PEDIATRIC NURSING III: COMMON

DISORDERS
 Hemolytic Disorders

❖Pathologic jaundice (w/in 1st 24 hours) is

the result of hemolytic disease of the
newborn
❑ Treatment: phototherapy (bilirubin lights) to let bilirubin
break down and exit the body through stool, exchange
transfusion
*** If Pathologic jaundice continues to rise, it causes brain
damage
Kernicterus, = increased bilirubin in brain tissue Jaundice
mgmt. - Routine assessment
- Bilimeter: routinely done once they are 8 hours of age
- Serum bilirubin levels: drawn on babies who are at risk
or appear to have jaundice
- Phototherapy
- Exchange blood transfusion
⚫ Phototherapy uses lightwaves
to treat certain skin conditions.
The skin is exposed to an ultraviolet
(UV) light for a set amount of time.
Phototherapy uses a man-made
source of UV light. UV light also comes
from the sun. When combined with a
medication called psoralen, the procedure
is known as psoralen UVA (PUVA).
 Blood incompatibility

▪ Rh incompatibility: mom rh- and baby rh+

▪ If baby is rh+, and blood mixes antibodies will build up in
mom’s blood and attack the baby
▪ Everyone gets RhoGAM at 28 weeks and w/in the first 72
hours after birth to protect the next pregnancy.
***RhoGAM is a medicine that stops your blood from making
antibodies that attack Rh-positive blood cells.
▪ We don’t know babies blood type until birth so any mom who is
rh- will get RhoGAM throughout pregnancy
▪ Indirect Coombs test: drawn on mom for screening test
⚫ + = a chance baby will have pathologic jaundice
⚫ - = baby will not have pathologic jaundice
 ABO incompatibility

⚫ When a major blood group antigen of the fetus is different from the
moms
⚫ If mixing of blood where in antibodies form attacks the opposite blood
type
❑ Prevention: giving RhoGAM within 72 hours of event causing blood to
mix, intrauterine transfusion, exchange transfusion
*** Intrauterine transfusion: infuses blood through the umbilical vein
into the fetus
*** Exchange transfusion: removing small amts of blood and replacing
it with compatible blood if indirect Coombs is + -
❑ Diagnosis: recognizing jaundice, drawing a direct Coombs test (done on
baby using umbilical cord blood) o + direct Coombs = @ risk of having
hemolytic disorders
 Immune System

⚫ Passive immunity from mom, immunoglobulin G

IgG
⚫ Baby hasn’t developed IgG yet, offer DTap and flu
shot
-Breast milk provides immunity= lessens the risk of
allergies & food intolerance
- Capable of immune response to vaccines
- Inflammatory and immune mechanisms hypo-
functioning
 Neonatal infections

Sepsis: presence of toxins/infection

⚫ Occurs easier in newborns due to immature immune
defenses
⚫ Can occur in utero, during, or shortly after birth -
Increased risk
⚫ Maternal infection/fever, prolonged ROM > 18
hours, PROM, preterm birth, asphyxia during birth,
invasive procedures, stress and congenital anomalies
⚫ Group B strep - Not an STI and usually asymptomatic in women, test
mom at 36 wks
- Extremely virulent for newborns: harms newborns very quickly
- Not all babies exposed get infected, if mom is + baby stays in the
hospital for 48hrs
- Acquired at birth or in utero if the membranes are ruptured
- Intrapartum decrease early onset but not late onset
Risk factors: preterm birth, untreated GBS in mom, mom with
previous newborn with GBS infection, chorioamnionitis, precipitous
delivery
Tx: ampicillin and gentamicin IV to newborn with possible GBS; PCN
G to newborn with positive GBS
- If baby is symptomatic, we take a culture then immediately start
antibiotics (abx)
⚫ TORCH complex – a group of virus’s mom can be
infected with during pregnancy
⚫ Toxoplasmosis: avoid cat feces or uncooked meat, if
fetus has it there is nothing you can do about it
⚫ Hepa B Vaccine: offer vaccine to all newborns, if
mom is + baby will get an additional injection (HBV
immunoglobulin)
⚫ Parovirus: 2nd exposure is more serious, if mom is +
it can cause aplastic crises in baby (reduced count of
reticulocytes – immature RBCs)
⚫ Varicella: can cause many birth defects
⚫ Syphilis: can be transferred to baby without knowing that
mom has it
⚫ Listeriosis: can cause birth defects but depends on when mom
is exposed during pregnancy
⚫ Rubella: for pregnant, cannot give vaccine, do not give for 28
days after MMR
: could cause severe birth defects
⚫ Cytomegalovirus: can be contracted through pregnancy
⚫ Herpes Simplex Virus: can be transmitted at birth and deadly
to baby, must deliver via c/s
Prevention: give antiviral meds at 36 wks. prophylactically
 Integumentary System

NORMAL
⚫ Vernix caseosa: cheese like substance to protect the baby’s
skin
⚫ Acrocyanosis is normal up until 24 hours, after that, it may
only appear intermittently
⚫ Lanugo: fine/thin downy hair that covers the body
⚫ Chart any bruising, edema, petechiae, signs of birth injury
⚫ Creases on palms and soles should be assessed
Term infants will have more creases
Premature infants have fewer creases on the soles of
their feet
Integumentary Variations
⚫ Single palmar crease: one single crease across the
hand, common finding in baby’s with downs
syndrome, normal in a baby with Asian descent
⚫ Milia: tiny white sebaceous glands, little dots on nose
or forehead, “baby acne”
⚫ Desquamation: skin peeling off, usually seen in post
term babies
⚫ Mongolian spots: dark pigmentation on the back and
buttocks, usually seen in darker skin, fades over the
years
Vernix caseosa Lanugo Acrocyanosis

Milia Desquamous Mongolian Spots

⚫ Nevi: “stork bite or angle kisses”, flat pink capillary angiomas,
blanches white
⚫ Port wine stain: does not blanch white, capillary malformations
in the skin, they tend to get darker as children grow and do not
resolve on their own
⚫ Erythema toxicum: newborn rash that appears in the first 24-72
hours, inflammatory response due to baby coming in contact with
all new substances, usually on the face, no treatment needed
⚫ Pallor/plethora, petechiae, central cyanosis, or jaundice must be
investigated
Pallor: deep purple color
Petechiae: little purple dot
 Nevi Port wine stain

Petechiae erythema toxicum

 Reproductive System

⚫ Swollen breasts (especially on females) and labia changes is

normal
⚫ Due to mom’s high estrogen levels
- Witch’s milk: a thin discharge from the breasts, can be seen
in both sexes
- Swollen, darker labia with hymenal tag, slight bloody spotting
- In preterm, clitoris is prominent
⚫ Labia folds have not filled out to cover the clitoris yet
⚫ In term baby, labia cover the clitoris
⚫ Palpable descended testes
- Teach parents not to try to wash off all the vernix from the
labial folds
Signs of Reproductive Problems
Cryptorchidism: undescended testicle
Epispadias: urethral opening above, no circumcisions
Hypospadias: urethral opening underneath, ventral side, no
circumcisions
Hydrocele: accumulation of fluid around the testes, gets worse
with crying
Ambiguous genitalia: unable to tell if baby is female or male
based on external parts, requires UTZ to tell us what is internal
Inguinal hernia: intestines bulge through the abdominal wall,
more present when an infant cries
Rectovaginal fistula: stool is coming from the vagina
Cryptorchidism Hydrocele

Ambiguous genitalia Inguinal hernia Rectovaginal fistula

 Skeletal System

NORMAL
⚫ Molding occurs to allow movement through birth canal
⚫ Suture lines can be palpated, sometimes overlapping
⚫ Fontanels should be palpable
- Anterior fontanel is a diamond, closes at 18 months -
Posterior fontanel is triangle shaped, closes at 6-8 wks./1-2mo
after birth
⚫ Best to examine them when baby is lying flat and not crying
-Bulging fontanels = too much fluid, crying
- Sunken in fontanels = dehydration
⚫ Spine should be straight with no pilonidal dimple (dimple at
the base of the spine)
Skeletal variations and problems
⚫ Caput succedaneum: generalized edema of the scalp
that crosses suture lines, commonly found on the back
of the skull (occiput), may appear with bruising or
after vacuum extraction
-Can occur from sustained pressure of the
presenting part (it can happen from the baby sitting in
the birth canal)
⚫ Cephalohematoma: collection of blood, does not cross
over suture lines, can occur with caput, may occur
with spontaneous vaginal deliver
Capput succedaneum Cephalohematoma
Subgaleal hemorrhage: bleeding in the skull, not the brain
Oligodactyly: not having enough fingers/toes
Polydactyly: having too many fingers/toes
-If the extra finger/toe doesn’t have a bone in it they put a
mitten on baby and tie a suture around it to let it fall off, if it
has a bone, it is surgically removed
Syndactyly: having webbed fingers/toes
Developmental dysplasia of the hip: birth defect where the hips
are not even, one is lower than the other
Asymmetric moro reflex: one side doesn’t respond to the moro
reflex, could be due to a broken clavicle
*** check the clavicles to make sure they are even
 oligodactyly Polydactyly Syndactyly

Dev’t dysplasia of the hip Asymmetric moro reflex

Birth injuries - Occur during labor and birth, most are
avoidable except long difficult labors and abnormal fetal
presentations
- Few are fatal, but some cause lasting injury Skeletal
injuries
- Molding of soft skull to prevent fractures, but fractures
still can occur.
⚫ Usually linear fractures and require no treatment
⚫ Clavicle bone is most common fracture during birth due to
shoulder dystocia
⚫ Humerus or femur are less common
Treatment: immobilization with slings, splints, swaddling
⚫ neuromuscular system - Transient tremors of mouth
and chin when crying
- Flexion of arms at elbows and legs at knees
- Babies respond to pain Signs of
neuromuscular problems
- Persistent tremors, seizures, hypotonia: poor
tone, hypertonia: increased tone (seen in babies with
moms addicted to drugs), lack of response to painful
stimuli
⚫ Peripheral nervous system injuries - Brachial plexus injuries
occur when any part of the nerves from the spine through the
neck into the arms is injured.
⚫ Moro reflex absent on affected side
in all plexus injuries

Erb’s palsy: an upper plexus injury, causes paralysis of affected

extremity and muscles. Arm hangs limp rotated internally, hand or
wrist not affected
⚫ Treatment – prevent contractures, positioning, passive ROM
Complete recovery from stretched nerves takes 3-6 months. If
nerves are completely damaged or pulled out, permanent damage
occurs
⚫ Facial nerve injuries: s/s affected side
Nursing care: help with sucking/feeding techniques,
may require gavage feedings, protect affected eye
(often tape shut and administer eye drops daily)
- Phrenic nerve paralysis causes diaphragmatic
paralysis
Treatment – position on affected side so that
expansion of the unaffected side can be maximized,
same nursing care of any infant with respiratory
distress
 Normal Newborn Behavioral Characteristics

Normal newborn reflexes

Sucking and rooting Tonic neck or fencing

one arm bent and other arm straight out to the side the
baby is facing
 Moro or startle reflex Babinski or plantar reflex

on the bottom of the

foot, + = normal in
newborns up to a year
old, flexing of the toes
⚫ Normal newborn
Sensory - Preterm babies will sleep more, fatigue easier,
show physiologic stress and need quiet time
⚫ Full term
-Newborn eyes are structurally incomplete with immature
muscles
-Follow bright light and track parents’ eyes
-Prefer patterns
-Recognize smell of mom’s breast and milk
-Can distinguish sweet vs sour
⚫ Touch is essential to normal growth and development
Hearing screen is performed before discharge
- Recognizes moms/familiar voice
⚫ Response to external stimuli
- Crying – may signal hunger
Infants respond to cold, overstimulation, &
uncomfortable stimuli w/ crying
High pitched, inconsolable cry with hyperirritability
and tremors indicate baby may be withdrawing from
medication/drugs from in utero
DRUG EXPOSED INFANT
⚫ We want baby to “withdraw” in the hospital
⚫ Prognosis depends on type of drug and what stage of
fetal development when taken
⚫ At risk for failure to thrive if s/s of withdrawal are not
recognized prior to discharge
⚫ Decrease stimuli, swaddle them snugly
⚫ Touch times: Q 3 hours, they usually scream when
touched
- Provide adequate nutrition and promote mother-
infant bonding
⚫ Methamphetamine
- Associated with higher risk of placental abruption, fetal
growth restriction, preterm labor, smaller head circumference
and lower birth weights
=Withdrawal s/s: agitation, vomiting, tachypnea, poor feeding
⚫ Marijuana
- Associated with decreased fetal growth, low birth weight and
length
Selective serotonin reuptake inhibitors
-Withdrawal s/s: hypertonia, tremulousness, wakefulness,
high pitched crying and feeding problems o Passes in breast
milk
⚫ Narcotics cross the placenta - Neonatal abstinence
syndrome (NAS): when baby has withdrawal
symptoms after they were exposed to narcotics in
utero
⚫ S/S: diaphoresis, irritability, poor feeding, frantic
uncoordinated suck, high pitched cry
⚫ Heroin: usually shows signs of withdrawal in 12 hours
⚫ Methadone: signs usually appear in 1-2 days
-Breastfeeding would be contraindicated if mom is still
using drugs
⚫ Alcohol exposure - The quantity of alcohol required
to produce fetal effects is unclear - Fetal alcohol
withdrawal: jitteriness, increased tone and reflex
responses, irritability, seizures - Can have obvious
facial features, learning disabilities, and growth
abnormalities - Some infants have withdrawal
without diagnosis of syndrome - Usually seen with
abuse of tranquilizers, sedatives, or other drugs
 Newborn’s Standard Precautions

⚫ Standard precautions:
1. Wear gloves until baby has a bath, protects nurse from infection
2. Maintain airway and adequate oxygenation*
3. Maintain body temp: remove wet towels, wrap in a warm blanket
4. Eye prophylaxis: azithromycin to each eye to prevent chlamydia &
gonorrhea infections
5. Vitamin K prophylaxis
6. Promote bonding: skin to skin once we know baby is okay
7. Maintain protective environment
8. Listen to HR
9. Assess umbilical cord=2 arteries & 1 vein (AVA)
10. APGAR at 1 min and 5 min
**regardless of 1 min score
PHYSICAL ASSESSMENT OF THE NEWBORN
⚫ General appearance, vitals, baseline measurements
of physical growth (length, wt, head circumference),
neuro assessment (reflexes) Gestational age
assessment – using Dubowitz or ballard chart.-
Then, based on gestational age plot on graph along
with birth wt. (determines LGA, AGA, or SGA)
⚫ Do blood sugar checks if SGA or LGA
DUBOWITZ OR
BALLARD SCORING
Use chart to determine
neuromuscular and
physical maturity score
which will determine
gestational age based
on exam.
⚫ Classification of newborns by gestational age and birth wt - SGA, AGA,
LGA
⚫ Preterm or premature: baby born before 37 weeks - Late preterm: born
between 34 and 37 wks
Early term: born between 37 to 38 wks
Term: 37 wks to 42 6/7 wks
Post term or post date: after 42 weeks Post term infants
Signs of being post term
– Placental dysfunction (placenta starts to die)
– increased mortality
– Absence of lanugo, very little vernix, abundant scalp hair, long
fingernails, cracked desquamating skin
– Wasted physical appearance
– At risk for meconium aspiration
 NICU Care
1. Frequency of vitals determined by infant’s acuity
2. Accurate I&O, ongoing labs, temp control, infection prevention, keep hydrated,
maintain nutrition, skin care, developmental care, touch times
3. Q3 hours for feedings or vitals, promote skin to skin if possible Infants of
diabetic mothers
- Glycemic control before conception and in first trimester can prevent
malformation
- Macrosomia but sometimes you will see SGA b/c the baby isn’t getting the
nutrition they need due to maternal diabetes
*Increased risk of shoulder dystocia, congenital anomalies, hypocalcemia,
hypomagnesemia, polycythemia, hyperbilirubinemia - Leads to Respiratory Distress
Syndrome (RDS)
❑ high risk - Hypoglycemia: they have to eat early, and we have to check blood
sugars
Symptomatic: feed, if unable to feed give IV dextrose continuously
 NEWBORN SCREENINGS

Newborn Screening Test (NBS)-

⚫ Universal newborn screening
- blood collected via heel stick after 24 hours of birth until 2 weeks.
⚫ Newborn Hearing Screening Test (NBHST)
⚫ Heart Defect Screening: pulse ox on the hand and one on the feet
(checking preductal) to see if it is within 3 points of each other
Result: If yes, baby can go home
If no, repeat in one hour
If still not within 3 points further testing because that
could mean a cardiac problem.
 DEVELOPMENTAL STAGES AND AGES

⚫ Infant (0-1)
⚫ Toddler (1-3)
⚫ Preschooler (3-5)
⚫ School age (5-12)
⚫ Adolescent (13-18)
Psychosexual Development
Preparation for Hospitalization
1. Admission assessment - ADLs, meds, physical
assessment to get a baseline
2. Preparing the child for admission
3. Prehospital counseling, room assignment (choose
room assignment based on the kids age, situation,
and gender
4. Do your best to adapt to the child’s normal
⚫ Effects of hospitalization on the child - Effects may be seen
before admission, during hospitalization, or after discharge
⚫ Childs concept of illness is more important than intellectual
maturity in predicting anxiety
⚫ Child may or may not be affected by previous hospitalizations
⚫ Individual risk factors are present
**A kid who struggles with adjustment will struggle more with
hospitalization (bad temperament) o
**Kids b/w 6 mo and 5 yrs struggle with stress more
** Males are more affected
** Continued repeating stressors increase stress during
hospitalizations
Nursing Interventions
1. Preventing or minimizing separation- Important in kids less than 5
2. Preventing or minimizing parental absence
3. Minimizing loss of control: give them choices and promote freedom of
movement **more control = less stress
4. Preventing or minimizing fear of bodily injury
5. Providing developmentally appropriate activities
**Provide opportunities for play and expression
⚫ Diversional activities o Expressive activities (ex: creative expression and
dramatic play)
⚫ Make things into a game if possible eg. Toys –
⚫ Utilize a child life specialist: they are trained in education, play therapy,
and helping children through procedures
⚫ Tell parents to not go and buy new toys, the child needs familiarity
⚫ Nursing care of the family
- Supporting family members: warn parents and sibling about what the kid may look like when
they see them
- Providing info: teach about disease, what is normal and abnormal, what to expect when you go
home
- Encourage parent participation: incorporate them in care of the child - Preparing for discharge
and home care (begins at admission) Maximizing potential benefits of hospitalizations
- Fostering parent child relationships
- Providing educational opportunities
- Promoting self-mastery: having a challenge, coping, and overcoming that challenge
- Providing socialization Special hospital situations
- Ambulatory or outpatient setting: decrease stress of hospitalization, decrease risk of infection,
cheaper, teaching is important
- Isolation: a big stress on families, talk to kid like they are special because they are on isolation
- Emergency admission: most traumatic, lots of education, let the parent be with the kid as much
as possible while in the ER
- ICU: explain every tube and line, help the parents cope, be honest with the parents, ask the
parents what the child likes Pediatric variations in nursing interventions
General Concepts
1. Informed consent: capable of giving consent at 18 w/o a parent, if younger than
18 get consent from guardian, child must give assent (agree), must act
voluntarily
2. Prep for procedures: education, be honest with kid, be trustworthy
3. Safety - Environmental factors: pay attention to little things kids can swallow,
make sure furniture is not where a child can pull it on top of them, high fall risk
4. Infection control: standard precautions
5. Transporting infants and children: transport kids in their crib, wagon,
bassinets, or the bed (do not carry kids around the hallway), protect the head
and neck of younger kids, when transporting ICU kids have 2 staff and
resuscitation equipment with you
6. Restraints o Behavioral restraints: more serious, require an order, doctor has to
assess pt Q hour then Q 4 hours, assessed Q 15 by nurse
Medical surgical restraints: authorized Q day, may be protocol for certain
procedures (cleft palate surgery=elbow immobilizers, IV), monitor Q2
COLLECTION OF SPECIMENS
-Urine specimens or Clean catch: can only be used on a kid who is mature/old
enough
-For pedia use urine bag (wee bag), sticks over the urethra, empty the bladder and
discard the first one, urine must be kept on ice

- Catherization: prevent this if possible

**Collect a nonsterile specimen 1st then decide (based on the results of that
specimen) if a catheter is needed, if a kid is under 3 months old with unknown cause
of fever, they must have a catheter
- Stool specimens: get from diaper, may be hard if watery stool (lay saran wrap
down first)
- Blood specimens: try not to stick the kid a lot of times, 2 nurses to help hold the
child down, let the parent be the hero
Medication administration
- Safety is very important
- Liver and kidneys aren’t fully developed
- Meds are weight based
- Use accurate measuring devices
- Identify the child
*may need the parent to do so
*use nursing judgement and developmental considerations for
administration using particular routes
-Parenteral fluid therapy - Site and equipment: pick the site based on the
kid, gather all equipment before you go in (take extra supplies with you)
-Infusion pumps - Securing lines: secure it well with proper dressing (a
clear dressing)
- Check IV Q 1-2 hours
 PAIN ASSESSMENT AND MANAGEMENT

Three types of measures to assess child’s pain

1. Behavioral (FLACC, NIPS): you watch the behavior of the kid and calculate a
score for them, used for infants and kids younger than 4 or nonverbal kids,
not as reliable for chronic pain
2. Physiologic: looking at HR, RR, BP (VS) – not the best indicator of pain
3. Measures of self-report: the kid telling you, not valid for kids under 3
4. Test sequential understanding before using a self-report scale
⚫ Chronic pain Pain assessment in specific populations
-Children with communication and cognitive impairment
-Non communicating children’s pain checklist
-Pain indicators or communicatively impaired children
-Trust the parents when they say their kid is in pain
- Cultural differences
-Alchers pain scale is culture specific
- Children with chronic illness and complex pain
⚫ Nonpharmacology Pain Management
1.Distraction
2.Relaxation - Guided imagery
3.Cutaneous stimulation: rubbing/massage
4.Containment and swaddling - Nonnutritive sucking:
pacifier
5. Kangaroo care: skin to skin
⚫ Sucrose Pharmacologic Pain Management
1.Acetaminophen - NSAIDs
2. Opioids: work on the CNS, need to be weaned off, work better
3. Co-analgesia or adjuvant analgesia: giving a med to help with the s/e of
another
4. Patient-controlled analgesia: only the kid pushes the button, we are
concerned about the respiratory status, end tidal CO2 monitor ordered (if
end tidal CO2 gets too high, the PCA pump will lock them out)
%.Transdermal Analgesia (topical): can be used for circumcisions, simple
procedures (IV), EMLA topical lidocaine - Side Effects - Kids metabolize
drugs quicker and may need to be dosed more frequently

**A patient with a normal O2 sat may still have a high end tidal CO2 and
could cause respiratory distress.
⚫ Consequences of untreated pain
- Infant pain often inadequately managed
- Mismanagement of infant pain partially because of misconceptions
regarding effects of pain
- Chemical and hormonal responses
- Greater morbidity for neonates in NICU - Kids who have better managed
pain have shorter stays in the hospital, lower cost of stay, decreased
intubation time Impact of cognitive or sensory impairment on the child and
family Cognitive impairment
- “Cognitive impairment” (CI) is a general term that encompasses any type of
mental difficulty or deficiency, used synonymously with “intellectual
disability”
- This is a diagnosis made after a period of suspicion by family or health
professionals - In some instances, decision made at birth ‘
- Classified as mild, moderate, severe, or profound determined by IQ
 COGNITIVE IMPAIRMENT

Causes of Cognitive Impairment

- Intrauterine infection and intoxication
- Trauma (prenatal, perinatal, postnatal)
- Metabolic or endocrine disorders
-Inadequate nutrition
- Postnatal brain disease
-Unknown prenatal influences
-Chromosomal anomalies
-Prematurity
- Low birth weight
-Postmaturity
-Psychiatric disorders with onset in childhood
-Environmental influences
Nursing care of children with impaired cognitive function
- Educate child and family

Early intervention
- Teach child self-care skills: focus on the what and not the why (they will not understand
why they have to do things a certain way)
- Promote child’s optimal development
- Encourage play and exercise
- Assess what their abilities are and what their deficits are
- Positive reinforcement and motivation are important
- Try to boost their self esteem
- Provide means of communication
- Establish discipline
- Encourage socialization
-Teach social norms
- Provide information on sexuality
-Educate child on appropriate physical boundaries
- Help families adjust to future care
- Care for the child during hospitalization
-Phrase questions in a positive manner, include parents
- Praise good behavior
 HEARING IMPAIRMENT

⚫ Hospitalized care for child with hearing impairment

- Promote Communication
- Reassess understanding of instructions given
- Supplement with visual and tactile media
- Encourage parents to be there
⚫ Provide communication devices o
-Picture board with common words
- Assistance of child life specialist
-Additional aids: cochlear implants - May need lip reading (speak
at an even rate) or sign language –
-Make sure hearing aids are working properly - Kids should be
able to see you before you do anything
 VISUAL IMPAIRMENT

Hospitalized care for child with visual impairment

- Provide a safe environment
- Provide reassurance during all treatments
- Kid needs to be able to hear you before you do anything
- Orient child to surroundings
- Make sure kid can get around the room
- Encourage independence
- Treatment team members should be consistent
⚫ Nursing care of the family and child
-Assessment: assess their ability to cope, ask about current stressors in their
life, ask about need for resources
- Providing support at time of diagnosis
- Supporting family’s coping methods
- Educate about the disorder and general health care
- Promote normal development
⚫ Establish realistic future goals
- Teaching: how and who to communicate in case of emergencies, what to
expect caring for their kid at home Perspectives on care of children at end of
life
- Principles of palliative care o Pain and symptom management, we are not
going to treat to cure, it focuses on quality of life
- Decision making at end of life
⚫ Ethical considerations, physicians, health care team, parents, the dying child
⚫ Treatment options for terminally ill children
Hospital o Home care o Hospice:
-have to have a life expectancy of less than 6 months, advantages:
hospice nurses can predict things better than others
- Don’t tell a kid they aren’t going to die, if they are
- Talk openly and honestly at the beginning of diagnosis versus the end
- Make sure kid has a say Nursing care of child and family at end of life
- Child and family usually experience fears
Fear of pain and suffering
Fear of dying alone (child) or not being present at death (parent)
Fear of actual death
⚫ Grief and mourning
Grief: a process, not an event
- Highly individualized
- Anticipatory guidance
Mourning process: you may hear the child’s voice or smell them
- Recognition of when grief becomes “complicated” or “abnormal”
-Complicated: lasts longer than a year and interferes with daily living
- Parental grief vs Sibling grief
Kids grieve longer than adults but at different stages
- Nurse’s reactions to caring for dying children
⚫ Explain to families what to expect and educate them on how to
know when it becomes complicated grief
 Respiratory disorders

⚫ Childs respiratory system

- Airways are shorter and narrower, so obstruction can
occur easier - 0-5 y/o
- Trachea is narrower = more airway problems
- Children less than 6 y/o use their diaphragm to breathe
- Babies up to 5 m/o get sicker bc there’s not a lot of smooth
muscle lining the airways to trap foreign invaders Retractions
- Occur when the airway is severely obstructed, like in Croup
- Retractions accompanied by the use of accessory muscles
indicates severe distress
- Retractions require immediate assessment and
intervention
⚫ Oxygen delivery
- Make sure airway is open when delivering O2
- Pedia Protocol: tells you parameters on what the RR and O2 levels should
be
- Mist Tent: provide humidified O2, common in kids with Croup who need
the extra support, parent CAN get in the bed with the child, sheets get wet easier
- Keep bed changed/sheets clean
- Treat the patient, not the monitor
- Pediatric flow meter: smaller increments of O2 (can go down to ¼L of
O2)
- Children may require more O2 at night when they sleep
- To be discharged
- Baby should not need the O2 at night anymore Apnea
- No respirations for over 20 seconds or irregular breathing accompanied
with cyanosis, paleness, hypertonia, or a low HR
- Differentiate from irregular respirations normal for infants
⚫ Life threatening event
- Sudden combination of apnea, change in color, change in muscle tone, and choking, gagging or
coughing o Can occur at sleep, awake, or during feeding
- Diagnostic evaluation: based on description of what is happening
- Potential causes: reflux, seizures, neuromuscular disorder, respiratory issues, congenital heart
disorder, arrhythmias, obstructive sleep apnea, abuse or neglect
- Management: observing and assessing (HR, RR, pulse ox), support to parents, educate on how to
use apnea monitor at home, parents should be certified on CPR and choking Croup syndromes
- Swelling of the upper epiglottis all the way down to the trachea/bronchi Acute epiglottitis
- Haemophilus influenza is usually the cause but the Hib vaccine is now available - Medical
emergency! Swelling of the epiglottis can completely block the airway
- Symptoms: absence of spontaneous cough, drooling, agitation, irritability, muffled voice, fever,
inflamed throat, tripod positioning
⚫ Do NOT visually inspect unless you have intubation ready to happen, do not put anything in the
child's mouth
⚫ Nursing management: do not leave this child unattended, leave them in the upright position, try
to prolong anxiety induced activities
⚫ We don’t want baby to cry, get a culture once intubated, assess the child and monitor their O2 -
Treatment: IV antibiotics, steroids, fluids
⚫ Laryngotracheobronchitis
- Usually caused by viruses such as influenza, child is sick with upper respiratory s/s
for a few days
- Symptoms: starts with URI symptoms, progress to barky cough, hoarseness,
tachypnea, and inspiratory stridor
Stridor- decrease swelling in the airway first, then give O2 Nursing management:
nebulized racemic epinephrine, humidified cool O2, steroids (for edema in the
airway)
If stridor is not present s/s can be managed at home: cool air
-Tell parents they can put the child in the car with the windows down if it’s cool
outside
Acute spasmodic laryngitis - Recurrent paroxysmal attacks of laryngeal obstruction
that occur mostly at night
- Signs of inflammation absent and followed by uneventful recovery
- Allergies may predispose this virus
- Management same as infectious croup
⚫ Brachial tracheitis
- Secondary infection following LTB
Symptoms: starts as URI, croupy cough, retractions, stridor unaffected by
positional changes, high fever, copious thick secretions, but generally NO
drooling
-Believed to be a complication due to staph, strep, and other bacteria
- Child may get worse with therapy
- Management: oxygen, intubation, antipyretics, and antibiotics Bronchiolitis
- Lower Respiratory Disorder
- If untreated can lead to more serious illnesses
- RSV  common cause of October to march = RSV season
- Child will have lots of secretions and not want to eat or drink
- If stable  treat at home with steroids and breathing treatments
- If O2 is compromised  hospital admission
Pneumonia – inflammation/infection of the bronchioles and alveolar space
Causes: virus, bacterial, mycoplasmal, aspiration o Viral associated with URI & is
more common o Mycoplasma pneumonia is most common community acquired,
occurs more in the fall and winter months o Bacterial pneumonia has a faster onset
and can follow a viral
⚫ These children appear more ill
⚫ Can occur primarily or as a secondary complication
Symptoms: fever, rhonchi or crackles, cough, dyspnea, tachypnea, restlessness,
decreased breath sounds in areas of consolidation, chest pain, anorexia
Symptoms can depend on age and cause of infection
⚫ Infants with pneumonia: grunting, nasal flaring, irritability, lethargy, diminished
appetite
Nursing management
supportive care, respiratory assessments, pain and fever mgmt., antibiotics, O2
support, IV fluids to maintain hydration, nebulized bronchodilators, encourage oral
fluid intake to thin secretions, infection control
Foreign body aspiration - Can be from food or objects
- Items placed in the nose can get into the trachea and cause
obstruction
- X ray may not show object
Symptoms: coughing, gagging, dysphonia, wheezing,
dyspnea, respiratory distress, anxious, if objects are causing
severe obstruction the kid may not make a sound o Depend on
location of obstruction of the airway
Nursing management: assess (listen to lungs, watch O2
level, watch for signs of respiratory distress), prepare for CXR
or endoscopy, BLS protocol for choking (5 back blows and 5
chest thrusts, Heimlich in a child older than 1)
⚫ BLS protocol for choking
⚫ Heimlich Manuever
Pulmonary edema - Cardiogenic and noncardiogenic
Cardiogenic: from increased pulmonary venous pressure
-valve disorder, excessive IV fluids, L ventricular failure
Noncardiogenic: from increased pulmonary capillary permeability
- lung or brain injury

Symptoms: extreme Shortness of breath (SOB), cyanosis, tachypnea, diminished

breath sounds, anxiety, agitation, confusion, orthopnea, diaphoresis, crackles,
wheezing, murmurs (if cardiogenic), JVD, tachycardia, abnormal BP

Medical management: O2, PEEP, CPAP, ventilator if respiratory failure occurs, if

cardiogenic  diuretics, digoxin, and vasodilators

Nursing care: monitor O2 levels, respiratory assessments, monitor I&O, promote

comfort (high fowlers), provide support and education for family and child
Smoke inhalation injury
Heat Injury: thermal injuries to the upper airways, reflex
closure of the epiglottis will prevent injury to the lower
airway
Chemical Injury: gases during combustion of materials
can go deep into the respiratory tract, can cause damage to
the alveoli and capillaries, can lead to bronchiolitis and acute
respiratory distress syndrome o Plastic = very toxic o
Chemical burn in the airway = painless
Systemic Injury: occur when gases are nontoxic to the
airway o Carbon monoxide may quickly bond to hgb  leads
to hypoxia
Treatment and nursing care: symptomatic care,
place child on 100% humidified O2, monitor for
distress, intubation equipment available
-intubation may be necessary if the child has burns to
the face, nose, and mouth that cause swelling and
obstruction, monitor ABGs
Obstructive sleep disorder behavior - Ranges from mild
partial obstruction to Obstruction sleep apnea syndrome (OSAS)
Symptoms: habitual snoring, interrupted or disturbed sleep
patterns, enuresis, and daytime sleepiness (common in obese
children), neurobehavioral problems
Diagnosis: done via sleep study
Management: removal of tonsils and
the adenoids to open up the airway, topical
intranasal steroids, CPAP

Early intervention and teaching to

the child and family is important
⚫ Respiratory failure - Inability of the respiratory system to
maintain adequate oxygenation of the blood with or without
carbon dioxide retention
S/S: nonspecific and can vary, hypoxemia will persist even if you
are supplementing them with O2
Diagnosis: presence or history of a condition that might predispose
the patient to respiratory failure, observation of respiratory failure,
and measurement of ABGs and pH Management: administer O2,
positioning (towel under infants' neck), stimulation, suctioning,
early intubation, maintain ventilation, maximize O2 delivery, treat
underlying cause, minimize organ failure, monitor patient closely,
anticipate complications, educate family and help w/ coping, if child
needs resuscitation  let family be present if they want
 Gastrointestinal alterations

Appendicitis - Inflammation of the appendix

Symptoms: abdominal pain, McBurney’s point rebound tenderness,
fever, N/V, guarding or McBurney's point is on the R side of the
abdomen then Sudden relief of pain when appendix rupture
Diagnosis: hx and physical, CBC, urinalysis, CT scan
If rupture- surgery (appendectomy)
Not ruptured - supportive care in hospital
Medical Management: maintain hydration, antibiotics, NG tube
until bowel sounds return, advance diet slowly after surgery, keep
incision CDI, respiratory support (incentive spirometer)
Nursing Management: pain support, monitor for s/s infection,
discharge – avoid contact sports for a period of time, provide support
of body image in adolescents due to scar
Meckel diverticulum - Out-pouching of ileum containing gastric or
pancreatic tissue that secretes acid and causes irritation, ulceration, and
inflammation
- Most common congenital malformation of the GI tract, common in males -
Symptoms: often asymptomatic
Painless rectal bleeding (varied amounts), red “currant jelly” stools, abdominal pain, or signs
of obstruction, hypotension if bleeding severe Diagnosis: hx and physical, imaging and
scanning of the bowels to confirm diagnosis
Treatment: surgical removal of the infected area of the bowel, if severe manage s/s of shock
prior to surgery
Nursing management:
BLEEDING  reassure child, preop care, postop care
Preop: IV therapy, I&O, test stool for blood
Postop: pain control, watch for s/s of infection, NG tube, monitor bowel function

Peptic ulcer disease - Chronic condition of ulcers affecting stomach or duodenum

Symptoms: epigastric abdominal pain, nocturnal pain, oral regurgitation, heartburn, weight
loss, hematemesis, and melena (dark stools)
Diagnostics: history and physical, upper GI endoscopy, biopsy for H. pylori Management:
relieve discomfort, promote healing, prevent complications, antacids, PPI, mucosal protective
agents, if H. pylori is the cause (triple drug therapy, 2 antibiotics + PPI/mucosal protective
agents)
If severe : surgery, Give H2 blockers prophylactically to prevent ulcers from the stress of
hospitalization
Hepatitis
A and E- similar, and they are transmitted through contaminated water or food and do not
cause liver disease
B and D- similar, D only occurs in children already infected with B, Hep B is acquired from
an infected mother perinatally
C- transmitted from blood and body fluids, chronic, can lead to cancer of the liver
G - new type
- cause mild acute and chronic hepatitis infection
- parenterally, sexual and from mother to child transmission

Treatment: early detection & prevention, recognize if it will progress to liver disease
Prevention: teach hand hygiene, standard precautions, standard immunoglobulin to
prevent Hep A if travel to places with high Hep A cases, vaccines for Hep A & B

Nursing management:
-often cared for at home
-explain infectious control procedures and disease process
-encourage a well-balanced diet (low fat) and rest, caution parents on med administration
because the liver may not be able to detoxify and excrete the med that can be harmful
Cirrhosis - Occurs as a result of hepatitis, biliary
atresia, infection, autoimmune disorders, or chronic
disease such as hemophilia and cystic fibrosis
Irreversible damage
Symptoms: jaundice, poor growth, lethargy, ascites,
edema, anemia, abdominal pain
Management: no treatment
- Poor prognosis without liver transplant
Goals: monitor liver function and prevent further
complications Many children die waiting on liver
transplant because there is a shortage
Biliary atresia -Extrahepatic bile ducts fail to develop or are close
- cause is unknown, but could be viral
- If this isn’t treated may cause cirrhosis, end stage liver disease, then death
- Most common cause of pathologic jaundice in infants
- Leading indication for pediatric liver transplant
Symptoms
-Newborn asymptomatic
-Mild jaundice first 6-8 weeks after birth, failure to grow, abdominal distension,
hepatomegaly
-progresses to splenomegaly, easy bruising, prolonged bleeding time, intense
itching, putty-like white or clay colored stools, tea-colored urine –
Medical management
-Kasai procedure is when a piece of the intestine gets connected to the liver and
works as a port
-Baby will still need liver transplant after kasai procedure
⚫ Kasai procedure
Nursing management: early diagnosis is key to
survival
-Infants who have surgery within the first 60 days of life
have 80% chance of establishing bile flow
- Teaching: vitamin K injections prior to any invasive
procedures to help with clotting factors, baby can breast
feed, formula feed, get enteral feedings, or TPN, tepid
baths may help the child relieve some of that itching, keep
fingernails trimmed, cluster care to promote rest, teach
nutritional needs, include teaching about medications,
teach ways to watch for worsening liver disease
Cleft lip and palate - Maxillary processes fail to fuse, can occur together or separate, a cleft palate w/o a
cleft lip is more difficult to assess
- Can be caused by folic acid deficiency, smoking/drug exposure
- Common in Native Americans and Asians
Cleft lip is usually repaired at 2-3 months of age
-Early repair and intervention can interfere with skeletal development of the face
- Postponing to after child is speaking their first words may lead to speech disorders
- Any time this is found on assessment you should look for other congenital anomalies

Medical management
-plastic surgeon, speech therapy, social work, hearing specialist
- may be prone to more recurrent ear infections

Nursing Management
before surgery : Assessment at birth important (Feeding)
- If only cleft lip; may have no problems breastfeeding
- If cleft lip AND palate ; adapted bottle (pigeon bottle), child will swallow excessive amounts of air -
frequent burping, high risk for aspiration
-keep syringe and suction close by Promote Bonding
ng
Nursing Management after surgery or Pain
mgmt. and Positioning
- NO proning
- Elbow immobilizer to prevent child from trying to
suck their thumb or put their fingers in their mouth for
7-10 days
- Incision/suture care
-Petroleum jelly to suture line o Feedings: resume
when tolerated
- No suction, oral thermometers, pacifiers, or straws
Esophageal atresia and tracheoesophageal fistula –
- Esophagus ends in blind pouch or connects to trachea by fistula
- Associated with maternal hx of polyhydramnios
Symptoms: excessive salivation, drooling, apnea, increased respiratory distress
after feeding, abdominal distension

3 classic signs (3 c’s)

choking
cyanosis
coughing

Diagnosis: when unable to pass a NG tube through the stomach (they feel
resistance)
Or Can be diagnosed prenatally via US
 Medical management: NPO, IV fluids and antibiotics, NG
tube to suction
Surgical emergency: surgery can occur in stages
Nursing management: assessment in newborn period,
maintain patent airway
- Postoperative management: manage gastrostomy drainage,
administer antibiotics, monitor feeding and growth and
Emotional support
Teaching: educate and teach on procedures happening,
teach about gastrostomy feedings and tube care, teach s/s of
infection to watch for
Hypertrophic pyloric stenosis
- Hypertrophy of pyloric muscle with obstruction of gastric outlet
- Often occurs in white males with family history of this
- Symptoms: begins 2-8 weeks after birth
- Projectile vomiting up to 3 feet after eating, irritable, hungry,
dehydrated, failure to thrive, visible peristalsis with olive-sized mass in upper
abdomen (RUQ)

Diagnosis: US, UGI, labs to check the level of dehydration

- Surgery : pyloromyotomy
After surgery :start with clear fluids by mouth and slowly progress, watch for
infection, manage pain, teach family about incision care, do not lift babies' legs
when changing the diaper, IV fluids for adequate hydration

Nursing management -Keep child NPO until surgery, NG tube for

decompression of the stomach, monitor weight, promote rest and comfort
Diaphragmatic hernia -is a birth defect where there is a hole in the
diaphragm (the large muscle that separates the chest from the abdomen).
- Abdominal contents protrude into lung cavity through the diaphragm
⚫ Diaphragm did not close completely and the lungs don’t develop normally.

Symptoms: respiratory distress, dyspnea, cyanosis, barrel chest, sunken

abdomen, bowel sounds in chest

Diagnosis: US prenatally, X ray after birth

Medical management
baby is in NICU
⚫ Intubate them asap, avoid bag and mask ventilation because air inflating the
intestines can further compromise the respiratory system
⚫ Surgery, respiratory support, NGT to decompress the stomach, IV fluids,
prophylactic antibiotics
Nursing management:
1. elevate head higher than the abdomen to keep gastric contents down
2. decrease stimulation
3. cluster care
4. post-op care emotional support for family
Omphalocele and gastroschisis - Protrusion of
abdominal contents through abdomen
Omphalocele: is a birth defect of the abdominal (belly)
wall. The infant's intestines, liver, or other organs stick
outside of the belly through the belly button.
Gastroschisis: is a birth defect where there is a hole in
the abdominal wall beside the belly button.

Diagnosis: AFT (alpha feta protein)

will be elevated around 16 wks, US,
obvious after delivery.
Medical management:
1.cover with saline soaked sterile gauze to protect the organs
baby in NICU, put baby feet 1st into a bowel bag to prevent heat and moisture loss
from the organs
2. abdominal contents are placed into a silo outside of the abdomen and slowly put
back in the abdomen to prevent them from pushing on the diaphragm and causing
breathing difficulties.
**silo-a long plastic pouch
**Mom can deliver vaginally or by c/s

Nursing management:
1. Monitor temperature
2. Keep hydration
3. Communicate with parents
Surgery
1. Baby is NPO before surgery
2. NGT for bowel decompression
3. Antibiotics prophylactically with IV fluids
4. After surgery monitor lower extremities for pulses
and circulation, bowel function, watch fluid and
electrolyte balance, parenteral nutrition, support and
teach parents
Intussusception
Portion of intestine prolapses then telescopes/twists into
another
Causes obstructive blood flow, ischemia, and necrosis
Can lead to hemorrhage or perforation if untreated, common in
boys 3 mos. to 6 yrs
Symptoms
abdominal pain with vomiting, red, currant jelly stools, palpable
sausage shaped mass in RUQ or mid-upper abdomen

Diagnosis: X ray and US

Treatment
1. Barium enema guided with air or fluid to move the
bowel back into place
2. NG tube for decompression
3. Insert IV fluid
4. Start antibiotic therapy
5. If enemas don’t work : surgical repair
Result : If normal brown stool means this has
improved and may change the patients plan of care:
call provider
Nursing management
1. Fluid and electrolyte balance before surgery,

Postoperative care
2. Post op make sure NG tube is patent
3. Monitor for recurrence of this happening
4. Clear liquid diet until bowel sounds return and advance as
tolerated
Volvulus - Twisting of the intestine
Causes
1. Obstruction
2. Decrease of blood flow
3. Necrosis of the bowel

Symptoms:
4. intermittent bilious (yellow/green) vomiting
5. firm abdomen with distention
6. irritability from pain, bloody stools

Diagnosis: upper GI w/ contrast

Treatment
Emergency surgery

Post op: if uncomplicated the management is same as

intussusception
Ostomies - Opening into the small or large intestine that diverts fecal matter providing an
outlet

Pediatric considerations
1. Affects child’s lifestyle and body image (provide support & education)
2. anxiety (teach reduction)
3. electrolyte imbalance & nutritional deficiency: monitor

Preoperative care
4. focus on education
5. teach on the developmental level of the child
6. explain pain/what to expect post op
7. include family

Postoperative care
8. similar to abdominal care
9. teach stoma management
10. evaluate for complications
Poisoning - is injury or death due to swallowing, inhaling,
touching or injecting various drugs, chemicals, venoms or gases.
**Keep cabinets locked, keep dangerous things out of reach of
the child, make sure parents know the number to poison control
and Always call poison control BEFORE intervening
Common Ingested Agents:
1. corrosives (batteries, household cleaners, denture cleaner)
2. hydrocarbons (gasoline, lighter fluid, paint thinner)
3. acetaminophen, salicylate (aspirin)
4. iron (vitamin or mineral supplement)plants
Emergency treatment
1. Assess the victim
2. Initiate CPR if needed (airway, breathing, circulation)
3. Take VS, reevaluate routinely
4. Treat associated complications

Terminate exposure:
5. Empty mouth
6. Flush eyes with NSS or room temp tap water for 15-20 min
7. Flush skin and wash with soap and water
8. remove contaminated clothes
9. Identify the poison: Ask questions and look for environmental clues
10. Prevent poison absorption:
-Place child in side-lying, sitting, or kneeling position with head below chest to
prevent aspiration
-Administer activated charcoal if ordered (usually 1g/kg unless amount of toxin is
known)
-Administer drug antidote,
-or perform gastric lavage
Lead poisoning- occurs when lead builds up in the body, often over months or
years.
-Children younger than 6 years are especially vulnerable to lead poisoning, which
can severely affect mental and physical development.

Management
1. Depends on concern, urgency, and need for
intervention based on lead level in the body
2. Education
3. Chelation- Chelation therapy uses special drugs that bind to metals in your
blood.
4. May be required to remove lead from the body, very painful to the child
5. Monitor for side effects, promote adequate hydration by excreted through the
kidneys, use large muscle sites and rotate them