, the extent of the obstruction and response to
treatment.
Provocational testing
Exercise challeng- determines effect of exercise on trigging airway obstruction
Cold air challenge-test for airway hyperresponsiveness.

Allergy evaluation
Blood test- IgE level
Skin testing- test for allergen sensitivity
Chest radiograph to rule out congenital lung malformation

Severe asthma is most effectively managed with an interdisciplinary
approach.an experienced respiratory physician confirms the diagnosis and
prescribe management strategies.
A specialist nurse provides education, administer therapies and coordinate

disease management.
An accredited respiratory scientist conducts lung function assessment to

confirm disease and determine disease phenotypes.
A pharmacist provides inhaler technique training and provide advice about

concomitant medications.
Management of the patients comorbidities is done by dieticians, psychologists,

sleep physicians, gastroenterologist, otolaryngologists and physiotherapists.
They coordinate to provide consistent and integrated care.
Patient should be encouraged to adhere to treatment regime for proper control of

asthma attacks.
All medications should be explained and potential risk and benefits reviewed.
Patients should be provided with a written asthma plan, outlining the action plan for
managing exacerbations.
Patients should;
avoid irritants such as dust, mites, tobacco, fumes

Nursing Care: Health Promotion CONT’D
Minimise dust exposure
Minimise stuffed animals, quilts, books and clutter.
Use dust proof coverings on mattresses, pillows
Wash pillows blankets and sheet in hot water.
Avoid molds
Avoid pets if allergic.

Liam, a 10-year-old male who is a known asthmatic, was rushed to the emergency department by his
parents due to a sudden onset of severe shortness of breath, chest tightness, audible wheezing, and
increased work of breathing. His parents note that Liam has been experiencing a cough and mild
wheezing for the past two days, but it has progressively worsened over the last few hours, leading to
significant respiratory distress. His parents state that he has been using his quick-relief inhaler more
frequently without significant relief. They also stated that his symptoms worsen at night and in the
early morning, affecting his sleep. They attribute his asthma exacerbation to him having a recent cold
approximately 2 weeks ago.
On examination, Liam appears anxious and is in moderate respiratory distress. He complaint of chest
tightness, his respirations were rapid and laboured, he had an elevated respiratory rate, decreased
oxygen saturation, use of accessory muscles and nasal flaring noted. Audible wheezing heard and
wheezing heard upon auscultation of the lung field.
Nursing Careplan #1: Ineffective Breathing Pattern
Assessment
Subjective data:
Patient verbalized “I can’t breathe, and my chest feels tight especially when coughing.”
The parents stated that his symptoms started to worsen two days ago and that his symptoms worsen at nights
and in the early morning, his inhaler would usually help however, it was not helping much this time around.
Objective data:
● Breathlessness with speech
● Respirations laboured, and tachypnoeic
● RR 32 bpm (Normal range:15- 25 bpm), spO2- 93% on room air.
● Turbinates of nose enlarged, and minimal rhinorrhoea observed.
● Nasal flaring observed.
● Persistent coughing with minimal, white-coloured sputum being expectorated.
● Use of accessory muscles (shoulders) observed
● Chest expansion equal bilaterally but inadequate
Nursing Diagnosis:
Ineffective breathing pattern r/t bronchoconstriction AEB patient verbalizing “I can’t breathe, and my
chest feels tight especially when coughing.”, Breathlessness with speech, Respirations laboured, and
tachypnoeic, RR 32 bpm (Normal range:15- 25 bpm), spO2- 93% on room air, Turbinates of nose enlarged,
and minimal rhinorrhoea observed, Nasal flaring observed, Persistent coughing with minimal,
white-coloured sputum being expectorated, Use of accessory muscles (shoulders) observed, Chest
expansion equal bilaterally but inadequate.
Plan:
Within 1 hour of the nursing shift following nursing and collaborative interventions, the patient will
achieve an improvement in breathing pattern AEB the patient verbalizing “I can breathe a little better
now.”, reduction in audible wheezing and nasal flaring, minimal or no use of accessory muscles, reduced
respiratory rate from 32 bpm to 28-22 bpm, and oxygen saturation increasing from 93% on room air to
95%-99% on oxygen.
Interventions & Rationales:
1. Place patient in an upright or semi fowlers position. R: To allow for maximal lung expansion.
2. Nebulize patient with a short-acting beta 2 agonist bronchodilator such as Ventolin (8 puffs), and an
anticholinergic such as Atrovent (4 puffs) via a Metered Dose Inhaler (MDI) and spacer as ordered. R:
Bronchodilators and anticholinergics help to reduce bronchoconstriction by relaxing and dilating the
narrowed airways, thereby allowing for adequate gaseous exchange, subsequently helping the patient to
breathe easier.
3. Nebulize patient with an isotonic fluid such as 0.9% Normal saline (3cc) via a nebulizer as ordered. R:
Nebulized normal saline helps to thin and loosen secretions, thereby making secretions easier to expectorate,
as excess mucus can make it difficult to breathe.
4. Medicate patient with a corticosteroid such as prednisone 50 mg PO and an antihistamine such as
Diphenhydramine expectorant 10 mls PO as ordered. R: Oral corticosteroids such as prednisone are used to
treat asthma exacerbations as they aid with reducing the inflammation and oedema in the airways. An
antihistamine such as Diphenhydramine alleviate asthma symptoms such as wheezing and coughing by
helping to reduce the inflammation in the airways by blocking the action of histamine, a chemical released
by the body in response to an allergen.
Interventions & Rationales
5. Provide supplemental humidified oxygen (5L/min) via a face mask as ordered. R: oxygen supplies the
tissues with additional oxygen, thereby increasing oxygen levels and improving patient’s breathing.
6. Monitor patient’s respiratory rate, depth, quality as well as oxygen saturation and lung sounds ¼ hourly.
R: To determine adequacy of ventilation. An elevated respiratory rate, laboured breathing, a decreased
oxygen saturation level and adventitious lung sounds such as rhonchi and wheezing are signs of inadequate
ventilation and respiratory distress.
7. Monitor patient’s Arterial Blood Gases (ABGs). R: ABG measurements can provide information on the
patient’s oxygenation, acid-base status, and carbon dioxide retention, which can help guide treatment
decisions.
8. Demonstrate and instruct patient to do deep breathing exercises. R: Deep breathing exercises, help to
improve ventilation by increasing oxygenation.
Evaluation:
At the end of 1 hour of the nursing shift following nursing and collaborative interventions,
the patient achieved an improvement in breathing pattern AEB (S) the patient verbalizing a
reduction in shortness of breath by stating “Nurse I’m not feeling as breathless as before.”
(O) No breathlessness with speech noted, reduction in audible wheezing, no nasal flaring, or
use of accessory muscles noted, reduced respiratory rate from 32 bpm to 21bpm, and sp02
increasing from 93% on room air to 98% on 5L oxygen.
Nursing Careplan #2: Risk for Deficient Fluid Volume
Assessment:
Subjective data:
Patient verbalized “I only drank a little bit of tea this morning.” and “I’m not really hungry or thirsty.”
Parents state that his last meal was lastnight, in which he only ate a small amount and that his appetite is
decreased due to the coughing and SOB that he has been experiencing and due to him feeling unwell.
Objective data:
● Patient has not drank anything since this am,

● Increased respiratory effort
● Mucous membranes of eyes and mouth pink and moist,
● Skin turgor prompt,
● Uurine output 40mls per hour
● BP 110/74 mmHg (Normal range: 97/57 mmHg – 115/76 mmHg)
● PR 112 bpm (Normal range: 75- 120 bpm)
Nursing Diagnosis:
Risk for deficient fluid volume AEB inadequate fluid intake- last meal 17 hours ago, has not
drank anything since this a.m.; increased respiratory effort, mucous membranes of eyes and
mouth pink and moist; skin turgor prompt; urine straw coloured, urine output 40mls/hr, BP
110/74 mmHg, PR 112 bpm.
Plan:
At the end of the 4-hour nursing shift following nursing and collaborative interventions, the
patient will maintain an adequate hydration status AEB pink and moist mucous membranes,
straw coloured urine, urine output >30mls/hr, prompt skin turgor.
5. Monitor intake and output and urine colour. R: To determine fluid and hydration status. A urine output
less than 30mls/hr and concentrated urine indicates fluid deficit.
6. Monitor for signs of insensible losses (increased respiratory effort, sweating), as well as the patient’s
mucous membrane, and skin turgor for signs of dehydration (slow skin turgor, dry mucous membranes). R:
To assess hydration status.
7. Monitor BP and P q 2 hours. R: Changes in BP and PR can indicate hypovolemia, electrolyte imbalances,
or compensation mechanisms.
8. Perform and monitor dipstick urine analysis. R: High specific gravity (>1.030) suggests that the
concentration of urine is too high. This can be a sign of dehydration.
9. Monitor laboratory studies such as a U&Es. R: This is used to check for any electrolyte imbalances. R:
Dehydration can lead to imbalances in electrolyte levels, such as low sodium or potassium.
Evaluation:
interventions, the patient maintained an adequate hydration status AEB pink
and moist mucous membranes, straw coloured urine, urine output 75mls/hr,
prompt skin turgor.
Nursing Careplan #3: Anxiety
Assessment:
Subjective data:
Patient verbalized “Nurse I can’t breathe properly, am I going to die?”
Objective data:
● Patient appeared anxious and restless.
● Voice quivering
● Worried expression on face (furrowed brows, frowned lips)
● Jittery
Nursing diagnosis:
Anxiety R/T uncertainty of outcome AEB (S) Patient verbalizing “I can’t breathe
properly, mommy I’m nervous, am I going to die?” (O) Patient appeared anxious and
restless, voice quivering and worried facial expression noted.
Plan:
At the end of the 4-hour nursing shift flowing nursing and collaborative interventions,
the patient will achieve an improvement in anxiety AEB (S) the patient verbalizing “I
don’t feel like I’m going to die anymore” or “I don’t feel as nervous as before.” (O)
Patient does not appear restless or anxious.
1. Provide emotional support by staying with patient and allowing his family members to stay
R: This helps to facilitate rapport and allay anxiety.
2. Create a calm and quit environment (Reduce unnecessary noise, dim lights, and speak
softly). R: To help alleviate anxiety and promote relaxation.
3. Allow patient to express his concerns and ask questions- to which factual information can
be provided. R: This helps to clear up any misconceptions, as some fears are based on
inaccurate information, in which correct information can relieve.
4. Explain procedures and tests before they occur using age-appropriate language. R: This can
help to alleviate their anxiety by providing them with the information they need to feel more
in control, confident, and prepared.
5. Reassure patient that all that can be done is being done. R: This helps to reduce the patient’s anxiety by
providing reassurance that everything possible is being done to address the situation or problem at hand. This
phrase also showcases that their situation is being taken seriously and that all available resources are being
utilized to address it.
6. Demonstrate and encourage patient to do deep breathing exercises. R: Deep breathing exercises, help to
relax the muscles, which can counteract the physiological effects of stress and anxiety such as a “fight or
flight” response.
Evaluation:
Goal met. At the end of the 4-hour nursing shift flowing nursing and collaborative interventions, the patient
achieved an improvement in anxiety AEB (S) the patient verbalizing “I’m not as nervous as before.” (O)
Patient does not appear restless or anxious, no voice quivering noted.
● Fluid therapy is often necessary to restore and maintain adequate fluid balance.
● Adequate hydration is essential to thin and break up trapped mucous plugs in the narrowed
airways.
● An intravenous infusion may be needed if the child cannot meet fluid needs by mouth, and
for administering certain medications and glucose.
● Monitor the child’s intake, output, and specific gravity to avoid overhydration that could lead
to pulmonary edema in severe asthma episodes.
● As respiratory difficulty diminishes, offer oral fluids slowly. The child’s fluid preferences
should be determined and choices given where possible.
● Involve parents to help gain the child’s cooperation in taking oral fluids.
1. Hand hygiene: Teach the child to wash hands regularly for at least 20 seconds or use
hand sanitizer with 60% alcohol.
2. Respiratory hygiene: Encourage the child to cover their mouth and nose with a tissue or
elbow when coughing or sneezing and properly dispose of used tissues.
3. Avoidance of triggers: Help the child identify and avoid asthma triggers like smoke, pet
dander, dust, mold, pollen, and strong odors.
4. Regular cleaning and disinfection: Keep the child's living space clean, regularly clean
surfaces and objects, and follow disinfection guidelines.
5. Immunizations: Ensure the child is up to date with vaccinations, including the annual
influenza vaccine.
6. Avoid sharing personal items: Encourage the child to avoid sharing items like inhalers,
nebulizers, and water bottles.
7. Regular medical check-ups: Ensure the child's asthma is regularly monitored by healthcare
providers.
8. Promote good overall health practices: Encourage healthy habits such as exercise, a
balanced diet, adequate sleep, and stress management.. This can help to improve the child’s
immune system.
Medication
Long-acting beta-agonists (LABAs): These medications, such as formoterol and

salmeterol, help relax the muscles around the airways and are often prescribed in
combination with inhaled corticosteroids.
Leukotriene modifiers: Drugs like montelukast, zafirlukast, and zileuton target

specific chemicals involved in the inflammatory process of asthma.
Medication
Theophylline: It is a bronchodilator that helps relax the airway muscles and can be
taken in tablet or liquid form.
Immunomodulators: Medications like omalizumab and mepolizumab are used in

severe asthma cases to modify the immune response and reduce inflammation.
Medication
Quick-relief medications (also known as rescue or reliever medications):
Short-acting beta-agonists (SABAs): Medications like albuterol (salbutamol) provide

rapid relief by relaxing the airway muscles during an asthma attack or when
experiencing symptoms.
Medication
Anticholinergics: Ipratropium bromide is a medication that helps relax the airways

and can be used alongside SABAs in managing acute symptoms
Health education Family and patient
1Understanding Asthma:
Explain what asthma is, its causes, and common triggers (e.g., allergens, respiratory
infections, exercise).
Describe how asthma affects the airways, causing inflammation,

bronchoconstriction, and increased mucus production.
Emphasize that asthma is a chronic condition that requires long-term management

Health education family and patient
Asthma Triggers:
Discuss common triggers, such as dust mites, pollen, pet dander, mold, tobacco
smoke, air pollution, and respiratory infections.
Encourage patients to identify and avoid their specific triggers whenever possible
Health education family and patient
Lifestyle Modifications:
Encourage maintaining a healthy lifestyle with regular exercise and a balanced diet to
support overall respiratory health.
Discuss the benefits of maintaining a clean and allergen-free home environment.
Advise against smoking or exposure to secondhand smoke

Discharge teaching
Medications: Review the proper use of all prescribed medications, including

inhalers and any additional medications such as oral steroids. Explain the
purpose of each medication, when and how to take them, and any potential
side effects.
Discharge teaching
Inhaler Technique: Demonstrate and ensure the correct inhaler technique for
each type of inhaler. Emphasize the importance of using a spacer if prescribed
and the need to rinse the mouth after using corticosteroid inhalers.
Discharge teaching
Asthma Action Plan: Provide a written asthma action plan that outlines specific
steps to take in different situations, such as normal breathing, worsening
symptoms, or emergencies. Discuss when to adjust medication dosages and
when to seek medical assistance.
Discharge teaching
Recognizing Symptoms: Teach the patient to recognize early signs of

worsening asthma, such as coughing, wheezing, chest tightness, shortness of
breath, and nocturnal awakenings. Stress the importance of seeking medical
attention promptly if symptoms worsen.
Discharge teaching
Follow-up Appointments: Emphasize the importance of regular follow-up

appointments with their primary care physician or asthma specialist. Discuss
scheduling a visit and any necessary lung function tests or allergy evaluations
Discharge teaching
Trigger Management: Educate the patient on identifying and avoiding asthma

triggers, such as allergens (dust mites, pollen, pet dander), smoke, strong
odors, cold air, and exercise. Provide practical tips on reducing exposure to
triggers at home and work
References
Erik Waldman, & Mark Bianchi. (2019, October 31). Pediatric tonsillitis. Yale Medicine.
https://www.yalemedicine.org/conditions/tonsillitis#
Goff, S. (2022, April). Asthma facts and figures - aafa.org.
https://aafa.org/wp-content/uploads/2022/08/aafa-asthma-facts-and-figures.pdf
Burns
Definition
A burn is an injury to the skin or other organic tissue primarily caused by heat or
due to radiation, radioactivity, electricity, friction or contact with chemicals.
Thermal (heat) burns occur when some or all of the cells in the skin or other
tissues are destroyed by: hot liquids (scalds)
Incidence and prevalence
It is estimated that there are between 7 and 12 million people (up to 33,000
each day) who sustain burn injuries that require medical care, lead to a
prolonged absence from work or school, or result in death each year
Pathophysiology of burn
The pathophysiology of the burn wound is characterized by an inflammatory

reaction leading to rapid oedema formation, due to increased microvascular
permeability, vasodilation and increased extravascular osmotic activity.
Manifestations
Superficial ● Epidermis is affected
● Erythema (localized redness)
● No blisters
● Painful
● Mild swelling
Partial thickness ● Epidermis and apart of the dermis

● Appear red
● Pink or mottled, blisters noted
● painful; severe swelling; blanching
Manifestation cont’d
Deep partial thickness ● Epidermis and dermis is affected, muscles and tendons
may also be affected
● White or charred skin
● Painless due to damage to the nerve endings
full-thickness ● Penetrate deep tissue to fat, muscles and bone

● White or charred skin
● Painless due to damage to the nerve endings
Complications
The complications that occur in burns injury include:
• Hypovolaemia: immediate consequence of fluid loss & results in decreased

perfusion and oxygen delivery
• Decreased cardiac output: Cardiac output decreases before any significant

change in blood volume is evident
• Oedema: forms rapidly after burn injury • Decreased circulating blood volume:
decreases dramatically during burn shock
Complications cont’d
• Hyponatremia: is common during the first week of the acute phase as water shifts
from the interstitial space to the vascular space
• Hyperkalemia: immediately after burn injury hyperkalemia results from massive cell
destruction
• Hypothermia: Loss of skin results in an inability to regulate body temperature

Risk factors
● < 5 Years- playing with matches, cigarette lighters, trash fire, children reached
for pots, cups or dishes containing hot liquids sitting on a table or stove,
bathtub scalds often associated with lack of supervision, touching electrical
outlet
● 5 to 10 Years- often due to fire play and risk-taking behaviors.
● Adolescent- Injury associated with male peer-group activities involving
gasoline or other flammable products such as fireworks
●
The multidisciplinary team includes: Paediatric Surgery Consultants, burns Clinical
Nurse Consultant, burns Clinical Nurse, burns Registered Nurse, Social Worker,
Occupational Therapists, Physiotherapists, Music Therapy, Dietician, School teacher,
Research, Child and Youth Mental Health.
Estimating TBSA Total Body Surface Area (TBSA) is to be undertaken on admission to
Emergency department. While there are multiple techniques and apps that can assist
with this calculation the Lund and Browder formula is recommended because it gives a
more accurate when estimation of TBSA in paediatric patients.
Fluid Resuscitation
The systemic result following a burn injury causes increased capillary permeability
resulting in fluid shifting into the interstitial space around the burn. This can occur up to
around 24 hrs. Fluid Resuscitation is required to replace this large fluid loss over the first
24hrs. Fluid resuscitation should be administered if TBSA >10% in under 18mth old,
>15% in over 18mth old. The Parkland Baxter formula is recommended, with half given
over the first 8 hrs from the time of injury.
The remaining half is given over the following 16hrs.
(Parkland Baxter formula, 4ml*kg*TBSA= amount of fluid, then divide in 2)
Maintenance fluid should also be commenced BUT must be on a separate line and NOT
combined with fluid resuscitation. For large burns (>25%), Albumin has been shown to
decrease total amount of fluids required. Albumin should not be used within the first 6hrs
of sustaining a burn injury. After this time, Albumin should be given as a 50:50 ratio to the
resuscitation crystalloid.
Some children not requiring fluid resuscitation may require admission to ward to
monitor oral intake. It is common for children who have sustained burns involving the
face to have decreased oral intake over the following days. They may also require
insertion of a NGT if oral intake is poor.
Nutrition
Nutrition is an important facet of burns care especially within the paediatric burns
population. Children are more vulnerable to the metabolic demands and consequences
of a burn injury compared to adults. They have limited fat and lean body reserves,
increased body surface area in relation to weight, and extra need for nutrients for
growth and development. All children requiring Burns Fluid Resuscitation should have a
NGT inserted and commenced on enteral feeds. A dietician review is required to ensure
appropriate formula is used.
Pain Management
Pain management is an integral part of Burns care. No procedures should be undertaken

without adequate pain relief and constant reassessing of the patient. It has been proven
that there is a correlation between pain, stress, anxiety and their effect on burn wound
re-epithelialisation. Pain relief does not have to be just pharmaceutical. It is important to
have non pharmaceutical, age appropriate devices available for the children prior to
commencing the procedure.
Such items include:
Toys, TV, DVD, Music, breast feeding.
Certain burns that tend to require greater amounts of pain relief during dressing
procedures. These include; circumferential burns, contact burns from hot coals, burns >
5%.
Patients suffering anxiety - due to previous distressing dressing changes. For these
patients, please ensure you have adequate medical staff available when undertaking
these procedures and consult with the hospital guidelines to determine the most
Health promotion
You can help protect your child from heat burns in the following ways.
● Keep children away from kitchen appliances, irons, fireplaces, portable heaters, and
wall heaters.
● Use screens to block off areas, if needed.
● When outdoors, keep your child away from barbecue grills and campfires
● Install scald-resistant faucets in sinks, showers, and bathtubs that children use.
● Cook on the back burner with pot handles turned away from the edge of the stove.
● Be careful not to spill hot beverages when you carry or drink them around children.
● Keep your flammable garage items out of the reach of children.
Health promotion
● Place plug covers on all outlets.

● Unplug all electrical items that are in your child's reach
● Use extra caution when using electrical items in areas where water sources are
nearby.
● Do not let your child play with toys that must be plugged into an electrical outlet.
Ways to prevent friction burns include:
● Avoid dragging or pulling your child across carpet while playing

● Provide safety equipment for physical activities.
● Two examples are knee pads and elbow pads for roller skating or riding scooters
Health promotion
Keep the following types of items ● Bleach products

completely out of reach. ● Lime products
● Sparks from "sparklers" battery
● Toilet cleaners acid
● Plaster and mortar
● Fertilizers
● Oven and drain cleaners
Assessment:
8 month old Penelope was admitted to the hospital 8 weeks ago for receiving
deep partial and superficial partial thickness thermal burns to the head,
thorax, and upper limbs of the body, resulting from the spillage of hot water
from pulling on the cord of a kettle. It has been 8 weeks and 3 days since
patient S.F. has been admitted. TBSA: 24%
Subjective Data: Mother stated “She is crying like this because her dressing was done a few
minutes ago and it’s paining her”
Objective Data
● Crying inconsolable
● Knitted eyebrows
● Withdrawing right hand during assessment.
● FLACC Scale score 7/10 (Face-1, Legs-1, Activity-1, Cry-2, Consolability- 2

Nursing Diagnosis:
Acute Pain related to stimulation of nociceptors secondary to burn injury as evidenced by
child crying inconsolable, knitted eyebrows, FLACC scale score of 7/10 and withdrawing right
hand during assessment.
Plan:
At the end of 30 minutes following nursing and collaborative interventions, the patient will have a
reduction of pain as evidenced by nil crying, nil knitted eyebrows and FLACC scale score below 4/10.
Interventions:
1. Administer analgesic as ordered (Panadol 100mg) to disrupt pain pathway and reduce pain (Ball et. al, 2017).
2. Nurse the child in a comfortable position to reduce aggregation which may increases the child's pain (Ball et. al, 2017).
3. Use diversional therapy such as play to refocus attention from pain and to decrease pain perception (Ball et. al, 2017).
4. Pad side of cot to reduce the risk of the patient hitting affected areas on rails which will further increase pain (Ball et. al,
2017).
5. Group nursing actions to reduce aggregation which may increase pain (Ball et. al, 2017).
6. Reasses pain level. R:To evaluate whether pharmacological and non-pharmacological therapy is working
Evaluation:
Goal met- at the end of 30 minutes following nursing and collaborative interventions the patient had
reduction of pain as evidenced by no crying, no knitted eyebrows and FLACC scale score of 3/10 (Face-1,
Legs-0, Activity-1, Cry-0, consolability-1.

Medication
Normal saline (0.9% sodium chloride): This solution contains sodium and chloride
ions and is considered isotonic, meaning it has a similar concentration to the body's
fluids. It is often used initially in burn resuscitation.
Lactated Ringer's solution: This solution contains sodium, chloride, potassium,

calcium, and lactate. It is also isotonic and provides additional electrolytes.
Lactated Ringer's solution is commonly used once the initial resuscitation phase is
complete.
Medication
Pain medications: Depending on the severity of the burn, over-the-counter pain

relievers like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may be used to
help manage pain. For more severe burns, stronger prescription pain medications
may be required.
Medication
Topical antibiotics: Topical antibiotics are often prescribed to prevent or treat

infection in burned areas. Common options include silver sulfadiazine cream or
mafenide acetate cream. These medications help inhibit bacterial growth on
the burn wound.
Signs of infection: Educate the family on the signs and symptoms of infection
in a burn wound, such as increased redness, swelling, warmth, or drainage of
pus. Emphasize the importance of seeking medical attention promptly if any
signs of infection are noticed.
Dressing changes: Demonstrate and guide the family on proper wound care
techniques, including how to clean the burn area, apply prescribed ointments or
creams, and change dressings. Ensure they understand the importance of
maintaining good hand hygiene and using sterile or clean techniques during
dressing changes.
Nutrition and hydration: Highlight the significance of a balanced diet and

adequate fluid intake to promote wound healing. Encourage the family to
provide nutritious meals and offer fluids frequently to prevent dehydration
Scar management: Educate the family about scar management techniques,

such as gentle massage and moisturization, once the burn wound has healed.
Explain the importance of protecting the healing skin from excessive sun
exposure and using sunscreen.
Discharge teaching
Wash your hands thoroughly before touching the burn area.
Gently clean the burn wounds with mild soap and water or a prescribed wound
cleanser as instructed by the healthcare provider.
Apply prescribed ointments or dressings to the burn area as instructed.
Keep the burn area clean and dry between dressing changes.
Do not pop any blisters that may have formed

Discharge teaching
Encourage the child to rest and avoid strenuous activities that may aggravate the
burns.
Help the child maintain comfortable positions to reduce pain and pressure on the
affected area.
Ensure the child maintains a balanced diet that includes adequate protein, vitamins,
and minerals to support wound healing.
Encourage the child to drink plenty of fluids to stay hydrated

Pyloric Stenosis
Definition
Pyloric stenosis is an uncommon condition in infants that blocks food from

entering the small intestine.
In pyloric stenosis, the pylorus muscles thicken and become abnormally large,
blocking food from reaching the small intestine.
Pyloric stenosis typically first appears in babies between ages 4 and 6 weeks.
The condition is rare, occurring in about 3 out of 1,000 babies.
Pathophysiology
Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is

an uncommon condition in infants characterized by abnormal thickening of the
pylorus muscles in the stomach leading to gastric outlet obstruction. Clinically
infants are well at birth.
Manifestations
Vomiting after feeding- The baby may vomit forcefully (projectile), ejecting
breast milk or formula up to several feet away which may also contains blood.
Persistent hunger- Babies who have pyloric stenosis often want to eat soon
after vomiting.
Dehydration- The baby might cry without tears or become lethargic or changing
fewer wet diapers or diapers that aren't as wet as expected.
Manifestation Cont’d
Changes in bowel movements- Pyloric stenosis prevents food from reaching

the intestines as such babies might be constipated.
Weight problems- Pyloric stenosis can keep a baby from gaining weight, and
sometimes can cause weight loss.
Complications
Failure to grow and develop.
Dehydration- Frequent vomiting can cause dehydration and electrolytes

imbalance. Electrolytes help regulate many vital functions.
Stomach irritation- Repeated vomiting can irritate the baby's stomach and may
cause mild bleeding.
Risk factors
Premature birth- Pyloric stenosis is more common in babies born prematurely

than in full-term babies.
Smoking during pregnancy- This behavior can nearly double the risk of pyloric
stenosis.
Bottle-feeding- Some studies suggest that bottle-feeding rather than

breastfeeding can increase the risk of pyloric stenosis.
Diagnosis made by;
Careful physical examination which generally reveals a olive shape mass in the
mid-abdomen.
Blood tests done to evaluate dehydration and electrolyte imbalances.
Abdominal ultrasound- gold standard for diagnosing, used to reveal length and
thickness of pyloric muscle.
barium swallow/GI series - will show a narrowing of the and demonstrates delayed
Pyloric stenosis treated in 2 stages;
First IV fluids to treat dehydration and restore normal body chemistry.
Then pyloromyotomy- opens tight muscles and allows passage of food from stomach to
intestine
Following surgery
Pain medication such as acetaminophen to ease discomfort
Feedings- npo for two hours, then graduated diet is given.

Health promotion
There is no way to prevent pyloric stenosis. If it runs in the family inform the
healthcare provider. The health care provider will observe for any signs or
symptom of the condition.
It is important to also know the signs and symptoms of pyloric stenosis in

order to receive medical treatment as soon as possible.
Nursing Care: Assessment
In the emergency department, a mother brings in her 3-week-old male infant named Owen. She says that Owen started
vomiting with every feeding since two weeks of age, and occasionally he would vomit so forcefully that it sprayed her face.
When asked to describe the vomiting episodes in detail, she explains that Owen vomits near the end or shortly after every
feeding. The vomit is often white or cream-colored, and sometimes appears watery or resembles curdled milk. She
expresses that he is often very eager to eat, continually sucking, especially after vomiting. His mother comments that she
only changes his diaper two or three times a day, and the last time she changed his diaper was this morning. Over the
past week, he’s been increasingly irritable and fussy, especially after vomiting. But in the last two days, he’s become much
more sleepy, and today has been difficult to awaken. Diagnostic labs and screenings confirm hypertrophic pyloric stenosis,
and Owen is admitted to the Neonatal Intensive Care Unit pending pyloromyotomy.
On examination: Owen’s anterior fontanelle and eyes appear sunken, mucous membranes dry, his diaper looks and feels
dry. Skin turgour poor. Abdominal distension and visible peristaltic waves moving from left to right across the abdomen
was observed. Hyperactive bowel sounds auscultated. Olive-shaped mass felt upon light palpation of RUQ of abdomen.
Speaking softly and gentle touching does little to console him. Using the FLACC scale, facial grimacing is noted, and
Owen appears withdrawn and tense, occasionally shifting his legs and moaning (score: 6/10). Assessment of his vital signs
show he is slightly tachycardic with a heart rate of 172 (NR: 120-160), tachypneic with respirations of 65, hypotensive with
a blood pressure of 50/30, and feverish with a temperature of 99.9°F.
Nursing Care: Nursing Careplan
Assessment:
Subjective data:
Objective data:
Facial grimacing noted especially upon palpation of RUQ where an olive shaped mass is present,
appears withdrawn and tense, occasionally shifting of legs and moaning noted, FLACC pain scale score
6/10, (Face-1, Legs 1, Activity 1, Cry 1, Consolability 2), Olive-shaped mass felt upon light palpation of
RUQ of abdomen.
Nursing Diagnosis:
Acute pain r/t gastric obstruction AEB facial grimacing especially upon palpation of RUQ where an olive
shaped mass is present, appears withdrawn and tense, occasionally shifting his legs and moaning,
FLACC pain scale score 6/10, (Face-1, Legs 1, Activity 1, Cry 1, Consolability 2), Olive-shaped mass felt
upon light palpation of RUQ of abdomen.
Nursing Diagnosis:
Acute pain r/t gastric obstruction AEB facial grimacing especially upon palpation of RUQ where an olive shaped
mass is present, appears withdrawn and tense, occasionally shifting his legs and moaning, FLACC pain scale
score 6/10, (Face-1, Legs 1, Activity 1, Cry 1, Consolability 2), Olive-shaped mass felt upon light palpation of
RUQ of abdomen.
Plan:
At the end of 30 minutes following nursing and collaborative interventions, the patient will achieve an
improvement in acute pain AEB a reduction in falcc pain scale score from 6/10 to 4/10, minimal facial grimacing
noted.
1. Elevate the head of the cot (). R: Elevating the head of the cot helps to reduce gastric reflux and associated
pain.
2. Medicate patient with a non-opiod analgesic such as Panadol (Iv) as prescribed. R: This medication helps to
alleviate pain by inhibiting the COX- 1 and COX- 2 enzymes that help with the production of prostaglandin (a
hormone-like substance that causes inflammatory pain).
3. Provide non-pharmacological soothing pain relief techniques (swaddling infant, Holding and rocking baby,
stroking baby’s head, sing a lullaby, speak in a soothing voice). R:
4. Provide a calm and quiet environment. R: Reducing external stimuli can help minimize exacerbation of pain
and promote a calm environment for the baby.
5. Reassess pain level. R: To evaluate whether pharmacological and non-pharmacological therapy is working
6. Prepare patient for pyloromyotomy. R: This surgery provides relief provide relief from symptoms associated
with pyloric stenosis, such as vomiting, and abdominal pain.
Evaluation:
Goal met. At the end of 30 minutes following nursing and collaborative interventions, the patient
achieved an improvement in acute pain AEB a reduction in FLACC pain scale score from 6/10 to 3/10
(Face- 0, Legs- 1, Activity- 1, Cry- 0, Consolidating- 1), minimal facial grimacing noted.
Sex- Pyloric stenosis is seen more often in boys, especially firstborn children,
than in girls.
Early antibiotic use- Babies given certain antibiotics in the first weeks of life —
erythromycin to treat whooping cough, for example — have an increased risk of
pyloric stenosis. In addition, babies born to mothers who took certain
antibiotics in late pregnancy may have an increased risk of pyloric stenosis.
Medication
Intravenous (IV) fluids: IV fluids are administered to ensure proper hydration and
electrolyte balance, as pyloric stenosis can cause vomiting and dehydration.
Preoperative medications: Prior to surgery, infants may receive medications to stabilize

their condition and prepare them for the procedure. This may include intravenous fluids,
antibiotics to prevent infection, and medications to control vomiting.
Medication
Postoperative medications: After surgery, medications may be prescribed to

manage pain, prevent infection, and assist in the recovery process. These may
include pain relievers, such as acetaminophen or opioids, and antibiotics.
Explain pyloric stenosis: Start by describing pyloric stenosis as a condition that affects
the opening between the stomach and the small intestine. Emphasize that it leads to
narrowing of the pylorus, causing difficulties in food passing from the stomach to the
intestines.
Causes and symptoms: Discuss the possible causes of pyloric stenosis, which include
genetic factors and abnormal muscle development. Explain common symptoms such
as forceful vomiting, constant hunger, weight loss, and dehydration.
The main treatment for pyloric stenosis is surgery called pyloromyotomy, which widens
the stomach opening.
Before surgery, the baby will need to fast and have some tests and medications.
After surgery, the baby will need time to recover in the hospital. Parents will learn how to
care for the wound and manage any pain. They will also get guidance on feeding.
Parents should feed the baby in small amounts and burp them frequently to prevent
discomfort and vomiting.
Discharge teaching
Feeding: Follow your healthcare provider's instructions on how to feed your baby.
They may recommend smaller, more frequent feedings and a specific type of
formula or breastfeeding techniques.
Burping: Remember to burp your baby after each feeding to reduce discomfort. Your
healthcare provider can show you different ways to burp your baby.
Discharge teaching
Positioning: Hold your baby upright during and after feeding to aid digestion and
prevent discomfort.
Watch for feeding problems: Be aware of signs like frequent vomiting, poor weight
gain, or fussiness during or after feeding. If you notice any concerning symptoms,
contact your healthcare provider
Acute Lymphoblastic Leuckemia..
Definition
Acute lymphocytic leukaemia is a type of cancer that affects the white blood
cells which progresses quickly and aggressively and requires immediate
treatment
Acute lymphocytic leukaemia is more favorable in children with about 3.3 cases
per 100,000 children.
In 2023, an estimated 6,540 (3,660 boys and 2,880 girls) in the United States
will be diagnosed with ALL.
Pathophysiology
Similar to acute myeloid leukemia, acute lymphoblastic leukemia is caused by a

series of acquired genetic aberrations. Malignant transformation usually occurs
at the pluripotent stem cell level, although it sometimes involves a committed
stem cell with more limited capacity for self-renewal.
Manifestations
● Fever
● Shortness of breath
● Easy bruising or bleeding
● Painless lumps in the neck, underarm,
● Petechiae (flat, pinpoint, dark red spots
stomach or groin
under the skin caused by bleeding)
● Pain or feeling of fullness below the
● Weakness, feeling tired or looking pale
rib
● Bone or joint pain
● Loss of appetite
Complications
The three main complications of leukemia are:
● Anemia- caused by decreased erythrocyte production;

● Infection secondary to neutropenia;
● Bleeding tendencies- from decreased platelet production.
Risk factors
Genetics conditions such as: ● Wiskott-Aldrich syndrome- a rare

genetic immunodeficiency that
● Neurofibromatosis type 1 keeps a child's immune system
● Down syndrome from functioning effectively. It
● Ataxia-telangiectasia- is a rare also makes it difficult for a child's
inherited childhood neurological bone marrow to produce
disorder that affects the part of platelets, making a child prone to
the brain that controls motor bleeding. It occurs mostly in
males
movement and speech
● Bloom syndrome- this is marked by shorter than average height, a narrow

face, a red skin rash that occurs on sun-exposed areas of the body. The
rash usually occurs on the face, arms, and back of the hands
● Shwachman-Diamond syndrome- a rare, inherited bone marrow failure,

characterized by a low number of white blood cells, poor growth due to
difficulty absorbing food, and, in some cases, skeletal abnormalities.
● There is also environmental conditions such as being exposed to x-ray or

radiation before birth
Interdisciplinary management
The team typically includes
● Pediatric oncologists
● Hematologists
● Nurses
● Social workers
● Psychologists
● Nutritionists
● Healthcare professionals work together to take care of the child.
● They use different treatments like chemotherapy, radiation therapy, and bone marrow
transplantation to help the child get better.
● They provide support to manage side effects of treatment, help the child eat well, and
give emotional support to the child and their family.
● By working together, the team can give the child the best possible care and help them
get better.
Investigations
Acute leukemia is diagnosed through medical history evaluation, physical

examination, blood tests, and bone marrow aspiration and biopsy.
Health promotion
Alex, a 9-year-old boy diagnosed with acute lymphoblastic

leukemia (ALL), presents to the pediatric oncology clinic for his
routine chemotherapy session. He complains of persistent pain in
his joints, and his platelet and White blood cell count is low
putting him at risk for infection and bleeding. Platelet
count:100 x 109/L (Normal range: 150 to 400 × 109/L), White
blood cell count: 3.9/mm3 (Normal range: 4.8 – 10.8/mm3).
Nursing Careplan #1: Acute pain
Assessment:
Subjective data:
Patient verbalized “My knees are hurting me.” Patient complaint of experiencing pain in his knees of a
sharp characteristic which started yesterday. He states that the pain stops intermittently when he rests his
legs. Patient rates pain as 8/10 on the pain scale, but 10/10 when walking. Patient states that resting his
legs, a warm or cold compress and getting his pain medication makes the pain better, but moving his legs,
especially when walking makes the pain worse. Patient states that the pain is non-radiating. Other
symptoms accompanying pain are swelling and warmth. .
Objective data:
● Knees are warm, swollen, and tender to touch

● Crying
● Facial grimacing noted
● Guarding of affected area noted on palpation.
Nursing Diagnosis:
Acute Pain r/t infiltration of leukemic cells in the bone marrow causing mass formation and
compression of nociceptors (joints) AEB patient verbalizing “My knees are hurting me.”,
Patient rates pain as 8/10 on the pain scale; Knees are warm, swollen, and tender to touch,
Crying, Facial grimacing noted, Guarding of affected area noted on palpation.
Plan:
At the end of 30 minutes following nursing and collaborative interventions, the patient will
achieve an improvement in acute pain as evidenced by the patient verbalizing “My knees aren’t
hurting as much as before.” A reduction in pain from 8/10 to 4-5/10, minimal or no facial
grimacing, crying, and guarding.
1. Assist the patient into a comfortable position. Rationale: This helps to reduce pain
intensity and promotes rest and comfort.
2. Advocate and observe for the administration of an opioid analgesic (Morphine 10 mg
IV/IM) as ordered. Rationale: To decrease pain intensity by inhibiting pain pathways.
3. Provide diversional therapy (hold patient’s hand, talk with patient, deep breathing).
Rationale: To distract patient from pain.
4. Apply a warm compress to the affected area. Rationale: To decrease pain intensity via
vasodilation, thereby increasing blood flow and oxygen to the area.
5. Reassess pain level. Rationale: To evaluate whether pharmacological and
non-pharmacological interventions are working.
Evaluation:
Goal met. At the end of 30 minutes following nursing and collaborative
interventions, the patient achieved a reduction in pain AEB the patient verbalizing
“My knees aren’t hurting as much as before.”, patient voiced a reduction in pain from
8/10 to 4/10 on the pain scale, minimal facial grimacing, crying, and guarding
observed.
Nursing Careplan #2: Risk for bleeding
Assessment:
Subjective data:
Parent reports of excessive bleeding and prolonged clotting time and states that he bruises
easily.
Objective data:
● Low platelet count 100 x 109/L (Normal range: 150 to 400 × 109/L).
● Petechiae and ecchymosis are observed on his arms and legs
● Presence of invasive procedures (lumbar punctures)
● Frequent venepunctures
● Patient is medicated with cyclophosphamide (drug that cause gross haematuria)
Nursing Diagnosis:
Risk for bleeding AEB parent’s report of excessive bleeding and prolonged clotting time and
stating that he bruises easily; Low platelet count (100 x 109/L), Petechiae and ecchymosis are
observed on his arms and legs, Presence of invasive procedures (lumbar punctures), Frequent
venepunctures, medicated with cyclophosphamide (drug that cause gross haematuria)
Plan:
At the end of 4 hours following nursing and collaborative interventions, the patient will
demonstrate measures to prevent bleeding and recognizes signs of bleeding that need to be
reported immediately to a healthcare professional.
1. Pad bed and implement fall prevention measures, such as using bedrails, keeping the environment
free from obstacles, and providing adequate supervision. Rationale: Padded beds prevent bruising.
Falls can result in injuries that may lead to bleeding, so preventive measures are essential to minimize
the risk.
2. Instruct patient to maintain good oral hygiene with a soft toothbrush or cotton bud and water
irrigation device. Rationale: A hard bristle brush may cause bruising and increase the risk of
bleeding.
3. Maintain IvF therapy as ordered. Rationale: The patient is currently being treated with
cyclophosphamide. A side effect of this drug is gross haematuria. To curtail this, hydration with
intravenous fluids to attain a specific gravity of less than 1.010 prevents or reduces the severity of
hematuria.
4. Advocate to dietitian to increase fibres and vitamin K in diet (cereal, cooked green leafy vegetables).
Rationale: An increase in fibres helps to prevent straining which can cause trauma to rectal tissue.
Vitamin K plays a key role in helping the blood clot, preventing excessive bleeding.
5. Monitor for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival hemorrhage,
epistaxis, bleeding gums, bleeding at puncture sites. Rationale: Early detection of bleeding helps
initiate appropriate interventions and prevent further complications.
6. Educate the child and family members about the signs and symptoms of bleeding (petechiae,
ecchymosis, bleeding gums), the importance of avoiding aspirin or nonsteroidal
anti-inflammatory drugs, and the need to inform healthcare providers of any bleeding episodes.
Rationale: Education empowers the child and family to recognize signs of bleeding and take
appropriate measures to prevent further complications.
7. Observe urine to ensure not passing blood. Rationale: A side effect of cyclophosphamide is gross
haematuria.
8. Administer blood products or clotting factor replacement therapy as ordered. Rationale: To

manage bleeding episodes and maintain clotting factors within a safe range.
Evaluation:
Goal met. At the end of the four (4) hour shift following nursing and
collaborative interventions, the patient demonstrated measures to prevent
bleeding (using a soft bristle toothbrush) and recognized signs of bleeding
(Petechiae, blood in urine/stool) that need to be reported immediately to a
healthcare professional.
Nursing Careplan #3: Risk for infection
Assessment:
Subjective data:
Parents state that he gets frequently develops infections, such as respiratory tract infections and
skin infections, which take longer to resolve.
Objective data:
● Central line (for intravenous medications)

● Lumbar puncture procedure
● Immunocompromised (chemotherapy)
● Treated with corticosteroids (Prednisone)
● Low WBC- 4/mm3 (Normal range: 4.8 – 10.8/mm3)
● Temperature: 97.60F
Nursing Diagnosis:
Risk for infection AEB Central line (for intravenous medications), Lumbar puncture
procedure, Immunocompromised (chemotherapy), Treated with corticosteroids
(Prednisone), Low WBC- 4/mm3, Temperature: 97.60F
Plan:
At the end of four (4) hours following nursing and collaborative interventions, there
will be no signs of infection (warmth, edema, redness, purulent discharge) at the
lumbar puncture site or the skin surrounding same, and temperature maintained within
normal range (97-990F).
1. Perform meticulous handwashing before and after all procedures. Also instruct patient to
practice meticulous handwashing. Rationale: To prevent transmission of microorganisms.
2. Administer antibiotic prophylactic treatment and vitamins as ordered. Rationale:
Antibiotics prevent and treat infection by decreasing/killing bacterial growth. Vitamins will
help to strengthen the immune system.
3. Provide mouthcare with an anti-fungal such as nystatin as ordered. Rationale: To prevent
the development of oral thrush (yeast), a common side effect of most chemotherapy
medications.
4. Instruct patient and caregiver, that the patient is to avoid eating raw, vegetables and fruits
and uncooked meat. Rationale: Minimizes potential sources of bacterial contamination.
5. Advocate to dietitian to provide a diet high in protein and calories. Rationale: Proper nutrition
enhances the immune system.
6. Monitor for signs of infection (warmth, edema, redness, purulent discharge) at the lumbar puncture
site, and central line. Rationale: Presence of these signs can indicate the development of an infection.
7. Monitor patient’s vital signs, especially temperature every 2 hours. Rationale: High Temperatures
(100°F or 38°C) can indicate an infection.
Evaluation:
At the end of four (4) hours following nursing and collaborative interventions, there was no signs of
infection (warmth, edema, redness, purulent discharge,) at the lumbar puncture site or the skin
surrounding same, and temperature was maintained within normal range (97.80F).
Fluid Management
● Weight loss is the best measure of dehydration. Clinical signs can help
estimate the severity of dehydration but are often imprecise.
● If a child is hemodynamically stable that is in shock, prompt fluid resuscitation

with fluid boluses must be given, sepsis must be considered.
● Rehydration is normally done enterally unless severe dehydration or shock

occurs.
Infection Control
● All healthcare team members and relatives should takes steps to avoid exposing
the child to bacteria, viruses and other infection-causing agents: They should
practice frequent and vigorous hand washing or, in some cases, wearing masks,
gowns and/or gloves.
● Parents should discuss how to avoid infection with members of the healthcare team
if the child is receiving outpatient treatment. Caregivers need to be meticulous in
cleaning catheters to reduce the risk of bacteria entering the body.
● Wash hands thoroughly, especially before eating and before and after using the
bathroom. This applies to everyone — people in treatment and those around them.
● Avoid crowds and individuals with contagious diseases such as colds, flu, measles
Infection Control Cont’d
● Check with your child’s doctor about getting vaccinations. Find out whether the
child should avoid people who've recently been immunized with live, weakened
forms of organisms or viruses that cause the disease, such as measles, and how
long the child should stay away.
● Ensure the child’s rectal area is cleaned gently but thoroughly after each bowel
movement. Ask your doctor for advice if irritation or hemorrhoids are a problem.
Check with your healthcare team before using enemas or suppositories.
● Don't cut or tear fingernails' or toenails' cuticles.
● Avoid cuts or nicks when using scissors, needles or knives.
Infection Control Cont’d
● Use an electric shaver instead of a razor to prevent cuts
● Use an extra soft toothbrush that won't hurt the gums.
● Don't squeeze, pick, or scratch at wounds or blimishes.
● Clean cuts and scrapes immediately. Rinse the wound under running water. Wash
the skin around the wound with soap. To avoid irritation, don't use soap on the
wound.
● Take a warm (not hot) bath, shower or sponge bath every day. Don't rub skin to dry it;
use a light touch to pat skin dry. Use lotion or oil to soften and heal skin if it becomes
dry and cracked.
● Wear protective gloves when gardening or cleaning up after animals, young children
Medication
Induction therapy: Prednisone (remission induction), Vincristine (cell division

inhibition), Daunorubicin or Doxorubicin (leukemia cell destruction),
L-asparaginase (deprives leukemia cells of asparagine), Methotrexate (prevents
central nervous system involvement).
Medication
Consolidation therapy: High-dose Methotrexate (leukemia cell destruction),

Cytarabine (DNA replication interference), Thioguanine (DNA synthesis
inhibition), Mercaptopurine (DNA synthesis disruption), Pegaspargase
(depletion of asparagine).
Medication
Maintenance therapy: Mercaptopurine (leukemia cell growth suppression),

Methotrexate (prevents relapse), Vincristine (intermittent leukemia cell
destruction), Corticosteroids (enhance effectiveness of other medications).
Medication
Central nervous system prophylaxis: Intrathecal chemotherapy (Methotrexate,

Cytarabine - prevents spread to the central nervous system), Cranial irradiation
(in some cases - targets leukemia cells in the brain).
Medication
Targeted therapies: Imatinib, Dasatinib (Philadelphia chromosome-positive ALL

- target abnormal proteins), Blinatumomab, Inotuzumab ozogamicin
(immunotherapy drugs - recognize and destroy leukemia cells).
Discharge teaching
Medications: Review the drugs and their administration. Emphasize adherence and
inform about potential side effects.
Infection prevention: Stress the importance of hand hygiene, avoiding sick

individuals, and maintaining a clean environment.
Discuss immunizations for the child and close contacts
Avoid eating uncooked meats and fruits with skin still attached.
Avoid sharing personal items such as rags and towels

Rheumatic Fever
Rheumatic fever- Definition
Acute rheumatic fever (ARF) is an inflammatory disorder of

connective tissue that results from an autoimmune response to
some strains of group A beta-hemolytic streptococci (GAS).
This disorder may cause long-term damage to heart valves, and
affects the joints, brain, and skin tissues.
Rheumatic Fever- Incidence and Prevalence
Incidence and Prevalence:

● While ARF is a significant health problem in developing countries, the
incidence is very low in the United States and developed countries because
group A beta-hemolytic streptococci (GAS) infections are treated earlier.
● Only a small number of individuals infected with a strain of GAS that causes
pharyngitis develop ARF, but specific serotypes have not been identified
(AAP, 2015, p. 733).
● It occurs most commonly in children between 5 and 15 years old. A genetic
susceptibility to the disease may exist, such as in Pacific Islanders,
predisposing children to the disorder. An estimated 60% of patients with
ARF develop rheumatic heart disease (Chang, 2012).
Rheumatic Fever- Pathophysiology
The pathophysiology of Rheumatic fever is as follows:

● Streptococcal infection: Rheumatic fever typically follows a preceding
throat infection caused by group A streptococcus bacteria. The bacteria
produce certain antigens, which activate the immune response of the body.
● Immune Response: In susceptible individuals, the immune system produces
antibodies called antistreptococcal antibodies (ASO antibodies) in response to
the streptococcal infection. These antibodies target the antigens on the surface
of the bacteria.
● Molecular Mimicry: The antigens produced by the group A streptococcus
bacteria bear structural similarities to certain proteins found in various tissues
of the body, particularly in the heart, joints, and central nervous system.
Rheumatic Fever- Pathophysiology
The pathophysiology of Rheumatic fever is as follows:

● Cross-reactive immune response: Due to this molecular mimicry, the
antistreptococcal antibodies antibodies (ASO) generated against the
streptococcal antigens can mistakenly recognize and attack the host's own
tissues. This cross-reactive immune response leads to inflammation and
damage to various organs.
● Inflammatory response: The cross-reactive antibodies and immune cells,
such as T-cells, trigger an inflammatory response. Inflammation occurs in
different tissues, primarily affecting the heart (rheumatic carditis), joints
(polyarthritis), skin (erythema marginatum, subcutaneous nodules), and
brain (Sydenham's chorea- involuntary jerky movements).
Manifestations
The symptoms usually start about one to five weeks after a child has been infected
with strep bacteria. Each child’s symptoms may vary. Common symptoms can
include:
● Inflammation in joints such as the knees or ankles that causes swelling,

soreness, and redness
● Small, painless, hard bumps (nodules) under the skin, often over bony areas
Manifestations cont’d
● Unusual jerky movements, most often of the face and hands. This is often
noted by a change in a child's handwriting.
● Red rash with odd edges on the torso, arms or legs
● Fever
● Weight loss
● Lack of energy (fatigue)
● Stomach pains
Complications
● If rheumatic fever is not treated promptly, rheumatic heart disease may occur.
● Rheumatic heart disease weakens the valves between the chambers of the heart.
In this case, the child may not be allowed to do some kinds of physical activity and
sports.
● Additionally, the child would need to take special care when going to the dentist in
the future. Antibiotics may be needed before having dental work done to lower the
chance of an infection traveling to the heart during a dental procedure
Risk factors
Children ages 5 to 15 are most at risk for having rheumatic fever. They are most
at risk if they:
● Have strep infections such as strep throat, Scarlet fever, or impetigo that
were not treated or not treated enough
● Have strep infections often
● Have a family history of rheumatic fever
Infection control
● An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every
four weeks is the recommended regime for secondary prophylaxis for most patients
with rheumatic fever.
● The same dosage is administered every three weeks in areas where rheumatic fever
is endemic, in patients with residual carditis and in high risk patients.
This team may include a primary care physician, a cardiologist, a rheumatologist, a

nurse, a physical therapist, pharmacists and social worker, neurologists
The specific management plan will depend on the individual patient's symptoms and
needs. Treatment may include antibiotics, anti-inflammatory medications, pain
management, and physical therapy. In severe cases, hospitalization may be
necessary.
Diagnosis and investigation
Rheumatic fever is diagnosed through medical history, physical examination,

and laboratory tests. The Jones criteria are used to establish a diagnosis, which
includes major criteria like carditis and arthritis, and minor criteria like fever and
elevated markers of inflammation. Blood tests, such as ESR and CRP, can
confirm inflammation. An ECG and echocardiogram may be done to assess
heart involvement. The diagnosis is made by a healthcare professional based
on these findings
Promotion
To prevent rheumatic fever from worsening and promote overall health:
Seek immediate medical attention if experiencing symptoms.
Follow the prescribed treatment plan, including taking antibiotics.
Complete the full course of antibiotics.
Take preventive antibiotics if at risk.
Manage underlying conditions and monitor heart health

Nursing Assessment
Eleven year old Johnny presents to the ER with a low grade fever and joint pains for the
last 10 days. His mother gave a history of pain in the elbows and pain and swelling in
the left ankle and left knee for 5 days and because of the pain he has difficulty moving
his limbs. He has facial grimacing and does not want his joint areas to be touched and
rates the pain at 8/10. On examination heart rate is 144 bpm, respiration is 28 bpm and
temperature is 99.2 degrees fahrenheit. Johnny is not able to walk at this time because
his left ankle and left knee is swollen and tender on light palpation with limited ROM. He
is anxious, restless and verbalised “ nurse i am so scared, will i be able to walk again,
will the pain go away, what is going to happen now.”
Nursing Diagnosis #1
Needs: Rest, Comfort and activity
Subjective data: patient verbalised “i am having a lot of pain in my joints for 10 days now
it is terrible and constantly present no matter what i do , i rate it at 8/10. “When will the
pain go away.”
Objective data: restlessness, facial grimacing, HR 144bpm, RR 26bpm.
Nursing Diagnosis: Acute pain related to inflammation of the connective tissues of the
joints AEB patient verbalised “i am having a lot of pain in my joints for 10 days now it is
terrible and constantly present no matter what i do , i rate it at 8/10. “When will the pain
go away.”restlessness, facial grimacing, HR 144bpm, RR 26bpm.
Nursing Diagnosis #1 Cont’d
Goal: within ½ hour following nursing and collaborative interventions patient will
verbalise a reduction in pain intensity from a rating of 8/10 to 2/10 on standard pain
scale.
Interventions and rationales
Administer anti-inflammatory drugs such as aspirin or NSAIDS such as ibuprofen ® to

reduce inflammation and joint pain.
Apply warm moist compress to joints for local pain relief.(R) moist heat helps to reduce
pain by reducing inflammation.
Provide a calm quiet environment ® to decrease stimuli which will promote the action
and the effect of the NSAID or anti-inflammatory administered.
Allow child to assume a comfortable position ® a comfortable position aides in reducing

pain.
Assess pain intensity ½ hour after the administration of aspirin or ibuprofen ® to

determine effectiveness of treatment.
Evaluation: goal met within ½ hour following nursing and collaborative interventions
client voiced a reduction in pain with a rating of 2/10 on standard pain scale.
Diagnosis #2
Needs: Rest, comfort and activity
Subjective data: child verbalises, “ will i be able to walk again.” Mother verbalised, “ he has
pain in the elbows and pain and swelling in the left ankle and left knee for 5 days now and
he is unable to walk because of the pain”
Objective data: inability to walk at this, left ankle and left knee is swollen and tender on
light palpation with limited ROM
Nursing Diagnosis: Impaired Physical Mobility related to inflammation of connective
tissues of the joint AEB child verbalises, “ will i be able to walk again.” Mother verbalised,
“ he has pain in the elbows and pain and swelling in the left ankle and left knee for 5
days now and he is unable to walk because of the pain.” Inability to walk at this, left
ankle and left knee is swollen and tender on light palpation with limited ROM .
Goal: Within 4 hours following nursing and collaborative interventions patient will be able
to independently mobilise AEB patient displaying full ROM to lower limbs and being able
to stand and walk without assistance.
Intervention and rationales
Administer anti-inflammatory such as aspirin ® to reduce pain and swelling at the joints
and promote movement.
After administration of analgesics instruct patient to perform ROM exercises to

determine effectiveness of treatment.
Give positive reinforcement during ROM exercise ® to boost patient’s confidence and
promote willingness to move.
Instruct patient to walk as soon as pain becomes reduced and ability to perform ROM
Exercises has been achieved ® to keep patients limb functionally working.
Let the child accomplish ROM exercises, standing and walking activity at his own pace
hurrying the patient reduces his confidence and slows his period of recovery.
Evaluation: Goal met at the end of 4 hours following nursing and collaborative
interventions client achieved independence in mobility AEB client successfully
performing active ROM exercises, standing and walking without assistance.
Nursing Diagnosis #3
Needs: Psychosocial
Subjective Data: patient verbalised, “ nurse i am so scared, will i be able to walk again,
will the pain go away, what is going to happen now.”
Objective data: anxious, restless, HR 144bpm, RR28bpm
Nursing Diagnosis: Anxiety related to Uncertainty of outcome as evidenced by patient

verbalised, “ nurse i am so scared, will i be able to walk again, will the pain go away, what
is going to happen now ,anxious, restless, HR 144bpm,28bpm.
Nursing Diagnosis #3 cont’d
Goal: within 4 hrs following nursing and collaborative interventions patient will display a
reduction in the level of anxiety as evidenced by decreased restlessness, HR and RR
within normal range of (70-120bpm), (20-25 bpm) respectfully and client verbalising
that he now understands how his treatment will progress.
Interventions and rationales
Establish and maintain a therapeutic relationship with child ® to build trust and
facilitate further communication.
Allow child to express all concerns about treatment and progression of care ® to
Reassure child that all that is to be done is being done to allay anxiety.
Allow mother to stay with the child to provide comfort and allay anxiety.
Explain all procedures at a level the child can understand to allay anxiety.
Evaluation: Goal met at the end of 4 hours following nursing and collaborative
interventions patient displayed a reduction in level of anxiety AEB patient now calm and
verbalises he understands how his current treatment will progress HR 110 bpm, and
respiration 24 bpm.
Administer appropriate antibiotics and monitoring for effectiveness and side

effects.
Manage inflammation and symptoms with anti-inflammatory medications.
Monitor and manage cardiac complications.
Educate patients and families on adherence to antibiotic prophylaxis and

recognizing symptoms.
Medications
The goals of treatment for rheumatic fever are to treat the infection, relieve
symptoms, control inflammation and prevent the condition from returning.
Antibiotics such as penicillin to treat strep bacteria
Anti-inflammatory drugs. Aspirin or naproxen (Naprosyn, Naprelan, Anaprox DS)

can help reduce inflammation, fever and pain
Anticonvulsants such as valporic acid for severe involuntary movement caused

by sydenham cholera
Corticosteroids. If moderate to severe carditis is present as indicated by
cardiomegaly, third-degree heart block, or CHF, add PO prednisone to salicylate
therapy.
Discharge teaching
Make sure your child gets enough rest.
Have the child drink plenty of fluids if not contracindicated
Take and complete medications as prescribed

Call the doctor if:
The child has severe trouble breathing.
has a new sore throat.
The presence of new or worse joint problems.

Sickle cell Disease
● Sickle cell disease (SCD) is a hereditary hemoglobinopathy characterized by the partial or

complete replacement of normal hemoglobin (Hb A) with abnormal hemoglobin S (Hb S) in
red blood cells.
● As a result, the cells are more likely to hemolyze and cause occlusion of small blood vessels
that disrupt the flow of blood, ischemia, and damage to affected organs.
● Individuals with sickle cell trait have one sickle cell hemoglobin gene and one normal
hemoglobin gene. They are carriers of the disease and generally do not have symptoms,
although symptoms have been known to occur when the body is under extreme conditions
(Centers for Disease Control and Prevention, 2014).
Sickle Cell Disease- Incidence and Prevalence
Incidence and Prevalence:
● Sickle cell trait (carrying one gene for the disease) affects approximately 2 million
Americans.
● Approximately 1 in 12 African Americans are carriers of the disease (Maakaron & Taher,
2014).
● Worldwide, it is estimated that there are 300 million people with sickle cell trait and
one-third of this number are in sub-Saharan Africa (Ashorobi et al., 2022). The prevalence of
sickle cell trait is higher in areas where malaria is endemic (Ashorobi et al., 2022).
● About 300,000 babies are born every year with sickle cell anemia.
Sickle Cell Anemia- Etiology
Etiology:
● Sickle cell trait is caused by abnormal hemoglobin called sickle hemoglobin or Hb S.

● Sickle hemoglobin is as a result of a point mutation in the beta globin chain. This point
mutation replaces A with T at codon 6 of beta hemoglobin chain.
● This causes the switch from glutamic acid to valine amino acid.
● The valine-type hemoglobin causes red cells to sickle when exposed to a low oxygen
threshold.
● Patient with sickle cell trait inherits HbS from one parent and HbA from the other parent
making them heterozygous.
Sickle Cell Anemia- Pathophysiology
Pathophysiology:
● Sickle cell disease is an autosomal recessive disorder. If both parents have the trait, with
each pregnancy the risk of having a child with the disease is 25%.
● In the most common type of sickle cell disease (HbSS, also referred to as sickle cell
anemia), the hemoglobin in the RBC acquires an elongated crescent or sickle shape.
● The sickled cells are less flexible and more rigid, making them more prone to damage
and destruction.
● Their abnormal shape makes them sticky, leading to their adherence to the walls of blood
vessels, particularly in small capillaries which obstructs capillary blood flow
(vaso-occlusion).
● Microscopic obstructions lead to engorgement and tissue ischemia. This local tissue
hypoxia causes further sickling and ultimately large infarctions.
● Organ tissues become damaged by infarctions, leading to scarring and impaired function.
Pathophysiology:
● Sickling may be triggered by fever, hypoxia, emotional stress, or physical stress.
● Precipitating factors for sickle cell crisis include increased blood viscosity (such
as from a low fluid intake or fever) and hypoxia or low oxygen tension.
● Potential causes of hypoxia or low oxygen tension include high altitudes, poorly
pressurized airplanes, hypoventilation, vasoconstriction when cold, or an
emotionally stressful event.
● Any condition that increases the body’s need for oxygen or alters the transport
of oxygen (such as infection, trauma, or dehydration) may result in sickle cell
crisis.
Pathophysiology:
● Sickling may be triggered by fever, hypoxia, emotional stress, or
physical stress.
● Sickled cells can resume a normal shape when rehydrated and
reoxygenated.
● However, the membranes of these cells become more fragile, and cell
life is shortened to about 10 to 20 days rather than the usual 120 days.
● Chronic hemolytic anemia develops because of the continued
destruction of RBCs (hemolysis).
Interdisciplinary management for children with sickle cell anemia involves a team of
healthcare professionals from different specialties working together to provide
comprehensive care for the child.
The team typically includes a
hematologist,
pediatrician,
nurse, social worker, psychologist, and other specialists as needed.

Diagnosis
Sickle cell disease (SCD) is diagnosed through a combination of medical

history evaluation, physical examination, and laboratory tests. The main
diagnostic tests are hemoglobin electrophoresis, which identifies abnormal
hemoglobin S, and a complete blood count (CBC) to assess red blood cell
count and other abnormalities. Additional tests may be ordered, such as a
blood smear, reticulocyte count, bilirubin level, or hemoglobin solubility tes
Health Promotion
Regular medical care: Schedule regular check-ups with a healthcare provider

experienced in managing sickle cell disease.
Disease-modifying treatments: Discuss options like hydroxyurea with your

healthcare provider to reduce pain crises and organ damage.
Pain management: Work with your healthcare provider to develop a pain

management plan using medications and techniques like heat/cold therapy and
relaxation.
Health Promotion
Stay hydrated: Drink plenty of fluids, especially water, to prevent sickling of red
blood cells and reduce the risk of pain crises.
Infection prevention: Practice good hygiene, get recommended vaccinations,

and avoid close contact with sick individuals to prevent infections.
Avoid triggers: Identify and avoid factors that can trigger sickle cell crises.
Infection control
pharyngitis
gastroenteritis
Hirchsprung Disease
Cerebral palsy
Care of child with developmental delay
Cleft lip/palate
Esophageal Atresia
Congenital Heart Disorders
Nephrotic Syndrome
Hydrocephalus

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CONDITIONS AFFECTING

❏ Meningitis is an inﬂammation ❏ The tough outer membrane

Induction therapy: Prednisone (remission induction), Vincristine (cell division

● Fever or hypothermia ● Positive kernig’s sign (older

● Developmental delay ● Cerebral edema

● There is an infection caused by a number of viruses, bacteria, or

To reduce morbidity a collaborative approach is used. The triage nurse should

Incomplete vaccinations Additional testing of the CSF is dependent on

● Ensuring children are vaccinated ● The signs and symptoms of the

Careful management of ﬂuid to prevent overhydration and dehydration is important.

Patient c/o a headache and neck stiffness

Interventions and Rationales:

1. Monitor for changes in neurological status (consciousness, reflexes, and pupillary

Interventions and Rationales:

6. Advocate for the administration of anti-epileptic medication (e.g. dilantin). R: To prevent

Interventions and Rationales:

Interventions and Rationales:

Interventions and rationales:

Paracetamol syrup 10-15mg po

1. Provide parents with appropriate 3 Give speciﬁc instructions about

members are to receive antibiotic 4. Encourage regular health

1. Educating the family about the ● Keep follow up appointments to

2. Keep immunization schedules

CDC, (2022), Meningistis. Retrieved from:

Muller., L, M, (2019). Medscape. Pediatric Bacterial Meningitis. Retrieved from:

Smith, S. M. (2018). Meningitis: Diagnosis, treatment, and prevention. New

Acute glomerulonephritis results from inﬂammation of tiny tubes (glomeruli) in

In children, a common cause of glomerulonephritis is from a streptococcal

● Dark brown-colored urine

● Even with proper treatment, complications may develop. The kidney

● A systemic autoimmune ● Focal segmental

The goal of treatment is to maintain renal function, prevent complications and

Diagnosis is made based on:

Throat and skin cultures, Anistreptolisin O titer and erythrocyte sedimentation

KUB, abdominal x-ray will show enlarged kidneys in acute glomerulonephritis.

A CBC reveals decreased hematocrit, anemia, increased electrolyte levels, BUN

Feed child healthy unprocessed food.

Prevent the child contracting an infection by practising good hygiene.

The importance of completing the course of given antibiotics.

● Patient c/o SOB

● Rapid and shallow breathing

Interventions and rationales:

Interventions and rationales:

● Patient c/o SOB

● Oliguria (decreased urine output <30 mls/hr)

5. Administer an anti-hypertensive such as Enalapril as ordered. R: Enalapril (a ACE inhibitor)

● Impaired renal function puts the child at risk for infection.

Antihypertensive agents; vasodilators such as calcium channel blockers (e.g.,

Serum potassium-lowering agents (sodium polystyrene sulfonate [Kayexalate],

IV calcium is used to stabilize the myocardium in severe hyperkalemia (Johnson,

Penicillin is used in active poststreptococcal glomerulonephritis to prevent rheumatic

Maintain ﬂuid restrictions of Na K and Ca

Administering medications as ordered

Documenting promptly medication administration

Reporting any abnormalities in patient condition to doctor.

Monitoring laboratory values, such as urine output, serum electrolytes, and

Implementing infection control measures to prevent the spread of infection,

Assisting with dietary management by providing guidance on a low-sodium and

1. Reinforce medical explanation of the disease process

b. Alert the family to signs and symptoms of disease recurrence.

c. Be aware that microscopic hematuria may persist up to 2 years.

2. Reinforce activity recommendation; usually not restricted.

b. Obtain information regarding drug allergies before administering penicillin (Johnson,